Turkmenistan - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

Monitoring the Situation of Children and Women Turkmenistan Multiple Indicator Cluster Survey 2006 FINAL REPORT NATIONAL INSTITUTE OF STATE STATISTICS AND INFORMATION OF TURKMENISTAN UNITED NATIONS CHILDREN’S FUND Turkmenistan Multiple Indicator Cluster Survey 2006 TURKMENMILLIHASABAT National Institute of State Statistics and Information of Turkmenistan UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund Ministry of Foreign Affairs of Turkmenistan Ministry of Health and Medical Industry of Turkmenistan 2006 The Turkmenistan Multiple Indicator Cluster Survey (MICS) was carried out by the National Institute of State Statistics and Information of Turkmenistan (Turkmenmillihasabat) and assisted by the Ministry of Foreign Affairs of Turkmenistan and the Ministry of Health and Medical Industry of Turkmenistan. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). The Survey has been conducted as part of the third round of MICS (MICS3) carried out in more than 50 countries in 2005-2006, following the first two rounds of MICS conducted in 1995 and 2000. Survey tools were based on the models and standards developed by the global MICS project, which are designed to collect information on the situation of children and women around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. National Institute of State Statistics and Information of Turkmenistan. 2006. Turkmenistan Multiple Indicator Cluster Survey 2006, Final Report. Ashgabat, Turkmenistan: Turkmenmillihasabat. i Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Turkmenistan, 2006 Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1 13 Under-5 mortality rate 67 per 1,000 2 14 Infant mortality rate 56 per 1,000 NUTRITION Nutritional status 6 4 Underweight prevalence 11 percent 7 Stunting prevalence 15 percent 8 Wasting prevalence 6 percent Breastfeeding 45 Timely initiation of breastfeeding 60 percent 15 Exclusive breastfeeding rate 11 percent 16 Continued breastfeeding rate At 12-15 months At 20-23 months 7237 percent percent 17 Timely complementary feeding rate 54 percent 18 Frequency of complementary feeding 33 percent 19 Adequately fed infants 21 percent Salt iodization 41 Iodized salt consumption 87 percent Low birth weight 9 Low-birth-weight infants 4 percent 10 Infants weighed at birth 98 percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 99.8 percent 26 Polio immunization coverage 96.8 percent 27 DPT immunization coverage 98.4 percent 28 15 Measles immunization coverage 97.0 percent 31 Fully immunized children 93.5 percent 29 Hepatitis B immunization coverage 96.8 percent Care of illness 33 Use of oral rehydration therapy (ORT) 47 percent 34 Home management of diarrhoea 15 percent 35 Received ORT or increased fluids and continued feeding 25 percent 23 Care seeking for suspected pneumonia 83 percent 22 Antibiotic treatment of suspected pneumonia 50 percent Solid fuel use 24 29 Solid fuels 0.4 percent Source and cost of supplies 96 Source of supplies (from public sources) Oral rehydration salts 82 percent ENVIRONMENT Water and sanitation 11 30 Use of improved drinking water sources 71 percent 13 Water treatment 58 percent 12 31 Use of improved sanitation facilities 99 percent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 48 percent 98 Unmet need for family planning 16 percent 99 Demand satisfied for family planning 75 percent ii Topic MICS Indicator Number MDG Indicator Number Indicator Value Maternal and newborn health 20 Antenatal care 99.1 percent 44 Content of antenatal care Blood sample Blood pressure Urine sample Weight 98 95 97 90 percent percent percent percent 4 17 Skilled attendant at delivery 99.5 percent 5 Institutional deliveries 98 percent CHILD DEVELOPMENT Child development 46 Support for learning 80 percent 47 Father's support for learning 61 percent 48 Support for learning: children’s books 42 percent 49 Support for learning: non-children’s books 58 percent 50 Support for learning: materials for play 24 percent 51 Non-adult care 15 percent EDUCATION Education 52 Preschool attendance 24 percent 53 School readiness 32 percent 54 Net intake rate in primary education 97 percent 55 6 Net primary school attendance rate 99 percent 56 Net secondary school attendance rate 95 percent 57 7 Children reaching grade 5 99.9 percent 58 Transition rate to secondary school 99.8 percent 59 7b Primary completion rate 99.2 percent 61 9 Gender parity index Primary school Secondary school 1.00 1.00 ratio ratio Literacy 60 8 Adult literacy rate 99.2 percent CHILD PROTECTION Birth registration 62 Birth registration 96 percent Early marriage and polygyny 67 Marriage before age 15 Marriage before age 18 0.4 7 percent percent 68 Young women aged 15-19 currently married/in union 5 percent 69 Spousal age difference 4 percent Domestic violence 100 Attitudes toward domestic violence 38 percent HIV/AIDS AND ORPHANED CHILDREN HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young people 9 percent 89 Knowledge of mother- to-child transmission of HIV 19 percent 86 Attitude toward people with HIV/AIDS 6 percent 87 Women who know where to be tested for HIV 28 percent 88 Women who have been tested for HIV 12 percent 90 Counselling coverage for the prevention of mother- to-child transmission of HIV 35 percent 91 Testing coverage for the prevention of mother-to- child transmission of HIV 22 percent Support to orphaned and vulnerable children 75 Prevalence of orphans 6 percent 78 Children’s living arrangements* 1.5 percent 77 20 School attendance of orphans vs. non-orphans 1.00 ratio * Percentage of 0-17 children in households living separately from one of their biological parents iii Table of Contents Summary Table of Findings. i Table of Contents .iii List of Tables . v List of Figures .vii List of Abbreviations .viii Foreword .vix Acknowledgements . x Executive Summary . xi I. Introduction. 1 Background. 1 Survey Objectives. 2 II. Sample and Survey Methodology. 4 Sample Design. 4 Questionnaires . 4 Training and Fieldwork . 5 Data Processing . 5 III. Sample Coverage and the Characteristics of Households and Respondents . 6 Sample Coverage . 6 Characteristics of Households. 6 Characteristics of Respondents . 8 IV. Child Mortality. 10 V. Nutrition Nutritional Status. 13 Breastfeeding . 15 Salt Iodization. 17 Low Birth Weight. 18 VI. Child Health . 21 Immunization . 21 Oral Rehydration Treatment . 22 Care Seeking and Antibiotic Treatment of Pneumonia . 23 Solid Fuel Use. 24 Sources and Costs for Oral Dehydration Salts. 25 VII. Environment. 26 Water and Sanitation . 26 VIII. Reproductive Health. 29 Contraception . 29 Unmet Need . 29 Antenatal Care. 31 Assistance at Delivery . 32 IX. Child Development. 33 X. Education. 35 iv Preschool Attendance and School Readiness. 35 Primary and Secondary School Participation . 35 Adult Literacy . 37 XI. Child Protection. 38 Birth Registration . 38 Child Discipline. 39 Early Marriage. 39 Domestic Violence . 41 XII. HIV/AIDS, Sexual Behaviour, and Orphaned Children. 42 Knowledge of HIV Transmission . 42 Orphaned Children . 45 List of References . 46 Appendix A. Sample Design . A1 Appendix B. List of Personnel Involved in the Survey. A5 Appendix C. Estimates of Sampling Errors. A6 Appendix D. Data Quality Tables. A17 Appendix E. MICS Indicators: Numerators and Denominators . A24 Appendix F. Questionnaires. A28 v List of Tables Table HH.1: Results of household and individual interviews . 47 Table HH.2: Household age distribution by sex . 48 Table HH.3: Household composition. 49 Table HH.4: Women's background characteristics . 50 Table HH.5: Children's background characteristics……………………………………………………51 Table CM.1: Child mortality. 52 Table CM.2: Children ever born and proportion dead. 53 Table NU.1: Child malnourishment. 54 Table NU.2: Initial breastfeeding. 55 Table NU.3: Breastfeeding. 56 Table NU.4: Adequately fed infants. 57 Table NU.5: Iodized salt consumption . 58 Table NU.6: Low-birth-weight infants. 59 Table CH.1: Vaccinations in first year of life . 60 Table CH.1C: Vaccinations in first year of life (continued). 60 Table CH.2: Vaccinations by background characteristics . 61 Table CH.2C: Vaccinations by background characteristics (continued). 62 Table CH.3: Oral rehydration treatment . 63 Table CH.4: Home management of diarrhoea . 64 Table CH.5: Care seeking for suspected pneumonia. 65 Table CH.6: Antibiotic treatment of pneumonia. 66 Table CH.7: Knowledge of the two danger signs of pneumonia. 67 Table CH.8: Solid fuel use . 68 Table CH.9: Source and cost of supplies for oral rehydration salts. 69 Table EN.1: Use of improved water sources . 70 Table EN.2: Household water treatment . 71 Table EN.3: Time to source of water . 72 Table EN.4: Person collecting water . 73 Table EN.5: Use of sanitary means of excreta disposal. 74 Table EN.6: Use of improved water sources and improved sanitation. 75 Table RH.1: Use of contraception. 76 Table RH.2: Unmet need for contraception . 77 Table RH.3: Antenatal care provider . 78 Table RH.4: Antenatal care . 79 Table RH.5: Assistance during delivery. 80 Table CD.1: Family support for learning . 81 Table CD.2: Learning materials. 82 Table CD.3: Children left alone or with other children . 83 Table ED.1: Early childhood education . 84 Table ED.2: Primary school entry. 85 Table ED.3: Primary school net attendance ratio . 86 Table ED.4: Secondary school net attendance ratio . 87 Table ED 5: Secondary school-age children attending primary school (working table) . 88 Table ED.6: Children reaching grade 5 . 89 Table ED.7: Primary school completion and transition to secondary education . 90 Table ED.8: Education gender parity . 91 Table ED.9: Adult literacy . 92 Table CP.1: Birth registration. 93 Table CP.2: Child discipline. 94 Table CP.3: Early marriage. 95 Table CP.4: Spousal age difference . 96 vi Table CP.5: Attitudes toward domestic violence . 97 Table HA.1: Knowledge of preventing HIV transmission. 98 Table HA.2: Identifying misconceptions about HIV/AIDS . 99 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission . 100 Table HA.4: Knowledge of mother-to-child HIV transmission . 101 Table HA.5: Attitudes toward people living with HIV/AIDS. 102 Table HA.6: Knowledge of a facility for HIV testing. 103 Table HA.7: HIV testing and counselling coverage during antenatal care . 104 Table HA.8: Children's living arrangements and orphanhood. 105 Table HA.9: School attendance of orphaned children . 106 vii List of Figures Figure HH.1: Age and sex distribution of household population . 7 Figure HH.2: Age distribution of population in Turkmenistan. 7 Figure CM.1: Under-5 mortality rates by background characteristics . 11 Figure CM.2: Trend in under-5 mortality rates . 12 Figure CM.3: Infant mortality rates by different sources. 12 Figure NU.1: Percentage of children under 5 who are undernourished . 14 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth. 16 Figure NU.3: Infant feeding patterns by age: Percent distribution of children aged under 3 years, by feeding pattern by age group . 17 Figure NU.4: Percentage of households consuming adequately iodized salt. 18 Figure NU.5: Percentage of infants weighing less than 2500 grams at birth. 20 Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccination by 12 months . 22 Figure EN.1: Percentage distribution of household members by source of drinking water. 26 Figure HA.1: Percent of women who have comprehensive knowledge of HIV/AIDS transmission . 43 viii List of Abbreviations AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) DHS Demographic and Health Survey in Turkmenistan DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization HepB Hepatitis B Vaccine HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IUD Intrauterine Device LAM Lactational Amenorrhoea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH&MIT Ministry of Health and Medical Industry of Turkmenistan NAR Net Attendance Rate OPV Polio Vaccine ppm Parts Per Million SPSS Statistical Package for Social Sciences UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit For Children WHO World Health Organization ix FOREWORD The Multiple Indicator Cluster Survey (MICS) is a household survey developed by UNICEF to assist countries in filling data gaps for monitoring the situation of children and women, as well as assessing progress towards the Millennium Development Goals (MDGs) to which countries have pledged to achieve by the year 2015. It is capable of producing statistically sound, internationally comparable estimates of these indicators. The MICS was originally developed in response to the World Summit for Children to measure progress towards an internationally agreed set of mid-decade goals. The first round of MICS was conducted around 1995 in more than 60 countries. A second round of surveys was conducted in 2000, and resulted in an increasing wealth of data to monitor the situation of children and women. For the first time it was possible to monitor trends in many indicators and set baselines for other indicators. The current round of MICS is focused on providing a monitoring tool for the World Fit for Children (WFFC), the Millennium Development Goals (MDGs), as well as for other major international commitments, such as the UNGASS on HIV/AIDS. It is significant to mention that 21 of the 48 MDG indicators have been collected in the current round of MICS, offering the largest single source of data for MDG monitoring. MICS 2006 is the first internationally acceptable detailed social sector survey carried out in Turkmenistan that is being published for global use. It is unique in the sense that it provides vast range and set of data and indicators for Turkmenistan and allows dis-aggregation on most of them for sub national regions, gender and welfare indices. As such it is extremely valuable source for disparity analysis and an excellent planning baseline for social investments at national and local levels in the country. It is expected that the data will be widely used by national and local level authorities to not only plan for the children and women of their respective constituencies but use it as a guide for far reaching policy initiatives in the social sectors. UNICEF deeply appreciates the excellent and hard work carried out by the specialists of the National Institute of State Statistics and Information (NISSI) at the central and velayat levels during MICS preparatory and field works. Globally developed questionnaires comprising of three major sections; on household, women and children were professionally adapted to the realities of the country, based on which a total of 5208 households in all the five velayats and Ashgabat city area were surveyed by 90 trained staff of NISSI. Data collected from this vast number of households were subsequently entered and analysed through the standard programmes developed under the global MICS 3 project. UNICEF wishes to convey its sincere appreciation and thanks to the national authorities which supported the MICS process. This includes the National Institute of State Statistics and Information for carrying out the survey, Ministry of Foreign Affairs for its excellent coordination and Ministry of Health and Medical Industry, Ministry of Education and local level authorities for providing full support during the survey. UNICEF also would like to express its appreciation to the UN partners, in particular UNFPA for cooperating during the survey. In addition, we would like to extend our appreciation to UNICEF colleagues in the Regional Office and the UNICFEF Headquarters in New York for providing technical assistance throughout the process. Mahboob Shareef Representative United Nation’s Children’s Fund Ashgabat, Turkmenistan x Acknowledgements The Multiple Indicator Cluster Survey (monitoring situation of children and women), or MICS, was implemented by the National Institute of State Statistics and Information of Turkmenistan (Turkmenmillihasabat) in 2006. Before the Survey itself, questionnaires and guidelines were discussed by the Cabinet of Ministers of Turkmenistan (Deputy Chairman of the CMT for economy), Ministry of Health and Medical Industry of Turkmenistan (MoH&MIT), Ministry of Education, and Turkmenmillihasabat, with the support of the Ministry of Foreign Affairs of Turkmenistan (MFA). Comments and recommendations made by the Government of Turkmenistan were considered and approved by UNICEF. Turkmenmillihasabat expresses its profound gratitude to the Government of Turkmenistan (CMT, MFA) and to representatives of the national and local authorities for their help and assistance in carrying out this Survey. Turkmenmillihasabat also expresses its appreciation of the important part in the Survey performed by the health professionals of the MoH&MIT. In addition, Turkmenmillihasabat thanks UNICEF Headquarters and its Regional Office for their financial and technical support for MICS in Turkmenistan. We render special thanks to the UNICEF Country Representative in Turkmenistan, Mahboob Shareef; to Social Policy Officer Shohrat Orazov, for his efficient response to emerging problems and help with the Survey logistics; and to Guy Kalustov, for data editing and tabulation. An important contribution was made by the UNICEF international consultant Shuaib Muhammad, who provided his expertise to the project from beginning to end. He participated in the sample preparation, conducted training workshops, provided consultations on the contents of the questionnaires and was involved in organization of the Survey. We express our gratitude to the MICS3 Regional Coordinator/Eastern Europe and CIS UNICEF Officer in Geneva, Georgy Sakvarelidze, for the methodological support. Finally, Turkmenmillihasabat thanks all individuals directly or indirectly involved in this Survey, especially those members of households in Turkmenistan who kindly agreed, on a confidential basis, to answer the questionnaires and provide information useful for decision making and aimed at further improvement of the situation of women and children in the country. xi Executive Summary The Turkmenistan Multiple Indicator Cluster Survey (MICS) is a nationally representative sample of more than 5,000 households implemented in 2006 by the National Institute of State Statistics and Information of Turkmenistan (Turkmenmillihasabat). The Survey provided basic information on the situation of under-5 children and fertile-age women in Turkmenistan. Moreover, it allowed the monitoring of progress toward goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. The household sample provided the basis for the evaluation of main indicators of the situation of children and women, taking into account such background factors as gender, area of residence, region, age, level of education, wealth index, etc. Child mortality Through the use of the indirect estimation technique known as the Brass method, the under-5 child mortality rate and infant mortality rate were calculated for Turkmenistan as a whole as well as for the regions/provinces. The national infant mortality rate was estimated at 56 per 1,000 live births and the probability of dying among under-5 children at 67 per 1,000 live births; these estimates have been calculated by averaging mortality estimates obtained from women aged 25- 29 and 30-34, and refer to mid-2003. The MICS estimates show a decline in child mortality during the last 15 years, particularly pronounced during the period 1999-2004. Nutrition Anthropometric measurements of under-5 children were conducted and the findings compared with the WHO international standards. In Turkmenistan, every one in nine under-5-year-old children is moderately underweight (11 percent), with fewer than 2 percent considered severely underweight. Nearly 15 percent of children are moderately stunted, or short for their age, and slightly more than 6 percent are moderately wasted, or too thin for their height. Turning to the percentages of breastfed children under age 3 years and of low-birth-weight children, fewer than 11 percent of children younger than age 6 months were exclusively breastfed, which is significantly lower than recommended. An estimated 4 percent of newborns weighed less than 2500 grams, out of the 98 percent of newborns weighed after birth. Child health As immunization in Turkmenistan is mandatory and free for all children in Turkmenistan, rather high vaccination coverage is observed irrespective of the area of residence (urban/rural), educational level of mothers and households’ wealth. Environment In general over 71 percent of the population use improved sources for drinking water - 91 percent in urban and 58 percent in rural areas. The situation in the south-east (Mary velayat), where only 39 percent of the local population have access to improved drinking water, is worse than in the rest of the country. Around 99 percent of the households in Turkmenistan maintain improved sanitation facilities: 99.8 percent in the urban areas and 98 percent in the rural areas, respectively. Among the regions, the use of the improved sanitation is practically the same. xii On average, 70 percent of household use both improved sources of drinking water and improved sanitation facilities. At that, there are urban-rural and regional distinctions: the highest figures are in the capital city (95 percent) and Lebap velayat (more than 88 percent), the lowest – in Mary velayat (less than 39 percent); the figures are also higher in urban areas (91 percent) than in the rural areas (57 percent). Reproductive Health Nearly 16 percent of women aged 15-49 have an unmet need of contraceptives, encompassing 6 percent for planning birth spacing and 10 percent for limiting the number of children. The total demand for contraception stands at about 64 percent (using contraceptives and unmet need for contraceptives). Antenatal care coverage (services provided by a doctor, nurse or midwife) is high: more than 99 percent of women receive antenatal care, making at least one visit to a doctor during their pregnancy. Nearly all births – 99.5 percent – occurring in the year before the MICS Survey were delivered by skilled personnel, a notably high figure. Child Protection For its part, birth registration is a fundamental means of securing children’s rights. In Turkmenistan, the fact of birth has been registered for 96 percent of under-5 children. The percentage of under-1 children whose births were registered was less than 87 percent, while for 4-year old children it was more than 99 percent, which indicates a significant number of cases of “delayed” birth registration. Child Development During the Survey, information likewise was collected about various activities promoting early child learning (Child Development Module). Within three days prior to the Survey, adults in Turkmenistan said they were engaged in more than four activities promoting learning and school readiness for 80 percent of under-5 children. The average number of activities in which adults engaged with their children was 4.6, which remained virtually constant across areas of residence (urban/rural) as well as gender. Involvement of fathers was quite high – more than 61 percent in one or more activities. In addition, nearly one in four child (24 percent) aged 0-59 months had three or more playthings in their homes, while fewer than 4 percent had no playthings according to the responses of their mothers/caretakers. Education Turkmenistan has high figures of education coverage indicators. The Constitution of Turkmenistan guarantees compulsory secondary education free of charge, and school education coverage is high. As MICS shows, the net primary school attendance rate is 99 percent, and more than 95 percent of secondary school-age children attend secondary schools. The gender parity index both for primary and secondary school is 1.00, evidence of equality in attendance rates between boys and girls. The percentage of literate women aged 15-24 in the country also is high, at 99.2 percent. Orphaned children The percentage of orphaned children in Turkmenistan aged 0-17 is not high – 6 percent of children have lost one or both parents, with only 0.4 percent being double orphans. A total of 0.5 percent of children aged 10-14 had lost both parents; at present all attend school. Among children aged 10-14 whose parents are alive, or who have at least one parent, 99.6 percent attend school. Thus, double orphans’ access to school education is equal to that of non-orphaned children. HIV/ AIDS One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. More than half of the interviewed reproductive-age women (55 percent) had heard about AIDS. However, only slightly more than 12 percent of women knew all three primary ways of HIV prevention. I. Introduction Background This report is based on the Turkmenistan Multiple Indicator Cluster Survey, conducted in 2006 by the National Institute of State Statistics and Information of Turkmenistan (Turkmenmillihasabat). The Survey provides valuable information on the situation of children and women in Turkmenistan and was based, in large part, on the need to monitor progress toward goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress toward that end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” 2 In 2003 Turkmenistan prepared its National Report on progress toward the Millennium Development Goals, or MDGs (UNDP, Union of Economists, Turkmenmillihasabat, MoH&MIT, and MFA). Of the 18 MDG targets, 13 already had been achieved; the National Report therefore formulated a new set of targets for the country. Specifically, because global target 1 of the first MDG (“To reduce by half during 1990-2015 the proportion of people with income less than US$1 per day”) had been achieved in Turkmenistan by the year 2000, a new national target was set: “To reduce, by a factor of three during 2001-2015, the proportion of people with income less than 50 percent of monthly average income.” Global target 2 for the second MDG (“To ensure by 2015 that all children in the world, both boys and girls, have opportunity for full primary school education”) likewise was replaced, by the new national target “To expand the access of people to high-quality education at all levels and achieve world standards in education.” Turkmenistan also had already achieved global target 5 of the fourth MDG (“To reduce, by two-thirds during 1990-2015, under-5 child mortality”). To a greater extent, the country faces the challenge of further reducing infant mortality, which had been reduced by 2.2 times during 1991-2000; the new target is “To reduce infant mortality during 2000-2015 by a factor of 2.1.” Similarly, with regard to global target 6 of the fifth MDG (“To reduce, by three-fourths during 1990-2015, the maternal mortality rate”), Turkmenistan had achieved this by reducing the rate by a factor of more than 2 during 1990-2000. The new target thus set was “To reduce by half the maternal mortality rate during 2000-2015.” In 2004 Turkmenistan submitted to the United Nations its National Reports on implementation of three international Conventions: “On Elimination of All Forms of Racial Discrimination,” “On the Rights of the Child” and “On Elimination of All Forms of Discrimination against Women.” To monitor population living standards and measure progress of implementation of national social and economic programmes, statistics institutions carried out household (HH) sample surveys in all provinces; these were conducted jointly with the World Bank (WB) in 1998 and with the Asian Development Bank (ADB) in 2003. During the 1998 survey, anthropometric measurements of all HH members were taken. Findings of the subsequent 2003 living standards survey showed growth in practically all living standards indicators in Turkmenistan. This final report presents the results of the indicators and topics covered in the MICS Survey. Survey Objectives The 2006 Turkmenistan Multiple Indicator Cluster Survey has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women in Turkmenistan; 3  To furnish data needed for monitoring progress toward goals established by the Millennium Development Goals, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action;  To contribute to the improvement of data and monitoring systems in Turkmenistan and to strengthen technical expertise in the design, implementation, and analysis of such systems. These objectives have been achieved. Results of the 2006 Turkmenistan MICS made it possible:  To obtain reliable information about the situation of children and women of fertile age in the country;  To monitor the main indicators set by the Millennium Development Goals, Plan of Action of WFFC, and the national long-term development programme until 2020, which have shown improvement in living standards and the situation of children and women;  To identify factors (resources) for further improvement of the situation of children and women which will be taken into account by the Government of Turkmenistan in implementation of the national long-term programmes for social and economic development, such as Strategy for Economic, Political and Cultural Development of Turkmenistan for the Period up to 2020, the Health Programme, and others;  To enlarge statistical databases on situation of children and women (such as Genstat, Genstat Region, DevInfo);  To increase the capacity of the Turkmenmillihasabat staff in methodology, organization and conduct of sample surveys in the social sphere. 4 II. Sample and Survey Methodology Sample Design The sample for the Turkmenistan Multiple Indicator Cluster Survey (MICS) was designed to provide estimates on a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for six regions: the capital city of Ashgabat and the velayats (provinces) of Ahal, Balkan, Dashoguz, Lebap and Mary. Regions were identified as the main sampling domains and the sample was selected in two stages. Within each region, 42 census enumeration areas were selected, with probability proportional to size. After a household listing was carried out within the selected enumeration areas, a systematic sample of 1,008 households in Ashgabat and 840 households in each velayat was drawn. All selected enumeration areas were visited during fieldwork. The sample was stratified by region and is not self-weighting. For reporting national-level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the Survey: 1) a household questionnaire used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; and 3) an under-5 questionnaire, administered to mothers or caretakers of all children under 5 living in the household.1 The Household Questionnaire included the following modules: o Household Listing o Education o Water and Sanitation o Household Characteristics o Additional Household Characteristics o Child Discipline o Salt Iodization The Questionnaire for Individual Women included the following modules: o Child Mortality o Maternal and Newborn Health o Marriage and Union o Contraception o Attitudes Toward Domestic Violence o HIV Knowledge o Tuberculosis 1 The terms “children under 5”, “children aged 0-4 years” and “children aged 0-59 months” are used interchangeably in this report. 5 The Questionnaire for Children Under 5 was administered to mothers or caretakers of under-5 children living in the household. Usually the questionnaire was offered to mothers of the under-5 children; if a mother was not found in the household the main caretaker was identified and interviewed. The Questionnaire included the following modules: o Birth Registration and Early Learning o Child Development o Breastfeeding o Care of Illness o Immunization o Anthropometry o Immunization by Health Care Facility The questionnaires are based on the MICS3 model questionnaire2. From the MICS3 model English version, the questionnaires were translated into the Turkmen and Russian languages and were pre-tested in Ashgabat city during April 2006. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Turkmenistan MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of children aged under 5 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork Training for fieldwork was conducted for 10 days in June 2006 and included lectures on interviewing techniques and the contents of the questionnaires, as well as mock interviews between trainees to gain practice in asking questions. Toward the end of the training period, trainees spent 4 days in practice interviewing in each region/province. The data were collected by 18 teams; each was comprised of 4 interviewers, one driver, 3 editors and a supervisor. Fieldwork began in June 2006 and concluded in July 2006. Data Processing Data were entered on 12 microcomputers using the CSPro software, carried out by 12 data entry operators and 6 data entry supervisors. In order to ensure quality control, all questionnaires were double-entered and internal consistency checks performed. Procedures and standard programmes developed under the global MICS3 project and adapted to the Turkmenistan questionnaire were used throughout. Data processing began simultaneously with data collection in July 2006 and was completed in October 2006. Data were analysed using the Statistical Package for Social Sciences (SPSS) software programme, Version 14, and the model syntax and tabulation plans developed by UNICEF for this purpose. 2 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. 6 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 5,208 households selected for the sample, 5,204 were found to be occupied. Of these, 5,042 were successfully interviewed, for a household response rate of 96.9 percent. In the interviewed households, 7,177 women aged 15-49 were identified. Of these, 7,160 were successfully interviewed, yielding a response rate of 99.8 percent. In addition, 2,087 children under age 5 were listed in the household questionnaire. Questionnaires were completed for 2,075 of these children, corresponding to a response rate of 99.4 percent. Overall response rates of 96.7 percent and 96.3 percent are calculated for the women’s and under-5’s interviews respectively (Table HH.1). The response rate in the capital city of Ashgabat, at 93 percent, was the lowest compared to other regions. This can be explained by the fact that urban populations overall encompass higher levels of non-response than rural areas. Among the other five regions, the response rate was the lowest in Balkan velayat (95 percent), which also may be linked to the prevalence of urban population in this region in comparison with the other velayats. In general, the response rate in the rural areas (99.5 percent) was higher than that in the urban areas (94.6 percent). Characteristics of Households The age and sex distribution of the MICS 2006 population is provided in Table HH.2. This distribution also was used to produce the population pyramid in Figure HH.1. In the 5,042 households successfully interviewed, 25,364 household members were listed; of these, 12,294 were males, and 13,070 were females. These figures also support the average household size of 5.0. According to Survey findings, about one-third of the population are children under 15 (31 percent), 64 percent are aged 15-64 years, and 5 percent are aged 65 years and older. Children aged 0-17 comprise 38 percent of the population; male predominance is observed in this age group, linked to the larger number of male births. The largest age group for males and females, at more than 12 percent of the population, is aged 10-14 years. Each subsequent age group, starting from ages 15-19, shows a gradual decrease in the population pyramid. It should be noted that females disproportionately outnumber males in the 15-19 age group, given that household lists did not include men aged 18-19 who were doing their military service in the National Armed Forces (see Table DQ.1). This also influenced the overall male-female ratio. 7 Figure HH.1: Age and sex distribution of household population, Turkmenistan, 2006 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Percent Males Females Comparison of the Turkmenistan population census 1995 data and MICS 2006 data revealed certain changes in the age population structure (Figure HH.2). A decrease was seen in the percentage of the population under 15 and increase in the percentage of middle- and old-age groups. This can be explained by the decrease in birth rates over a period of several years. However, on the basis of the MICS data (see Table DQ.1), it can be assumed that within the last five years the birth rate has stabilized. Figure HH2. Age distribution of population, Turkmenistan, 2006 40.6 55.6 3.8 30.8 64.4 4.7 0 10 20 30 40 50 60 70 0-14 years 15-64 years 65 years and above Age groups Pe rc en t Census 1995 MICS 2006 8 Table HH.3 provides basic background information on the households. Within households, the sex of the household head, region, urban/rural status, number of household members, and mother tongue3 of the household head are shown in the table. These background characteristics also are used in subsequent tables in this report; figures in the table are further intended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, because sample weights were normalized (See Appendix A). The table also shows the proportions of households where at least one child under 18, at least one child under 5, and at least one eligible woman aged 15-49 were found. Of the total number of the households interviewed, 45.5 percent were in urban areas and 54.5 percent in rural areas. Percentage distribution of households among the regions was as follows: Ashgabat city, 13 percent; Ahal velayat, 14 percent; Balkan velayat, 9 percent; Dashoguz velayat, 18 percent; Lebap velayat, 22 percent; and Mary velayat, 24 percent. The heads of most households were men (75 percent). In the distribution of the households by the number of persons living in them, households with the largest proportional weight were those comprised of 4-5 members (39 percent), followed by households comprised of 6-7 persons (25 percent). The lowest proportions encompassed households consisting of one person (6 percent) and those of 10 or more persons (4 percent). The Turkmen language was indicated as the mother tongue of the household head in more than 80 percent of the households. At least one child under 18 was found in 79 percent of households and at least one child under 5 in 31 percent of households. In 88 percent of households lived at least one fertile-age woman. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15-49 and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, because sample weights have been normalized. The tables also are intended to show the numbers of observations in each background category; these categories are used in subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents aged 15-49. The table includes information on the distribution of women according to region, urban/rural areas, age, marital status, motherhood status, education4, wealth index quintiles5 and mother tongue. 3 This was determined by asking “What is the mother tongue of the household head?” 4 Unless otherwise stated, throughout this report “education” refers to educational level attended by the respondent when it is used as a background variable. 5 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and to obtain wealth scores for each household in the sample (The assets used in these calculations were as follows: source of water; sanitary [toilet] facility; main materials of the floor, roof and walls; number of rooms used for sleeping; type of fuel used for cooking; household effects (appliances and furniture). Each household was then weighted by the number of household members and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are 9 Thirty-nine percent of interviewed fertile-age women live in urban area; 61 percent live in rural area. By region, the distribution of women is as follows: Ashgabat city, 11 percent; Ahal velayat, 14 percent; Balkan velayat, 8 percent; Dashoguz and Lebap velayats, 21 percent each; and Mary velayat, 25 percent. The largest female group are women aged 15-24 (39 percent). A total of 46.5 percent of reproductive-age women are in the optimal age for childbearing – 20 to 35 years. The majority of the female respondents (more than 55 percent) are currently married or in union; nearly 38 percent have never been married, and about 7 percent are widows or were married (in union) before. More than 57 percent of women had given birth. More than 82 percent of the interviewed women had secondary education or less, 12 percent had secondary vocational (special/professional) education, and 5 percent had higher education. The mother tongue of almost 85 percent of women is Turkmen. According to the wealth index (for all its conditional and disputable methodology – UNICEF), 21 percent of women aged 15-49 live in the fifth quintile, or the richest households, against 19 percent living in first-quintile households with the lowest incomes. Some background characteristics of children under 5 are presented in Table HH.5. These include distribution of children by several attributes: sex, region and area of residence, age in months, mother’s or caretaker’s education, wealth, and mother tongue. Of the total number of children under 5, 50.6 percent are boys and 49.4 percent are girls. Because of higher birth rates in rural areas, 65 percent of children of this age are concentrated there, while 35 percent of children live in urban areas. A direct relation of the proportion of 0-4 children to the proportional weight of the rural population and reproductive-age women is observed in velayats, with the largest proportion in Mary velayat (26 percent) and the smallest in Balkan velayat (8 percent). The largest number of children (more than 22 percent) is aged 0-11 months. Also for children under 5, about 85 percent of women are native Turkmens whose mother tongue is Turkmen; more than 84 percent of women have basic primary and secondary education. A total of 57 percent of children under 5 live in households of middle and above middle level of wealth and, accordingly, 43 percent live in households below middle level of wealth. applicable for only the particular data set on which they are based. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. 10 IV. Child Mortality One of the overarching goals of both the MDGs and the WFFC is to reduce infant and under- 5 mortality. Specifically, the MDGs call for the reduction in under-5 mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective: Measuring childhood mortality may seem easy, but attempts at using direct questions, such as “Has anyone in this household died in the last year?,” give inaccurate results. Using direct measures of child mortality from birth histories is time-consuming, more expensive and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with those obtained from other sources. Indirect methods also minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing techniques. The infant mortality rate is the probability of dying before the first birthday, while the under-5 mortality rate reflects the probability of dying before the fifth birthday. In MICS surveys, infant and under-5 mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). Data used in the estimation are: the mean number of children ever born for five-year age groups of women aged 15 to 49, and the proportion of these children who are dead, also for five-year age groups of women. The technique converts these data into probabilities of dying by taking into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Turkmenistan, the East model life table was selected as most appropriate. Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the mortality rates for the national total. The infant mortality rate is estimated at 56 per 1,000, while the under-5 mortality rate (U5MR) is around 67 per 1,000. These estimates have been calculated by averaging mortality estimates obtained from women aged 25-29 and 30-34 and refer to mid-2003. Some difference exists between the probabilities of dying among males and females; infant and under-5 mortality rates are 1.6 times higher among males than females. Infant and under-5 mortality rates also are lowest in the metropolitan regions (Ahal velayat and Ashgabat city) as well as Balkan velayat, while the figures for the other three regions (Dashoguz, Lebap and Mary velayats) are about 1.7 times higher than that of Ahal velayat and about 1.3 times higher than that of Ashgabat and Balkan velayat. Significant differences in mortality also exist in terms of educational levels of mothers. In particular, the probabilities of dying among infants and under-5 children of mothers with secondary special (vocational) and higher education are considerably lower than the national average. In Turkmenistan, no correlations are observed between household wealth and infant/child mortality. Differentials in under-5 mortality rates by background characteristics also are shown in Figure CM.1. 11 Figure CM.2 shows the series of U5MR estimates, based on responses of women in different age groups and referring to various points in time, thus indicating the estimated trend in U5MR based on the Survey. The MICS estimates indicate a decline in mortality during the last 15 years but are higher than official statistics estimates of the mortality trend, which also show the decline. For example, the most recent MICS U5MR estimate (53 per 1,000 live births) is about two times higher than the estimate from official statistics for the same year. It should be noted, however, that such comparison may not be fully correct because of differences in the technique of estimation: MICS is an indirect-method, non-specialized sample survey, while official statistics are a direct method. The trend indicated by the MICS results are not in agreement with those estimated in the Demographic and Health Survey in 2000 (DHS 2000). DHS estimates depicted U5MR growth starting from 1995, while MICS estimates show a trend of decline. According to the MICS results, the most intensive decline in child mortality was observed during the period 1999-2004. Further qualification of these apparent declines and differences, as well as their determinants, should be taken up in a more detailed and separate analysis. Figure CM.1 Under-5 mortality rates by background characteristics, Turkmenistan, 2006 55 44 54 72 74 72 66 68 72 46 64 73 67 0 10 20 30 40 50 60 70 80 Regions Ashgabat city Ahal velayat Balkan velayat Dashoguz velayat Lebap velayat Mary velayat Area Urban Rural Mother's education None/primary/secondary Secondary professional (special)/higher Wealth quintiles Low-and middle-income HH -1, 2, 3 quintiles High-income HH – 4-5 quintiles Turkmenistan Per 1,000 live births 12 Figure CM.2: Trend in under-5 mortality rates, Turkmenistan 0 20 40 60 80 100 120 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 Year Pe r 1 00 0 liv e bi rth s MICS 2006 (indirect method) DHS 2000 (indirect method) Official statistics (direct method) Figure CM.3. Infant (under 1) mortality rates in Turkmenistan by various sources (pro mil ) 0 20 40 60 80 100 120 140 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 Year P er 1 00 0 liv e bi rth s Official statistics (direct method) DHS 2000 (direct method) DHS 2000 (indirect method) MICS 2006 (indirect method) Prognosis based on DHS 2000 (unjustified) 13 V. Nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness and are well cared for, they reach their growth potential and are considered well-nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and those who survive may have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition are only mildly or moderately malnourished, showing no outward sign of their vulnerability. The MDG target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The WFFC goal is to reduce the prevalence of malnutrition among children under 5 by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the goal of reducing child mortality. In a well-nourished population, a reference distribution exists for height and weight for children under 5. Undernourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the Survey was implemented. New WHO growth standards were made available in April 2006. Syntax programmes will be produced based on the new standards and will be provided to countries in due course, to facilitate the calculation of anthropometry data based on the new growth standards. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight for age is a measure of both acute and chronic malnutrition. Children whose weight for age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight for age is more than three standard deviations below the median are classified as severely underweight. Height for age is a measure of linear growth. Children whose height for age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height for age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight for height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or prevalence of disease. 14 In MICS, weights and heights of all children under 5 were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on anthropometric measurements taken during fieldwork. In addition, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (about 2 percent of children) and those whose measurements are outside a plausible range are excluded. Almost 1 in 9 children under age 5 in Turkmenistan are moderately underweight (11 percent), while less than 2 percent are classified as severely underweight (Table NU.1). Nearly 15 percent of children are moderately stunted, or too short for their age, and slightly above 6 percent are moderately wasted, or too thin for their height. Figure NU.1: Percentage of children under-5 who are undernourished, Turkmenistan, 2006 0 5 10 15 20 25 0 6 12 18 24 30 36 42 48 54 60 Age (in months) Pe rc en t Underw eight Stunted Wasted Children in the South (Ahal velayat) are more likely to be underweight and stunted than other children. The percentage of those wasted also is higher here than in other regions. Those children whose mothers have secondary or higher education are the least likely to be underweight and stunted, compared to children of mothers with lower educational levels. At the same time, it should be noted that in Turkmenistan there is no distinct inverse negative relationship between wasted children and the wealth of households. Boys appear slightly more likely to be underweight, stunted and wasted than girls. The age pattern shows that a higher percentage of children aged 12-23 months are undernourished according to two of the three indices, in comparison to children who are younger and older 15 (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food and the environment. Only 2.5 percent of children under 5 are overweight. The highest percentages of overweight children were found in households where mothers have higher education (6.4 percent) and in households with high levels of wealth (fourth and fifth quintiles, 3.4 and 4.6 percent respectively). Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients and is economical and safe. However, many mothers stop breastfeeding too soon and pressures often exist to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The WFFC goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to age 2 years and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first 6 months • Continued breastfeeding for 2 years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: 2 times per day for 6- to 8-month-olds; 3 times per day for 9- to 11-month-olds It also is recommended that breastfeeding be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate (< 6 months and < 4 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 and 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 provides the proportion of women who started breastfeeding their infants within one hour of birth and women who started breastfeeding within one day of birth (which includes those who started within one hour). The dominant majority of mothers – about 88 percent – started breastfeeding within one day of birth, including 60 percent (both in urban and rural areas) within one hour of birth, in compliance with recommended international standards. However, a significant difference exists in the breastfeeding rate among the regions, particularly within one hour of birth (Figure NU.2). The lowest proportion of mothers who started breastfeeding within one day of birth is in the capital city of Ashgabat (70 percent) and in Dashoguz velayat (83 percent); the highest percentage is in Balkan velayat (nearly 94 percent). Similarly, the lowest percentage of mothers who started breastfeeding within one hour of birth is in Dashoguz velayat (less than 43 percent), while the highest is in Balkan velayat (82 percent). An inversely 16 proportional relationship was found between the percentage of initiation of breastfeeding within one day, as well as within one hour of birth, and educational levels of mothers. Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Turkmenistan, 2006 70 92 94 83 88 93 82 91 88 52 66 82 43 49 77 60 60 60 0 10 20 30 40 50 60 70 80 90 100 As hg ab at cit y Ah al ve lay at Ba lka n v ela ya t Da sh og uz ve lay at Le ba p v ela ya t Ma ry ve lay at Ur ba n Ru ral Tu rkm en ist an Pe rc en t Within one day Within one hour In Table NU.3, breastfeeding status is based on reports by mothers/caretakers of children’s consumption of food and fluids in the 24 hours before the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements or medicine). The table shows exclusive breastfeeding of infants during the first 6 months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children aged 12-15 and 20-23 months. About 11 percent of children younger than 6 months are exclusively breastfed, a level considerably lower than recommended. At age 6-9 months, 54 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 72 percent of children are still being breastfed and by age 20-23 months, 40 percent are still breastfed. Girls were more likely to be exclusively breastfed than boys. The percentage of exclusive breastfeeding also is differentiated in terms of area of residence, being somewhat higher in rural areas than in urban. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breast milk. By the end of the sixth month the percentage of children exclusively breastfed is below 11 percent. 17 The adequacy of infant feeding in children under 12 months is provided in Table NU.4. Different criteria of adequate feeding are used, depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered adequate feeding. Infants aged 6-8 months are considered adequately fed if they are receiving breastmilk and complementary food at least two times per day, while infants aged 9-11 months are considered adequately fed if they are receiving breastmilk and eating complementary food at least three times a day. As a result of these feeding patterns, those adequately fed represent less than 11 percent of 0- to 5-month-old infants, slightly above 41 percent of 6- to 8-month-old infants, and less than 33 percent of 6- to 11-month-old infants. Adequate feeding among all infants (aged 0- 11 months) drops to 21 percent. The percentage of adequately fed girls is higher than that of boys, and that of infants aged 0-8 months is higher in rural areas than in urban. Salt Iodization Iodine Deficiency Disorder (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism and increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability and impaired work performance. The international goal has been to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Figure NU.3 Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Turkmenistan, 2006 0 10 20 30 40 50 60 70 80 90 100 0– 1 2– 3 4– 5 6– 7 8– 9 10 –1 1 12 –1 3 14 –1 5 16 –1 7 18 –1 9 20 –2 1 22 –2 3 24 –2 5 26 –2 7 28 –2 9 30 –3 1 32 –3 3 34 –3 5 Age (in m onths) P er ce nt Weaned (not breastfed) Breasfed and compl imentary foods Breastfed and other milk/formula Breastfed and non-milk l iquids Breastfed and plain water only Exclusively breastfed Breastfed and 18 In Turkmenistan, the first Turkmen President adopted the decree “On Salt Iodization and Flour Fortification with Iron” in May 1996 as a measure to strengthen the population’s health, preventing and eliminating widespread illnesses related to the deficiency of iodine, folic acid and iron. In November 2004, Turkmenistan was the first among CIS and Central Asian countries and the fourth in the world to be certified as having universal (100 percent) salt iodization, meeting generally accepted international standards. In 99.6 percent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodide or potassium iodate content. Table NU.5 shows that in a very small proportion of households (0.2 percent), no salt was available. In 86.5 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in Lebap velayat (slightly above 78 percent) and highest in Dashoguz velayat (more than 96 percent). A total of 89 percent of rural households were found to be using adequately iodized salt, compared to 84 percent in urban areas. (Figure NU.4). Interestingly, in the richest households this figure was lower (about 83 percent) than in other quintile groups; this can be explained by the fact that some urban residents, mostly of high levels of wealth, use imported salt (most often from Iran) for cooking, which has a lower iodine content than salt domestically produced in Turkmenistan. Figure NU.4. Percentage of households consuming adequately iodized salt, Turkmenistan, 2006 84 95 85 96 78 84 84 89 87 0 20 40 60 80 100 As hg ab at cit y Ah al ve lay at Ba lka n v ela ya t Da sh og uz ve lay at Le ba p v ela ya t Ma ry ve lay at Ur ba n Ru ral Tu rkm en ist an Pe rc en t Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status, but also of the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune 19 function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have the most impact: the mother's poor nutritional status before conception, short stature (due mostly to undernutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important because it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. A major challenge in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased in most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight, or the weight as recorded on a health card if the child was weighed at birth6 . Overall, 98 percent of births were weighed at birth, and about 4 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.6). Variation by region was insignificant (Figure NU.5). The percentage of low birth weight does not vary much by urban and rural areas or by mother’s education. 6 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 20 Figure NU.5. Percentage of infants weighing less than 2500 grams at birth, Turkmenistan, 2006 4.6 5.0 3.9 3.8 4.3 3.9 4.2 0 1 2 3 4 5 6 As hg ab at cit y Ah a l ve lay at Ba lka n v ela ya t Da sh og uz ve lay at Le ba p v ela ya t Ma ry ve lay at Tu rkm en ist an Pe rc en t 21 VI. Child Health Immunization Immunization plays a key part in MDG4, which is to reduce child mortality by two-thirds between 1990 and 2015. Indeed, immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide, 27 million children are still not covered by routine immunization – and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A WFFC goal is to ensure full immunization of children under 1 year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to the vaccination schedule/calendar (Immunization Card) approved by Order No. 2 of the Ministry of Health and Medical Industry of Turkmenistan on 02.01.2004, which complies with the UNICEF and WHO guidelines, a child should receive the following vaccinations by age 23 months:  Within the first 24 hours of life – a vaccination to protect against hepatitis B (HepB1)  On the second or third day of life – against tuberculosis (BCG1) and polio (Polio/OPV0)  At 2 months – against hepatitis B (HepB2); diphtheria, pertussis and tetanus (DPT1); and polio (Polio/OPV1)  At 3 months – against diphtheria, pertussis and tetanus (DPT2) and polio (Polio/OPV2)  At 4 months – against hepatitis B (HepB3); diphtheria, pertussis and tetanus (DPT3); and polio (Polio/OPV3)  At 12-15 months – against measles (MEASLES1) and parotitis  At 18 months - against diphtheria, pertussis and tetanus (DPT4) and polio (Polio/OPV4). Mothers were asked to provide vaccination cards for children under age 5, and interviewers copied vaccination information from the cards onto the MICS questionnaire. In addition, interviewers visited health facilities where they copied information on vaccinations of children under 5 from immunization cards there. Overall, 99.4 percent of children had health cards (Table CH.2). The mother also was asked to recall whether the child had received each vaccination and, for DPT and Polio, how many times. The percentage of children aged 18 to 29 months who received each of the vaccinations is shown in Table CH.1. The denominator for the table is comprised of children aged 18-29 months, so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children vaccinated at any time before the Survey, according to the vaccination card or the mother’s report. In the bottom panel, only those vaccinated before their first birthday/12 months (18 months for measles vaccination), as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. 22 A total of 99.8 percent of children aged 18-29 months received a BCG vaccination by age 12 months, with the first and second doses of DPT given to 99.6 and 99.1 percent respectively. For the third dose of DPT, the percentage declines to 98.4 percent (Figure CH.1). Similarly, 99.8 percent of children received Polio 1 by age 12 months, but this declines to 96.8 percent by the third dose. The coverage for measles vaccine by 18 months is 97 percent. Figure CH.1. Percentage of children aged 18–29 months who received the recommended vaccinations by 12 months (18 months for measles), Turkmenistan, 2006 99.8 99.6 99.1 98.4 99.8 99.3 96.8 93.5 97.0 90 91 92 93 94 95 96 97 98 99 100 BC G DP T1 DP T2 DP T3 Po lio 1 Po lio 2 Po lio 3 Me as les Al l Pe rc en t In Turkmenistan, vaccines against hepatitis B also are recommended as part of the immunization schedule. A total of 99.5 percent of children aged 18-29 months received HepB-1 vaccine by age 12 months. Subsequently, the percentage declined to 98.4 for the second dose and 96.8 for the third dose. Tables CH.2 and CH.2.C show vaccination coverage rates among children 18-29 months by background characteristics. The figures indicate children receiving the vaccinations at any time before the Survey and are based on information from both vaccination cards and mothers’/caretakers’ reports. Because immunization is compulsory and free for all children in Turkmenistan, a rather high vaccination coverage rate is observed everywhere, irrespective of the area of residence (urban/rural), mothers’ level of education or household wealth. Oral Rehydration Treatment Worldwide, diarrhoea is the second leading cause of death among children under 5. Most diarrhoea-related deaths in children result from dehydration caused by loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. Preventing dehydration and malnutrition by increasing 23 fluid intake and continuing to feed the child also are important strategies for managing diarrhoea. The goals are to: 1) reduce by one-half deaths due to diarrhoea among children under 5 between 2000 and 2010 (WFFC) and 2) reduce by two-thirds the mortality rate among children under 5 between 1990 and 2015 (MDGs). In addition, the WFFC calls for a reduction in the incidence of diarrhoea by 25 percent. Indicators include:  Prevalence of diarrhoea  Oral rehydration therapy (ORT)  Home management of diarrhoea  ORT or increased fluids and continued feeding In the MICS questionnaire, mothers or caretakers were asked to report whether their child had had diarrhoea in the two weeks before the Survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less that the child usually ate and drank. Overall, 5.5 percent of under-5 children had diarrhoea in the two weeks preceding the Survey (Table CH.3). Diarrhoea prevalence was different in all regions: the highest percentage of sick children was in Ashgabat city (9.2 percent) and Dashoguz velayat (6.3 percent), the lowest in Balkan velayat (3.2 percent). However, no significant differences were observed between the areas of residence (urban/rural). The peak of diarrhoea prevalence occurs in the weaning period, among children aged 6-23 months. Table CH.3 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Because mothers were able to name more than one type of liquid, percentages do not necessarily add up to 100. Slightly more than 40 percent received fluids from ORS packets, and about 15 percent received recommended homemade fluids. Overall, 47 percent of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or RHF), while 53 percent received no treatment. No interdependence between diarrhoea prevalence in children and background variables was found. About 39 percent of under-5 children with diarrhoea drank more than usual, while nearly 56 percent drank the same or less (Table CH.4). About 42 percent ate somewhat less, the same or more (continued feeding), but 55 percent ate much less or almost none. Given these figures, only slightly more than 15 percent of children received increased fluids and at the same time continued feeding. Combining the information in Table CH.4 with that in Table CH.3 on oral rehydration therapy, it is observed that 25 percent of children either received ORT or increased fluid intake and at the same time continued feeding, as is the recommendation. Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children, and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A WFFC goal is to reduce by one-third the deaths due to acute respiratory infections. 24 Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. Indicators include:  Prevalence of suspected pneumonia  Care seeking for suspected pneumonia  Antibiotic treatment for suspected pneumonia  Knowledge of the danger signs of pneumonia Table CH.5 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Only 1.3 percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the Survey. Of these, about 83 percent were taken to an appropriate provider. A total of 96 percent sought professional care for suspected pneumonia from public-sector providers/Government health care facilities. The majority of children were taken to a Government health centre (57 percent). Seeking care from non-Government health facilities was not reported, while care from a traditional practitioner was sought by slightly more than 4 percent. Table CH.6 presents the use of antibiotics for the treatment of suspected pneumonia in under-5s. More than 50 percent of under-5 children in Turkmenistan with suspected pneumonia had received an antibiotic during the two weeks before the Survey. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7. Clearly, mothers’ knowledge of the danger signs is an important determinant of care- seeking behaviour. Overall, it was found that slightly more than 12 percent of women know the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility was fever (about 92 percent). A total of 26.5 percent of mothers identified fast breathing, and slightly above 28 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Interestingly, the two danger signs of pneumonia were better known by less educated mothers (below secondary education – 13 percent; higher education – less than 10 percent), as well as by the native population (Turkmen – more than 13 percent). At the same time, the level of knowledge of low-income households (first quintile) is the lowest, at 7 percent. The level of knowledge of urban and metropolitan region residents is higher than in rural areas. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. 25 In Turkmenistan, solid fuels are practically not used for cooking, employed in only 0.4 percent of all households (Table CH.8). Solid fuels are not used at all in urban areas and not broadly in use in rural areas (0.7 percent). Some differentials exist with respect to household wealth and the educational level of the household head. The table clearly shows that the vast majority of households (93 percent) use natural (piped) gas for cooking, while slightly more than 6 percent use liquid propane gas (in cylinders) and 0.3 percent use electric stoves. It should be noted here that gas and electricity have been supplied to the citizens of Turkmenistan free of charge (by established average per-capita norms) since the beginning of 1993, making them highly accessible for the population. Free consumption of gas and electricity, as well as water and edible salt, by the citizens of Turkmenistan has been extended till 2030 by the XVI Halk Maslahaty (People’s Assembly). Sources and Costs of Oral Rehydration Salts In the Turkmenistan MICS, questions were included to collect information on the sources and costs of oral rehydration salts. Such information is very important in that it makes possible a population-based assessment of the reach of programmes and the extent to which particular target groups are covered. Such information also is useful for monitoring the provision of free or subsidized supplies and for the assessment of costs of supplies, since prices of supplies can be a barrier to use. For programme managers who wish to find out public and private shares in the provision of supplies, and the relative importance of each source, information on sources and costs of supplies can be crucial. The source and cost of supplies for oral rehydration salts for children under 5 are presented in Table CH.9. The main source of supplies for oral rehydration salts in Turkmenistan is the public sector, at more than 82 percent. A practice also exists in the country of providing oral rehydration salts for children under 1 year free of charge. 26 VII. Environment Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid and schistosomiasis. Drinking water also can be tainted with chemical, physical and radiological contaminants, with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children – especially in rural areas – who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The WFFC goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The lists of indicators used in MICS are as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot); public tap/standpipe; tubewell/borehole; protected well; protected spring; or rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. Figure EN.1. Percentage distribution of household members by source of drinking water, Turkmenistan, 2006 Piped into dw elling, yard or plot 41% Other unimproved 26%Surface w ater 4% Unprotected w ell or spring 1% Protected w ell or spring 11% Tubew ell/borehole 13% Public tap/standpipe 4% 27 Overall, 71 percent of the population of Turkmenistan is using an improved source of drinking water – 91 percent in urban areas and 58 percent in rural areas. The situation in the south-east (Mary velayat) is worse than in other regions; only 39 percent of the population in this region gets its drinking water from an improved source. The source of drinking water for the population varies strongly by region (Table EN.1). In the central region (the capital city), 86 percent of the population uses drinking water that is piped into their dwelling, yard or plot. In the south and west (Ahal and Balkan velayats), 55 and 64 percent respectively use piped water. In contrast, in the other regions the percentage of households using piped water is about the same: Dashoguz velayat, 27 percent, Mary velayat, 28 percent; and Lebap velayat, 30 percent. In the north and east (Dashoguz and Lebap velayats), the second most important source of drinking water is tubewell/borehole, while in Ahal and Balkan velayats, tanker-trucked water is used (unimproved water source) by 39 and 26 percent respectively. In the southeast (Mary velayat) tanker-trucked water is used by almost half of the total household population. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink; boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, for all households as well as for households using improved and unimproved drinking water sources. Overall, more than 70 percent of the population used water treatment methods, although only slightly more than 58 percent used appropriate water treatment methods. Differentials were found with respect to the area of residence. In Ashgabat, this indicator was below 56 percent. The highest value was found in Ahal velayat (about 70 percent); while in Dashoguz velayat it stood at 41 percent. In the other regions, appropriate methods of water treatment were used by 62 to 63 percent of population. Among water treatment methods, the most widely employed were boiling (more than 57 percent) and use of settled water (42 percent). It should be noted that in the capital city, about 10 percent of households use bottled water that needs no additional treatment, which affected the water treatment figure for this region. The highest percentage using water filters also is in the capital: about 3 percent, compared to an average of less than 1 percent. A relationship is observed between using improved sources of drinking water and background variables. In particular, the percentage is higher in urban areas than in rural areas, in households with a higher wealth index, and where household heads have higher levels of education. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one round-trip from home to a drinking water source. Information on the number of trips made in one day was not collected. Table EN.3 shows that for 80 percent of households, the drinking water source is on the premises; even so, this is more common for urban areas (91 percent) than rural areas (71 percent). For 18 percent of all households, it takes less than 30 minutes to get to the water source and bring water, while a very small percentage of households (0.2 percent) spend more than 1 hour for this purpose. Excluding those households with water on the premises, the average time to the source of drinking water is 13 minutes. The time spent in rural areas (14 minutes) in collecting water is slightly higher than in urban areas (12 minutes). It was 28 found that the time spent in Balkan velayat for collecting water was 27 minutes, which is explained by the geographical features of this region. At the same time, it should be noted that in Balkan velayat water is piped to the premises of 93 percent of households, one of the highest figures among the regions; only in the capital city it is slightly higher, at 97 percent. Table EN.4 shows that for the majority of households (70 percent), an adult female usually collects water when the source of drinking water is not on the premises. Adult men collect water in only 23 percent of cases, while for the rest of the households, female or male children under age 15 collect water (7 percent). Meanwhile, inadequate disposal of human excreta and personal hygiene is associated with a range of diseases, including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include flush or pour flush to a piped sewer system, septic tank or latrine; ventilated improved pit latrine; and pit latrine with slab. About 99 percent of the population of Turkmenistan is living in households using improved sanitation facilities (Table EN.5). This percentage is 99.8 in urban areas and 98 in rural areas. Among residents of the regions, use of improved facilities is virtually equal. The table indicates that use of improved sanitation facilities is, to a certain degree, correlated with wealth and educational level of household heads, but this differs profoundly between urban and rural areas. In rural areas, the population is mostly using pit latrines with slabs (83 percent); in contrast, the most common facilities in urban areas are flush toilets with connection to a sewage system or septic tank (51 percent). An overview of the percentage of households with improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.6. On average, 70 percent of households use both improved sources of drinking water and improved sanitary facilities. However, some residential and regional differentials exist: The highest figures are in the capital city (95 percent) and Lebap velayat (above 88 percent), with the lowest in Mary velayat (below 39 percent), and they are higher for urban areas (91 percent) than for rural areas (57 percent). Some interrelation between the level of using improved sources of drinking water and sanitation and the educational level of household head and household wealth was observed. 29 VIII. Reproductive Health Contraception Appropriate family planning is important to the health of women and children through: 1) preventing pregnancies too early or too late; 2) extending the period between births; and 3) limiting the number of children. A WFFC goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception was reported by 48 percent of women currently married or in union (Table RH.1). The most popular method is the IUD, used by 43 percent of married women in Turkmenistan. Other methods of contraception are little used: about 2 percent reported use of the pill, while less than 1 percent use injectables, condoms, periodic abstinence, withdrawal, vaginal methods or the lactational amenorrhoea method (LAM). Contraceptive prevalence is highest in the southeast region (Mary velayat), at 55 percent, and in the capital city, at 54 percent. Forty-eight percent of married women in the north (Dashoguz velayat), 45 percent in the south (Ahal velayat) and 43 percent in the east (Lebap velayat) use a method of contraception. In the west (Balkan velayat), contraceptive use is rarer (below 38 percent). Adolescents are far less likely to use contraception than older women. Less than 6 percent of married or in-union women aged 15-19 currently use a method of contraception, compared to 64 percent of 35- to 39-year-olds and about 58 percent of women aged 30-34 and 40-44. Women’s education level is somewhat associated with contraceptive prevalence. The percentage of women using any method of contraception rises from 46 percent among women with secondary education or below, to 54 percent among women with secondary special (vocational) education and 57 percent among women with higher education. In addition to differences in prevalence, the method mix varies by education. A total of 41 percent of contraceptive users with secondary education or below use IUD and only slightly more than 1 percent use the pill or LAM. As for contraceptive users with higher education, 46 percent use IUD, more than 4 percent use the pill and 3 percent use condom. Significant differentials in the use of contraceptives are found in relation to the number of children. Only slightly more than 1 percent of women with no children use contraceptives – i.e., they practically do not use them. At the same time, about 1 woman in 4 with one child and more than half of women with two or more living children use modern or traditional methods of contraception. Unmet Need Unmet need7 for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth or stop childbearing altogether. 7 Unmet need measurement in MICS is somewhat different than that used in other household surveys, such as the Demographic and Health Surveys (DHS). In DHS, more detailed information is collected on additional variables, such as postpartum amenhorroea, and sexual activity. Results from the two types of surveys are strictly not comparable. 30 Unmet need is identified in MICS by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity and fertility preferences. Women with unmet need for spacing includes women currently married or in union; fecund (currently pregnant or think they are physically able to become pregnant); currently not using contraception; and wanting to space their births. Pregnant women are considered to want to space their births when they did not want the child at the time they got pregnant. Women who are not pregnant are classified in this category if they want to have a(nother) child, but want to have the child at least two years later, or after marriage. Women with unmet need for limiting are those women currently married or in union; fecund (currently pregnant or think that they are physically able to become pregnant); currently not using contraception; and wanting to limit their births. The latter group includes women who are currently pregnant but had not wanted the pregnancy at all, and women who are not currently pregnant but do not want to have a(nother) child. Total unmet need for contraception represents the sum of unmet need for spacing and unmet need for limiting. Using information on contraception and unmet need, the percentage of demand for contraception satisfied also is estimated from the MICS data. The percentage of demand for contraception satisfied is defined as the proportion of women currently married or in union and currently using contraception, to the total demand for contraception. The total demand for contraception includes women who currently have an unmet need for spacing or limiting, plus those who are currently using contraception. Table RH.2 shows the results of the survey on contraception, unmet need and the demand for contraception satisfied. In Turkmenistan, the demand of more than 75 percent of fecund women for contraception is satisfied. In this respect, no significant differences by area of residence (urban/rural) or level of household wealth are observed. Less than 16 percent of women aged 15-49 have an unmet need for contraception, including 6 percent for birth spacing and 10 percent for limiting the number of births. The unmet need indicator differs by area of residence and regions. It is somewhat higher in urban areas (17 percent) than in rural areas (below 16 percent). The highest figure of unmet need was found in Lebap velayat (18.7 percent) and Ahal velayat (18.3 percent), the lowest in Mary velayat (less than 12 percent). The main need is limiting the number of births, with the exception of Dashoguz velayat, where the main need is planning of birth spacing; it should be noted that Dashoguz velayat has one of the highest birth rates in the country. Nationwide, an inversely proportional relation regularly exists between the educational level of fecund women and the level of unmet need for contraception, mostly for limiting the number of children. The figures and reasons for unmet need differ by the women’s age, with the main reason for women aged 15-30 being spacing, while it is limiting for women aged 30-49. No relationship between an unmet need and level of wealth or ethnicity is observed. The total demand for contraception stands at about 64 percent (currently using contraceptives and unmet need for contraceptives). 31 Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include:  Blood pressure measurement  Urine testing for bacteriuria and proteinuria  Blood testing to detect syphilis and severe anaemia  Weight measurement In addition, the following types of antenatal care were included in the Turkmenistan questionnaire:  Blood grouping  Gynaecological examination  Pregnancy term calculation (reckoning)  Ultrasonic examination Coverage of antenatal care (by a doctor, nurse, or midwife) is relatively high in Turkmenistan, with 99 percent of women receiving antenatal care at least once during the pregnancy. A lower level of antenatal care is found in Balkan velayat (slightly above 95 percent), while the in the capital city and Ahal velayat it equals 100 percent. Significant differentials with respect to other background variables were not found. The type of personnel providing antenatal care to women aged 15-49 who gave birth in the two years preceding the Survey is presented in Table RH.3. By far most antenatal care is provided by doctors (more than 95 percent), more so in urban areas (about 97 percent) than in rural areas (just over 94 percent). In rural areas, almost 4 percent of antenatal care is performed by medical nurses or midwives. The highest level of antenatal care coverage by doctors is in the capital city of Ashgabat (100 percent) and Mary velayat (about 99 percent), the lowest in Balkan velayat, at slightly above 88 percent. The highest percentage of uncovered antenatal care is in Balkan velayat, at 4 percent, with the average countrywide figure at 0.6 percent. Balkan velayat is the least populated region in Turkmenistan, with a 32 population density of 4.1 men per square kilometre (as of 01.01.2006), or less than 30 percent of the level of average population density nationwide (13.7 persons per sq.km). This region is characterized by some remoteness of settlements. Well-to-do reproductive-age women have higher figures of antenatal care by doctors. The types of services pregnant women received are shown in table RH.4. In Turkmenistan overall, no significant differentials in antenatal care by urban/rural status or other background variables were found. In the majority of regions, almost all pregnant women made at least one antenatal care visit (99.4 -100 percent). The lowest percentage of overall antenatal care provided to pregnant women is in Balkan velayat, at about 96 percent. More than 98 percent of pregnant women had their blood tested; 97 percent had urine tested; 96 percent were given gynaecological examinations and their pregnancy terms were calculated; and 95 percent had their blood pressure measured, while 93 percent had their blood group identified. Less than 90 percent were body-weight measured, and only 77 percent were given ultrasonic scanning. Assistance at Delivery Three-quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure that a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A WFFC goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator also is used to track progress toward the MDG target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. A total of 99.5 percent of births in Turkmenistan occurring in the year prior to the MICS were delivered by skilled personnel (Table RH.5), quite a high figure. Full coverage with skilled attendance at delivery was found in the capital region (Ashgabat city and Ahal velayat) and in the north (Dashoguz velayat), while the lowest was in the west (Balkan velayat), at 97.5 percent. The more educated a woman is, the more likely she is to have delivered with the assistance of a skilled attendant. The vast majority of births (88 percent) in the year before the Survey were delivered with assistance by a doctor. Nurses and midwives assisted with the delivery of 12 percent of births. The type of personnel providing delivery assistance differs by regions: in the west (Balkan velayat), 69 percent of births are delivered by a doctor, while 29 percent are delivered with the assistance of a nurse or midwife. In the rest of the regions, 82 to 95 percent of births are delivered by a doctor, while 4-17 percent is delivered with the assistance of a nurse or midwife. In Turkmenistan, almost 98 percent of births were institutional deliveries – i.e., the proportion of so-called “domestic deliveries” is very low (2 percent). 33 IX. Child Development It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, adult activities with children, presence of books in the home and the conditions of care are important indicators of quality of home care. A WFFC goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the Survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting or drawing things. In Turkmenistan, for 80 percent of under-5 children an adult engaged in more than four activities that promote learning and school readiness during the three days preceding the Survey (Table CD.1). The average number of activities that adults engaged in with children was 4.6, which did not vary significantly by area of residence (urban/rural) or gender. The table also indicates that the father’s involvement in such activities was sufficiently active. Fathers’ involvement with one or more activities was higher than 61 percent. Only 6 percent of children were living in a household without their fathers. The percentage of children living separately from their biological fathers noticeably varied by background characteristics: Specifically, in urban areas the proportion of such children is 4.5 times larger (almost 13 percent) than in rural areas (about 3 percent). This is connected to the significantly higher level of divorces in urban areas than in rural areas. No gender differentials exist in terms of adult activities with children; however, a larger proportion of them engaged in activities with male children (81 percent) than with female children (78 percent). A similar picture was observed in the engagement of fathers in learning activities with children. The percentage of adults engaged in learning and school readiness activities with children was equal in urban areas and rural areas; however, certain differentials by region and socioeconomic status were observed. For 85 percent of children living in the richest households, adult engagement in activities with children was greatest in Ashgabat city and Dashoguz velayat (87-88 percent), less so in Mary velayat (68 percent); these findings are somewhat higher than in other quintile groups. Fathers’ involvement did not reflect a similar pattern in terms of adults’ engagement in such activities. The highest figure among the regions was in Ahal velayat (76 percent), and fathers’ engagement in the richest households was somewhat lower (57 percent) than in other quintile groups. Note that more educated mothers and fathers engaged more frequently in activities with children than those with less education. Exposure to books in early years not only provides the child with a greater understanding of the nature of print, but may also give the child opportunities to see others reading, such as older siblings doing school work. The presence of books is important for later school performance and IQ scores. 34 A total of 58 percent of children in Turkmenistan are living in households where at least three non-children’s books are present (Table CD.2). Some 42 percent of children aged 0-59 months have children’s books. The median number of non-children’s books is higher than children’s books (5:2 ratio). While no gender differentials are observed, urban children appear to have more access to both types of books than those living in rural households; 69 percent of under-5 children in urban areas live in households with more than three non- children’s books (the median is 10 books), while the figure is 53 percent in rural households (the median is three books). The proportion of under-5 children who have three or more children’s books is 56 percent in urban areas, compared to 34 percent in rural areas. Strong differentials were found among the regions. It also was noted that with higher levels of mothers’ education and wealth index, the percentage of non-children’s and children’s books intensively increased. Table CD.2 also shows that nearly 1 child in 4 (24 percent) aged 0-59 months had three or more playthings in their homes, while less than 4 percent had none of the playthings that were the subject of the MICS query, including household objects, homemade toys, toys from a store, and objects and materials found outside the home (Table CD.2). It is interesting to note that the vast majority of children (92 percent) play with toys from a store; however, the percentage playing with other types of toys remains below 39 percent. The proportion of children who have three or more playthings is above 24 percent among male children and 23 percent among female children. Some urban-rural differentials are observed in this respect, in terms of mothers’ education and households’ socioeconomic status. The most noticeable differentials, however, are found among regions. The only background variable that appears to have a strong correlation with the number of playthings children have is the age of the child, a somewhat expected result. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In MICS, two questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the interview, and whether children were left in the care of other children under 10 years of age. Table CD.3 shows that 15 percent of children aged 0-59 months were left in the care of other children, while less than 4 percent had been left alone during the week preceding the interview. Combining the two care indicators, however, it is calculated that 15 percent of children were left with inadequate care during the week preceding the survey. No differences were observed by the sex of the child or between urban and rural areas. On the other hand, inadequate care was less prevalent among children whose mothers had professional (special secondary and higher) education, as opposed to children whose mothers had secondary or lower education. More children aged 24-59 months (20 percent) were left with inadequate care than those aged 0-23 months (10 percent). Differences also were observed with regard to the socioeconomic status of the household. 35 X. Education Preschool Attendance and School Readiness Attendance in preschool education in an organized learning or child education programme is important for the readiness of children to school. One of the WFFC goals is the promotion of early childhood education. About 1 in 4 children aged 36-59 months is attending preschool in Turkmenistan (Table ED.1). Urban-rural and regional differentials are significant – the figure is as high as 52 percent in urban areas, compared to 11 percent in rural areas. Among children aged 36-59 months, attendance in preschool is more prevalent in the central region (the capital) – above 67 percent – and lowest in the north (Dashoguz velayat), at below 11 percent. Similarly, differentials are significant by socioeconomic status and level of mothers’ education. More than 64 percent of children living in the richest households attend preschool, while the figure drops to 8-10 percent in low-income households. Gender differential is not significant. The proportion of children attending preschool at ages 36-47 months (23 percent) is somewhat smaller than that at 48-59 months (26 percent). The table also shows the proportion of children in the first grade of primary school who attended preschool the previous year (Table ED.1), an important indicator of school readiness. Overall, 32 percent of children who are currently age 7 and attending the first grade of primary school were attending preschool the previous year. The proportion among males is slightly higher (35 percent) than females (30 percent), while almost two-thirds of children in urban areas (64 percent) had attended preschool the previous year compared to less than 17 percent among children in rural areas. Regional differentials also are very significant: more than seven times the first graders in the central region (the capital), a very high 90 percent, have attended preschool than their counterparts in the north region (Dashoguz velayat). Socioeconomic status appears to have a positive correlation with school readiness – while the indicator is only 16 percent among low-income households (first quintile), it soars to 84 percent among children in the richest households (fifth quintile). This is explained by the fact that the households with a high wealth index (fourth and fifth quintiles) include mostly urban households with higher average per-capita incomes than rural households. Moreover, urban areas (especially the capital city) have more preschool institutions than rural areas. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the MDGs and WFFC. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous/exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. Indicators for primary and secondary school attendance include:  Net intake rate in primary education  Net primary school attendance rate  Net secondary school attendance rate 36  Net primary school attendance rate of children of secondary school age  Female-to-male education ratio (GPI) The indicators of school progression include:  Survival rate to grade 5  Transition rate to secondary school  Net primary completion rate Of children who are of primary school entry age (age 7) in Turkmenistan, about 97 percent are attending the first grade of primary school (Table ED.2). Urban-rural differentials do not exist; however, some differentials are present by region. In the north (Dashoguz velayat), for example, the value of the indicator reaches more than 98 percent, while it is below 92 percent in the south (Ahal velayat). Female children’s participation in primary school is timelier (98 percent) than that of male children (96 percent). No correlation with socioeconomic status of households is observed. Table ED.3 provides the percentage of children of primary school age attending primary or secondary school. The net school attendance rate in Turkmenistan is high, at 99 percent. Only a small proportion of children (1 percent) are out of school when they are expected to be participating. The values of the net primary and secondary school attendance rates are not affected by background variables. The secondary school net attendance ratio is presented in Table ED.4. More than 95 percent of the children of secondary school age are attending secondary school; however, the percentage of children aged 15 is far lower (77 percent). This is explained by the fact that among the children of this age are those who completed secondary school but have not continued further (vocational) education. Socioeconomic status does not affect the high level of the net secondary school attendance rate. The primary school net attendance ratio of children of secondary school age is presented in Table ED.5. Only a very small proportion (0.6 percent) of these children is attending primary school when they should be attending secondary school. These are mostly boys (0.9 percent) rather than girls (0.3 percent) aged 10-11 years. Of all background variables, only the differential by regions is significant: the highest percentage of such children is in the capital city (1.2 percent) and the lowest in Dashoguz velayat (0.1 percent). The percentage of children entering first grade who eventually reach grade 5 is presented in Table ED.6. In Turkmenistan, practically all children starting grade 1 (99.9 percent) will eventually reach grade 5. Notice that this number includes children that repeat grades and that eventually move up to reach grade 5. Of those female students who had entered first grade, 0.2 percent did not reach grade 5 in urban areas (Ashgabat city – 1 percent). The net primary school completion rate and transition rate to secondary education is presented in Table ED.7. At the time of the Survey, 99.2 percent of the children of primary completion age (9 years) were attending the last grade of primary education. This value should be distinguished from the gross primary completion ratio, which includes children of any age attending the last grade of primary school. A total of 99.8 percent of the children that successfully completed the last grade of primary education were attending secondary school at the time of the Survey. The transition to secondary education was not made by a 37 small percentage of girls (0.5 percent), in urban areas (0.6 percent), mostly in the capital (2 percent). The ratio of girls to boys attending primary and secondary education is provided in Table ED.8. These ratios are better known as the Gender Parity Index (GPI). The ratios included here are obtained from net attendance ratios rather than gross attendance ratios, the latter of which provide an erroneous description of the GPI, mainly because the majority of over- aged children attending primary education tend to be boys. The table shows that gender parity for both primary and secondary school in Turkmenistan equals to 1.00, evidence of equality and the absence of differences in school attendance between girls and boys. Adult Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy also is an MDG indicator, relating to both men and women. Because only a women’s questionnaire was administered in MICS, the results are based only on females aged 15-24. Literacy was assessed on the ability of women to read a short, simple statement or on school attendance. The percent literate is presented in Table ED.9. In Turkmenistan, the percentage of literate women aged 15-24 is high, at 99.2 percent. However, 0.3 percent was missed, i.e., the literacy level was not identified at the interview. The highest literacy level was in Lebap velayat, at 100 percent, and the lowest in Mary velayat, at 98.5 percent (0.9 percent missing). The level of literacy is not significantly affected by background variables, as in accordance with the Constitution citizens of Turkmenistan are guaranteed free compulsory secondary education irrespective of gender, ethnicity or other factors. 38 XI. Child Protection Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The WFFC encompasses the goal to develop systems to ensure the registration of every child at or shortly after birth, and to fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under 5 whose birth is registered. The births of about 96 percent of children under 5 in Turkmenistan have been registered (Table CP.1). Insignificant variations exist in birth registration across regions and by mothers’ education. Children in the southeast (Mary velayat) were somewhat less likely to have their births registered (94 percent) than children in other regions. Births of all children of mothers with higher education were registered. The most noticeable differentials were found in relation to the child’s age: the percentage of under-1 children whose birth was registered was below 87 percent, while for 4-year-olds it was above 99 percent – evidence of “delayed” birth registration cases. The main reason for this (75 percent of responses) was not included in the list of reasons offered in the “closed”-type model questionnaire and was entered as “Other.” Indeed, in the recent years there has been a downtrend of birth registration in Turkmenistan because of untimely applications to the civilian registry offices. Comparison of record data from civilian registries and health authorities revealed significant discrepancies in the number of births. As the practice shows, health authorities also sometimes under-record the number of births (domestic deliveries). To study modern reproductive behaviours and attitudes of fertile-age women and obtain accurate information on vital statistics, the National Institute of State Statistics and Information, jointly with the United Nations Population Fund in Turkmenistan, conducted a sample survey of 1,500 households in all regions (2,496 reproductive-age women) in 2003. This survey showed that not all children had birth certificates. The questionnaire was also of the “closed” type and, similarly to MICS, 80 percent of respondents specified the reason of non-registration as “Other.” The second significant reason was specified as “Did not have time to receive certificate” (more than 12 percent). However, the root primary reason for non-registration of child births is apparently the lack of necessity to register births, in parents’ opinion. For the most part, this category is comprised of non-working women (engaged in households and personal subsidiary plots – tax-exempt informal activities) who raise children at home. In such cases, however, birth certificates are starting to be obtained before the children’s enrolment in kindergartens (at age 3 years or above) or primary school. In order to improve the situation of birth registration and resolve other issues, Turkmenmillihasabat together with UNFPA: 1. Presented the sample survey results to representatives of the relevant Ministries and agencies (Ministries of Justice, Health and Medical Industry, Interior, Social Welfare, Economy and Finance, and local authorities) 39 2. Published booklets in the Turkmen and Russian languages advocating birth registration As the MICS results show, the situation of birth registration in Turkmenistan has somewhat improved compared to the data of the above-mentioned 2003 survey. Child Discipline As stated in A World Fit for Children, “children must be protected against any acts of violence …,” while the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In the Turkmenistan MICS survey, mothers/caretakers of children aged 2-14 years were asked a series of questions on the ways parents tend to discipline their children when they misbehave. Note that for the child discipline module, one child aged 2-14 per household was selected randomly during fieldwork. The following two indicators of the child discipline were selected from the list offered in this module for the questionnaire adopted for Turkmenistan: 1) number of children of 2-14 years of age subjected to psychological pressure as a method of punishment; and 2) number of parents/caretakers of 2-14 children who think that children should be subjected to corporal punishments in order to be properly brought-up. A total of 62 percent of children aged 2-14 years in Turkmenistan were disciplined by taking away privileges, forbidding something they liked or not allowing them to leave the house (Table CP.2). The percentage of children who were told why their behaviour was wrong stood at 86 percent. Male children were subjected more to such disciplinary methods than female children. Differentials with respect to many of the background variables were relatively small. It also is of importance to indicate that far fewer parents/caretakers nationwide (17 percent) believe that physical punishment is necessary to raise their children properly. Among the background variables, the widest range of this indicator was found in correlation with the regions: from 10 percent in Ashgabat city to 29 percent in Ahal velayat. Early Marriage Marriage before the age of 18 is a reality for many young girls. According to UNICEF's worldwide estimates, more than 60 million women aged 20-24 were married/in union before the age of 18. Factors that influence child marriage rates include: the state of the country's civil registration system, which provides proof of age for children; the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children, in hopes that the marriage will benefit them both financially and socially while also relieving financial burdens on the family. In actual fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to 'free and full' consent to a marriage is recognized in the Universal Declaration of Human Rights – with the recognition that consent cannot be 'free and full' when one of the parties involved is not sufficiently mature to make 40 an informed decision about a life partner. The Convention on the Elimination of All Forms of Discrimination Against Women mentions the right to protection from child marriage in Article 16, which states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights – such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful traditional practices – and is frequently addressed by the Committee on the Rights of the Child. Other international agreements related to child marriage are the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages, and the African Charter on the Rights and Welfare of the Child and the Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa. Child marriage also was identified by the Pan-African Forum Against the Sexual Exploitation of Children as a type of commercial sexual exploitation of children. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while still children themselves, married girls and child mothers face constrained decision making and reduced life choices. Boys also are affected by child marriage, but the issue has an impact on girls in far larger numbers and with more intensity. Cohabitation – when a couple lives together as if married – raises the same human rights concerns as marriage. Where a girl lives with a man and takes on the role of caregiver for him, the assumption is often that she has become an adult woman, even if she has not yet reached age 18. Additional concerns due to the informality of the relationship – for example, inheritance, citizenship and social recognition – might make girls in informal unions vulnerable in different ways than those in formally recognized marriages. Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered significant factors in determining a girl's risk of becoming married while still a child. Women who married at younger ages were more likely to believe that it is sometimes acceptable for a husband to beat his wife and were more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before age 18 tend to have more children than those who marry later in life. Pregnancy-related deaths are known to be a leading cause of mortality for both married and unmarried girls aged 15-19, particularly among the youngest of this cohort. Evidence suggests that girls who marry at young ages are more likely to marry older men, which puts them at increased risk of HIV infection. Parents seek to marry off their girls to protect their honour, and men often seek younger women as wives as a means to avoid choosing a wife who might already be infected. The demand for this young wife to reproduce, and the power imbalance resulting from the age differential, lead to very low condom use among such couples. Two of the indictors are to estimate the percentage of women married before age 15 and percentage married before age 18. The percentage of women married at various ages is provided in Table CP.3. In Turkmenistan, the percentage of women married before age 15 is very small (0.4 percent). Fewer than 7 percent of women entered in marriage/union before age 18. According to the 1998 Law of Turkmenistan “On Amendments to the Marriage and 41 Family Code” (Article 16), the marriage age is set at 16. An inverse proportional correlation was found between the percentage of women married before age 15, and particularly before age 18, and level of education. Another component is spousal age difference, with an indicator being the percentage of married/in union women with a difference of 10 or more years of age compared to their spouse. Table CP.4 presents the results of the age difference between husbands and wives. About 4 percent of women aged 15-19 and 20-24 that were currently married/in union have a husband/partner who is 10 or more years older. This number mostly includes women with basic secondary education or lower, i.e., without professional education. More than half of women aged 15-24 are married/in union with a man (husband or partner) who is 0-4 years older. Domestic Violence A number of questions were asked of women aged 15-49 to assess their attitudes toward whether husbands are justified to hit or beat their wives/partners for a variety of scenarios. These questions were asked to gain an indication of cultural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that women who agree with statements indicating that husbands/partners are justified in beating their wives/partners in reality tend to be abused by their own husbands/partners. The responses to these questions can be found in Table CP.5. Overall, in Turkmenistan about 38 percent of women aged 15-49 believe that a husband/partner is justified to hit or beat his wife/partner for any of the scenarios listed in the questionnaire. Among the offered scenarios of possible domestic violence, the highest percentage of responses was given to the scenario of a woman arguing with her husband/partner (about 32 percent). One in five women thinks that a husband/partner is justified to beat his wife/partner if she neglects the children. Other reasons received affirmative responses from nearly 16 percent of women. Significant differentials were found in correlation with all background characteristics, except for the woman’s age, where only small variations were observed. Specifically, the percentage of women who thought that a husband/partner was justified to beat his wife/partner for at least one of the offered reasons stood at only 10 percent in the capital city of Ashgabat, while in Ahal velayat it reached 62 percent. If in urban areas 1 in 4 women allows the possibility of domestic violence from a husband/partner, in rural areas it is 1 in 2. Fewer highly educated women than those with less education believe a husband is justified to beat his wife for any of the reasons listed. 42 XII. HIV/AIDS, Sexual Behaviour, and Orphaned Children Knowledge of HIV Transmission and Condom Use One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. Correct information is the first step toward raising awareness and giving young people the tools to protect themselves from infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions, although some appear to be universal (for example, that mosquito bites or sharing of food can transmit HIV). The United Nations General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. Indicators to measure this goal, as well as the MDG of reducing HIV infections by half, include improving the level of knowledge of HIV and its prevention, and changing behaviours to prevent further spread of the disease. The HIV module was administered to women aged 15-49. One indicator for both the MDGs and UNGASS is the percentage of young women who have comprehensive and correct knowledge of HIV prevention and transmission. Women were asked whether they knew of the three main ways of HIV transmission – having only one faithful, uninfected partner; using a condom every time; and abstaining from sex. The results are presented in Table HA.1. In Turkmenistan, more than half of the interviewed women (55 percent) had heard of AIDS. However, the percentage of women who knew of all three main ways of preventing HIV transmission was much lower, at just above 12 percent. More than 31 percent of women knew about having one faithful uninfected sex partner, 25 percent knew about using a condom every time, and 24 percent knew about abstaining from sex as main ways of preventing HIV transmission. While more than 40 percent of women overall knew at least one way of preventing HIV, that nonetheless indicates that a high proportion of women (60 percent) do not know any of the three ways. A clear correlation exists between the level of knowledge of the three main ways of HIV transmission and the level of education. Urban women are better informed than rural ones. As a rule, the level of knowledge of residents of the capital city is higher than in the regions. At the same time, however, the proportional weight of reproductive-age women in the capital city who know all three main ways to prevent HIV transmission (below 14 percent) is just slightly higher than the national average. Table HA.2 presents the percentage of women who can correctly identify misconceptions concerning HIV. The indicator is based on the two most common and relevant misconceptions in Turkmenistan, that HIV can be transmitted by supernatural means and mosquito bites. The table also provides information on whether women know that HIV cannot be transmitted by sharing food, and that HIV can be transmitted by sharing needles. Of the interviewed women, 16 percent rejected the two most common misconceptions and knew that a healthy-looking person can be infected. Forty-two percent of women knew that HIV cannot be transmitted by supernatural means and 31 percent knew it cannot be transmitted by mosquito bites, while 29 percent of women knew that a healthy-looking 43 person can be infected. A relationship exists between level of education and wealth of women and rejection of the two most common misconceptions as well as knowledge that a healthy-looking person can be infected. Urban women are almost two times better informed than rural women. Knowledge of misconceptions about HIV/AIDS is highest among the women in the capital city (29 percent) and lowest in Balkan and Mary velayats (8 percent each). Table HA.3 summarizes information from Tables HA.1 and HA.2 and presents the percentage of women who know two ways of preventing HIV transmission and reject three common misconceptions. Comprehensive knowledge of HIV prevention methods and transmission is still fairly low, although differences are found by area of residence. Overall, 9 percent of women were found to have comprehensive knowledge, which was slightly higher in urban areas (12 percent). As expected, the percentage of women with comprehensive knowledge increases with the woman’s education level (Figure HA.1). Fertile-age women in wealthy households also have higher levels of comprehensive knowledge about HIV/AIDS transmission, while women in metropolitan regions (Ashgabat city and Ahal velayat) have higher levels of comprehensive knowledge than women in other regions. Figure HA.1. Percent of women who have comprehensive knowledge of HIV/AIDS transmission, Turkemnistan, 2006 15 36 50 20 11 33 49 16 6 18 32 9 0 10 20 30 40 50 60 None/primary/secondary Secondary professional (special) Higher Turkmenistan Level of education Pe rc en t Knows 2 ways to prevent HIV Identify 3 m isconceptions Com prehens ive knowledge Knowledge of mother-to-child transmission of HIV also is an important first step for women to seek HIV testing when they are pregnant, to avoid infection in the baby. Women should know that HIV can be transmitted during pregnancy, delivery, and through breastfeeding. The level of knowledge among women aged 15-49 concerning mother-to-child transmission is presented in Table HA.4. Overall, 43 percent of women know that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 19 percent, while 12 percent of women did not know of any specific way. The same trend of correlation with background variables manifests itself here: the level of knowledge of reproductive-age women depends on their level of education, area of residence (higher in urban than in rural areas), and household wealth index. The highest level of knowledge about all three ways of mother-to-child transmission of HIV is among 44 women in Lebap velayat and the capital city (32-33 percent), the lowest in Dashoguz and Ahal velayats (10-11 percent). The indicators on attitudes toward people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four variables: 1) would care for family member ill with AIDS; 2) would buy fresh vegetables from a vendor who was HIV-positive; 3) thinks that a female teacher who is HIV-positive should be allowed to teach in school; and 4) would not want to keep HIV status of a family member a secret. Table HA.5 presents the attitudes of women in Turkmenistan toward people living with HIV/AIDS. More than 81 percent of women stated that they would not buy foodstuffs from an HIV- positive vendor, which was the most common discriminating statement. In addition, more than half (60 percent) of the women thought that a female teacher who is HIV-positive should not be allowed to teach in school and that the HIV status of a family member should be kept a secret (53 percent). The lowest percentage was found for the statement concerning denial of care for a family member ill with AIDS (below 15 percent). Acceptance of each of the offered discriminating statements depended mostly on the region and mother tongue of the female respondent. Overall, 94 percent of women agreed with at least one discriminating statement. Any significant differentials in terms of background characteristics were not observed. Only 6 percent of the fertile-age women did not agree with any of the discriminating statements, and more so in urban areas (8 percent) than in rural areas (4 percent). By the regions, the highest percentage of those who disagreed was in Balkan velayat – at more than 11 percent, and the lowest – in Dashoguz velayat at less than 2 percent. Another important indicator is the knowledge of where to be tested for HIV and use of such services. Table HA.6 presents responses to questions related to knowledge among women of a facility for HIV testing and whether they have ever been tested. About 28 percent of women know where to be tested, while only 12 percent have actually been tested. Of these, a large proportion had been told the result (more than 78 percent). Knowledge of urban women is slightly higher than rural women and is in direct relation to the level of their education. Among women who had given birth within the two years preceding the survey, the percentage who received counselling and HIV testing during antenatal care is presented in Table HA.7. In the context of antenatal care – nearly universal at 99 percent – more than 35 percent of women received information on HIV prevention during their visits to a doctor, 31 percent were tested for HIV and 22 percent were told the test results. Receiving information, testing for HIV and getting the test results during antenatal visits were differentiated by the level of education, a direct proportional relationship, and regions. The highest level was found among fertile-age women in Lebap velayat and the lowest in Balkan velayat. 45 Orphaned Children Children are defined as orphaned if they have experienced the death of either parent. The frequency of children living with neither parent, mother only, and father only is presented in Table HA.8. In Turkmenistan more than 86 percent of children of 0-17 years of age live with both parents; 6 percent have lost one or both parents, while only 0.4 percent are double orphans. Four percent of the children have experienced the death of their father and less than 2 percent the death of their mother. The proportion of double orphans does not differ significantly by background variables. Overall, the proportional weight of orphaned children is slightly higher in urban areas (just above 7 percent) than in rural areas (6 percent). Among the regions, the highest proportion of orphans is in the capital city (above 8 percent); the lowest is in Balkan velayat (5 percent). Gender differentials were not found. The proportion of orphaned children grows with the age, from 1.5 percent at 0-4 years to 12 percent at age 15- 17. One of the measures developed for the assessment of the status of orphaned and vulnerable children relative to their peers looks at the school attendance of children aged 10-14 for children who have lost both parents (double orphans) versus children whose parents are alive (and who live with at least one of these parents). If children whose parents have died do not have the same access to school as their peers, then families and schools are not ensuring that these children’s rights are being met. A total of 0.5 percent of children in Turkmenistan aged 10-14 have lost both parents. All of these children (100 percent) are currently attending school. Among the children aged 10-14 who have not lost a parent and who live with at least one parent, 99.6 percent are attending school. This would suggest that double orphans are not disadvantaged compared to non- orphaned children in terms of school attendance. 46 List of References Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. “Data on Birth Weight in Developing Countries: Can Surveys Help?” Bulletin of the World Health Organization, 74(2), 209-16. Blanc, A. and Wardlaw, T., 2005. "Monitoring Low Birth Weight: An Evaluation of International Estimates and an Updated Estimation Procedure".WHO Bulletin, 83 (3), 178-185. Filmer, D. and Pritchett, L., 2001. “Estimating Wealth Effects Without Expenditure Data – or Tears: An Application to Educational Enrolments in States of India. “ Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. UNICEF, 2006. Monitoring the Situation of Children and Women. Multiple Indicator Cluster Survey Manual, New York. United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations Publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Population Division. United Nations, 1990b. Step-by-Step Guide to the Estimation of Child Mortality. New York, UN. WHO and UNICEF, 1997. The Sisterhood Method for Estimating Maternal Mortality. Guidance Notes for Potential Users, Geneva. www.childinfo.org 47 Table HH.1: Results of household and individual interviews Number of households, women and children under 5, by results of the household, women's and under-5s interviews, and household, women's and under-5s response rates, Turkmenistan, 2006 Residence Region Total Urban Rural Ashgabat city Ahal Balkan Dashoguz Lebap Mary Number of households Sampled 2768 2440 1008 840 840 840 840 840 5208 Occupied 2764 2440 1008 840 837 840 840 839 5204 Interviewed 2614 2428 937 832 795 840 815 823 5042 Response rate 94.6 99.5 93.0 99.0 95.0 100.0 97.0 98.1 96.9 Number of women Eligible 3246 3931 1098 1292 993 1419 1146 1229 7177 Interviewed 3237 3923 1094 1289 993 1419 1137 1228 7160 Response rate 99.7 99.8 99.6 99.8 100.0 100.0 99.2 99.9 99.8 Overall response rate 94.3 99.3 92.6 98.8 95.0 100.0 96.3 98.0 96.7 Number of children under 5 Eligible 849 1238 262 358 291 397 395 384 2087 Mother/caretaker interviewed 843 1232 261 356 291 395 392 380 2075 Response rate 99.3 99.5 99.6 99.4 100.0 99.5 99.2 99.0 99.4 Overall response rate 93.9 99.0 92.6 98.5 95.0 99.5 96.3 97.1 96.3 48 Table HH.2: Household age distribution by sex Percent distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, Turkmenistan, 2006 Males Females Total Number Percent Number Percent Number Percent Age 0-4 1103 9.0 1074 8.2 2178 8.6 5-9 1283 10.4 1208 9.2 2491 9.8 10-14 1600 13.0 1545 11.8 3145 12.4 15-19 1271 10.3 1499 11.5 2770 10.9 20-24 1289 10.5 1366 10.5 2655 10.5 25-29 1145 9.3 1111 8.5 2256 8.9 30-34 873 7.1 920 7.0 1793 7.1 35-39 766 6.2 858 6.6 1624 6.4 40-44 757 6.2 795 6.1 1552 6.1 45-49 667 5.4 748 5.7 1415 5.6 50-54 496 4.0 585 4.5 1082 4.3 55-59 337 2.7 430 3.3 767 3.0 60-64 198 1.6 235 1.8 433 1.7 65-69 230 1.9 275 2.1 505 2.0 70+ 278 2.3 420 3.2 698 2.8 Dependency age groups < 15 3986 32.4 3828 29.3 7814 30.8 15-64 7799 63.4 8547 65.4 16346 64.4 65 + 508 4.1 695 5.3 1203 4.7 Children aged 0-17 4950 40.3 4743 36.3 9693 38.2 Adults 18+ 7344 59.7 8327 63.7 15671 61.8 Total 12294 100.0 13070 100.0 25364 100.0 49 Table HH.3: Household composition Percent distribution of households by selected characteristics, Turkmenistan, 2006r Number of households Weighted percent Weighted Unweighted Sex of household head Male 74.9 3776 3756 Female 25.1 1266 1286 Region Ashgabat city 13.2 666 937 Ahal 13.5 683 832 Balkan 9.0 455 795 Dashoguz 17.9 904 840 Lebap 22.1 1117 815 Mary 24.1 1217 823 Residence Urban 45.5 2292 2614 Rural 54.5 2750 2428 Number of household members 1 5.5 278 297 2–3 18.7 943 1007 4–5 38.5 1942 1944 6–7 24.5 1237 1190 8–9 8.7 437 408 10+ 4.1 205 196 Language Turkmen 80.3 4050 4015 Uzbek 6.9 346 301 Russian 8.2 411 499 Other 4.7 235 227 Total 100.0 5042 5042 At least one child aged < 18 years 78.8 5042 5042 At least one child aged < 5 years 31.2 5042 5042 At least one woman aged 15-49 years 87.5 5042 5042 50 Table HH.4: Women's background characteristics Percent distribution of women aged 15-49 years, by background characteristics, Turkmenistan, 2006 Number of women Weighted percent Weighted Unweighted Region Ashgabat city 10.7 769 1094 Ahal 14.5 1040 1289 Balkan 7.8 556 993 Dashoguz 20.9 1498 1419 Lebap 21.3 1529 1137 Mary 24.7 1769 1228 Residence Urban 39.0 2794 3237 Rural 61.0 4366 3923 Age 15-19 20.6 1472 1456 20-24 18.7 1341 1301 25-29 15.2 1088 1086 30-34 12.6 901 920 35-39 11.8 843 849 40-44 10.9 781 803 45-49 10.3 734 745 Marital/union status Currently married/in union 55.3 3961 3933 Formerly married/in union 6.9 494 527 Never married/in union 37.8 2705 2700 Motherhood status Ever gave birth 57.3 4102 4107 Never gave birth 42.7 3058 3053 Education None/primary/secondary 82.3 5890 5809 Secondary vocational/professional (special) 12.4 889 932 Higher 5.3 381 419 Wealth index quintiles Poorest 19.1 1369 1200 Second 19.7 1409 1239 Middle 19.8 1415 1338 Fourth 20.4 1461 1603 Richest 21.0 1506 1780 Language Turkmen 84.9 6082 6079 Uzbek 7.1 505 454 Russian 4.3 306 371 Other 3.7 266 256 Total 100.0 7160 7160 51 Table HH.5: Children's background characteristics Percent distribution of children under 5 years of age, by background characteristics, Turkmenistan, 2006 Number of under-5 children Weighted percent Weighted Unweighted Sex Male 50.6 1050 1046 Female 49.4 1025 1029 Region Ashgabat city 8.6 178 261 Ahal 13.5 281 356 Balkan 7.6 158 291 Dashoguz 19.6 407 395 Lebap 24.9 517 392 Mary 25.7 534 380 Residence Urban 34.6 718 843 Rural 65.4 1357 1232 Age < 6 months 11.7 242 237 6-11 months 10.4 217 215 12-23 months 19.5 406 410 24-35 months 20.0 416 412 36-47 months 20.7 429 432 48-59 months 17.7 366 369 Mother’s education None/primary/secondary 84.5 1753 1732 Secondary vocational/professional (special) 11.2 232 239 Higher 4.3 90 104 Wealth index quintiles Poorest 23.4 485 427 Second 20.0 414 377 Middle 21.0 435 422 Fourth 18.8 389 429 Richest 16.9 351 420 Language Turkmen 84.8 1759 1764 Uzbek 9.3 193 178 Russian 2.6 54 72 Other 3.3 69 61 Total 100.0 2075 2075 52 Table CM.1: Child mortality Infant and under-5 mortality rates (East model), Turkmenistan, 2006 Infant mortality rate* Under-5 mortality rate** Sex Male 68 81 Female 44 52 Region Ashgabat city 47 55 Ahal 38 44 Balkan 46 54 Dashoguz 59 72 Lebap 61 74 Mary 59 72 Residence Urban 55 66 Rural 57 68 Mother’s education None/primary/secondary 60 72 Secondary vocational/professional (special)/higher 40 46 Wealth index quintiles Low-income and mid-income HH – 1-2 & 3 quintiles 54 64 High-income HH – 4-5 quintiles 61 73 Language Turkmen 60 72 Other 38 44 Total 56 67 * MICS indicator 2; MDG indicator 14 ** MICS indicator 1; MDG indicator 13 53 Table CM.2: Children ever born and proportion dead Mean number of children ever born and proportion dead, by age of women, Turkmenistan, 2006 Mean number of children ever born Proportion dead Number of women Age 15-19 yrs 0.023 0.000 1472 20-24 yrs 0.401 0.043 1341 25-29 yrs 1.263 0.059 1088 30-34 yrs 2.171 0.067 901 35-39 yrs 2.962 0.078 843 40-44 yrs 3.704 0.084 781 45-49 yrs 4.124 0.094 734 Total 1.721 0.078 7160 54 Table NU.1: Child malnourishment Percentage of children aged 0-59 months who are severely or moderately malnourished, Turkmenistan, 2006 Weight for age Height for age Weight for height Number of children aged 0- 59 months % below % below % below % below % below % below % above - 2 SD* - 3 SD* - 2 SD** - 3 SD** - 2 SD*** - 3 SD*** + 2 SD Sex Male 11.9 1.8 15.8 5.0 7.1 1.0 1.9 1021 Female 10.2 1.4 13.3 3.8 5.2 0.6 3.2 989 Region Ashgabat city 4.4 0.4 12.7 4.9 5.9 0.4 6.9 171 Ahal 18.3 2.6 19.6 5.5 12.7 2.3 4.1 271 Balkan 5.0 0.3 8.2 1.8 1.8 0.0 1.1 151 Dashoguz 11.4 1.8 17.5 7.0 4.1 1.0 1.5 400 Lebap 10.3 1.3 10.2 1.2 4.7 0.0 1.3 507 Mary 11.7 2.0 16.6 5.8 7.1 1.1 2.6 508 Residence Urban 9.4 0.9 13.1 4.3 6.6 0.9 3.7 694 Rural 11.9 1.9 15.4 4.5 5.9 0.8 1.9 1315 Age < 6 months 3.2 0.0 3.5 0.8 4.6 1.5 5.0 227 6-11 months 16.5 3.6 12.2 3.2 13.3 1.3 1.7 207 12-23 months 17.7 2.9 20.2 7.1 12.0 1.3 4.3 392 24-35 months 13.5 2.1 16.0 5.1 4.6 0.6 1.9 407 36-47 months 6.3 0.5 15.7 3.9 2.6 0.5 1.6 417 48-59 months 8.4 0.7 14.0 4.4 2.5 0.2 1.2 359 Mother’s education None/primary/secondary 11.4 1.8 14.6 4.6 6.7 0.8 2.3 1696 Secondary vocational/professional (special) 11.5 0.4 14.8 4.3 3.9 0.9 2.7 224 Higher 3.4 0.0 14.1 1.7 1.8 0.0 6.4 89 Wealth index quintiles Poorest 12.3 2.5 15.5 4.0 5.0 0.4 2.0 475 Second 15.0 0.9 15.2 5.2 6.6 0.7 1.2 396 Middle 10.4 2.1 13.5 3.8 7.5 1.2 1.9 421 Fourth 11.7 2.0 18.8 6.1 5.9 1.4 3.4 373 Richest 4.8 0.0 9.5 3.1 5.9 0.3 4.6 344 Language Turkmen 10.9 1.4 14.3 4.2 6.4 0.9 2.6 1703 Uzbek 9.1 0.5 17.0 6.3 3.6 0.0 2.3 189 Russian 2.3 0.0 3.9 0.0 4.2 0.0 2.7 51 Other 27.5 9.4 22.5 9.6 9.6 1.6 1.9 66 Total 11.0 1.6 14.6 4.4 6.2 0.8 2.5 2009 * MICS indicator 6; MDG indicator 4 ** MICS indicator 7 *** MICS indicator 8 55 Table NU.2: Initial breastfeeding Percentage of women aged 15-49 years with a birth in the two years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, Turkmenistan, 2006 Percentage who started breastfeeding within one hour of birth* Percentage who started breastfeeding within one day of birth Number of women with a live birth in the two years preceding the Survey Region Ashgabat city 52.2 70.2 72 Ahal 66.2 91.7 108 Balkan 82.0 93.9 71 Dashoguz 42.6 82.8 172 Lebap 49.2 88.4 229 Mary 76.7 92.8 218 Residence Urban 60.2 81.7 327 Rural 59.6 91.4 543 Months since birth < 6 months 57.7 91.3 253 6-11 months 61.6 84.4 233 12-23 months 60.1 87.4 383 Mother’s education None/primary/secondary 60.4 89.2 745 Secondary vocational/professional (special) 59.4 83.0 86 Higher (48.5) (69.5) 38 Wealth index quintiles Poorest 55.1 91.2 183 Second 50.9 88.5 182 Middle 65.8 91.8 176 Fourth 72.0 88.1 178 Richest 54.9 77.4 151 Language Turkmen 63.0 88.1 728 Uzbek 34.0 89.9 88 Russian (46.2) (66.9) 21 Other (66.7) (86.7) 32 Total 59.8 87.7 869 * MICS indicator 45 56 Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at each age group, Turkmenistan, 2006 Children 0-3 months Children 0-5 months Children 6-9 months Children 12-15 months Children 20-23 months Percent exclusively breastfed Number of children Percent exclusively breastfed* Number of children Percent receiving breastmilk & solid/ mushy food** Number of children Percent breastfed*** Number of children Percent breastfed*** Number of children Sex Male 12.8 77 10.2 109 44.9 65 75.9 66 34.9 81 Female 16.4 90 11.4 133 62.8 61 67.1 66 38.9 62 Region Ashgabat city (*) 9 (0.0) 17 (*) 11 (*) 14 (*) 14 Ahal (8.3) 20 (5.9) 28 (*) 13 (68.5) 21 44.1 21 Balkan (*) 12 (22.2) 19 (*) 12 (*) 7 (*) 13 Dashoguz (6.4) 32 (4.5) 45 (*) 22 (84.9) 34 (56.3) 26 Lebap (20.9) 49 16.2 71 (68.1) 34 (80.9) 36 (33.9) 35 Mary (15.4) 45 (11.3) 62 (*) 34 (*) 21 (*) 34 Residence Urban 13 60 9.0 87 50.7 53 71.3 42 33.9 62 Rural 15.7 107 11.9 155 55.6 73 71.6 91 38.8 81 Mother’s education None/primary/secondary 15.8 144 11.6 211 52.7 108 70.4 110 39.0 120 Secondary vocational/professional (special) (*) 17 (*) 22 (*) 12 (*) 15 (*) 17 Higher (*) 6 (*) 9 (*) 7 (*) 7 (*) 6 Wealth index quintiles Poorest (21.1) 41 (15.4) 57 (*) 24 (71.0) 33 (*) 24 Second (14.1) 33 (10.4) 49 (*) 25 (78.9) 30 (36.6) 31 Middle (7.1) 37 (5.4) 49 (45.4) 27 (70.2) 25 (34.5) 30 Fourth (29.1) 28 19.8 47 (60.1) 27 (66.2) 22 (38.5) 26 Richest (1.7) 28 (1.2) 40 (*) 23 (69.1) 23 (26.2) 31 Language Turkmen 18.3 134 13.2 199 54.5 106 72.6 112 35.2 120 Uzbek (*) 19 (0.0) 28 (*) 12 72.6 (*) 57.5 (*) Russian (*) 4 (*) 5 (*) 4 66.7 (*) 41.5 (*) Other (*) 10 (*) 10 (*) 4 47.0 (*) 21.0 (*) Total 14.7 167 10.9 242 53.6 126 71.5 133 36.7 143 * MICS indicator 15 ** MICS indicator 17 *** MICS indicator 16 57 Table NU.4: Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6-11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday, and percentage of infants adequately fed, Turkmenistan, 2006 Percent of infants 0-5 months exclusively breastfed 6-8 months who received breastmilk and complementary food at least 2 times in prior 24 hours 9-11 months who received breastmilk and complementary food at least 3 times in prior 24 hours 6-11 months who received breastmilk and complementary food at least the minimum recommended number of times per day* 0-11 months who were appropriately fed** Number of infants aged 0-11 months Sex Male 10.2 36.6 23.6 29.3 19.8 219 Female 11.4 46.5 28.9 36.1 22.5 239 Region Ashgabat city 0.0 8.5 31.4 22.0 11.4 36 Ahal 5.9 27.2 13.0 17.6 11.7 54 Balkan 22.2 26.1 23.6 24.4 23.3 36 Dashoguz 4.5 63.4 29.2 41.9 21.9 84 Lebap 16.2 51.7 47.5 49.6 30.7 126 Mary 11.3 35.9 13.2 23.5 17.3 122 Residence Urban 9.0 39.2 29.9 34.5 21.4 170 Rural 11.9 43.1 24.5 31.5 21.0 289 Mother’s education None/primary/secondary 11.6 39.4 25.7 31.4 20.9 398 Secondary vocational/professional (special) (2.2) (59.2) (28.0) (42.9) (21.4) 41 Higher (*) (*) (*) (*) (*) 19 Wealth index quintiles Poorest 15.4 63.4 22.7 39.6 25.8 100 Second 10.4 34.6 33.3 33.8 22.4 100 Middle 5.4 28.6 20.7 24.2 14.1 92 Fourth 19.8 50.7 26.3 34.6 27.1 94 Richest 1.2 32.5 26.5 30.0 14.4 74 Language Turkmen 13.2 38.8 25.8 31.2 21.9 383 Uzbek (0.0) (59.9) (31.1) (41.9) (17.9) 49 Russian (*) (*) (*) (*) (*) 11 Other (*) (*) (*) (*) (*) 16 Total 10.9 41.3 26.3 32.7 21.2 459 * MICS indicator 18 ** MICS indicator 19 58 Table NU.5: Iodized salt consumption Percentage of households consuming adequately iodized salt, Turkmenistan, 2006 Percent of households in which salt was tested Number of households interviewed Percent of households with Number of households in which salt was tested or with no saltNo salt salt test result < 15 PPM 15+ PPM* Total Region Ashgabat city 97.5 666 0.7 15.8 83.5 100.0 655 Ahal 100.0 683 0.0 5.0 95.0 100.0 683 Balkan 99.5 455 0.4 14.3 85.3 100.0 454 Dashoguz 100.0 904 0.0 3.8 96.2 100.0 904 Lebap 100.0 1117 0.0 21.7 78.3 100.0 1117 Mary 99.8 1217 0.2 15.7 84.1 100.0 1217 Residence Urban 99.1 2292 0.4 16.1 83.5 100.0 2280 Rural 100.0 2750 0.0 11.0 89.0 100.0 2750 Wealth index quintiles Poorest 100.0 885 0.0 16.2 83.8 100.0 885 Second 100.0 932 0.0 11.2 88.8 100.0 932 Middle 100.0 907 0.0 9.1 90.9 100.0 907 Fourth 99.9 972 0.1 11.8 88.1 100.0 972 Richest 98.5 1346 0.6 16.9 82.5 100.0 1334 Total 99.6 5042 0.2 13.3 86.5 100.0 5030 * MICS indicator 41 59 Table NU.6: Low birth weight infants Percentage of live births in the 2 years preceding the Survey that weighed below 2500 grams at birth, Turkmenistan, 2006 Percent of live births: Number of live birthsBelow 2500 grams* Weighed at birth** Region Ashgabat city 4.6 92.1 72 Ahal 5.0 96.5 108 Balkan 3.9 95.0 71 Dashoguz 3.8 97.5 172 Lebap 4.3 98.8 229 Mary 3.9 99.3 218 Residence Urban 4.1 97.0 327 Rural 4.2 97.9 543 Mother’s education None/primary/secondary 4.2 97.5 745 Secondary vocational/professional (special) 4.1 97.5 86 Higher (3.2) (98.5) 38 Wealth index quintiles Poorest 4.8 97.8 183 Second 3.7 98.2 182 Middle 3.9 99.4 176 Fourth 4.1 95.3 178 Richest 4.3 96.8 151 Language Turkmen 4.3 97.1 728 Uzbek 3.7 100.0 88 Russian (1.8) (96.6) 21 Other (3.4) (100.0) 32 Total 4.2 97.5 869 * MICS indicator 9 ** MICS indicator 10 60 Table CH.1: Vaccinations in first year of life Percentage of children aged 18-29 months immunized against childhood diseases at any time before the Survey and before the first birthday (18 months for measles), Turkmenistan, 2006 Percentage of children who received: Number of children aged 18-29 monthsBCG* DPT1 DPT2 DPT3** OPV0 OPV1 OPV2 OPV3*** Measl es**** All ***** None Vaccinated at any time before the Survey According to: Vaccination card 99.3 99.7 99.7 99.3 98.5 99.2 99.0 98.9 97.6 97.3 0.0 413 Mother’s report 0.6 0.3 0.3 0.6 1.3 0.8 0.8 0.1 1.0 0.0 0.0 413 Total 99.8 100.0 100.0 99.9 99.8 100.0 99.9 99.1 98.6 97.3 0.0 413 Vaccinated by 12 months of age 99.8 99.6 99.1 98.4 99.8 99.8 99.3 96.8 97.0 93.5 0.0 413 * MICS indicator 25 ** MICS indicator 27 *** MICS indicator 26 **** MICS indicator 28; MIDG indicator 15 ***** MICS indicator 31 Table CH.1C: Vaccinations in first year of life (continued) Percentage of children aged 18-29 months immunized against childhood diseases at any time before the Survey and before the first birthday (18 months for measles), Turkmenistan, 2006 Percentage of children who received: Number of children aged 18-29 monthsHepB1 HepB2 HepB3* Vaccinated at any time before the survey According to: Vaccination card 99.3 99.3 98.9 413 Mother’s report 0.7 0.4 0.4 413 Total 100.0 99.7 99.3 413 Vaccinated by 12 months of age 99.5 98.4 96.8 413 * MICS indicator 29 61 Table CH.2: Vaccinations by background characteristics Percentage of children aged 18-29 months currently vaccinated against childhood diseases, Turkmenistan, 2006 Percentage of children who received: Percent with health card Number of children aged 18-29 monthsBCG DPT1 DPT2 DPT3 OPV0 OPV1 OPV2 OPV3 Measles All None Sex Male 99.7 100.0 100.0 100.0 99.5 100.0 100.0 99.5 98.1 97.3 0.0 100.0 202 Female 100.0 100.0 100.0 99.8 100.0 100.0 99.7 98.6 99.0 97.4 0.0 98.9 212 Region Ashgabat city 98.6 100.0 100.0 100.0 100.0 100.0 100.0 98.5 96.7 93.7 0.0 98.5 45 Ahal 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 53 Balkan 100.0 100.0 100.0 98.5 100.0 100.0 98.3 96.5 95.0 90.2 0.0 95.1 33 Dashoguz 100.0 100.0 100.0 100.0 98.6 100.0 100.0 97.2 98.6 95.8 0.0 100.0 74 Lebap 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 107 Mary 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 98.3 98.3 0.0 100.0 101 Residence Urban 99.6 100.0 100.0 99.7 100.0 100.0 99.7 98.9 97.7 95.9 0.0 98.6 165 Rural 100.0 100.0 100.0 100.0 99.6 100.0 100.0 99.2 99.1 98.3 0.0 100.0 248 Mother’s education None/primary/secondary 100.0 100.0 100.0 99.9 99.7 100.0 100.0 99.3 98.5 97.6 0.0 99.7 353 Secondary vocational/professional (special) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (98.5) (100.0) (98.5) (0.0) (98.5) 47 Higher (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 14 Wealth index quintiles Poorest 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 82 Second 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 98.1 98.1 0.0 100.0 85 Middle 100.0 100.0 100.0 100.0 98.8 100.0 100.0 97.6 99.4 97.0 0.0 100.0 86 Fourth 100.0 100.0 100.0 99.4 100.0 100.0 100.0 100.0 97.0 96.3 0.0 99.4 77 Richest 99.2 100.0 100.0 100.0 100.0 100.0 99.3 97.8 98.2 95.3 0.0 97.8 84 Language Turkmen 100.0 100.0 100.0 99.9 99.7 100.0 100.0 99.4 98.5 97.8 0.0 99.9 350 Other 99.0 100.0 100.0 100.0 100.0 100.0 99.1 97.1 98.9 95.0 0.0 97.1 64 Total 99.8 100.0 100.0 99.9 99.8 100.0 99.9 99.1 98.6 97.3 0.0 99.4 413 62 Table CH.2C: Vaccinations by background characteristics (continued) Percentage of children aged 18-29 months currently vaccinated against childhood diseases, Turkmenistan, 2006 Percentage of children who received Percent with health card Number of children aged 18-29 monthsHepB1 HepB2 HepB3 Sex Male 100.0 99.6 99.3 100.0 202 Female 100.0 99.7 99.2 98.9 212 Region Ashgabat city 100.0 98.4 97.0 98.5 45 Ahal 100.0 100.0 100.0 100.0 53 Balkan 100.0 98.3 95.1 95.1 33 Dashoguz 100.0 100.0 100.0 100.0 74 Lebap 100.0 100.0 100.0 100.0 107 Mary 100.0 100.0 100.0 100.0 101 Residence Urban 100.0 99.2 98.2 98.6 165 Rural 100.0 100.0 100.0 100.0 248 Mother’s education None/primary/secondary 100.0 100.0 99.7 99.7 353 Secondary vocational/professional (special) (100.0) (100.0) (98.6) (98.5) 47 Higher (*) (*) (*) (*) 14 Wealth index quintiles Poorest 100.0 100.0 100.0 100.0 82 Second 100.0 100.0 100.0 100.0 85 Middle 100.0 100.0 100.0 100.0 86 Fourth 100.0 100.0 98.5 99.4 77 Richest 100.0 98.5 97.8 97.8 84 Language Turkmen 100.0 100.0 99.7 99.9 350 Other 100.0 98.0 97.1 97.1 64 Total 100.0 99.7 99.3 99.4 413 63 Table CH.3: Oral rehydration treatment Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), Turkmenistan, 2006 Had diarrhoea in last two weeks Number of children aged 0-59 months Children with diarrhoea who received: ORT Use Rate * Number of children aged 0-59 months with diarrhoea Fluid from ORS packet Recommen ded homemade fluid No treatment Sex Male 5.8 1050 41.8 18.6 49.1 50.9 61 Female 5.1 1025 38.1 10.1 57.3 42.7 52 Region Ashgabat city 9.2 178 (*) (*) (*) (*) 16 Ahal 6.0 281 (*) (*) (*) (*) 17 Balkan 3.2 158 (*) (*) (*) (*) 5 Dashoguz 6.3 407 (35.7) (32.1) (52.3) (47.7) 26 Lebap 4.3 517 (*) (*) (*) (*) 22 Mary 5.1 534 (*) (*) (*) (*) 27 Residence Urban 5.7 718 (31.7) (4.1) (68.3) (31.7) 41 Rural 5.4 1357 44.8 20.6 44.3 55.7 73 Age Under 6 months 4.2 242 (*) (*) (*) (*) 10 6–11 months 7.1 217 (*) (*) (*) (*) 15 12–23 months 9.4 406 (51.0) (10.8) (44.2) (55.8) 38 24–35 months 6.0 416 (31.8) (12.0) (62.7) (37.3) 25 36–47 months 2.0 429 (*) (*) (*) (*) 8 48–59 months 4.5 366 (*) (*) (*) (*) 16 Mother’s education None/primary/secondary 5.5 1753 40.0 15.0 51.8 48.2 97 Secondary vocational/professional (special) 4.0 232 (*) (*) (*) (*) 9 Higher 7.7 90 (*) (*) (*) (*) 7 Wealth index quintiles Poorest 4.7 485 (*) (*) (*) (*) 23 Second 3.7 414 (*) (*) (*) (*) 15 Middle 7.0 435 (43.8) (24.8) (42.3) (57.7) 30 Fourth 5.2 389 (*) (*) (*) (*) 20 Richest 6.9 351 (29.7) (4.4) (70.3) (29.7) 24 Language Turkmen 5.5 1759 37.7 11.8 55.1 44.9 97 Other 5.2 316 (*) (*) (*) (*) 16 Total 5.5 2075 40.1 14.7 52.9 47.1 113 * MICS indicator 33 64 Table CH.4: Home management of diarrhea Percentage of children aged 0-59 months with diarrhoea in the last two weeks who took increased fluids and continued to feed during the episode, Turkmenistan, 2006 Had diarrhoea in last two weeks Number of children aged 0-59 months Children with diarrhoea who: Home manage- ment of diarrhoea* Received ORT or increased fluids and continued feeding** Number of children aged 0-59 months with diarrhoea Drank more Drank the same or less Ate somewh at less, same or more Ate much less or none Sex Male 5.8 1050 42.1 52.6 47.6 49.6 20.6 31.9 61 Female 5.1 1025 34.8 59.1 35.1 61.3 9.2 17.4 52 Region Ashgabat city 9.2 178 (*) (*) (*) (*) (*) (*) 16 Ahal 6.0 281 (*) (*) (*) (*) (*) (*) 17 Balkan 3.2 158 (*) (*) (*) (*) (*) (*) 5 Dashoguz 6.3 407 (24.1) (67.9) (24.2) (71.8) (4.1) (8.1) 26 Lebap 4.3 517 (*) (*) (*) (*) (*) (*) 22 Mary 5.1 534 (*) (*) (*) (*) (*) (*) 27 Residence Urban 5.7 718 (48.1) (47.7) (50.6) (46.4) (18.3) (31.4) 41 Rural 5.4 1357 33.4 60.1 36.9 59.8 13.6 21.7 73 Age 0-11 months 5.6 459 (23.9) (61.0) (44.1) (47.9) (5.0) (13.4) 25 12-23 months 9.4 406 (50.5) (46.8) (40.7) (56.6) (24.4) (31.1) 38 24-35 months 6.0 416 (53.4) (44.5) (38.6) (59.3) (16.6) (25.8) 25 36-47 months 2.0 429 (*) (*) (*) (*) (*) (*) 8 48-59 months 4.5 366 (*) (*) (*) (*) (*) (*) 16 Mother’s education None/primary/ secondary 5.5 1753 34.9 58.5 38.2 58.1 12.3 20.2 97 Secondary vocational/ professional (special) 4.0 232 (*) (*) (*) (*) (*) (*) 9 Higher 7.7 90 (*) (*) (*) (*) (*) (*) 7 Wealth index quintiles Poorest 4.7 485 (*) (*) (*) (*) (*) (*) 23 Second 3.7 414 (*) (*) (*) (*) (*) (*) 15 Middle 7.0 435 (19.0) (77.7) (32.1) (67.9) (7.1) (15.6) 30 Fourth 5.2 389 (*) (*) (*) (*) (*) (*) 20 Richest 6.9 351 (63.4) (34.3) (51.6) (48.4) (27.9) (36.3) 24 Language Turkmen 5.5 1759 39.2 55.2 44.0 53.3 16.8 26.6 97 Other 5.2 316 (*) (*) (*) (*) (*) (*) 16 Total 5.5 2075 38.7 55.6 41.8 55.0 15.3 25.2 113 * MICS indicator 34 ** MICS indicator 35 65 Table CH.5: Care seeking for suspected pneumonia Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks taken to a health provider, Turkmenistan, 2006 Had acute respiratory infection1 Number of children aged 0–59 months Children with suspected pneumonia who were taken to: Any appropriate provider* Number of children aged 0–59 months with suspected pneumonia Public sources Other source Govt hospital Govt. health center Govt. health post Village health worker Pharmacy Traditional practitioner Total 1.3 2075 (23.8) (56.9) (17.3) (18.2) (5.0) (4.4) (82.7) 28 * MICS indicator 23 66 Table CH.6: Antibiotic treatment of pneumonia Percentage of children aged 0-59 months with suspected pneumonia who received antibiotic treatment, Turkmenistan, 2006 Percentage of under-5s with suspected pneumonia who received antibiotics in the last two weeks* Number of children with suspected pneumonia in the two weeks prior to the Survey Total (50.4) 28 * MICS indicator 22 67 Table CH.7: Knowledge of the two danger signs of pneumonia Percentage of mothers/caretakers of children aged 0-59 months by knowledge of types of symptoms for taking a child immediately to a health facility, and percentage of mothers/caretakers who recognize fast and difficult breathing as signs for seeking care immediately, Turkmenistan, 2006 Percentage of mothers/caretakers of children aged 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/caretakers who recognize the two danger signs of pneumonia* Number of mothers/caretakers of children aged 0- 59 months Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has difficult breathing Has blood in stool Is drinking poorly Has other symptoms Region Ashgabat city 28.5 52.1 87.9 30.5 34.9 23.1 13.9 8.8 20.6 178 Ahal 46.2 65.0 89.9 42.6 51.7 42.9 18.1 12.3 31.9 281 Balkan 19.1 50.1 93.9 12.3 17.7 9.4 10.0 12.6 2.0 158 Dashoguz 25.7 56.1 92.3 31.0 30.2 20.4 24.4 4.6 9.4 407 Lebap 17.1 44.1 90.9 14.1 13.9 5.6 1.1 12.2 1.0 517 Mary 29.2 65.0 94.1 29.6 29.1 25.8 19.6 8.0 15.7 534 Residence Urban 26.6 52.4 91.3 23.4 29.1 21.8 14.3 11.1 13.4 718 Rural 27.2 57.6 92.1 28.2 27.7 19.9 14.6 8.5 11.8 1357 Mother’s education None/primary/secondary 28.3 54.9 91.3 27.4 28.6 20.6 15.2 8.5 12.8 1753 Secondary vocational/professional (special) 20.8 63.1 96.2 21.9 25.4 19.3 11.7 14.8 10.2 232 Higher 17.3 55.0 91.6 21.3 28.2 23.1 7.8 12.1 9.6 90 Wealth index quintiles Poorest 23.7 58.3 90.8 26.1 21.3 17.1 11.4 5.1 7.0 485 Second 30.1 59.3 92.8 30.6 29.5 22.7 19.5 6.5 15.2 414 Middle 26.8 51.6 95.0 26.9 34.1 23.1 16.2 12.1 14.4 435 Fourth 32.7 58.0 90.2 26.5 30.3 22.5 14.1 10.4 14.6 389 Richest 21.7 51.1 90.2 21.8 26.5 17.4 11.4 14.2 11.5 351 Language Turkmen 26.6 58.9 91.3 26.6 28.4 22.2 13.9 9.4 13.3 1759 Uzbek 29.0 39.0 94.4 31.4 29.0 11.3 21.9 8.6 7.9 193 Russian 16.8 38.9 94.2 13.4 21.8 14.9 5.5 18.2 5.2 54 Other 38.6 36.9 96.2 20.1 27.2 8.2 15.8 4.9 6.6 69 Total 27.0 55.8 91.8 26.5 28.2 20.5 14.5 9.4 12.4 2075 68 Table CH.8: Solid fuel use Percent distribution of households according to type of cooking fuel, and percentage of households using solid fuels for cooking, Turkmenistan, 2006 Percentage of households using: Electricity Liquified Petroleum Gas (LPG) Natural Gas Wood Total Solid fuels for cooking* Number of households Region Ashgabat city 0.2 0.0 99.8 0.0 100.0 0.0 666 Ahal 0.6 0.3 99.2 0.0 100.0 0.0 683 Balkan 0.1 11.1 88.8 0.0 100.0 0.0 455 Dashoguz 0.2 2.4 97.3 0.1 100.0 0.1 904 Lebap 0.2 16.7 81.5 1.6 100.0 1.6 1117 Mary 0.2 4.9 94.8 0.1 100.0 0.1 1217 Residence Urban 0.1 3.1 96.8 0.0 100.0 0.0 2292 Rural 0.4 9.0 89.8 0.7 100.0 0.7 2750 Education of household head None/primary/secondary 0.3 7.0 92.1 0.5 100.0 0.5 3161 Secondary vocational/professional (special) 0.1 6.3 93.2 0.4 100.0 0.4 1026 Higher 0.2 3.9 95.9 0.0 100.0 0.0 854 DK/Missing (*) (*) (*) (*) 100.0 (*) 2 Wealth index quintiles Poorest 0.5 31.0 66.3 2.1 100.0 2.1 885 Second 0.3 2.2 97.4 0.2 100.0 0.2 932 Middle 0.1 2.1 97.7 0.0 100.0 0.0 907 Fourth 0.3 0.4 99.3 0.0 100.0 0.0 972 Richest 0.2 0.1 99.7 0.0 100.0 0.0 1346 Language Turkmen 0.3 6.1 93.4 0.3 100.0 0.3 4050 Uzbek 0.3 14.0 83.6 2.1 100.0 2.1 346 Russian 0.2 0.5 99.4 0.0 100.0 0.0 411 Other 0.6 10.0 89.4 0.0 100.0 0.0 235 Total 0.3 6.3 93.0 0.4 100.0 0.4 5042 *MICS indicator 24; MDG indicator 29 69 Table CH.9: Source and cost of supplies for oral rehydration salts Percent distribution of children aged 0-59 months with diarrhoea during the two weeks preceding the Survey, by source of oral rehydration salts for treatment of diarrhoea, and percentage of children aged 0-59 months with diarrhoea during the two weeks preceding the Survey for whom oral rehydration salts were obtained for free, Turkmenistan, 2006 Source of oral rehydration salts Number of children with diarrhoea in prior 2 weeks who received oral rehydration salts Percentage free Median cost for those not free Public* Private Other Total Public Private Public Private Total (82.3) (7.9) (9.9) 100.0 45 (27.1) (*) (*) (*) * MICS indicator 96 70 Table EN.1: Use of improved water sources Percent distribution of household members according to main source of drinking water and percentage of household members using improved drinking water sources, Turkmenistan, 2006 Main source of drinking water Total Improved source of drinking water * Number of house- hold members Improved sources Unimproved sources Piped into dwelling Piped into yard/plot Public tap/ stand- pipe Tube- well/ bore- hole Pro- tected well Pro- tected spring Rain water Bottled water1 Unpro- tected well Unpro- tected spring Tanker truck Cart with tank/ drum Surface water Other Region Ashgabat city 70.6 14.9 0.0 0.0 0.0 0.0 0.0 9.5 0.0 0.0 5.0 0.0 0.0 0.0 100.0 95.0 2639 Ahal 21.7 33.4 2.9 0.0 2.7 0.0 0.1 0.0 0.0 0.0 38.7 0.3 0.2 0.0 100.0 60.8 3751 Balkan 43.7 20.6 0.0 2.8 0.0 0.1 5.3 0.1 0.0 1.4 26.0 0.0 0.0 0.0 100.0 72.6 1941 Dashoguz 9.7 17.4 15.3 26.5 13.8 0.2 0.0 0.0 0.4 0.6 14.9 0.0 1.1 0.3 100.0 82.9 5302 Lebap 15.5 14.6 2.6 28.2 27.1 1.5 0.0 0.0 0.8 0.3 3.8 0.0 5.5 0.1 100.0 89.5 5525 Mary 14.6 13.8 0.5 6.2 4.0 0.0 0.0 0.0 1.3 0.4 47.7 0.4 11.3 0.0 100.0 39.0 6205 Residence Urban 54.9 23.2 4.7 4.2 1.0 0.0 0.5 2.6 0.0 0.0 8.7 0.2 0.0 0.1 100.0 91.1 9676 Rural 3.1 15.2 4.0 19.1 15.8 0.6 0.4 0.0 0.9 0.6 33.2 0.1 6.8 0.1 100.0 58.2 15688 Education of household head None/primary/second ary 17.5 19.3 4.6 13.9 11.3 0.3 0.5 0.2 0.7 0.4 26.0 0.1 5.0 0.1 100.0 67.7 16388 Secondary vocational/profession al (special) 32.4 15.5 3.6 13.9 8.6 0.6 0.4 1.2 0.3 0.4 19.3 0.2 3.5 0.1 100.0 76.1 4871 Higher 33.1 17.4 3.8 10.9 7.2 0.2 0.1 3.9 0.5 0.1 20.7 0.1 1.8 0.0 100.0 76.7 4091 Wealth index quintiles Poorest 0.2 15.8 1.8 19.8 21.5 1.8 0.0 0.0 0.7 0.3 28.9 0.0 9.2 0.0 100.0 61.0 5073 Second 0.1 14.2 6.2 23.5 14.8 0.0 0.3 0.0 0.3 0.7 34.2 0.2 5.2 0.3 100.0 59.2 5073 Middle 2.0 25.3 7.1 17.5 11.0 0.0 0.6 0.0 1.4 1.0 30.8 0.0 3.2 0.1 100.0 63.5 5072 Fourth 23.6 32.8 4.7 6.1 3.5 0.0 1.2 0.0 0.6 0.0 23.6 0.5 3.4 0.0 100.0 71.9 5074 Richest 88.4 3.1 1.7 0.1 0.0 0.0 0.1 5.0 0.0 0.0 1.7 0.0 0.0 0.0 100.0 98.3 5071 Language Turkmen 19.9 17.2 4.7 13.2 11.9 0.1 0.5 0.8 0.7 0.4 27.7 0.2 2.7 0.1 100.0 68.3 21307 Uzbek 15.1 36.4 4.4 28.5 0.9 3.7 0.0 0.0 0.0 0.8 5.1 0.0 5.2 0.0 100.0 89.0 1898 Russian 86.1 4.3 0.1 2.1 0.0 0.0 0.0 6.8 0.0 0.0 0.5 0.1 0.0 0.0 100.0 99.4 1137 Other 29.6 21.5 1.1 2.3 2.0 0.0 0.0 1.3 0.0 0.0 4.1 0.0 38.0 0.0 100.0 57.9 1022 Total 22.9 18.3 4.3 13.4 10.2 0.4 0.4 1.0 0.6 0.4 23.8 0.1 4.2 0.1 100.0 70.8 25364 * MICS indicator 11; MDG indicator 30 71 Table EN.2: Household water treatment Percent distribution of household population according to drinking water treatment method used in the household, and percentage of household population that applied an appropriate water treatment method, Turkmenistan, 2006 Water treatment method used in the household All drinking water sources Improved drinking water sources Unimproved drinking water sources None Boil Add bleach/ chlorine Strain through a cloth Use water filter Solar dis- infection Let it stand and settle Other Don't know Appropriat e water treatment method* Number of house- hold member s Appropriat e water treatment method Number of house- hold member s Appropriat e water treatment method Number of house- hold member s Region Ashgabat city 37.2 54.2 0.0 0.3 2.7 0.0 21.0 0.8 0.0 55.6 2639 57.9 2507 11.5 132 Ahal 16.1 69.3 2.2 0.2 0.0 0.1 67.8 0.0 0.0 69.6 3751 62.5 2280 80.5 1471 Balkan 14.8 54.3 8.6 6.9 1.4 0.3 52.3 0.5 0.0 63.3 1941 63.2 1409 63.5 532 Dashoguz 57.9 40.7 0.0 0.0 0.3 0.0 12.5 0.1 0.0 40.7 5302 45.5 4393 17.6 909 Lebap 25.5 63.4 0.0 0.6 0.2 0.0 47.8 0.0 0.0 63.4 5525 62.9 4944 67.3 581 Mary 19.3 60.9 0.9 0.3 0.9 0.3 51.0 0.2 0.0 61.5 6205 58.3 2420 63.6 3785 Residence Urban 30.2 59.1 1.4 1.5 1.1 0.1 36.9 0.3 0.0 60.6 9676 60.3 8816 64.3 860 Rural 29.5 56.2 1.1 0.4 0.5 0.1 44.7 0.1 0.0 56.9 15688 54.5 9137 60.2 6551 Education of household head None/primary/ secondary 29.5 56.4 1.3 0.8 0.3 0.1 43.0 0.2 0.0 57.2 16388 56.4 11096 58.8 5292 Secondary vocational/ professional (special) 29.5 59.8 1.2 1.1 1.2 0.1 39.5 0.1 0.0 61.0 4871 58.2 3708 69.8 1164 Higher 30.7 57.9 0.9 0.5 2.0 0.1 39.2 0.5 0.0 59.6 4091 59.6 3136 59.6 955 Wealth index quintiles Poorest 32.0 56.7 1.1 0.3 0.2 0.0 47.2 00.0 0.0 57.4 5073 54.8 3093 61.6 1981 Second 28.9 57.2 0.9 0.3 0.5 0.2 42.0 0.1 0.0 57.5 5073 56.3 3004 59.2 2069 Middle 30.4 57.4 1.5 0.7 0.6 0.0 42.7 0.2 0.0 58.5 5072 56.2 3223 62.6 1849 Fourth 27.5 56.2 2.3 1.1 0.1 0.2 45.9 0.1 0.0 57.7 5074 56.4 3649 61.1 1425 Richest 29.9 59.0 .3 1.6 2.1 0.1 30.7 0.6 0.0 60.3 5071 60.9 4983 25.8 88 Language Turkmen 27.6 58.6 1.4 0.8 0.6 0.1 44.0 0.2 0.0 59.6 21307 59.3 14543 60.3 6764 Uzbek 59.4 40.4 0.0 0.1 0.0 0.0 16.7 0.0 0.0 40.4 1898 35.8 1689 78.2 209 Russian 26.6 63.1 0.0 2.1 4.6 0.2 28.6 0.9 0.0 65.8 1137 66.1 1130 (*) 7 Other 24.0 54.5 0.3 1.0 0.8 0.2 55.3 0.0 0.0 55.0 1022 52.8 591 58.0 430 Total 29.8 57.3 1.2 0.8 0.7 0.1 41.7 0.2 0.0 58.3 25364 57.3 17953 60.7 7411 * MICS indicator 13 72 Table EN.3: Time to source of water Percent distribution of households according to time to go to source of drinking water, get water and return, and mean time to source of drinking water, Turkmenistan, 2006 Time to source of drinking water Mean time to source of drinking water* Number of households Water on premises Less than 15 minutes 15 minutes to less than 30 minutes 30 minutes to less than 1 hour 1 hour or more Don't know Total Region Ashgabat city 96.6 3.4 0.0 0.0 0.0 0.0 100.0 4.9 666 Ahal 92.8 5.9 1.0 0.0 0.0 0.3 100.0 6.7 683 Balkan 93.4 2.1 2.0 0.9 1.6 0.0 100.0 27.0 455 Dashoguz 53.7 21.0 18.8 6.1 0.1 0.4 100.0 15.6 904 Lebap 73.9 19.6 5.3 1.1 0.0 0.0 100.0 8.3 1117 Mary 83.2 9.0 3.8 3.6 0.2 0.1 100.0 16.1 1217 Residence Urban 90.5 6.2 1.9 1.2 0.0 0.1 100.0 11.7 2292 Rural 70.8 16.4 9.1 3.2 0.4 0.1 100.0 13.7 2750 Education of household head None/primary/secondary 76.2 13.6 7.3 2.6 0.2 0.1 100.0 13.4 3161 Secondary vocational/professional (special) 84.7 9.5 3.2 2.3 0.2 0.1 100.0 13.1 1026 Higher 86.7 7.9 3.6 1.4 0.3 0.1 100.0 13.1 854 Wealth index quintiles Poorest 67.1 17.4 10.8 3.8 0.8 0.0 100.0 15.0 885 Second 68.8 18.0 8.9 3.9 0.1 0.2 100.0 13.2 932 Middle 74.1 14.0 8.5 3.1 0.1 0.2 100.0 13.6 907 Fourth 83.0 11.7 3.3 1.7 0.1 0.2 100.0 11.2 972 Richest 97.5 2.0 0.4 0.0 0.0 0.1 100.0 7.5 1346 Language Turkmen 78.8 13.0 5.9 1.9 0.2 0.1 100.0 12.3 4050 Uzbek 75.0 10.9 9.6 4.5 0.0 0.0 100.0 16.0 346 Russian 99.1 0.8 0.2 0.0 0.0 0.0 100.0 9.6 411 Other 67.7 11.3 9.1 10.1 1.2 0.6 100.0 22.5 235 Total 79.6 11.8 5.9 2.3 0.2 0.1 100.0 13.3 5042 * The mean time to source of drinking water is calculated based on those households that do not have water on the premises. 73 Table EN.4: Person collecting water Percent distribution of households according to the person collecting drinking water used in the household, Turkmenistan, 2006 Person collecting drinking water Number of households Adult woman Adult man Female child under age 15 Male child under age 15 Total Region Ashgabat city (70.8) (29.2) (0.0) (0.0) 100.0 20 Ahal 92.1 4.9 1.5 1.5 100.0 49 Balkan (52.4) (22.6) (14.6) (10.3) 100.0 30 Dashoguz 64.0 28.4 4.3 3.4 100.0 419 Lebap 76.2 19.1 2.3 2.3 100.0 291 Mary 69.4 21.1 6.1 3.3 100.0 205 Residence Urban 66.2 24.8 2.3 6.7 100.0 211 Rural 70.7 22.5 4.7 2.2 100.0 804 Education of household head None/primary/ secondary 69.8 23.8 3.9 2.5 100.0 751 Secondary vocational/ professional (special) 67.1 20.3 5.6 7.0 100.0 155 Higher 72.9 21.3 4.2 1.6 100.0 107 Wealth index quintiles Poorest 73.0 20.1 4.7 2.2 100.0 291 Second 68.3 23.8 4.5 3.4 100.0 291 Middle 65.5 28.0 4.1 2.4 100.0 235 Fourth 73.3 19.6 3.1 4.0 100.0 165 Richest (65.6) (20.7) (3.4) (10.3) 100.0 32 Language Turkmen 70.7 22.7 4.3 2.3 100.0 850 Uzbek 71.1 17.1 2.5 9.3 100.0 87 Russian (*) (*) (*) (*) 100.0 4 Other 58.8 30.5 5.4 5.4 100.0 74 Total 69.7 23.0 4.2 3.1 100.0 1014 74 Table EN.5: Use of sanitary means of excreta disposal Percent distribution of household members according to type of toilet facility used by the household, and the percentage of household members using sanitary means of excreta disposal, Turkmenistan, 2006 Type of toilet facility used by household Total Percentage of population using improved sanitary means of excreta disposal* Number of household members Improved sanitation facility Unimproved sanitation facility Flush/pour flush to: Ventilated improved pit latrine Pit latrine with slab Flush/ pour flush to some- where else Pit latrine without slab/ open pit Other Piped sewer system Septic tank Pit latrine Region Ashgabat city 74.3 3.9 8.3 8.3 5.2 0.0 0.0 0.0 100.0 100.0 2639 Ahal 5.6 0.9 3.1 22.1 68.1 0.1 0.0 0.0 100.0 99.9 3751 Balkan 38.1 1.4 1.4 22.0 36.3 0.2 0.5 0.1 100.0 99.2 1941 Dashoguz 8.4 0.1 0.1 7.0 82.0 0.9 1.3 0.1 100.0 97.6 5302 Lebap 13.6 0.6 0.3 20.8 63.0 1.7 0.0 0.0 100.0 98.3 5525 Mary 10.3 0.0 0.0 19.8 68.4 1.4 0.1 0.0 100.0 98.4 6205 Residence Urban 48.9 2.1 3.2 20.0 25.6 0.1 0.1 0.0 100.0 99.8 9676 Rural 0.1 0.0 0.5 14.6 82.8 1.5 0.5 0.0 100.0 98.0 15688 Education of household head None/primary/secondary 12.7 0.5 1.6 15.0 68.7 1.0 0.5 0.1 100.0 98.5 16388 Secondary vocational/professional (special) 28.6 0.9 1.0 15.7 52.5 1.1 0.2 0.0 100.0 98.7 4871 Higher 31.2 1.9 1.8 24.3 40.0 0.7 0.1 0.0 100.0 99.2 4091 Wealth index quintiles Poorest 0.0 0.0 0.0 6.4 91.8 1.2 0.6 0.0 100.0 98.2 5073 Second 0.0 0.0 0.2 6.6 91.7 1.1 0.4 0.0 100.0 98.5 5073 Middle 0.0 0.0 0.2 20.6 77.1 1.4 0.7 0.1 100.0 97.8 5072 Fourth 5.7 1.7 5.1 43.4 43.1 1.0 0.1 0.0 100.0 98.9 5074 Richest 87.8 2.3 2.2 6.3 1.4 0.0 0.0 0.0 100.0 100.0 5071 Language Turkmen 15.2 0.8 1.6 17.8 63.2 0.9 0.4 0.0 100.0 98.7 21307 Uzbek 12.2 0.4 0.3 11.5 75.4 0.3 0.0 0.0 100.0 99.7 1898 Russian 89.1 1.6 1.9 3.6 3.8 0.0 0.0 0.0 100.0 100.0 1137 Other 25.0 0.1 1.9 16.7 52.0 3.2 1.2 0.0 100.0 95.6 1022 Total 18.7 0.8 1.5 16.6 61.0 0.9 0.4 0.0 100.0 98.7 25364 * MICS indicator 12; MDG indicator 31 75 Table EN.6: Use of improved water sources and improved sanitation Percentage of household population using both improved drinking water sources and sanitary means of excreta disposal, Turkmenistan, 2006 Percentage of household population: Using improved sources of drinking water* Using sanitary means of excreta disposal** Using improved sources of drinking water and using sanitary means of excreta disposal Number of household members Region Ashgabat city 95.0 100.0 95.0 2639 Ahal 60.8 99.9 60.7 3751 Balkan 72.6 99.2 72.0 1941 Dashoguz 82.9 97.6 80.6 5302 Lebap 89.5 98.3 88.5 5525 Mary 39.0 98.4 38.9 6205 Residence Urban 91.1 99.8 91.0 9676 Rural 58.2 98.0 57.1 15688 Education of household head None/primary/secondary 67.7 98.5 66.8 16388 Secondary vocational/professional (special) 76.1 98.7 75.5 4871 Higher 76.7 99.2 76.3 4091 Wealth index quintiles Poorest 61.0 98.2 59.5 5073 Second 59.2 98.5 58.2 5073 Middle 63.5 97.8 62.4 5072 Fourth 71.9 98.9 71.8 5074 Richest 98.3 100.0 98.2 5071 Language Turkmen 68.3 98.7 67.4 21307 Uzbek 89.0 99.7 88.7 1898 Russian 99.4 100.0 99.4 1137 Other 57.9 95.6 56.9 1022 Total 70.8 98.7 70.0 25364 * MICS indicator 11; MDGS indicator 30 ** MICS indicator 12; MDG indicator 31 76 Table RH.1: Use of contraception Percentage of married or in union women aged 15-49 who are using (or whose partner is using) a contraceptive method, Turkmenistan, 2006 Not using any method Percent of women (currently married or in union) who are using: Number of women currently married or in unionPill IUD Injectio ns Implants Condom Female condom Diaph- ragm/ foam/ jelly LAM Periodic abstin- ence With- drawal Other Any modern method Any tradi- tional method Any method * Region Ashgabat city 46.3 5.1 41.7 0.6 0.0 4.0 0.3 0.2 0.4 1.1 0.0 0.3 51.9 1.9 53.7 397 Ahal 55.0 2.3 39.5 0.9 0.4 0.3 0.0 0.0 1.3 0.1 0.1 0.0 43.4 1.6 45.0 590 Balkan 62.4 1.6 32.3 0.0 0.2 1.7 0.7 0.0 0.0 0.5 0.4 0.2 36.4 1.2 37.6 302 Dashoguz 52.5 0.5 45.9 0.4 0.1 0.0 0.0 0.0 0.0 0.3 0.3 0.0 47.0 0.5 47.5 775 Lebap 56.7 1.1 35.5 0.9 0.1 0.7 0.0 0.0 1.9 0.0 2.6 0.5 38.3 5.0 43.3 895 Mary 44.8 1.3 51.3 0.6 0.0 0.5 0.0 0.1 0.9 0.0 0.4 0.1 53.8 1.4 55.2 1002 Residence Urban 53.1 3.1 39.4 0.5 0.0 2.0 0.1 0.0 0.6 0.5 0.3 0.3 45.2 1.7 46.9 1529 Rural 51.3 0.7 44.4 0.7 0.2 0.2 0.0 0.1 1.1 0.0 1.1 0.1 46.3 2.3 48.7 2432 Age 15–19 94.5 0.9 4.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.5 0.0 5.5 74 20–24 77.6 1.7 17.1 0.0 0.0 0.4 0.0 0.0 2.7 0.2 0.3 0.0 19.3 3.1 22.4 469 25–29 58.4 2.1 35.1 0.1 0.2 1.1 0.1 0.0 1.8 0.1 0.9 0.1 38.7 2.9 41.6 741 30–34 42.5 1.4 51.9 0.8 0.0 0.8 0.2 0.0 1.0 0.1 1.3 0.1 55.0 2.4 57.5 702 35–39 35.9 2.1 56.9 1.3 0.3 1.2 0.2 0.1 0.2 0.2 1.0 0.7 62.0 2.1 64.1 703 40–44 42.3 2.2 51.6 1.1 0.0 1.0 .1 0.2 0.2 0.6 0.4 0.2 56.2 1.4 57.7 674 45–49 59.6 0.4 38.1 0.2 0.4 0.5 0.0 0.0 0.0 0.1 0.8 0.0 39.5 0.9 40.4 599 Number of living children** 0 98.6 0.4 0.8 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 1.4 346 1 72.7 2.9 20.2 0.1 0.0 1.2 0.0 0.0 2.5 0.1 0.2 0.1 24.4 2.9 27.3 629 2 42.9 2.0 50.8 0.3 0.1 1.0 0.3 0.0 0.9 0.2 1.1 0.4 54.5 2.6 57.1 1020 3 36.9 1.7 57.1 0.9 0.2 1.2 0.0 0.1 0.7 0.4 0.8 0.0 61.2 1.9 63.1 884 4 and more 45.9 1.0 48.9 1.1 0.2 0.5 0.1 0.1 0.4 0.3 1.1 0.2 52.0 2.0 54.1 1082 Education None/primary/secondary 53.7 1.3 41.4 0.6 0.1 0.6 0.1 0.0 1.1 0.1 0.8 0.1 44.1 2.1 46.3 3120 Secondary vocational/professional (special) 46.4 2.2 46.6 1.1 0.2 1.5 0.2 0.1 0.2 0.4 0.7 0.3 51.9 1.6 53.6 592 Higher 43.5 4.4 46.0 0.3 0.0 2.7 0.2 0.0 0.0 1.2 0.8 0.9 53.6 2.8 56.5 250 Wealth index quintiles Poorest 54.1 0.5 40.6 0.9 0.1 0.5 0.0 0.0 1.9 0.1 1.4 0.0 42.5 3.4 45.9 791 Second 52.6 0.7 43.9 0.7 0.3 0.2 0.0 0.0 0.8 0.0 0.7 0.2 45.8 1.6 47.4 788 Middle 51.5 1.6 43.5 0.8 0.1 0.2 0.2 0.2 0.7 0.1 1.0 0.0 46.7 1.8 48.5 783 Fourth 49.9 1.1 46.1 0.3 0.2 0.5 0.1 0.0 0.8 0.4 0.4 0.2 48.3 1.8 50.1 788 Richest 51.9 4.4 38.4 0.4 0.0 2.9 0.1 0.1 0.3 0.5 0.5 0.6 46.2 1.9 48.1 812 Language Turkmen 52.4 1.2 42.6 0.7 0.2 0.6 0.1 0.1 1.0 0.2 0.9 0.1 45.3 2.3 47.6 3370 Uzbek 48.1 1.8 48.2 0.4 0.0 0.5 0.0 0.0 0.0 0.3 0.7 0.0 50.9 1.0 51.9 311 Russian 45.5 11.8 34.1 0.5 0.0 5.0 0.8 0.0 0.0 0.5 0.0 1.9 52.2 2.3 54.5 145 Other 58.4 2.0 36.9 0.0 0.0 2.6 0.0 0.0 0.0 0.0 0.0 0.0 41.6 0.0 41.6 135 Total 52.0 1.7 42.5 0.6 0.1 0.9 0.1 0.1 0.9 0.2 0.8 0.2 45.9 2.1 48.0 3961 * MICS indicator 21; MDG indicator 19C 77 Table RH.2: Unmet need for contraception Percentage of women aged 15-49 years currently married or in union with an unmet need for family planning and percentage of demand for contraception satisfied, Turkmenistan, 2006 Current use of contraception* Unmet need for contraception Number of women currently married or in union Percentage of demand for contraception satisfied*** Number of women currently married or in union with need for contraceptionFor spacing For limiting Total** Region Ashgabat city 53.7 4.6 8.7 13.3 397 80.1 266 Ahal 45.0 7.6 10.7 18.3 590 71.1 373 Balkan 37.6 5.1 11.3 16.4 302 69.6 163 Dashoguz 47.5 9.4 8.3 17.6 775 72.9 505 Lebap 43.3 5.7 13.0 18.7 895 69.8 554 Mary 55.2 4.8 6.7 11.5 1002 82.7 669 Residence Urban 46.9 5.8 10.9 16.6 1529 73.8 972 Rural 48.7 6.7 8.8 15.5 2432 75.9 1560 Age 15-19 (*) (*) (*) (*) (*) (*) 20 20-24 22.4 19.1 3.5 22.6 469 49.8 211 25-29 41.6 12.5 5.2 17.7 741 70.1 439 30-34 57.5 6.3 7.9 14.3 702 80.1 504 35-39 64.1 1.2 14.1 15.3 703 80.7 558 40-44 57.7 0.0 13.5 13.5 674 81.0 479 45-49 40.4 0.0 13.1 13.1 599 75.5 320 Education None/primary/ secondary 46.3 6.7 9.8 16.4 3120 73.8 1956 Secondary vocational/ professional (special) 53.6 4.6 9.6 14.2 592 79.0 401 Higher 56.5 6.0 7.3 13.3 250 80.9 174 Wealth index quintiles Poorest 45.9 6.9 9.4 16.3 791 73.8 492 Second 47.4 7.4 8.3 15.6 788 75.2 496 Middle 48.5 5.9 9.5 15.4 783 75.9 500 Fourth 50.1 6.2 9.2 15.4 788 76.5 516 Richest 48.1 5.3 11.4 16.8 812 74.2 527 Language Turkmen 47.6 6.1 9.5 15.6 3370 75.3 2131 Uzbek 51.9 8.2 9.7 17.9 311 74.3 218 Russian 54.5 6.0 9.5 15.4 145 77.9 102 Other 41.6 8.5 10.3 18.8 135 68.9 81 Total 48.0 6.3 9.6 15.9 3961 75.1 2532 * MICS indicator 21; MDG indicator 19C ** MICS indicator 98 *** MICS indicator 99 78 Table RH.3: Antenatal care provider Percent distribution of women aged 15-49 who gave birth in the two years preceding the Survey, by type of personnel providing antenatal care, Turkmenistan, 2006 Person providing antenatal care No antenatal care received Total Any skilled personnel* Number of women who gave birth in the preceding two years Medical doctor Nurse/ midwife Traditional birth attendant Other Region Ashgabat city 100.0 0.0 0.0 0.0 0.0 100.0 100.0 72 Ahal 95.6 4.4 0.0 0.0 0.0 100.0 100.0 108 Balkan 88.3 6.9 0.7 0.0 4.1 100.0 95.2 71 Dashoguz 95.7 3.6 0.0 0.0 0.6 100.0 99.4 172 Lebap 92.3 6.9 0.0 0.8 0.0 100.0 99.2 229 Mary 98.8 0.6 0.0 0.0 0.6 100.0 99.4 218 Residence Urban 96.6 2.2 0.2 0.6 0.5 100.0 98.8 327 Rural 94.5 4.8 0.0 0.0 0.7 100.0 99.3 543 Age 15-19 (95.5) (4.5) (0.0) (0.0) (0.0) 100.0 (100.0) 29 20-24 96.0 3.8 0.0 0.0 0.2 100.0 99.8 281 25-29 96.3 2.9 0.0 0.6 0.2 100.0 99.2 302 30-34 94.7 4.0 0.3 0.0 1.0 100.0 98.7 161 35-39 91.2 6.1 0.0 0.0 2.7 100.0 97.3 73 40-44 (91.8) (5.7) (0.0) (0.0) (2.5) 100.0 (97.5) 23 45-49 (*) (*) (*) (*) (*) 100.0 (*) 1 Education None/primary/secondary 95.2 4.2 0.1 0.0 0.6 100.0 99.4 745 Secondary vocational/professional (special) 95.0 1.5 0.0 2.2 1.2 100.0 96.5 86 Higher (98.6) (1.4) (0.0) (0.0) (0.0) 100.0 (100.0) 38 Wealth index quintiles Poorest 91.8 6.2 0.0 0.0 2.0 100.0 98.0 183 Second 94.6 5.4 0.0 0.0 0.0 100.0 100.0 182 Middle 96.6 3.4 0.0 0.0 0.0 100.0 100.0 176 Fourth 96.4 3.3 0.3 0.0 0.0 100.0 99.7 178 Richest 97.6 0.0 0.0 1.3 1.1 100.0 97.6 151 Language Turkmen 94.9 4.2 0.1 0.3 0.6 100.0 99.1 728 Uzbek 97.3 1.5 0.0 0.0 1.2 100.0 98.8 88 Russian (100.0) (0.0) (0.0) (0.0) (0.0) 100.0 (100.0) 21 Other (96.1) (3.9) (0.0) (0.0) (0.0) 100.0 (100.0) 32 Total 95.3 3.8 0.1 0.2 0.6 100.0 99.1 869 * MICS indicator 20 79 Table RH.4: Antenatal care Percentage of pregnant women receiving antenatal care among women aged 15–49 years who gave birth in two years preceding the survey and percentage of pregnant women receiving specific care as part of the antenatal care received, Turkmenistan, 2006 Percent of pregnant women receiving ANC one or more times during pregnancy Percent of pregnant women who had:: Number of women who gave birth in two years preceding Survey Blood test taken* Blood pressure measured* Urine specimen taken* Blood group identified* Gynaecological examination conducted* Pregnancy term determined * Ultrasonic examination conducted * Weight measured* Region Ashgabat city 100.0 100.0 100.0 100.0 99.0 91.4 99.0 99.0 100.0 72 Ahal 100.0 98.5 100.0 99.3 99.2 98.5 97.7 89.5 97.0 108 Balkan 95.9 92.7 91.1 94.2 86.6 88.8 95.9 80.7 89.7 71 Dashoguz 99.4 96.9 80.5 92.0 82.9 98.1 94.5 71.1 86.9 172 Lebap 100.0 100.0 100.0 98.8 98.2 98.2 94.7 78.4 97.1 229 Mary 99.4 98.7 98.1 97.9 93.7 92.9 98.1 64.2 76.7 218 Residence Urban 99.5 98.5 96.6 97.3 96.0 95.3 97.8 89.6 95.4 327 Rural 99.3 98.2 94.0 96.9 91.7 95.7 95.5 68.9 86.1 543 Age 15–19 (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (79.2) (100.0) 29 20–24 99.8 98.7 94.2 97.7 89.4 96.7 97.2 78.4 90.5 281 25–29 99.8 98.7 95.7 98.4 95.2 93.8 96.0 72.1 88.0 302 30–34 99.0 97.8 93.4 94.2 95.0 97.5 94.9 76.3 87.4 161 35–39 97.3 95.9 96.5 95.9 94.1 94.6 96.2 85.7 91.0 73 40–44 (97.5) (97.5) (97.5) (89.5) (97.5) (89.5) (97.5) (85.6) (97.5) 23 45–49 (*) (*) (*) (*) (*) (*) (*) (*) (*) 1 Education None/primary/secondary 99.4 98.2 94.3 96.8 92.5 95.4 96.0 75.1 89.1 745 Secondary vocational/professional (special) 98.8 98.8 98.8 98.8 97.8 96.5 98.8 83.5 90.8 86 Higher (100.0) (100.0) (100.0) (97.2) (100.0) (96.8) (97.2) (92.9) (97.2) 38 Wealth index quintiles Poorest 98.0 96.0 96.3 95.8 92.0 95.2 93.4 65.7 85.6 183 Second 100.0 99.4 92.2 97.9 90.1 96.6 98.9 66.7 84.9 182 Middle 100.0 99.2 92.2 96.8 92.8 95.9 94.3 73.9 88.3 176 Fourth 100.0 99.6 97.3 98.0 95.6 93.8 97.3 85.5 94.9 178 Richest 98.9 97.1 97.1 96.4 96.7 96.5 98.2 94.9 95.3 151 Language Turkmen 99.4 98.5 98.2 96.9 96.0 95.4 96.2 74.7 89.2 728 Uzbek 98.8 96.4 65.6 96.4 68.0 96.1 95.2 89.2 90.1 88 Russian (100.0) (97.5) (97.5) (97.5) (97.5) (94.3) (100.0) (100.0) (86.3) 21 Other (100.0) (100.0) (100.0) (100.0) (100.0) (97.9) (100.0) (70.9) (100.0) 32 Total 99.4 98.3 95.0 97.0 93.3 95.6 96.3 76.7 89.6 869 * MICS indicator 44 80 Table RH.5: Assistance during delivery Percent distribution of women aged 15-49 with a birth in two years preceding the Survey, by type of personnel assisting at delivery, Turkmenistan, 2006 Person assisting at delivery No attendant Total Any skilled personnel * Delivered in health facility** Number of women who gave birth in preceding two years Medical doctor Nurse/ midwife Traditional birth attendant Other Region Ashgabat city 87.3 12.7 0.0 0.0 0.0 100.0 100.0 99.1 72 Ahal 88.9 11.1 0.0 0.0 0.0 100.0 100.0 100.0 108 Balkan 68.9 28.6 0.0 0.8 1.6 100.0 97.5 91.3 71 Dashoguz 93.8 6.2 0.0 0.0 0.0 100.0 100.0 95.7 172 Lebap 82.2 17.3 0.6 0.0 0.0 100.0 99.4 98.2 229 Mary 95.1 4.3 0.6 0.0 0.0 100.0 99.4 99.4 218 Residence Urban 85.3 14.7 0.0 0.0 0.0 100.0 100.0 98.7 327 Rural 89.5 9.7 0.5 0.1 0.2 100.0 99.2 97.2 543 Age 15-19 (86.5) (13.5) (0.0) (0.0) (0.0) 100.0 (100.0) (100.0) 29 20-24 88.5 11.5 0.0 0.0 0.0 100.0 100.0 99.6 281 25-29 89.1 9.8 0.9 0.0 0.2 100.0 98.9 96.6 302 30-34 86.3 13.3 0.0 0.0 0.4 100.0 99.6 95.7 161 35-39 83.7 15.5 0.0 0.8 0.0 100.0 99.2 98.4 73 40-44 (90.2) (9.8) (0.0) (0.0) (0.0) 100.0 (100.0) (100.0) 23 45-49 (*) (*) (*) (*) (*) 100.0 (*) (*) 1 Education None/primary/secondary 87.5 11.9 0.4 0.1 0.2 100.0 99.4 97.4 745 Secondary vocational/professional (special) 87.7 12.3 0.0 0.0 0.0 100.0 100.0 100.0 86 Higher (95.9) (4.1) (0.0) (0.0) (0.0) 100.0 (100.0) (100.0) 38 Wealth index quintiles Poorest 86.7 12.3 0.0 0.3 0.6 100.0 99.0 97.0 183 Second 90.3 8.3 1.4 0.0 0.0 100.0 98.6 97.6 182 Middle 87.4 12.6 0.0 0.0 0.0 100.0 100.0 95.8 176 Fourth 86.6 13.4 0.0 0.0 0.0 100.0 100.0 98.7 178 Richest 88.5 11.5 0.0 0.0 0.0 100.0 100.0 100.0 151 Language Turkmen 87.4 12.2 0.2 0.1 0.2 100.0 99.6 98.0 728 Uzbek 93.9 6.1 0.0 0.0 0.0 100.0 100.0 96.0 88 Russian (88.4) (11.6) (0.0) (0.0) (0.0) 100.0 (100.0) (100.0) 21 Other (82.0) (14.0) (4.0) (0.0) (0.0) 100.0 (96.0) (96.0) 32 Total 87.9 11.6 0.3 0.1 0.1 100.0 99.5 97.8 869 * MICS indicator 4; MDG indicator 17 ** MICS indicator 5 81 Table CD.1: Family support for learning Percentage of children aged 0-59 months for whom household members are engaged in activities that promote learning and school readiness, Turkmenistan, 2006 Percentage of children aged 0-59 months For whom household members engaged in four or more activities that promote learning and school readiness* Mean number of activities household members engage in with the child For whom the father engaged in one or more activities that promote learning and school readiness** Mean number of activities the father engaged in with the child Living in a household without their natural father Number of children aged 0-59 months Sex Male 80.7 4.6 62.8 1.2 5.6 1050 Female 78.3 4.5 60.0 1.1 7.0 1025 Region Ashgabat city 87.6 5.1 62.2 1.2 16.5 178 Ahal 82.0 4.7 75.9 1.5 3.5 281 Balkan 82.3 4.6 63.5 1.3 10.4 158 Dashoguz 87.3 4.8 71.2 1.4 4.1 407 Lebap 79.9 4.5 54.8 1.1 7.0 517 Mary 68.3 4.2 51.9 0.8 4.1 534 Residence Urban 79.1 4.6 60.0 1.2 12.8 718 Rural 79.7 4.5 62.1 1.1 2.8 1357 Age 0-23 months 63.1 3.8 55.2 1.0 5.3 864 24-59 months 91.2 5.1 65.8 1.3 7.0 1211 Mother’s education None/primary/ secondary 78.8 4.5 61.0 1.1 4.9 1753 Secondary vocational/ professional (special) 81.4 4.8 63.1 1.4 12.7 232 Higher 89.1 5.2 65.3 1.4 16.0 90 Father’s education None/primary/ secondary 78.4 4.5 64.2 1.2 na 1453 Secondary vocational/ professional (special) 78.1 4.7 65.9 1.3 na 269 Higher 82.8 4.9 73.6 1.5 na 223 Father not in HH 88.6 5.0 na na na 130 Wealth index quintiles Poorest 81.1 4.5 62.5 1.1 3.3 485 Second 76.7 4.5 59.5 1.1 4.4 414 Middle 78.8 4.5 63.7 1.1 2.7 435 Fourth 76.6 4.5 63.3 1.3 5.4 389 Richest 84.6 4.9 57.2 1.2 18.1 351 Language Turkmen 77.7 4.5 60.6 1.1 5.0 1759 Uzbek 92.4 4.8 76.1 1.4 5.3 193 Russian 89.2 5.3 38.4 1.1 47.4 54 Other 81.4 4.4 59.4 1.1 10.1 69 Total 79.5 4.6 61.4 1.2 6.3 2075 * MICS indicator 46 ** MICS indicator 47 82 Table CD.2: Learning materials Percentage of children aged 0-59 months living in households containing learning materials, Turkmenistan, 2006 Children living in households with: Child has: Child plays with: Number of children aged 0–59 months 3 or more non- child- ren’s books* Median number of non- child- ren’s books 3 or more child- ren’s books** Media n numb er of child- ren’s books House- hold objects Objects and materials found outside the home Home made toys Toys that came from a store No play- things mentioned Three or more types of play- things*** Sex Male 59.6 5 39.8 2 16.5 41.2 39.4 91.7 3.6 24.3 1050 Female 57.2 5 44.1 2 22.5 32.3 38.5 91.9 3.6 23.1 1025 Region Ashgabat city 90.5 10 79.0 10 27.2 22.5 24.1 91.9 2.3 15.4 178 Ahal 77.2 7 66.4 4 33.1 44.5 54.8 95.6 1.2 39.1 281 Balkan 40.0 0 27.2 0 41.3 44.8 39.4 86.2 5.5

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