Turkmenistan - Multiple Indicator Cluster Survey - 2016

Publication date: 2016

Turkmenistan Multiple Indicator Cluster Survey 2015-2016 Final Report January, 2017 The 2015-2016 Turkmenistan Multiple Indicator Cluster Survey (MICS) was carried out in 2015-2016 by the State Committee of Statistics of Turkmenistan, as part of the global MICS programme. Technical support was provided by the United Nations Children’s Fund (UNICEF). Financial costs of the survey were covered by the Government of Turkmenistan and UNICEF with additional support of the United Nations Population Fund (UNFPA). The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Also, MICS data can be used as a baseline to monitor progress towards the Sustainable Development Goals (SDGs). The State Committee of Statistics of Turkmenistan and UNICEF. 2016. 2015-2016 Turkmenistan Multiple Indicator Cluster Survey, Final Report. Ashgabat, Turkmenistan: The State Committee of Statistics of Turkmenistan and UNICEF. This material may be reprinted, quoted or otherwise reproduced, providing that the source is properly acknowledged. State Committee of Statistics of Turkmenistan 72 Magtumguly Street Ashgabat city, Turkmenistan, 744000 Tel.: (+993 12) 942465 Fax: (+993 12) 942608 Internet: www.stat.gov.tm United Nations Children’s Fund (UNICEF) in Turkmenistan UN House, 40 Galkynysh Street Ashgabat city, Turkmenistan, 744013 Tel.: (+996 12) 425681/82/85/86 Fax: (+996 12) 420830 Internet: www.unicef.org P a g e | iii Summary Table of Survey Implementation and the Survey Population, Turkmenistan, 2015-2016 Survey implementation Sample frame Updated Population census 2012 June – July 2015 Questionnaires Household Women (age 15-49) Children under five Form for Immunization Records at Health Facility Interviewer training August – September 2015 Fieldwork September 2015 – January 2016 Survey sample Households Sampled Occupied Interviewed Response rate (percent) 6,101 5,974 5,861 98.1 Children under five Eligible Mothers/caretakers interviewed Response rate (percent) 3,785 3,765 99.5 Women Eligible for interviews Interviewed Response rate (percent) 7,693 7,618 99.0 Survey population Average household size 5.1 Percentage of population living in Urban areas Rural areas Ashgabat city Ahal velayat Balkan velayat Dashoguz velayat Lebap velayat Mary velayat 39.1 60.9 12.1 13.3 6.7 23.6 19.4 24.8 Percentage of population under: Age 5 Age 18 13.3 36.4 Percentage of women age 15-49 years with at least one live birth in the last 2 years 19.4 Housing characteristics Household or personal assets Percentage of households with Electricity Finished floor Finished roofing Finished walls 100.0 97.1 99.0 99.8 Percentage of households that own Any type of television A refrigerator Farm animals/livestock Percentage of households that have agricultural land 99.7 99.4 55.3 59.7 Mean number of persons per room used for sleeping 1.96 Percentage of households where at least a member has or owns a Mobile phone Passenger car 98.6 54.5 P a g e | iv Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Turkmenistan, 2015-2016 CHILD MORTALITY Early childhood mortalitya, b MICS Indicator Indicator Description Value 1.1 Neonatal mortality rate Probability of dying within the first month of life 13 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 21 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 8 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 6 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 27 a Rates refer to the 5-year period preceding the survey. b See the discussion on quality of mortality data in the corresponding chapter. NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 3.2 0.7 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 11.5 2.7 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 4.2 1.1 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 5.9 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 98.5 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 73.4 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 58.9 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 81.4 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 64.1 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 19.5 1 See Appendix E for a detailed description of MICS indicators P a g e | v 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 16.1 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 56.9 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 82.3 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 91.0 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day 92.5 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 85.2 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 73.3 82.9 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 21.8 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodide or iodate 96.7 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 3.3 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 99.3 CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 99.9 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 97.9 3.3 Diphtheria, pertussis and tetanus (DPT) immunization coverage Percentage of children age 12-23 months who received the third dose of DPT vaccine (DPT3) by their first birthday 98.0 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 24-35 months who received measles vaccine by their second birthday 99.3 3.5 Hepatitis B immunization coverage Percentage of children age 12-23 months who received the third dose2 of Hepatitis B vaccine (HepB32) by their first birthday 98.0 3.6 Haemophilus influenzae type B (Hib) immunization coverage Percentage of children age 12-23 months who received the third dose of Hib vaccine (Hib3) by their first birthday 98.0 3.8 Full immunization coverage Percentage of children age 24-35 months who received all3 vaccinations recommended in the national immunization schedule by their first birthday (measles by second birthday) 95.3 2 Corresponds to HepB4 according to the national calendar as the birth dose is labeled as HepB1 in Turkmenistan. 3 Full vaccination includes the following: one dose of BCG, four doses of the Polio and HepB vaccines (the birth dose and doses 1-3), three doses of the DPT and Hib vaccines by 12 months of age, and one dose of the measles vaccine (administered as MMR) by 24 months of age. P a g e | vi Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 1.9 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 51.4 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 6.6 3.S14 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding5 Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet or increased fluids) and continued feeding during the episode of diarrhoea 39.4 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 0.4 3.13 Care-seeking for children with ARI symptoms6 Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider (*) 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics (*) (*) Figures that are based on fewer than 25 unweighted cases. Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 0.0 Fever MICS Indicator Indicator Description Value - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 5.6 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 59.3 WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 82.8 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 69.2 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 98.6 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 60.5 4 The indicator numbering system #.S# denotes a survey specific indicator calculated by the introduction of a non–standard module or question(s) to this survey that is not part of the global MICS5 Questionnaires or by applying a non-standard calculation method that is not included in the global MICS5 Tabulation Plan. 5 This is comparable to MICS Indicator 3.12 “Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding” with the exception that recommended homemade fluids are not included as part of the institutional approach in Turkmenistan. 6 The indicators 3.13 and 3.14 are not presented in a table in the reporte because of low number of unweighted cases. P a g e | vii WATER AND SANITATION MICS Indicator Indicator Description Value 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap are present 99.4 4.6 Availability of soap7 Percentage of households with soap 99.9 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women age 15-49 years 3.2 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 28 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 1.4 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 50.2 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 12.1 Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 99.9 96.4 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 99.4 5.S1 Content of antenatal care (includes ultrasound) Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured, gave urine and blood samples and had an ultrasound during the last pregnancy that led to a live birth 97.9 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 100.0 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 99.5 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 6.3 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 99.8 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 99.8 7 The indicator name has been changed from the standard “MICS indicator 4.6 - Availability of soap or other cleansing agent” since other cleansing agents such as ash, mud or sand are not applicable for Turkmenistan. P a g e | viii 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 99.8 CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 42.8 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 94.4 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 14.8 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 80.6 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 48.0 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 53.0 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 0.8 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning 90.9 LITERACY AND EDUCATION8, A MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young women Percentage of young women age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 99.6 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 44.1 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school9 94.2 7.4 MDG 2.1 Primary schoolB net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 98.1 7.5 Secondary schoolC net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 98.4 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 100.0 8 Education indicators, wherever applicable, are based on information on reported school attendance (at any time during the school year), as a proxy for enrolment. 9 In accordance with the Law on Education of Turkmenistan from 4th May 2013, starting from the 2013/2014 school year school-entry age is 6 years (previously 7 years). When calculating this indicator the age of the child was calculated on the basis of the year of birth (without months) in order to reflect timely admission of children to school, in accordance with Article 21, Paragraph 3 of the Law. P a g e | ix 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 102.8 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 99.8 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 0.99 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.00 A Data collected during the 2015/2016 school year. B Primary school consists of grades 1-3. C Secondary school consists of grades 4-11. CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 99.6 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 0.3 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month10 36.6 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of women age 15-49 years who were first married or in union before age 15 0.2 8.5 Marriage before age 18 Percentage of women age 20-49 years who were first married or in union before age 18 5.9 8.6 Young women age 15-19 years currently married or in union Percentage of young women age 15-19 years who are married or in union 6.0 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 3.3 2.7 10 See the notes on the quality of child disciplining data in the corresponding chapter. P a g e | x Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of women age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 26.3 8.S1 Attitudes towards domestic violence (including additional circumstance) Percentage of women age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food, (6) she does not respect her husband’s parents 35.0 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 1.2 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 3.5 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 0.9 HIV/AIDS HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of women age 15-49 years who have heard of AIDS 80.7 9.1 MDG 6.3 Knowledge about HIV prevention among young women Percentage of young women age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 25.4 9.2 Knowledge of mother-to- child transmission of HIV Percentage of women age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV 65.3 9.3 Accepting attitudes towards people living with HIV Percentage of women age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 1.0 HIV testing 9.4 Women who know where to be tested for HIV Percentage of women age 15-49 years who state knowledge of a place to be tested for HIV 64.1 9.5 Women who have been tested for HIV and know the results Percentage of women age 15-49 years who have been tested for HIV in the last 12 months and who know their results 10.3 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 74.6 9.8 HIV testing during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 55.6 P a g e | xi Orphans 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non- orphans11 Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents (*) (*) Figures that are based on fewer than 25 unweighted cases. ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 Exposure to mass media Percentage of women age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 20.7 Use of information/communication technology 10.2 Use of computers Percentage of young women age 15-24 years who used a computer during the last 12 months 57.5 10.3 Use of internet Percentage of young women age 15-24 years who used the internet during the last 12 months 39.3 11 This indicator is not presented in a table in the report because of the low number of unweighted cases. P a g e | xii Table of Contents Summary Table of Survey Implementation and the Survey Population, Turkmenistan, 2015-2016 . iii Summary Table of Findings . iv Table of Contents . xii List of Tables .xiv List of Figures . xviii List of Abbreviations . xix Acknowledgements .xx Executive Summary . xxii I. Introduction . 1 Background . 1 Survey Objectives . 2 How to read tables . 3 II. Sample and Survey Methodology . 4 Sample Design . 4 Questionnaires . 4 Training and Fieldwork . 6 Data Collection and Data Processing. 6 III. Sample Coverage and the Characteristics of Households and Respondents . 7 Sample Coverage . 7 Characteristics of Households . 9 Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under-5. 13 Housing characteristics, asset ownership, and wealth quintiles . 17 IV. Child Mortality . 21 V. Nutrition . 29 Low Birth Weight . 29 Nutritional Status . 31 Breastfeeding and Infant and Young Child Feeding . 35 Salt Iodization . 46 VI. Child Health . 48 Vaccinations . 48 Care of Illness . 55 VII. Water and Sanitation . 70 Use of Improved Water Sources . 70 Use of Improved Sanitation . 78 Handwashing . 85 VIII. Reproductive Health . 88 Fertility . 88 Contraception. 93 Unmet Need . 97 Antenatal Care . 100 Assistance at Delivery. 105 Place of Delivery . 107 Post-natal Health Checks. 109 P a g e | xiii IX. Early Childhood Development . 120 Early Childhood Care and Education . 120 Quality of Care . 122 Developmental Status of Children . 128 X. Literacy and Education . 131 Literacy among Young Women . 131 School Readiness . 132 Primary and Secondary School Participation . 133 XI. Child Protection . 144 Birth Registration . 144 Child Labour . 146 Child Discipline . 153 Early Marriage . 154 Attitudes toward Domestic Violence . 159 Children’s Living Arrangements . 161 XII. HIV/AIDS . 164 Knowledge about HIV Transmission and Misconceptions about HIV . 164 Accepting Attitudes toward People Living with HIV. 169 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 171 HIV Indicators for Young Women . 175 XIII. Access to Mass Media and Use of Information/Communication Technology. 178 Access to Mass Media . 178 Use of Information/Communication Technology. 180 Appendix A. Sample Design . 182 Sample Size and Sample Allocation . 182 Sampling Frame and Selection of Clusters . 184 Listing Activities . 184 Selection of Households . 185 Calculation of Sample Weights. 186 Appendix B. List of Personnel Involved in the Survey . 188 Appendix C. Estimates of Sampling Errors . 190 Appendix D. Data Quality Tables . 202 Appendix E. 2015-2016 Turkmenistan MICS5 Indicators: Numerators and Denominators . 215 Appendix F1. Household Questionnaire . 226 Appendix F2. Questionnaire for Individual Women . 243 Appendix F3. Questionnaire for Children Under Five . 269 Appendix F4. Questionnaire Form for Immunization Records at Health Facility . 288 Appendix G. Primary school entry (calculated by age until 1 September 2015) . 290 P a g e | xiv List of Tables Table HH.1: Results of household, women's and under-5 interviews . 8 Table HH.2: Age distribution of household population by sex . 9 Table HH.3: Household composition . 12 Table HH.4: Women's background characteristics . 14 Table HH.5: Under-5's background characteristics . 16 Table HH.6: Housing characteristics . 17 Table HH.7: Household and personal assets . 19 Table HH.8: Wealth quintiles . 20 Table CM.1: Early childhood mortality rates . 22 Table CM.2: Early childhood mortality rates by socioeconomic characteristics . 23 Table CM.3: Early childhood mortality rates by demographic characteristics . 24 Table NU.1: Low birth weight infants . 30 Table NU.2: Nutritional status of children . 33 Table NU.3: Initial breastfeeding . 37 Table NU.4: Breastfeeding . 39 Table NU.5: Duration of breastfeeding . 41 Table NU.6: Age-appropriate breastfeeding . 42 Table NU.7: Introduction of solid, semi-solid, or soft foods . 42 Table NU.8: Infant and young child feeding (IYCF) practices . 44 Table NU.9: Bottle feeding . 45 Table NU.10: Iodized salt consumption . 46 Table CH.1: Vaccinations in the first years of life . 50 Table CH.2: Vaccinations by background characteristics . 53 Table CH.2A: Coverage of the DPT-HepB-Hib combination vaccine . 54 Table CH.3: Reported disease episodes . 56 Table CH.4: Care-seeking during diarrhoea . 57 Table CH.5: Feeding practices during diarrhoea . 58 Table CH.6: Oral rehydration solutions and zinc . 59 Table CH.7: Oral rehydration therapy with continued feeding and other treatments . 60 Table CH.8: Source of ORS and zinc . 62 Table CH.9: Knowledge of the two danger signs of pneumonia . 64 Table CH.10: Care-seeking during fever . 66 Table CH.11: Treatment of children with fever . 67 P a g e | xv Table CH.12: Solid fuel use . 69 Table WS.1: Use of improved water sources . 71 Table WS.2: Household water treatment . 74 Table WS.3: Time to source of drinking water . 76 Table WS.4: Person collecting water . 77 Table WS.5: Types of sanitation facilities . 79 Table WS.6: Use and sharing of sanitation facilities . 80 Table WS.7: Drinking water and sanitation ladders . 82 Table WS.8: Disposal of child's faeces . 84 Table WS.9: Water and soap at place for handwashing . 86 Table WS.10: Availability of soap . 87 Table RH.1: Fertility rates . 88 Table RH.2: Adolescent birth rate and total fertility rate . 90 Table RH.3: Early childbearing . 91 Table RH.4: Trends in early childbearing . 92 Table RH.4A: Knowledge of specific contraceptive methods . 93 Table RH.4B: Knowledge of contraceptive methods . 94 Table RH.5: Use of contraception . 95 Table RH.6: Unmet need for contraception . 98 Table RH.7: Antenatal care coverage . 101 Table RH.8: Number of antenatal care visits and timing of first visit . 102 Table RH.9: Content of antenatal care. 104 Table RH.10: Assistance during delivery and caesarian section . 106 Table RH.11: Place of delivery . 108 Table RH.12: Post-partum stay in health facility. 110 Table RH.13: Post-natal health checks for newborns . 112 Table RH.14: Post-natal care visits for newborns within the first week following discharge from health facility. 114 Table RH.15: Post-natal health checks for mothers . 116 Table RH.16: Post-natal care visits for mothers within the first week following discharge from health facility . 118 Table RH.17: Post-natal health checks for mothers and newborns . 119 Table CD.1: Early childhood education . 121 Table CD.2: Support for learning. 123 Table CD.3: Learning materials . 125 Table CD.4: Inadequate care . 127 P a g e | xvi Table CD.5: Early child development index . 129 Table ED.1: Literacy . 131 Table ED.2: School readiness . 132 Table ED.3: Primary school entry . 134 Table ED.4: Primary school attendance and out of school children . 135 Table ED.5: Secondary school attendance and out of school children . 137 Table ED.6: Children reaching last grade of primary school . 138 Table ED.7: Primary school completion and transition to secondary school . 140 Table ED.8: Education gender parity . 141 Table ED.9: Out of school gender parity . 142 Table CP.1: Birth registration . 145 Table CP.2: Children's involvement in economic activities. 148 Table CP.3: Children's involvement in household chores . 150 Table CP.4: Child labour . 152 Table CP.5: Early marriage . 155 Table CP.6: Trends in early marriage . 156 Table CP.7: Spousal age difference . 158 Table CP.8: Attitudes toward domestic violence . 160 Table CP.9: Children's living arrangements and orphanhood . 162 Table CP.10: Children with parents living abroad . 163 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission . 165 Table HA.2: Knowledge of mother-to-child HIV transmission . 168 Table HA.3: Accepting attitudes toward people living with HIV . 170 Table HA.4: Knowledge of a place for HIV testing . 172 Table HA.5: HIV counselling and testing during antenatal care . 174 Table HA.6: Key HIV and AIDS indicators . 176 Table MT.1: Exposure to mass media . 179 Table MT.2: Use of computers and internet . 181 Table SD.1. The base information for sample size calculation and expected outputs for base sub-populations . 183 Table SD.2: The sample allocation of sample segments (clusters) and households by region/urban- rural strata . 184 Table SE.1: Indicators selected for sampling error calculations . 192 Table SE.2: Sampling errors: Total sample . 193 Table SE.3: Sampling errors: Urban . 194 Table SE.4: Sampling errors: Rural . 195 P a g e | xvii Table SE.5: Sampling errors: Ashgabat city . 196 Table SE.6: Sampling errors: Ahal velayat . 197 Table SE.7: Sampling errors: Balkan velayat . 198 Table SE.8: Sampling errors: Dashoguz velayat . 199 Table SE.9: Sampling errors: Lebap velayat . 200 Table SE.10: Sampling errors: Mary velayat . 201 Table DQ.1: Age distribution of household population . 202 Table DQ.2: Age distribution of eligible and interviewed women . 203 Table DQ.3: Age distribution of children in household and under-5 questionnaires . 204 Table DQ.4: Birth date reporting: Household population . 204 Table DQ.5: Birth date and age reporting: Women . 205 Table DQ.6: Birth date and age reporting: Under-5s . 205 Table DQ.7: Birth date reporting: Children, adolescents and young people . 205 Table DQ.8: Birth date reporting: First and last births . 206 Table DQ.9: Completeness of reporting . 206 Table DQ.10: Completeness of information for anthropometric indicators: Underweight . 206 Table DQ.11: Completeness of information for anthropometric indicators: Stunting . 207 Table DQ.12: Completeness of information for anthropometric indicators: Wasting . 207 Table DQ.13: Heaping in anthropometric measurements . 207 Table DQ.14: Observation of birth certificates . 208 Table DQ.15: Observation of vaccination cards at home and in health facility . 209 Table DQ.16: Observation of places for handwashing . 210 Table DQ.17: Respondent to the under-5 questionnaire . 210 Table DQ.18: School attendance by single age . 211 Table DQ.19: Sex ratio at birth among children ever born and living . 212 Table DQ.20: Births by periods preceding the survey . 212 Table DQ.21: Reporting of age at death in days . 213 Table DQ.22: Reporting of age at death in months . 214 Table ED.3A: Primary school entry . 290 P a g e | xviii List of Figures Figure HH.1: Age and sex distribution of household population . 10 Figure HH.2: Population distribution by age groups . 11 Figure CM.1: Early childhood mortality rates . 22 Figure CM.2: Under-5 mortality rates (for the 0-4 year period preceding the survey) by area and regions. 25 Figure CM.3: Trend in under-5 mortality rates according to different sources . 26 Figure CM.4: Ratios of infant to under-five mortality, neonatal to infant mortality and neonatal to under-five mortality . 27 Figure CM.5: Model life tables and 2015-2016 Turkmenistan MICS and 2000 Turkmenistan DHS estimates . 28 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe). 34 Figure NU.2: Initiation of breastfeeding . 38 Figure NU.3: Infant feeding patterns by age. 40 Figure NU.4: Consumption of iodized salt . 47 Figure CH.1: Vaccinations by age 12 months (measles by 24 months) . 52 Figure WS.1: Percent distribution of household members by source of drinking water . 72 Figure WS.2: Use of improved drinking water sources and improved sanitation facilities by household members . 83 Figure RH.1: Age-specific fertility rates by area . 89 Figure RH.2: Differentials in contraceptive use . 96 Figure ED.1: Education indicators by sex . 143 Figure CP.1: Early marriage among women . 157 Figure HA.1: Women with comprehensive knowledge of HIV transmission . 167 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . 171 Figure DQ.1: Household population by single ages . 203 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points . 208 P a g e | xix List of Abbreviations AIDS Acquired Immune Deficiency Syndrome ARI Acute Respiratory Infection ASFR Age-specific fertility rates BCG Bacillus Calmette-Guérin (Tuberculosis) CAPI Computer-Assisted Personal Interviewing CBR Crude birth rate CEECIS Central and Eastern Europe and the Commonwealth of Independent States CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DPT Diphteria Pertussis Tetanus DHS Demographic and Health Survey ECDI Early Child Development Index EPI Expanded Programme on Immunization GAPPD Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea GARPR Global AIDS Response Progress Reporting GFR General Fertility Rate GPI Gender Parity Index Hib Haemophilus influenzae type b HIV Human Immunodeficiency Virus HepB Hepatitis B IDD Iodine Deficiency Disorders ILO International Labour Organisation IMCI Integrated Management of Childhood Illness IMR Infant Mortality Rate IUD Intrauterine Device IYCF Infant and Young Child Feeding JMP WHO / UNICEF Joint Monitoring Programme LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MMR Measles, Mumps, and Rubella antigens NN Neonatal Mortality NMR Neonatal Mortality Rate OPV Oral polio vaccine ORS Oral Rehydration Salts ORT Oral Rehydration Treatment ppm Parts Per Million PNC Post-natal Care PNHC Post-natal Health Checks PNN Post-neonatal Mortality PPS Probability proportional to size PSU Primary Sampling Units RHF Recommended home fluid SDG Sustainable Development Goals SPSS Statistical Package for Social Sciences TFR Total Fertility Rate Turkmenstat State Committee of Statistics of Turkmenistan UN United Nations 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 U5MR Under-5 Mortality Rate WHO World Health Organization P a g e | xx Acknowledgements In 2016, Turkmenistan will be celebrating the 25-th anniversary of its independence. Our country, where it is declared at the constitutional level, that the person is the main value of the society, is one of the fastest growing, prosperous and peaceful nations of the world. That can be seen through the rapid pace of reforms, followed by large-scale international cooperation, and one of the clearest indicators is a close and constructive partnership with the United Nations. Based on the decision of the Government of Turkmenistan and with the support of UNICEF and UNFPA, the Multi Indicator Cluster Survey (MICS) was conducted in 2015-2016 which covered more than 6,000 households. This Survey was conducted with the purpose of monitoring the situation of women and children and measuring key indicators, which allow to trace progress in achieving UN Millennium Development Goals and other international commitments. Turkmenistan is the first country in the CIS and Eastern European region to have held the 5-th round of the MICS on tablets (CAPI). The State Committee of Statistics of Turkmenistan expresses profound gratitude to the Government of Turkmenistan (Cabinet of Ministers of Turkmenistan, Ministry of Foreign Affairs of Turkmenistan), to representatives of national and local administrative bodies for assistance provided in conducting the Survey. We express our profound gratitude to the Representative in the UNICEF Country Office in Turkmenistan – Ms. Shaheen Nilofer and Ms. Oyunsaihan Dendevnorov, ex- Representative of UNICEF Country Office in Turkmenistan; to the Deputy Representative in the UNICEF Country Office in Turkmenistan Ms. Alyona Salchonak, to UNICEF specialists Mr. Shohrat Orazov and Ms. Dilyara Ayazova for efficient resolution of evolving challenges and assistance in organizing and conducting the Survey. A great contribution to the work was made by the UNICEF international consultant Ms. Tatjana Karaulac who has consulted the project from the beginning to its completion. Contribution in the organisation of the training and during the fieldwork was also made by the national consultant Mr. Hoshgeldy Halnazarov. We express profound gratitude to Mr. Atilla Hancioglu (UNICEF, New-York), the MICS Global Coordinator and in his name to dozens of UNICEF staff members all around the world who had held a number of training workshops, developed standard questionnaires and programs for data entry and data procesing and who provided general management for this global Survey programme, in particular, to Mr. Siraj Mahmudlu (UNICEF, Geneva), MICS Regional Coordinator at the UNICEF Regional Office who provided maximum assistance to the State Committee of Statistics (Turkmenstat) employees in preparing and conducting this Survey in Turkmenistan. Special gratitude shall be accorded to Ivana Bjelic – Statistics Specialist (data processing), UNICEF, New-York; Turgay Unalan, Statistics Specialist (Household Surveys), UNICEF New York; Yadigar Coskun, Statistics and Monitoring Specialist, UNICEF New York; Ana Abdelbasit – Regional Household Survey Consultant (UNICEF, Geneva); to Ikhtier Kholmatov – Regional Data Processing Consultant (UNICEF, Geneva) for assistance in preparing and conducting this computer assisted Survey (CAPI). Methodological assistance in sampling for MICS from Mr. Ahmet Sinan Turkyilmaz, Regional Sampling Consultant, deserves a special mention. We extend our thanks to UNFPA for providing co-financing during MICS fieldwork. P a g e | xxi Employees of the Ministry of Health and Medical Industry of Turkmenistan played an important role in conducting the Survey. We extend my thanks to them as well. We express profound gratitude to all heads of velayats/city Departments of Statistics, to supervisors, interviewers and those individuals who were doing measurements of children. In conclusion we thank all persons involved in this Survey, who directly or indirectly rendered assistance in conducting this work: residents of Turkmenistan (household members), who kindly agreed to provide information in the questionnaires on the basis of confidentiality. This information will be useful for administrative bodies in making decisions aimed at further improving the situation of women and children of the country in the long term. P a g e | xxii Executive Summary This Final Report is based on the findings of the 2015-2016 Turkmenistan Multiple Indicator Cluster Survey (MICS), conducted between September 2015 and January 2016 by the State Committee of Statistics of Turkmenistan. Financial support was provided by the Government of Turkmenistan and United Nations Children’s Fund (UNICEF), with additional support of the United Nations Population Fund (UNFPA). Technical support was provided by UNICEF. The 2015-2016 Turkmenistan MICS is a nationally representative survey of 6,101 households, of which 5,974 were found to be occupied. Of these, 5,861 were successfully interviewed for a household response rate of 98 percent. In the interviewed households 7,693 women (age 15-49 years) were identified and 3,785 children under age five. Individual questionnaires were completed for 7,618 women and for 3,765 children. The sample allows for the estimation of some key indicators at the national level, for urban and rural areas, and for 6 regions (Ashgabat city and 5 velayats). The 2015-2016 Turkmenistan MICS is expected to contribute to the evidence base of several important policies and strategies as well as to form part of the baseline data for the post-2015 era, in particular for monitoring progress towards the Sustainable Development Goals (SDGs). Low Birth Weight Overall, 99 percent of babies were weighed at birth and approximately 3 percent of infants are estimated to weigh less than 2,500 grams at birth. Nutritional Status In Turkmenistan, 3 percent of children under the age of five are underweight and 1 percent are classified as severely underweight. 12 percent of children are stunted or too short for their age and 4 percent are wasted or too thin for their height. 6 percent of children are overweight or too heavy for their height. Breastfeeding and Infant and Young Child Feeding In Turkmenistan, 73 percent of babies are breastfed for the first time within one hour of birth, while 94 percent of newborns start breastfeeding within one day of birth. Approximately 59 percent of children age less than six months are exclusively breastfed and 81 percent predominantly breastfed. 93 percent of the children age 6-23 months receive solid, semi-solid and soft foods the minimum number of times and 85 percent of children receive the minimum dietary diversity, or foods from at least 4 food groups. Almost all older (18-23 month old) children (98 percent) achieve the minimum dietary diversity compared to younger (6-8 month old) children (44 percent). The overall assessment using the indicator of minimum acceptable diet revealed that 77 percent of children age 6-23 monhs benefit from a diet sufficient in both diversity and frequency. Salt Iodization In almost all interviewed 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. It was found that P a g e | xxiii 97 percent of household consume sufficiently iodized salt, i.e. salt which was found to contain 15 parts per million (ppm) or more of iodine. Vaccinations The vaccination coverage estimates are predominantly based on vaccination records from health facilities, and to a smaller degree on vaccination cards/passports kept at home and the mother’s report of vaccinations received by the child. Since in Turkmenistan all children should receive vaccines for free, there is very high level of coverage regardless of household wealth. The percentage of children age 24-35 monthswho had all the recommended vaccinations by their first birthday (MMR by their second birthday) is 95 percent. Care of Illness Overall, 2 percent of children under five were reported to have had diarrhoea in the two weeks preceding the survey, less than 1 percent symptoms of ARI, and 6 percent an episode of fever. Overall, 67 percent of children with diarrhoea received ORS (oral rehydration salts) or increased fluids. 39 percent of children received recommended treatment (ORT with continued feeding) . Only 2 percent of children did not receive any treatment or drug. Less than half of mother/caretakers (47 percent) know at least one of the two danger signs of pneumonia – fast and/or difficult breathing. Water and Sanitation Overall, 83 percent of the population uses an improved source of drinking water – 98 percent in urban areas and 73 percent in rural areas. More than half of the population (54 percent) uses piped water, 21 percent use source drinking water from a tube-well/bore-hole and 16 percent from a tanker truck (an unimproved source). The entire population of Turkmenistan use improved sanitation. In rural areas, the population primarily uses ventilated improved pit latrines (68 percent), or pit latrines with slab (28 percent). In contrast, the most common facilities in urban areas are flush toilets/pour flush toilets (59 percent). Fertility The total fertility rate for the three years preceding the 2015-2016 Turkmenistan MICS, is 3.2 births per woman, this number is slightly higher in rural areas (3.3 births per woman) than in urban areas (3.0 births per woman). The age-specific fertility rate for women age 15-19 years is 28 births per 1,000 women. Contraception and Unmet Need Almost all currently married/in-union women have heard of a method of contraception and the mean number of methods known by women is 6 (of 14 methods). While the majority are familiar with the most common traditional and modern methods of contraception, there are modern methods they are less familiar with (12 percent for diaphragm, 12 percent for implants, 16 percent for female condom and 20 percent for emergency contraception). P a g e | xxiv Current use of contraception was reported by half of all (50 percent) women currently married or in union. 12 percent of women age 15-49 years currently married or in union, have an unmet need for contraception. Antenatal Care, Assistance at Delivery and Post-natal Health Checks In Turkmenistan, practically all women receive antenatal care (100 percent). The majority of antenatal care is provided by medical doctors (99 percent). All births (100 percent) occurring in the two years preceding the MICS survey were delivered by skilled personnel, which tells about universal access to skilled care during the birth in Turkmenistan. Doctors assisted with the delivery of 99 percent of births and nurses or midwives assisted with 1 percent. All mothers (100%) receved health checks following birth while in the medical facility or at home. Almost all newborns in Turkmenistan receive a health check following birth while in a facility or at home, as well as a health check following discharge. Early Childhood Care and Education In Turkmenistan, 43 percent of children age 36-59 months are attending an organised early childhood education programme. This figure is 70 percent in urban areas, compared to 29 percent in rural areas. With the majority (94 percent) of children age 36-59 months, an adult household member engaged in four or more activities that promote learning and school readiness during the 3 days preceding the survey. The mean number of activities that adults engaged with children was 5.6. Almost half of children (48 percent) age 0-59 months live in households where at least 3 children’s books are present for the child. In Turkmenistan, 91 percent of children age 36-59 months are developmentally on track. School Readiness Overall, 44 percent of children who are currently attending the first grade of primary school were attending pre-school the previous year. Almost 74 percent of the children in first grade in urban areas had attended pre-school the previous year compared to 26 percent of children living in rural areas. Primary and Secondary School Participation Of children who are of primary school entry age (age 6) in Turkmenistan, 94 percent are attending the first grade of primary school. The percentage of children of primary school age that are attending school is very high (98 percent). In Turkmenistan, of all children starting grade one, all will eventually reach grade 3. The percentage of children of secondary school age (10-17 years) attending secondary school or higher is more than 98 percent. Gender parity for primary school is 0.99 and 1.00 for secondary school. P a g e | xxv Birth Registration The births of almost all children under five years in Turkmenistan have been registered, indicating equal chances for birth registration. Child Labour In Turkmenistan, among children age 5-11 years less than 1 percent are involved in an economic activity for at least one hour. Among children age 12-14 years, 4 percent are involved in an economic activity for less than 14 hours, while less than 1 percent are involved for 14 hours or more. 7 percent of children age 15-17 years are involved in an economic activity for less than 43 hours while there are no children involved in economic activity for 43 hours or more. Involvement of children in household chores, for all age groups, is below the age-specific threshold that classifies it as child labour. The overall percentage of children age 5-17 years involved in child labour is less than 1 percent. Early Marriage In Turkmenistan, the percentage of women age 15-49 years who were married/in union before age 15 is less than 1 percent. 6 percent of women age 20-49 years were married/in union before age 18. Attitudes toward Domestic Violence Overall, 26 percent of women age 15-49 years in Turkmenistan feel that a husband is justified in hitting or beating his wife in at least one of five situations. Women who justify a husband’s violence, in most cases agree and justify violence in instances when a wife neglects the children (20 percent), or argues with him (12 percent) or if she demonstrates her autonomy, exemplified by going out without telling her husband (8 percent). Around 3 percent of women believe that wife-beating is justified if the wife refuses to have sex with the husband and a similar percentage, if she burns the food. Children’s Living Arrangements In Turkmenistan, 89 percent of children age 0-17 years live with both their parents, 8 percent live with their mothers only and 2 percent live with their fathers only. 1 percent of children live with neither of their biological parents while both of them are alive. In Turkmenistan, only 1 percent of children age 0-17 have one or both parents living abroad. HIV/AIDS In Turkmenistan, 81 percent of the women age 15-49 years have heard of AIDS. However, the percentage of women who know of both main ways of preventing HIV transmission – having only one faithful uninfected partner and using a condom every time – is only 56 percent. The prevalence of comprehensive knowledge of HIV prevention methods and transmission is 35 percent among women age 15-49 years and 25 percent among women age 15-24 years. The percentage of women age 15-49 years who know all three ways of mother-to-child transmission of HIV is 65 percent. 64 percent of women know where to be tested for HIV. P a g e | xxvi Access to Mass Media and Use of Information/Communication Technology 41 percent of women in Turkmenistan read a newspaper or magazine, 32 percent listen to the radio, and 99 percent watch television at least once a week. Overall, less than 1 percent do not have regular exposure to any of the three media, while almost 100 percent are exposed to at least one and 21 to all the three types of media on a weekly basis. The survey showed, 86 percent of 15-24 year old women ever used a computer, 58 percent used a computer during the last year and 45 percent used at least once a week during the last month. Overall, 47 percent of women age 15-24 ever used the internet, while 39 percent used during the last year. P a g e | 1 I. Introduction Background This report is based on the 2015-2016 Turkmenistan Multiple Indicator Cluster Survey (MICS), conducted in 2015-2016 by the State Committee of Statistics of Turkmenistan, as part of the global MICS programme and with technical support of the United Nations Children’s Fund (UNICEF). Financial costs of the survey were covered by the Government of Turkmenistan and UNICEF with additional support of the United Nations Population Fund (UNFPA). The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the 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 of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” The 2015-2016 Turkmenistan MICS results are expected to form part of the baseline data for the post-2015 era, in particular for monitoring progress towards the Sustainable Development Goals (SDGs). P a g e | 2 Improving the standard of living of the population has been a priority of the public policy during the entire period of country independence. Social orientation of economic reforms in the country especially intensified in recent years. The National Strategy of Economic, Political and Cultural Development of Turkmenistan for the Period until 2020 (endorsed in 2003), provided high dynamics of diversification of economy and socially oriented reforms. The National Program for the Socio-Economic Development of Turkmenistan for 2011-2030 was adopted in May 2010 and the medium-term Programme of the Socio-Economic Development of Turkmenistan for 2012-2016 was adopted in February 2012. These programmes among the main areas of the future socio-economic development of the country provides large investments in the development of a healthy and highly intellectual human capital. The Government of Turkmenistan in its policy of sustainable socio-economic development gives increasing importance to the issued faced by children and to the implementation of commitments included in related international documents. Long-term programmes and plans of actions for children designed to comprehensively address and resolve children’s issues are developed and being implemented. The system of legal protection of children’s interests is practically anew created and constantly improved with regard to the new socio-economic condition, taking into account national characteristics and traditions. In particular, the Law “On State Guarantees of Children’s Rights” (since May 2014), “On guarantees of the rights of young people at work” (2005), “On protection of the health of the citizens” (2002, new edition since 2005), Code of Turkmenistan “On social protection of the population” (2007), “On the protection and promotion of breastfeeding and requirements for children’s food” (2009), “On quality and safety of food products” (2009), “Health Code of Turkmenistan” (2009), “The Labour Code of Turkmenistan”, and others. The Convention on the Rights of the Child, the World Declaration and Plan of Action adopted at the World Summit for Children, as well as the MDGs were and remain one of the main benchmarks in the development of the social and economic policies of the Government of Turkmenistan. The 2015-2016 Turkmenistan MICS is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2015-2016 Turkmenistan MICS has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women in Turkmenistan;  To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention;  To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; http://www.apromiserenewed.org/ http://www.who.int/woman_child_accountability/en/ http://www.who.int/woman_child_accountability/en/ P a g e | 3  To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable;  To contribute to the generation of baseline data for the post-2015 agenda;  To validate data from other sources and the results of focused interventions. How to read tables The tables of this report present data collected through this survey in a standard way, intuitively easy to understand. However, the reader should be aware of the following remarks. Values in parenthesis indicate that the percentage or proportion is based on only 25–49 unweighted cases and should be treated with caution. An asterisk in tables indicates that the percentage or proportion has been suppressed because it is based on fewer than 25 unweighted cases while a dash denotes 0 unweighted cases. 0.0 indicates no cases of an occurance or an insignificant value. Age groups presented in this report also include those persons that had reached the full age indicated by the upper limit for an age group; for instance, respondents age 15–49 include persons who had fully reached 49 years of age. Similarly, the age group of children age 20–23 months includes those who had fully reached 23 months. The education category “None” is based on fewer than 25 unweighted cases and is therefore not shown in the tables. Also, in the tables and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. P a g e | 4 II. Sample and Survey Methodology Sample Design The sample for the 2015-2016 Turkmenistan Multiple Indicator Cluster Survey was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for 6 regions: Ahal, Balkan, Dashoguz, Lebap and Mary velayat and Ashgabat city. The urban and rural areas within each region were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size. In order to have a total target sample of 6,200 households, a sample of 310 enumeration areas was selected at the first sampling stage. After a household listing was carried out within the selected enumeration areas, a systematic sample of 20 households was drawn in each sample enumeration area. Five of the selected enumeration areas were not visited because they were inaccessible due to demolition of buildings during the fieldwork period, leading to a sample size of 6,100 households.12. The sample was stratified by region, urban and rural areas, and is not self-weighting. For reporting all survey results, sample weights are used. The sampling procedures take into account the administrative and territorial changes that occurred in 2013 in Ashgabat city and Ahal velayat. A more detailed description of the sample design can be found in Appendix A, Sample Design. Questionnaires Four sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; and 3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 living in the household, including a questionnaire form for immunization records at health facility for children under 3. The questionnaires included the following modules: The Household Questionnaire included the following modules:  List of Household Members  Education  Child Labour  Child Discipline  Household Characteristics  Water and Sanitation  Handwashing  Salt Iodization The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: 12 The final sample size was 6,101 households due to one additional household being found in a dwelling unit that was visited during fieldwork. P a g e | 5  Woman’s Background  Access to Mass Media and Use of Information/Communication Technology  Fertility/Birth History  Desire for Last Birth  Maternal and Newborn Health  Post-natal Health Checks  Illness Symptoms  Marriage/Union13  Contraception  Unmet Need  Attitudes Toward Domestic Violence  HIV/AIDS The Questionnaire for Children Under Five was administered to mothers (or caretakers) of children under 5 years of age14 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules:  Age  Birth Registration  Early Childhood Development  Breastfeeding and Dietary Intake  Immunization  Care of Illness  Anthropometry For all children age 0-2 years with a completed Questionnaire for Children Under Five an additional form, the Questionnaire Form For Immunization Records At Health Facility, was used to record vaccinations from the registers at health facilities. The questionnaires are based on the MICS5 model questionnaire15. From the MICS5 model English and Russian version, the questionnaires were customised and translated into the Turkmen language and were pre-tested. A pre-test of the paper version of questionnaires in Russian and Turkmen languages (first pre-test, 12 days) was conducted in Ahal velayat (rural area) and Ashgabat city in July 2015. 200 households were interviewed – 100 using the Turkmen language questionnaires and 100 using Russian language questionnaires. A second pre-test was conducted in August 2015 in 100 households using tablets with revised questionnaires. Based on the results of the pre-tests, modifications were made to the wording and translation of the questionnaires as well as in the application for tablets. A copy of the 2015-2016 Turkmenistan MICS questionnaires is provided in Appendices F1 to F4. 13 Part of the Marriage/Union module and the modules on Contraception and Unmet Need were administered only to those women who have ever been married/in union. 14 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. 15 The model MICS5 questionnaires can be found at http://mics.unicef.org/tools http://mics.unicef.org/tools P a g e | 6 In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for handwashing, and measured the weights and heights of children age under 5 years. Details and findings of these observations and measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 30 working days in the period August-September 2015. Training was divided into 2 phases. In the first phase (2 weeks), training was conducted using paper questionnaires and in the second phase using tablets. Training included lectures on interviewing techniques and the contents of the questionnaires, and conducting interviews between trainees to gain practice in asking questions, practical work on tablets, such as assigning households by supervisors, sending and receiving assigned households, data collection, error solving. Towards the end of the training period (September 2015), trainees spent two days in practice interviewing in Ashgabat city (urban area) and Ahal velayat (rural area) and one day on the anthropometric measurement in the preschool institutions in Ashgabat city. The data were collected by 6 teams; each was comprised of 4 interviewers (1 reserve), two drivers, one measurer and a supervisor. Fieldwork began in September 2015 and concluded in January 2016. Data Collection and Data Processing Data were entered using the CSPro software, Version 5.0. Data collection was carried out on tablets by 37 interviewers and 6 supervisors. Using a tablets facilitated many tasks related to control and management, including:  assigning households to the interviewers,  receiving collected data from the interviewers,  checking household questionnaires and individual questionnaires,  finalising the cluster,  preparing the data files to be sent to the Central Office. Procedures and standard programs developed under the global MICS programme and adapted to the 2015-2016 Turkmenistan MICS questionnaire were used throughout. Data processing began simultaneously with data collection in September 2015 and was completed in January 2016. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version 21. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. Regular monitoring of the data collection and other relevant processes was carried out by UNICEF staff, consultants (both national and international) as well as by management and staff of the State Committee of Statistics (Turkmenstat) responsible for implementation of the 2015-2016 Turkmenistan MICS. P a g e | 7 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 6,10016 households selected for the sample, one dwelling unit was found to be occupied by two households, leading to a total of 6,101 households in the final sample. Of the 6,101 households, 5,974 were found to be occupied. Of these, 5,861 were successfully interviewed for a household response rate of 98 percent. In the interviewed households 7,693 women (age 15-49 years) were identified. Of these, 7,618 were successfully interviewed, yielding a response rate of 99 percent within the interviewed households. There were 3,785 children under age five listed in the household questionnaires. Questionnaires were completed for 3,765 of these children, which corresponds to a response rate of almost 100 percent within interviewed households. Overall response rates of 97 and 98 percent are calculated for the individual interviews of women and under-5s, respectively (Table HH.1). 16 A total target sample of 6,200 households from 310 enumeration areas were selected. Five of the selected enumeration areas were not visited because they were inaccessible due to demolition of buildings during the fieldwork period, leading to a sample size of 6,100 households. P a g e | 8 Table HH.1: Results of household, women's and under-5 interviews Number of households, women, and children under 5 by interview results, and household, women's and under-5's response rates, Turkmenistan, 2015-2016 Total Area Region Urban Rural Ashgabat city Ahal velayat Balkan velayat Dashoguz velayat Lebap velayat Mary velayat Households Sampled 6101 3400 2701 1160 900 1240 880 961 960 Occupied 5974 3288 2686 1083 900 1229 877 946 939 Interviewed 5861 3183 2678 990 899 1224 873 940 935 Household response rate 98.1 96.8 99.7 91.4 99.9 99.6 99.5 99.4 99.6 Women Eligible 7693 3726 3967 1131 1403 1252 1306 1337 1264 Interviewed 7618 3668 3950 1086 1401 1251 1299 1317 1264 Women's response rate 99.0 98.4 99.6 96.0 99.9 99.9 99.5 98.5 100.0 Women's overall response rate 97.2 95.3 99.3 87.8 99.7 99.5 99.0 97.9 99.6 Children under 5 Eligible 3785 1652 2133 451 813 511 696 721 593 Mothers/caretakers interviewed 3765 1634 2131 433 813 511 696 719 593 Under-5's response rate 99.5 98.9 99.9 96.0 100.0 100.0 100.0 99.7 100.0 Under-5's overall response rate 97.6 95.8 99.6 87.8 99.9 99.6 99.5 99.1 99.6 P a g e | 9 Some small differences were observed in household response rates by region and area of residence. Overall, household response rate in urban areas (97 percent) was slightly lower than in rural areas (almost 100 percent) mainly due to the response rate in the capital - Ashgabat city, where the response rate was 91 percent. In the other five regions, household response rates were almost 100 percent. Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 5,861 households successfully interviewed in the survey, 29,871 household members were listed. Of these, 14,635 were males, and 15,237 were females. Table HH.2: Age distribution of household population by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Turkmenistan, 2015-2016 Total Males Females Number Percent Number Percent Number Percent Total 29871 100.0 14635 100.0 15237 100.0 Age 0-4 3979 13.3 2097 14.3 1882 12.4 5-9 3015 10.1 1531 10.5 1484 9.7 10-14 2347 7.9 1174 8.0 1173 7.7 15-19 2335 7.8 1079 7.4 1256 8.2 20-24 2861 9.6 1386 9.5 1475 9.7 25-29 2816 9.4 1394 9.5 1422 9.3 30-34 2370 7.9 1200 8.2 1170 7.7 35-39 1901 6.4 907 6.2 995 6.5 40-44 1763 5.9 883 6.0 879 5.8 45-49 1606 5.4 795 5.4 811 5.3 50-54 1599 5.4 734 5.0 865 5.7 55-59 1383 4.6 611 4.2 772 5.1 60-64 857 2.9 406 2.8 451 3.0 65-69 441 1.5 187 1.3 255 1.7 70-74 223 0.7 101 0.7 121 0.8 75-79 224 0.8 95 0.7 129 0.8 80-84 89 0.3 39 0.3 50 0.3 85+ 58 0.2 15 0.1 43 0.3 Missing/DK 2 0.0 1 0.0 2 0.0 Dependency age groups 0-14 9341 31.3 4802 32.8 4540 29.8 15-64 19492 65.3 9395 64.2 10097 66.3 65+ 1036 3.5 437 3.0 599 3.9 Missing/DK 2 0.0 1 0.0 2 0.0 Child and adult populations Children age 0-17 years 10865 36.4 5599 38.3 5266 34.6 Adults age 18+ years 19005 63.6 9035 61.7 9969 65.4 Missing/DK 2 0.0 1 0.0 2 0.0 P a g e | 10 The current shape of the age pyramid indicates extended type of reproduction of the population in a country with a high percentage of young population and a low percentage of the elderly. Age group 0-4 years is the largest age group in the population distribution by five-year age groups (13 percent). This is due to noticeable increase of the birth rate over the last few years most probably linked to the adoption of the Code of Turkmenistan “On social protection of the population” in 2007 – lump sum payment on the birth and monthly benefits for child care from birth until six months. The Law of Turkmenistan “On Amendments to the Code of Turkmenistan “On social protection of the Population”” (March 6, 2009) introduced increased child allowance (at birth and for child care) and payment period – from six months to three years. There is a disproportion in relation between males and females in the age group 15-19 years (Figure DQ.1 in Appendix D. Data Quality Tables). The percentage of males in this age group is lower due to the used definition for household members – males aged 18-19 years who are in the service of National Armed Forces were not included in household listing (not considered as household members, and service starts at age 18). This affected the overall ratio between the male and female population. The proportion of children age 0-17 years in total population is 36 percent. It is noted that there is a slight predominance of males in this age group which is associated with a higer proportion of male births. Figure HH.1: Age and sex d istr ibut ion of household populat ion , Tur kmenistan , 2015 – 2016 P a g e | 11 There are some differences when comparing data from the 2015-2016 Turkmenistan MICS and data from the 2012 Census of Population and Housing in Turkmenistan. According to MICS data the percentage of the population under the age of 15 years was 31 percent and 21 percent according to Census data (Figure HH.2). This is expected due to the progressive rise in the birth rate in the country in recent years. Percentage of population age 15-64 years is slightly different, 65 percent form survey data and 70 percent in the 2012 Census, and the lowest difference is for the age group 65+ years (3 percent and 4 percent, respectively). Figure HH.2: Populat ion distr ibut ion by age groups , Tur kmenistan Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49, and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provide background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.17 Table HH.3 provides basic background information on the households, including the sex of the household head, region, area, number of household members, education of household head, and language18 of the household head are shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. 17 See Appendix A: Sample Design, for more details on sample weights. 18 This was determined by asking: What is the mother tongue/native language of the head of this household? P a g e | 12 Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Turkmenistan, 2015-2016 Weighted percent Number of households Weighted Unweighted Total 100.0 5861 5861 Sex of household head Male 76.0 4457 4348 Female 24.0 1404 1513 Region Ashgabat city 15.1 883 990 Ahal velayat 11.5 674 899 Balkan velayat 8.5 497 1224 Dashoguz velayat 21.1 1236 873 Lebap velayat 18.4 1079 940 Mary velayat 25.4 1491 935 Area Urban 44.9 2634 3183 Rural 55.1 3227 2678 Number of household members 1 5.0 291 340 2 7.7 450 512 3 11.9 700 734 4 18.5 1086 1078 5 19.9 1165 1163 6 14.9 872 840 7 9.0 526 507 8 4.8 284 260 9 2.7 159 143 10+ 5.6 329 284 Education of household head None 0.1 3 3 Primary 0.6 33 28 Secondary 61.4 3598 3538 Primary vocational 7.2 422 386 Secondary vocational 15.2 889 936 Higher 15.6 915 970 Language of household head Turkmen 82.8 4853 4871 Uzbek 8.1 473 356 Russian 7.3 426 512 Other 1.9 110 122 Mean household size 5.1 5861 5861 The weighted and unweighted total number of households are equal, since sample weights were normalized. The table also shows the weighted mean household size estimated by the survey. The percentages of households in rural areas is higher (55 percent) that in urban areas (45 percent). There are differences in percentage distribution of households by regions - from 9 percent in Balkan P a g e | 13 velayat 25 to percent in Mary velayat. A largest proportion of household heads are male (76 percent). The distribution of households by number of household members shows that the highest percentages of households consisted of four and five persons (19 percent and 20 percent respectively) followed by households consisting of six persons (15 percent). In 83 percent of households, the Turkmen language is the mother tongue/native language of the household head. Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In all three tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. P a g e | 14 Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Turkmenistan, 2015- 2016 Weighted percent Number of women Weighted Unweighted Total 100.0 7618 7618 Region Ashgabat city 12.8 975 1086 Ahal velayat 13.2 1007 1401 Balkan velayat 6.3 482 1251 Dashoguz velayat 23.4 1779 1299 Lebap velayat 19.1 1455 1317 Mary velayat 25.2 1920 1264 Area Urban 39.5 3006 3668 Rural 60.5 4612 3950 Age 15-19 15.7 1197 1165 20-24 18.4 1400 1401 25-29 17.7 1351 1333 30-34 14.7 1117 1117 35-39 12.4 946 960 40-44 11.0 835 838 45-49 10.1 772 804 Marital/Union status Currently married/in union 64.2 4887 4861 Widowed 1.6 123 146 Divorced 4.1 312 319 Separated 0.7 56 62 Never married/in union 29.4 2240 2230 Motherhood and recent births Never gave birth 35.5 2708 2686 Ever gave birth 64.5 4910 4932 Gave birth in last two years 19.4 1476 1467 No birth in last two years 45.1 3435 3465 Education None 0.1 8 6 Primary 0.1 8 6 Secondary 79.9 6088 6030 Primary vocational 7.9 601 595 Secondary vocational 6.9 527 547 Higher 5.1 387 434 Wealth index quintile Poorest 20.0 1521 1139 Second 19.7 1502 1253 Middle 19.6 1495 1485 Fourth 19.6 1490 1738 Richest 21.1 1610 2003 Language of household head Turkmen 86.1 6563 6641 Uzbek 8.2 623 482 Russian 4.1 315 375 Other 1.5 117 120 P a g e | 15 Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to region, area, age, marital/union status, motherhood status, births in last two years, education19, wealth index quintiles20, 21, and language of the household head. 39 percent of interviewed women age 15-49 years live in urban areas and 61 percent in rural areas. Similar to the household distribution by regions, regional differences in the population of women age 15-49 years are notable – the highest percent of women is found in Mary and Dashoduz velayats (25 percent and 23 percent respectively) and the lowest in the Balkan velayat (6 percent). Half of all women age 15-49 years belong to the optimal age for giving birth – from 20 to 35 years. Around two-thirds of women (64 percent) are currently married/in union, 5 percent are divorced or separated, and 2 percent are widowed. 29 percent of women age 15-49 years never married. 60 percent of women this age have ever gave birth and of those, every fifth woman (19 percent) gave birth in the last two years. The majority of women age 15-49 years (80 percent) have secondary education, 8 percent have primary vocational, 7 percent have secondary vocational and 5 percent have higher education. 86 percent of women lives in the households where Turkmen language is the mother tongue/native language of the household head. 19 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 20 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In 2015-2016 Turkmenistan MICS, the following assets were used in these calculations: source of drinking water; location of water source; number of rooms used for sleeping; main material of dwelling roof and exterior walls; type of household fuel; presence in the household of radio, a television (not plasma and not monomorphic, and LCD), non-mobile phone, refrigerator, air conditioner, washing machine, vacuum cleaner, computer/notebook, video recorder or DVD, cassette player or CD player, sewing machine, factory carpet, handmade carpet (wool or silk), sofa, sideboard, embroidery machine; presence in the household of a watch, mobile phone, bicycle, motorcycle/scooter, passenger car, truck, tractor/combine harvester, tablet; possession of a bank account; ownership of livestock: cattle, mule, goats, sheep, chickens, other poultry, pigs, camels and rabbits; and water present at handwashing place in the dwelling. 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. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in 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, SO and Johnson, K. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6; and Rutstein, SO. 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. 21 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest population quintile”, which is used interchangeably with “women in the wealthiest survey population”, “women living in households in the richest population wealth quintile”, and similar. P a g e | 16 Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age in months, respondent type, mother’s (or caretaker’s) education, wealth, and language. Of the total number of children under 5 years, 53 percent are boys and 47 percent are girls. 65 percent of all children this age live in rural areas and 35 percent live in urban areas. The highest proportion of children under five is in Dashoguz and Mary velayats (25 percent and 23 percent respectively) and the lowest in Balkan velayat (5 percent). The distribution of children under 5 by single age is almost uniform. 87 percent of children have a mother with secondary education. Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Turkmenistan, 2015-2016 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 3765 3765 Sex Male 52.7 1984 1982 Female 47.3 1781 1783 Region Ashgabat city 10.2 385 433 Ahal velayat 15.3 576 813 Balkan velayat 5.2 195 511 Dashoguz velayat 25.2 950 696 Lebap velayat 20.7 780 719 Mary velayat 23.3 879 593 Area Urban 35.2 1324 1634 Rural 64.8 2441 2131 Age 0-5 months 9.1 343 342 6-11 months 10.1 380 382 12-23 months 20.7 778 787 24-35 months 19.8 746 736 36-47 months 20.1 758 760 48-59 months 20.2 760 758 Respondent to the under-5 questionnaire Mother 99.0 3725 3724 Other primary caretaker 1.0 40 41 Mother’s educationa None 0.0 1 1 Primary 0.2 8 6 Secondary 86.4 3252 3206 Primary vocational 6.7 251 265 Secondary vocational 3.4 128 144 Higher 3.3 124 143 Wealth index quintile Poorest 21.9 826 628 Second 21.2 799 686 Middle 21.1 793 784 Fourth 19.6 737 878 Richest 16.2 610 789 Language of household head Turkmen 87.4 3291 3360 Uzbek 8.8 333 259 Russian 2.0 74 87 Other 1.8 68 59 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. P a g e | 17 Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. All households in Turkmenistan have electricity (100 percent). The majority of households have a finished floor (97 percent). In Ashgabat city, Dashoguz and Mary velayats the percentage of households with a finished floor is 99 percent. The percentages are slightly lower in other regions: in Ahal and Balkan velayats at 96 percent and in Lebap velayat at 82 percent. Almost all households have finished exterior walls. The percentage of households with a finished roof is also very high (99 percent). The mean number of persons per room used for sleeping is 1.96. In rural areas this number is higher than in urban areas (2.06 and 1.84 respectively). Furthermore, there are some differences by region. The mean number of persons per room used for sleeping in Ahal velayat is 2.18 compared to 1.57 in Balkan velayat and 1.79 in Ashgabat city. In other regions, this number is somewhat similar (ranging from 1.96 to 2.06). Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Turkmenistan, 2015-2016 Total Area Region Urban Rural Ashgabat city Ahal velayat Balkan velayat Dashoguz velayat Lebap velayat Mary velayat Electricity Yes 100.0 99.9 100.0 99.9 100.0 100.0 100.0 99.9 100.0 No 0.0 0.1 0.0 0.1 0.0 0.0 0.0 0.1 0.0 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Flooring Rudimentary floor 1.7 1.4 1.9 0.6 0.2 3.6 0.9 4.5 1.0 Finished floor 97.1 98.1 96.3 99.3 95.9 96.4 99.1 92.0 98.8 Other 1.2 0.4 1.8 0.1 3.9 0.0 0.0 3.5 0.2 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Roof Rudimentary roofing 0.4 0.0 0.7 0.0 0.0 0.0 1.5 0.3 0.0 Finished roofing 99.0 99.7 98.4 100.0 100.0 99.9 98.5 96.2 100.0 Other 0.7 0.3 1.0 0.0 0.0 0.1 0.0 3.5 0.0 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Exterior walls Rudimentary walls 0.1 0.1 0.1 0.0 0.0 0.2 0.1 0.1 0.0 Finished walls 99.8 99.9 99.7 99.8 99.7 99.8 99.9 99.4 100.0 Other 0.2 0.1 0.2 0.2 0.3 0.0 0.0 0.4 0.0 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rooms used for sleeping 1 10.4 15.4 6.3 18.8 7.2 13.0 7.8 9.4 9.1 2 33.8 38.7 29.9 42.2 31.6 27.9 33.0 31.6 34.3 3 or more 55.7 45.8 63.7 39.0 61.2 59.0 59.3 58.7 56.7 Missing/DK 0.1 0.0 0.1 0.0 0.0 0.1 0.0 0.3 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 5861 2634 3227 883 674 497 1236 1079 1491 Mean number of persons per room used for sleeping 1.96 1.84 2.06 1.79 2.18 1.57 2.06 2.03 1.96 In Table HH.7 households are distributed according to ownership of assets by households and by individual household members. This also includes ownership of dwelling. P a g e | 18 Almost every household has a television (100 percent), factory carpet (100 percent) and refrigerator (99 percent). Possession of mobile phone by at least one household member is also very high (99 percent). Most households have a sideboard (84 percent), video recorder or DVD (79 percent), washing machine (75 percent), air conditioner and vacuum cleaner (each 74 percent), sewing machine (72 percent). Approximately every second household owns a passenger car (55 percent), a non-mobile phone (51 percent) and bicycle (48 percent). There are differences by area of residence and regions. The greatest difference by area of residence were found in the presence of a non-mobile phone (85 percent in urban and 22 percent in rural areas). In urban areas every second household has a computer/notebook (51 percent), as does one in three households in rural areas (35 percent). Availability of air conditioner, washing machine and vacuum cleaner is more characteristic for urban areas (from 87 to 90 percent), whereas the presence of these items in rural areas varies from 60 to 64 percent. Households in Dashoguz velayat compared with other regions are the least likely to have an air conditioner (35 percent), washing machine and vacuum cleaner (each 52 percent), whereas the availability of these items in Ashgabat city is very high (from 94 to 98 percent). A handmade carpet (wool or silk) was found in 44 percent of households. 60 percent of households have land that can be used for agriculture and 55 percent have farm animals/livestock. Use of agricultural land and presence of livestock is typical for households in rural areas (89 and 82 percent respectively) while those are around 23 percent each in urban areas. 83 percent of households inhabit a dwelling owned by a household member. P a g e | 19 Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Turkmenistan, 2015-2016 Total Area Region Urban Rural Ashgabat city Ahal velayat Balkan velayat Dashoguz velayat Lebap velayat Mary velayat Percentage of households that own a Radio 15.1 13.3 16.6 13.8 31.5 7.7 9.5 9.4 19.8 Any type of television 99.7 99.8 99.7 99.7 99.9 99.9 100.0 99.6 99.5 Television (not plasma and not mesomorphic) 72.4 56.3 85.5 35.0 74.9 53.5 86.1 78.3 84.2 Plasma or mesomorphic (LCD) television 57.7 69.8 47.8 81.3 72.4 71.7 49.9 43.4 49.1 Non-mobile telephone 50.5 85.0 22.3 93.5 52.6 92.3 28.1 53.7 26.3 Refrigerator 99.4 99.7 99.1 99.9 99.6 99.6 99.0 99.0 99.6 Air Conditioner 73.9 90.6 60.3 98.2 99.1 99.2 35.4 66.9 76.8 Washing machine 74.5 87.3 64.0 94.4 82.0 87.4 51.7 78.7 71.0 Vacuum cleaner 73.7 87.1 62.8 94.3 90.8 93.7 52.0 63.2 72.8 Computer / Notebook 41.2 50.6 33.5 53.7 33.6 46.4 37.1 49.8 32.8 Video recorder or DVD 78.9 80.3 77.8 81.9 93.4 76.8 74.1 71.2 80.7 Cassette player or CD player 30.8 28.5 32.6 26.0 37.6 23.3 23.5 31.2 38.8 Sewing machine 71.5 64.1 77.6 58.1 93.3 80.2 49.0 75.8 82.3 Factory carpet 99.6 99.6 99.7 99.4 99.5 99.6 100.0 99.6 99.6 Handmade carpet (wool or silk) 44.3 42.9 45.5 36.3 49.5 74.2 46.2 33.9 42.9 Sofa 59.3 69.2 51.2 66.1 68.0 62.5 51.3 66.0 51.9 Sideboard 83.9 86.2 82.0 85.1 94.8 95.0 86.7 71.6 81.2 Embroidery machine 13.3 11.5 14.9 13.7 28.1 17.1 6.8 8.0 14.5 Percentage of households that own Agricultural land 59.7 23.3 89.4 12.1 87.7 26.9 57.0 68.8 81.7 Farm animals/Livestock 55.3 22.8 81.8 8.8 78.6 38.7 60.7 64.6 66.6 Percentage of households where at least one member owns or has a Watch 51.8 61.0 44.4 67.8 56.8 70.8 56.5 35.9 41.5 Mobile telephone 98.6 98.1 99.0 97.5 99.7 96.3 99.3 99.0 98.6 Bicycle 47.5 34.7 57.9 27.5 52.8 26.2 38.7 63.2 59.8 Motorcycle or scooter 13.5 4.5 20.8 0.9 22.3 16.3 9.5 21.9 13.2 Passenger car 54.5 52.9 55.8 54.1 67.7 52.2 53.4 51.6 52.5 Truck 5.3 3.6 6.7 3.2 9.3 6.8 4.7 5.7 4.5 Tractor / Combine harvester 3.2 0.9 5.1 1.5 2.0 0.4 5.3 3.8 3.5 Tablet 9.8 15.3 5.3 22.0 20.2 12.5 3.5 6.0 5.1 Bank account 37.0 50.6 25.9 51.4 40.2 58.6 32.0 34.9 25.6 Ownership of dwelling Owned by a household member 82.8 67.7 95.2 63.7 86.0 70.9 88.7 82.9 91.8 Not owned 17.2 32.3 4.8 36.3 14.0 29.1 11.3 17.1 8.2 Rented 17.2 32.3 4.8 36.3 14.0 29.1 11.3 17.1 8.2 Rented from a private individual 1.8 3.5 0.4 4.5 0.8 3.3 0.7 2.1 0.7 Rented from the State or State Institution 15.4 28.7 4.5 31.7 13.1 25.9 10.6 14.8 7.5 Other 0.1 0.1 0.0 0.1 0.0 0.0 0.0 0.2 0.0 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 5861 2634 3227 883 674 497 1236 1079 1491 P a g e | 20 Table HH.8 shows how the household populations in areas and regions are distributed according to household wealth quintiles. It should be noted that the information provided in this table is not equivalent to information about the level of income of the population and is related to the availability of different items to the household members (described in tables HH.6 and HH.7). The distribution of population by Wealth index quintiles is extremely uneven depending on area of residence and region. Half of the household population in urban areas (51 percent) belongs to the fifth (richest) wealth index quintile while there are no such households in rural areas. Among the regions, the most favourable situation is in Ashgabat city and Balkan velayat where most of the household population (99 and 77 percent respectively) belong to the fourth and fifth quintiles. Distributions by region and area of residence are closely related – all households in Ashgabat city and 82 percent in Balkan velayat are found in urban areas (data calculated separately, not presented in Tables in the Report). Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintile, according to area of residence and regions, Turkmenistan, 2015-2016 Wealth index quintile Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 29871 Area Urban 3.0 2.0 4.3 39.6 51.2 100.0 11666 Rural 30.9 31.6 30.1 7.5 0.0 100.0 18206 Region Ashgabat city 0.0 0.2 0.5 20.6 78.8 100.0 3613 Ahal velayat 3.3 17.7 43.4 26.5 9.2 100.0 3967 Balkan velayat 3.0 5.6 14.2 36.3 41.0 100.0 2013 Dashoguz velayat 48.7 21.2 8.7 14.9 6.5 100.0 7058 Lebap velayat 17.1 27.7 21.0 18.0 16.3 100.0 5799 Mary velayat 18.2 27.8 28.5 18.4 7.1 100.0 7421 P a g e | 21 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) was to reduce infant and under-five mortality. Specifically, the MDGs called for the reduction of under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but challenging objective. The importance of continuing and accelerating progress in reducing child mortality has been reflected in the newly agreed Sustainable Development Goals (SDG), which call upon ending preventable deaths of newborns and children under 5 years of age by 2030. The SDGs specify that all countries should aim to reduce the neonatal mortality rate to at least as low as 12 deaths per 1,000 live births and under-five mortality to at least as low as 25 deaths per 1,000 live births. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Women’s Questionnaires. All interviewed women were asked whether they had ever given birth, and if yes, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): the probability of dying within the first month of life • Post-neonatal mortality (PNN): the probability of dying after the first month of life but before the first birthday (the difference between infant and neonatal mortality rates) • Infant mortality (1q0): the probability of dying between birth and the first birthday • Child mortality (4q1): the probability of dying between the first and the fifth birthdays • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday Rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one. P a g e | 22 Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Turkmenistan, 2015-2016 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Years preceding the survey 0-4 13 8 21 6 27 5-9 24 14 38 3 41 10-14 15 18 33 2 35 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-five mortality rates for the three most recent five-year periods before the survey. Neonatal mortality in the most recent 5-year period is estimated at 13 per 1,000 live births, while the post-neonatal mortality rate is estimated at 8 per 1,000 live births. Figure CM.1: Ear ly chi ldhood mortal i t y rates , Tur kmenistan , 2015-2016 The infant mortality rate in the five years preceding the survey is 21 per 1,000 live births and under- five mortality is 27 deaths per 1,000 live births for the same period, indicating that 78 percent of under-five deaths are infant deaths. P a g e | 23 The table and figure also show the mortality trends at the national level, during the last 15 years. Under-five mortality was 35 per 1,000 during the 10-14 year period preceding the survey, 41 per 1,000 during the 5-9 year period preceding the survey and 27 per 1,000 live births during the most recent 5-year period, roughly referring to the years 2011-2015. Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child and under-five mortality rates for the five year period preceding the survey, by socioeconomic characteristicsa, Turkmenistan, 2015-2016 Neonatal mortality rate1 Post-neonatal mortality rate2, b Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 13 8 21 6 27 Region Ashgabat city (18) (7) (25) (6) (31) Ahal velayat 14 8 22 8 30 Balkan velayat 2 14 16 (0) (16) Dashoguz velayat 16 5 21 (4) (25) Lebap velayat 7 9 16 8 24 Mary velayat 13 11 24 (6) (30) Area Urban 7 9 17 5 22 Rural 15 8 23 7 30 Wealth index quintile Poorest 23 11 33 (9) (42) Second 13 6 19 6 24 Middle 12 9 21 7 28 Fourth 5 9 14 4 19 Richest 7 7 14 4 18 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Due to the low number of unweighted cases, the background characteristics "Mother's education" and “Language of household head” are not shown. b Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates ( ) Figures that are based on 250-499 unweighted cases of children exposed. P a g e | 24 Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child and under-five mortality rates for the five year period preceding the survey, by demographic characteristics, Turkmenistan, 2015-2016 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 13 8 21 6 27 Sex of child Male 17 10 27 7 33 Female 8 7 15 5 20 Mother's age at birth Less than 20 (*) (*) (*) (*) (*) 20-34 13 8 21 5 26 35-49 (12) (13) (25) (*) (*) Birth order 1 12 6 18 7 25 2-3 13 9 22 5 27 4-6 13 8 22 (7) (28) 7+ (*) (*) (*) (*) (*) Previous birth intervalb < 2 years 14 9 22 7 30 2 years 15 12 27 (7) (33) 3 years (8) (6) (14) (*) (*) 4+ years 9 11 20 2 22 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates b Excludes first order births ( ) Figures that are based on 250-499 unweighted cases of children exposed. (*) Figures that are based on fewer than 250 unweighted cases of children exposed. Tables CM.2 and CM.3 provide estimates of child mortality by socioeconomic and demographic characteristics. At the national level, under-5 mortality rate for boys was 33 per 1,000 live births and 20 per 1,000 live births for girls in 2011-2015. There are no statistically significant differences by regions and area of residence (see Tables SE.2 – SE.10 in Appendix C). Figure CM.2 provides a graphical presentation of these estimates with corresponding 95percent confidence intervals. P a g e | 25 Figure CM.2: Under -5 mortal i t y rates ( for the 0 -4 year per iod preceding the sur vey ) by area and regions, Tur kmenistan, 2015-2016 Figure CM.3 compares the findings of 2015-2016 Turkmenistan MICS on under-5 mortality rates with those from other data sources. The most recent data from the 2015-2016 Turkmenistan MICS for under-5 mortality rate (direct method) corresponds with data from the official statistics report of State Committee of Statistics (Turkmenstat) for 2013 based on data from the Civil Registry Office (27 per 1,000 live births). The 2015-2016 Turkmenistan MICS results are lower than previous data and data from other sources which can be associated with potential under-reporting of deaths by respondents. P a g e | 26 Figure CM.3: Trend in under -5 mortal i ty rates according to d i f fer ent sources , Turkmenistan In addition to inconsistencies between different data sources shown in Figure CM.3, preliminary assessment of mortality data from the 2015-2016 Turkmenistan MICS shows some unusual patterns, a few examples of which are described below. Ratios of infant mortality to under-five mortality for 2008 and 2003 are high, given the under-five mortality level (Figure CM.4), and the ratio of infant mortality to under-five mortality for 2013 is lower than the ratios for 1998 and 1993 (Figure CM.4). P a g e | 27 Figure CM.4: Rat ios of in fant to under - f ive mortal i t y, neonatal to in fant mortal i t y and neonatal to under - f ive mortal i t y, Turkmenistan, 2015 -2016 The age pattern of mortality for the most recent period when comparing the survey data to model life tables is not expected for the Turkmenistan model (Figure CM.5). Namely, the age patterns of mortality from the 2000 Turkmenistan DHS and the 2015-2016 Turkmenistan MICS are close to the UN Chilean life table model in general. The observation of the 2015-2016 MICS for the most recent period is closer to the North model, while the patterns of mortality for previous periods, also estimated by this survey, are very much in line with the East Model expected for Turkmenistan. Further characterization of these apparent differences as well as its determinants should be taken up in a more detailed and separate analysis. P a g e | 28 Figure CM.5: Model l i fe tab les and 2015 -2016 Turkmenist an MICS and 2000 Tur kmenistan DHS est imat es The findings of the preliminary data quality assessment of the mortality data from the 2015-2016 Turkmenistan MICS data might suggest potential data quality issues, including underreporting of deaths. It is recommended therefore that the child mortality estimates from the survey are to be used with caution and are used to inform policy and program decisions only in conjunction with data from other sources. P a g e | 29 V. Nutrition Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of 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, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.22 22 For a detailed description of the methodology, see Boerma, JT et al. 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization 74(2): 209-16. P a g e | 30 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Turkmenistan, 2015-2016 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live-born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 0.8 6.5 76.2 16.2 0.3 100.0 3.3 99.3 1476 Mother's age at birth Less than 20 years 1.3 10.4 71.4 16.9 0.0 100.0 4.5 100.0 56 20-34 years 0.8 6.5 76.3 16.0 0.3 100.0 3.3 99.2 1305 35-49 years 0.0 4.1 77.3 18.6 0.0 100.0 2.1 100.0 115 Birth order 1 0.3 10.1 74.6 15.0 0.0 100.0 3.6 99.2 440 2-3 0.9 4.6 77.3 16.7 0.5 100.0 3.0 99.1 823 4-5 1.4 6.7 73.1 18.8 0.0 100.0 3.8 100.0 178 6+ (0.0) (5.5) (87.5) (7.0) (0.0) 100.0 (2.5) (100.0) 35 Region Ashgabat city 1.3 9.1 76.1 13.5 0.0 100.0 4.2 100.0 160 Ahal velayat 0.3 2.3 87.6 9.7 0.0 100.0 2.1 100.0 226 Balkan velayat 0.0 5.7 85.8 7.3 1.1 100.0 2.5 99.0 75 Dashoguz velayat 1.4 10.0 80.1 7.7 0.8 100.0 4.6 99.2 395 Lebap velayat 1.1 5.5 64.0 29.3 0.0 100.0 3.2 98.9 300 Mary velayat 0.0 4.9 72.6 22.5 0.0 100.0 2.2 99.0 320 Area Urban 0.8 5.9 74.8 18.3 0.2 100.0 3.1 99.5 529 Rural 0.8 6.8 77.0 15.0 0.3 100.0 3.3 99.2 947 Mother’s educationa Primary (*) (*) (*) (*) (*) 100.0 (*) (*) 1 Secondary 0.9 6.8 77.1 15.0 0.3 100.0 3.4 99.4 1265 Primary vocational 0.0 4.3 68.9 26.4 0.3 100.0 2.1 97.8 112 Secondary vocational 0.0 5.8 73.5 20.7 0.0 100.0 2.4 100.0 50 Higher 0.0 5.4 72.5 22.1 0.0 100.0 2.3 100.0 46 Missing/DK (*) (*) (*) (*) (*) 100.0 - - 0 Wealth index quintile Poorest 1.3 10.0 74.5 13.3 1.0 100.0 4.4 99.5 322 Second 1.1 5.9 75.9 17.1 0.0 100.0 3.4 99.4 313 Middle 0.0 3.4 79.9 16.7 0.0 100.0 2.0 98.6 313 Fourth 0.3 6.4 75.1 17.8 0.3 100.0 2.9 99.9 270 Richest 1.3 6.6 75.4 16.7 0.0 100.0 3.7 99.2 259 Language of household head Turkmen 0.6 6.5 76.3 16.3 0.3 100.0 3.1 99.4 1301 Uzbek 2.1 6.2 80.2 11.4 0.0 100.0 4.4 100.0 124 Russian (0.0) (8.2) (67.6) (24.2) (0.0) 100.0 (2.9) (100.0) 27 Other (*) (*) (*) (*) (*) 100.0 (*) (*) 24 Missing/DK (*) (*) (*) (*) (*) 100.0 - - 0 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. "–" denotes 0 unweighted case in that cell or in the denominator. P a g e | 31 All medical institutions in Turkmenistan that are providing prenatal and postnatal care are technically equipped for weighing infants. Overall, 99 percent of babies were weighed at birth and approximately 3 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.1). 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. Undernutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards23. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height - can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height can be used to assess wasting and overweight status. Children whose weight-for- height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. 23 http://www.who.int/childgrowth/standards/technical_report http://www.who.int/childgrowth/standards/technical_report P a g e | 32 Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended24 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. 24 See MICS Supply Procurement Instructions: http://mics.unicef.org/tools http://mics.unicef.org/tools P a g e | 33 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Turkmenistan, 2015-2016 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z-Score (SD) Stunted Mean Z-Score (SD) Wasted Overweight Mean Z-Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Total 3.2 0.7 -0.1 3718 11.5 2.7 -0.4 3713 4.2 1.1 5.9 0.2 3706 Sex Male 3.2 0.8 -0.1 1963 11.5 2.7 -0.4 1958 4.4 1.3 6.0 0.2 1953 Female 3.2 0.7 -0.2 1756 11.4 2.7 -0.4 1755 3.9 1.0 5.7 0.1 1753 Region Ashgabat city 2.4 0.5 0.1 364 7.0 1.3 -0.1 362 2.4 0.7 5.0 0.2 361 Ahal velayat 1.6 0.5 0.3 576 8.2 3.0 0.0 575 5.0 1.4 14.4 0.4 574 Balkan velayat 3.7 0.0 -0.4 194 12.9 1.3 -0.5 193 1.8 0.6 2.2 -0.1 193 Dashoguz velayat 3.2 0.5 -0.2 936 15.5 3.7 -0.6 936 5.2 1.4 4.8 0.2 930 Lebap velayat 3.7 1.8 -0.2 772 12.8 3.4 -0.7 771 2.6 0.7 5.1 0.3 771 Mary velayat 3.9 0.6 -0.4 877 9.6 1.5 -0.5 876 5.2 1.4 3.4 -0.2 877 Area Urban 4.1 1.2 -0.1 1292 12.2 3.0 -0.4 1288 4.0 1.2 6.1 0.2 1285 Rural 2.7 0.5 -0.2 2426 11.1 2.5 -0.5 2425 4.3 1.1 5.8 0.2 2421 Age 0-5 months 9.0 3.2 -0.2 340 10.4 3.3 0.1 339 15.4 5.3 6.7 -0.4 335 6-11 months 4.4 0.5 0.0 376 6.0 2.4 0.2 376 6.0 1.5 4.4 0.0 376 12-17 months 2.2 0.2 0.0 416 8.2 2.8 -0.2 415 3.0 0.0 5.3 0.1 415 18-23 months 1.8 0.9 0.0 350 10.9 1.1 -0.5 349 2.1 0.7 6.6 0.4 349 24-35 months 3.2 0.8 -0.2 741 12.3 3.8 -0.6 740 3.4 0.8 4.7 0.2 741 36-47 months 2.7 0.7 -0.2 747 17.0 2.8 -0.8 747 3.3 0.8 7.7 0.3 747 48-59 months 1.5 0.0 -0.2 748 10.4 1.8 -0.7 748 1.4 0.6 5.6 0.3 743 Mother’s educationa Primary (*) (*) (*) 8 (*) (*) (*) 8 (*) (*) (*) (*) 8 Secondary 3.0 0.7 -0.2 3217 11.7 2.8 -0.5 3214 4.1 1.0 6.1 0.2 3206 Primary vocational 3.7 1.5 -0.1 247 9.1 1.8 -0.3 247 5.7 1.6 3.9 0.1 247 Secondary vocational 4.0 0.8 -0.1 123 10.6 0.8 -0.3 122 2.8 2.8 5.8 0.0 122 Higher 4.3 0.8 0.0 121 10.1 3.8 -0.1 121 4.5 0.0 4.5 0.2 121 Wealth index quintile Poorest 4.4 0.4 -0.3 815 15.5 4.1 -0.7 815 5.2 1.5 4.8 0.1 814 Second 1.9 0.6 -0.2 793 9.7 1.6 -0.5 793 3.2 0.6 6.1 0.2 790 Middle 2.1 0.6 -0.1 791 9.7 2.1 -0.3 790 4.3 1.2 7.3 0.2 790 Fourth 3.1 1.0 -0.1 723 10.8 2.2 -0.4 721 4.1 1.5 5.7 0.2 719 Richest 4.6 1.4 -0.1 596 11.4 3.4 -0.3 595 3.8 0.9 5.4 0.1 593 Language of household head Turkmen 3.1 0.7 -0.1 3258 11.1 2.5 -0.4 3254 4.0 1.1 5.8 0.2 3249 Uzbek 3.4 1.1 -0.2 322 15.5 5.0 -0.7 322 5.8 1.2 6.2 0.2 320 Russian 3.4 1.4 0.3 71 8.8 1.1 0.0 70 2.1 1.5 7.0 0.4 70 Other 4.8 0.0 -0.4 68 11.7 0.0 -0.3 68 8.3 2.1 4.9 -0.3 68 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 34 Children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.10, DQ.11, and DQ.12 in Appendix D. The tables show that due to implausible measurements, and/or missing weight and/or height, 1 percent of children have been excluded from calculations of the weight-for-age indicator, 1 percent from the height-for-age indicator, and 2 percent for the weight-for-height indicator. There is no evidence of heaping on age or out- transference of children under-5 that would affect to some extent the representativeness of the anthropometric results (Tables DQ.3 and DQ.6), however Table DQ.13 shows some evidence that measurers had a tendency in some cases to avoid rounding both weight and height/length measurements to decimal digits 0 and 5. Around 3 percent of children under the age of five in Turkmenistan are underweight and 1 percent are classified as severely underweight (Table NU.2). 12 percent of children are stunted or too short for their age and 4 percent are wasted or too thin for their height. 6 percent of children are overweight or too heavy for their height. Among child nutrition indicators, the largest regional differences are found in the prevalence of stunting and overweight. The prevalence of stunted children ranges from 7 percent in Ashgabat city to 16 percent in Dashoguz velayat. The percentage of overweighed children is highest in Ahal velayat. Notable differences in the prevalence of underweighted or wasted children by mother’s education, area of residence or regions are not observed. The age pattern shows that a higher percentage of children age 0-5 months are underweighted and wasted (9 and 15 percent respectively) in comparison to children who are older (Figure NU.1). Figure NU.1: Under weight , s tunted, wast ed and over weight ch i ldren under age 5 (moderat e and sever e) , Turkmenist an, 2015-2016 P a g e | 35 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.25 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.26 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.27 A summary of key guiding principles28, 29 for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are:  continued breastfeeding;  appropriate frequency of meals (but not energy density); and  appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).30 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received:  the appropriate number of meals/snacks/milk feeds;  food items form at least 4 food groups; and  breastmilk or at least 2 milk feeds (for non-breastfed children). 25 Bhuta, Z. et al. 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 26 WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February, 2003. 27 WHO. 2003. Global Strategy for Infant and Young Child Feeding. 28 PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. 29 WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age. 30 WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. P a g e | 36 Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups31 eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na In Turkmenistan, a national program “For the protection and support of breastfeeding in Turkmenistan” has been operating since 1998. New WHO breastfeeding approaches were introduced in the practice of all medical institutions: antenatal preparation of pregnant women on lactation issues, early initiation of breastfeeding, avoiding use of baby formula and bottles with nipples, mother and child staying in the same room, on-demand breastfeeding and supporting the continuation of exclusive breastfeeding. As a result of the implementation of those principles in practice, 87 percent of maternity wards in the country received the international certificate “Baby friendly hospital”. A consistent continuation of the policy in the area of correct and rational infant feeding is the Law of Turkmenistan “On the protection and promotion of breastfeeding and requirements for children’s food” (2009) and the Law of Turkmenistan “On the promotion and support of breastfeeding” (2016), which are aimed at providing optimal nutrition, growth and development of children, prevention of diseases and improvement of the health of infants and young children by improving their nutrition. Active promotion of breastfeeding is conducted among the population, and every year in the first week of September “National Breastfeeding Week” is celebrated in the country. 31 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. P a g e | 37 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a prelacteal feed, Turkmenistan, 2015-2016 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live-born children in the last two years Within one hour of birth2 Within one day of birth Total 98.5 73.4 94.4 2.3 1476 Region Ashgabat city 97.3 79.6 89.7 3.6 160 Ahal velayat 98.2 47.1 96.2 2.3 226 Balkan velayat 99.4 77.5 99.0 0.5 75 Dashoguz velayat 99.7 66.6 95.4 2.3 395 Lebap velayat 99.6 87.9 95.8 3.3 300 Mary velayat 96.5 82.7 91.9 1.0 320 Area Urban 98.7 75.7 91.8 3.9 529 Rural 98.4 72.1 95.9 1.3 947 Months since last birth 0-11 months 98.6 71.3 94.2 2.5 730 12-23 months 98.4 75.4 94.6 2.1 746 Assistance at delivery Skilled attendant 98.5 73.4 94.4 2.3 1476 Place of delivery Home (*) (*) (*) (*) 8 Health facility 98.5 73.2 94.4 2.3 1468 Public 98.5 73.2 94.4 2.3 1466 Private (*) (*) (*) (*) 2 Mother’s educationa Primary (*) (*) (*) (*) 1 Secondary 98.4 72.9 95.1 1.9 1265 Primary vocational 99.6 75.9 89.3 5.7 112 Secondary vocational 98.1 80.4 90.0 3.6 50 Higher 98.0 72.9 91.3 2.7 46 Wealth index quintile Poorest 98.0 75.2 96.0 1.2 322 Second 99.0 73.8 94.8 1.6 313 Middle 97.6 70.6 95.0 1.5 313 Fourth 98.7 74.1 95.5 1.7 270 Richest 99.3 73.4 90.0 5.9 259 Language of household head Turkmen 98.4 73.6 94.5 2.2 1301 Uzbek 100.0 69.9 97.1 1.9 124 Russian (95.1) (67.1) (78.4) (9.1) 27 Other (*) (*) (*) (*) 24 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.32 In Turkmenistan, 73 percent of babies are breastfed for the first time within one hour of birth, while 94 percent of newborns start breastfeeding within one day of birth. The findings are presented in Figure NU.2 by region and area. 32 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). P a g e | 38 There are no differences in the percentage of children breastfed within one hour by background characteristics with the exception of regions. The percentage of children who are breastfed for the first time within one hour of birth in Ahal velayat (47 percent) is much lower than in other regions. Figure NU.2: In i t iat ion of breastfeeding, Turkmenistan , 2015 - 2016 The set of Infant and Young Child Feeding indicators reported in tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed; referring to infants age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. P a g e | 39 Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Turkmenistan, 2015-2016 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed1 Percent predominant ly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Total 58.9 81.4 343 64.1 268 19.5 234 Sex Male 61.0 81.3 190 65.7 145 19.9 114 Female 56.3 81.6 153 62.2 122 19.2 120 Region Ashgabat city (41.3) (60.5) 34 (33.0) 28 (2.3) 30 Ahal velayat 57.8 72.0 61 53.4 39 (6.9) 32 Balkan velayat (75.6) (100.0) 14 (71.7) 13 (20.2) 16 Dashoguz velayat 56.9 85.0 106 70.9 81 (14.5) 58 Lebap velayat 63.4 84.7 66 75.3 59 (44.6) 42 Mary velayat (64.4) (88.3) 63 (63.9) 47 (22.3) 55 Area Urban 54.7 80.2 131 54.3 97 16.4 97 Rural 61.5 82.1 212 69.7 171 21.8 137 Mother’s educationa Primary (*) (*) 1 - 0 - 0 Secondary 58.9 81.4 301 64.1 238 19.4 195 Primary vocational (*) (*) 21 (*) 16 (16.0) 24 Secondary vocational (*) (*) 11 (*) 7 (*) 7 Higher (*) (*) 7 (*) 6 (*) 8 Wealth index quintile Poorest (58.4) (79.1) 67 (82.0) 54 (26.4) 50 Second 57.5 86.4 71 (71.3) 47 (19.9) 49 Middle 62.5 80.5 70 63.3 61 (22.4) 45 Fourth 64.8 88.4 72 61.9 59 22.7 43 Richest 50.5 71.4 64 40.3 47 6.3 47 Language of household head Turkmen 59.7 79.9 296 65.5 227 20.4 208 Uzbek (57.6) (96.9) 40 (*) 30 (*) 15 Russian (*) (*) 3 (*) 4 (*) 7 Other (*) (*) 4 (*) 6 (*) 4 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.8 - Predominant breastfeeding under 6 months 3 MICS indicator 2.9 - Continued breastfeeding at 1 year 4 MICS indicator 2.10 - Continued breastfeeding at 2 years a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. "–" denotes 0 unweighted case in that cell or in the denominator. Approximately 59 percent of children age less than six months are exclusively breastfed and 81 percent are predominantly breastfed. By age 12-15 months, 64 percent of children are breastfed and by age 20-23 months 20 percent are breastfed. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. At the age 0-1 months, the proportion of children exclusively breastfed is 83 percent while at age 4-5 months the percentage decreases to 37 percent at which point breastfeeding is increasingly being supplemented with plain water and milk/formula. Only about 15 percent of children are receiving breast milk at age 2 years. P a g e | 40 Figure NU.3: Infant feeding patterns by age , Turkmenist an, 2015-2016 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 16.1 months for any breastfeeding, 3.3 months for exclusive breastfeeding, and 5.0 months for predominant breastfeeding. The median duration of any breastfeeding in Ashgabat city is 11.4 months, while children are breastfed longer in other regions: from 14.4 months in Ahal velayat to 19.5 months in Lebap velayat. P a g e | 41 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Turkmenistan, 2015-2016 Median duration (in months) of: Number of children age 0- 35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median 16.1 3.3 5.0 2247 Sex Male 16.0 3.3 4.9 1201 Female 16.3 3.1 5.0 1046 Region Ashgabat city 11.4 2.1 3.3 237 Ahal velayat 14.4 3.2 4.6 353 Balkan velayat 17.2 4.1 5.6 113 Dashoguz velayat 17.8 3.3 5.3 593 Lebap velayat 19.5 3.6 5.1 456 Mary velayat 15.4 3.5 5.3 496 Area Urban 15.4 2.9 5.1 806 Rural 16.4 3.4 4.9 1441 Mother’s educationa Primary - - - 5 Secondary 16.0 3.3 5.0 1951 Primary vocational 15.4 3.7 5.2 155 Secondary vocational 21.2 2.8 3.7 68 Higher 16.6 2.6 4.1 66 Wealth index quintile Poorest 18.2 3.2 4.7 483 Second 15.5 3.1 5.0 473 Middle 16.7 3.7 5.1 478 Fourth 16.0 3.6 5.6 441 Richest 12.9 2.5 4.4 372 Language of household head Turkmen 15.9 3.3 4.9 1965 Uzbek 19.6 3.7 5.5 197 Russian 11.7 - 2.4 45 Other (13.8) (3.9) (3.9) 41 Mean 16.4 3.5 4.9 2247 1 MICS indicator 2.11 - Duration of breastfeeding a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. "–" denotes 0 unweighted case in that cell or in the denominator. The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breastmilk and solid, semi-solid or soft food. As a result of feeding patterns, 56 percent of children age 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children age 0-23 months is at same level (57 percent). Approximately a third of all children (36 percent) age 0-23 months in Ashgabat city are appropriately breastfeed, whereas values of this indicator are higher in other regions and vary from 54 to 65 percent. Among children age 6-23 months there is correlation with wealth index, 66 percent of the children from the poorest quintile were appropriately breastfeed and only 41 percent of children from the richest wealth quintile. P a g e | 42 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Turkmenistan, 2015-2016 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriatel y breastfed2 Number of children Total 58.9 343 56.2 1158 56.9 1501 Sex Male 61.0 190 56.5 593 57.5 783 Female 56.3 153 56.0 565 56.1 718 Region Ashgabat city (41.3) 34 34.5 124 36.0 158 Ahal velayat 57.8 61 52.9 172 54.2 233 Balkan velayat (75.6) 14 57.3 64 60.5 77 Dashoguz velayat 56.9 106 61.0 309 59.9 415 Lebap velayat 63.4 66 65.0 240 64.6 306 Mary velayat (64.4) 63 54.8 249 56.8 312 Area Urban 54.7 131 49.0 399 50.4 531 Rural 61.5 212 60.1 759 60.4 971 Mother’s educationa Primary (*) 1 (*) 2 (*) 3 Secondary 58.9 301 56.4 1001 57.0 1303 Primary vocational (*) 21 51.6 84 54.1 104 Secondary vocational (*) 11 (62.7) 36 60.5 47 Higher (*) 7 (56.0) 35 55.2 42 Wealth index quintile Poorest (58.4) 67 66.3 262 64.7 329 Second 57.5 71 59.5 249 59.1 320 Middle 62.5 70 55.0 247 56.7 316 Fourth 64.8 72 54.9 212 57.4 283 Richest 50.5 64 41.0 189 43.4 252 Language of household head Turkmen 59.7 296 56.0 1022 56.8 1318 Uzbek (57.6) 40 65.6 93 63.2 133 Russian (*) 3 (42.3) 22 (36.8) 25 Other (*) 4 (*) 21 (*) 25 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. Overall, 82 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day (Table NU.7). Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Turkmenistan, 2015-2016 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods Number of children age 6- 8 months Percent receiving solid, semi-solid or soft foods1 Number of children age 6-8 months Total 81.4 169 (*) 16 82.3 185 Sex Male 81.2 92 (*) 8 82.6 100 Female 81.8 77 (*) 8 82.0 85 Area Urban 81.1 55 (*) 11 84.3 66 Rural 81.6 114 (*) 5 81.3 119 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 43 93 percent of the children age 6-23 months were receiving solid, semi-solid and soft foods the minimum number of times (Table NU.8). The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups, was lower (85 percent) than that for minimum meal frequency. Almost all older (18-23 month old) children (98 percent) were achieving the minimum dietary diversity compared to younger (6-8 month old) children (44 percent). The overall assessment using the indicator of minimum acceptable diet revealed that 77 percent were benefitting from a diet with a minimum diversity and frequency. The proportion of children age 6-23 months receiving minimum acceptable diet increases with household wealth, ranging from 72 percent of children from the first quintile (poorest) to 85 percent of children from fifth quintile (richest). P a g e | 44 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Turkmenistan, 2015-2016 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6- 23 months Percent of children who received: Number of children age 6- 23 months Percent of children who received: Number of children age 6- 23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Total 77.3 89.1 73.3 684 96.6 97.6 82.9 91.0 457 85.2 92.5 77.1 1158 Sex Male 75.9 89.7 72.3 353 96.1 99.4 83.7 91.3 233 84.1 93.6 76.8 593 Female 78.9 88.4 74.3 331 97.2 95.7 82.1 90.7 224 86.3 91.4 77.5 565 Age 6-8 months 44.3 77.7 43.6 169 (*) (*) (*) (*) 15 43.6 78.7 42.7 185 9-11 months 80.6 92.1 77.2 175 (*) (*) (*) (*) 18 81.9 92.9 76.6 194 12-17 months 91.0 93.3 84.3 247 98.4 98.0 82.8 90.3 165 94.1 95.1 83.7 420 18-23 months 95.1 93.3 90.8 93 99.0 97.6 86.7 91.6 260 98.0 96.5 87.8 359 Region Ashgabat city 73.9 88.3 68.3 46 95.6 97.6 86.4 95.4 76 87.7 94.1 79.6 124 Ahal velayat 69.5 95.6 69.5 95 98.1 100.0 89.0 95.0 76 82.3 97.6 78.2 172 Balkan velayat 83.5 92.6 80.8 38 100.0 100.0 92.7 92.7 25 90.2 95.5 85.5 64 Dashoguz velayat 78.2 84.6 70.5 196 96.5 92.7 81.5 94.2 109 85.0 87.5 74.4 309 Lebap velayat 85.9 89.0 84.6 168 96.9 98.6 84.4 88.9 69 89.3 91.8 84.6 240 Mary velayat 70.7 90.5 65.9 142 95.4 100.0 73.9 82.4 101 80.9 94.4 69.2 249 Area Urban 81.8 92.2 79.2 206 97.1 97.2 86.5 93.1 188 89.2 94.6 82.7 399 Rural 75.4 87.8 70.7 478 96.3 97.9 80.4 89.6 268 83.1 91.4 74.2 759 Mother’s education Primary (*) (*) (*) 1 (*) (*) (*) (*) 1 (*) (*) (*) 2 Secondary 76.5 88.8 72.2 591 97.4 97.3 83.3 90.7 395 85.0 92.2 76.7 1001 Primary vocational (87.2) (95.6) (85.1) 44 (92.5) (100.0) (76.1) (89.0) 38 89.8 97.6 80.9 84 Secondary vocational (75.8) (79.8) (70.7) 26 (*) (*) (*) (*) 9 (76.2) (85.1) (70.2) 36 Higher (*) (*) (*) 20 (*) (*) (*) (*) 13 (88.1) (97.2) (87.6) 35 Wealth index quintile Poorest 73.4 88.9 68.7 178 96.8 96.5 78.2 88.1 78 81.0 91.2 71.6 262 Second 77.8 88.8 72.2 153 95.7 96.9 80.0 89.0 93 84.8 91.9 75.2 249 Middle 75.7 86.1 72.5 149 96.3 100.0 85.1 94.2 93 83.3 91.4 77.3 247 Fourth 79.8 90.6 76.2 123 96.5 96.5 82.7 88.3 87 86.8 93.1 78.9 212 Richest 84.5 93.4 82.2 80 97.6 97.9 87.3 94.5 106 92.1 96.0 85.1 189 Language of household head Turkmen 77.0 88.5 72.8 603 96.2 98.1 82.5 90.5 405 84.8 92.3 76.7 1022 Uzbek (77.5) (93.8) (75.0) 62 (*) (*) (*) (*) 28 85.0 92.5 78.1 93 Russian (*) (*) (*) 9 (*) (*) (*) (*) 11 (95.9) (95.3) (80.1) 22 Other (*) (*) (*) 9 (*) (*) (*) (*) 12 (*) (*) (*) 21 1 MICS indicator 2.17a - Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 - Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 - Minimum dietary diversity 5 MICS indicator 2.15 - Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non- breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 45 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that, in Turkmenistan, prevalence of bottle-feeding to the greatest extent depends on the region. Overall, 22 percent of children under 24 months are fed using a bottle with a nipple. The majority of children in Ashgabat city (65 percent) are fed using a bottle with a nipple, while such feeding practice is notably less common in other regions. Bottle-feeding is almost two times more common in urban than in rural areas (31 and 17 percent respectively). Percentages increase with the level of mother’s education and wealth index. Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Turkmenistan, 2015- 2016 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Total 21.8 1501 Sex Male 21.1 783 Female 22.5 718 Age 0-5 months 16.7 343 6-11 months 29.9 380 12-23 months 20.0 778 Region Ashgabat city 65.1 158 Ahal velayat 30.8 233 Balkan velayat 15.4 77 Dashoguz velayat 10.2 415 Lebap velayat 15.1 306 Mary velayat 16.6 312 Area Urban 30.6 531 Rural 16.9 971 Mother’s educationa Primary (*) 3 Secondary 20.2 1303 Primary vocational 25.7 104 Secondary vocational 40.4 47 Higher 39.6 42 Wealth index quintile Poorest 10.3 329 Second 15.8 320 Middle 23.3 316 Fourth 20.4 283 Richest 43.9 252 Language of household head Turkmen 22.4 1318 Uzbek 7.4 133 Russian (65.6) 25 Other (*) 25 1 MICS indicator 2.18 - Bottle feeding a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 46 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In order to strengthen the monitoring system for production, distribution and transportation of iodized salt, order №61 was issued by the Ministry of Health and Medical Industry of Turkmenistan on May 6, 2012 “On permanent implementation of laboratory control and monitoring of the quality of iodized salt”. In 2013, with the participation of international experts, a nationally representative survey was conducted, and in 2014 Turkmenistan was the first of the CEECIS countries and fourth in the world that, on behalf of UNICEF, WHO and the International Council for Control of Iodine Deficiency Disorder, was awarded the International Certificate for achieving optimal iodine nutrition in the population through salt iodization and sustained elimination of iodine deficiency disorders. Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Turkmenistan, 2015-2016 Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Total 99.8 5861 0.2 0.2 3.0 96.7 100.0 5857 Region Ashgabat city 99.2 883 0.8 0.6 6.5 92.2 100.0 879 Ahal velayat 100.0 674 0.0 0.1 1.2 98.7 100.0 674 Balkan velayat 100.0 497 0.0 0.0 0.8 99.2 100.0 497 Dashoguz velayat 99.9 1236 0.1 0.0 0.0 99.9 100.0 1236 Lebap velayat 99.9 1079 0.1 0.1 7.3 92.5 100.0 1079 Mary velayat 99.9 1491 0.1 0.1 1.8 98.0 100.0 1491 Area Urban 99.7 2634 0.3 0.2 4.0 95.5 100.0 2630 Rural 99.9 3227 0.1 0.1 2.2 97.6 100.0 3227 Wealth index quintile Poorest 99.8 1155 0.2 0.2 2.2 97.4 100.0 1155 Second 100.0 1055 0.0 0.1 3.2 96.7 100.0 1055 Middle 100.0 1031 0.0 0.0 2.6 97.4 100.0 1031 Fourth 99.9 1212 0.1 0.0 2.5 97.4 100.0 1211 Richest 99.5 1408 0.5 0.4 4.2 94.9 100.0 1404 1 MICS indicator 2.19 - Iodized salt consumption In almost all households (100 percent), 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.10 shows that in less than 1 percent of households, there was no salt available. These households are included in the denominator of the indicator. In 97 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in Ashgabat city (92 percent) and highest in Dashoguz velayat (100 percent). There are no differences in consumption of iodized salt by area of residence (urban, rural) and wealth index. P a g e | 47 The consumption of adequately iodized salt is graphically presented in Figure NU.4 together with the percentage of salt containing less the 15 ppm. Figure NU.4: Consumption of iodized sa lt , Tur kmenistan , 2015-2016 P a g e | 48 VI. Child Health Vaccinations The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. The WHO Recommended Routine Immunizations for Children33 recommends all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B (HepB), haemophilus influenzae type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. The National Programme of Immunization in Turkmenistan includes the following vaccination of children before the first birthday: birth doses of BCG, Polio (within 2-3 days of life), and Hepatitis B vaccines (within 24 hours of birth); three doses of the Pentavalent vaccine containing DPT, Hepatitis B, and Haemophilus influenzae type b (Hib) antigens, and three doses of the Polio vaccine. At the age of 12-15 months, the child should receive one dose of the MMR vaccine containing measles, mumps, and rubella antigens, and, at the age of 18 months, a fourth dose of DPT and Polio (booster doses). Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the Turkmenistan MICS are based on children age 24-35 months. Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards/passport. If the vaccination card/passport for a child was available, interviewers copied vaccination information from the cards/passports onto the MICS questionnaire. If no vaccination card/passport was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, DPT, Hepatitis B and Hib, how many doses were received. Information was also obtained from vaccination records at health facilities. Final vaccination coverage estimates were calculated primarily by using information collected from health facility records. If heath facility records were unavailable, 33 http://www.who.int/immunization/policy/immunization_tables/en/. Table 2 includes recommendations for all children and additional antigens recommended only for children residing in certain regions of the world or living in certain high-risk population groups. http://www.who.int/immunization/policy/immunization_tables/en/ P a g e | 49 information from cards/passports kept at home was used, and if this information was unavailable data collected through mother’s recall were used for estimating coverage. P a g e | 50 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Turkmenistan, 2015-2016 Children age 12-23 months: Children age 24-35 months: Vaccinated at any time before the survey according to: Vaccinated by 12 months of agea Vaccinated at any time before the survey according to: Vaccinated by 12 months of age (measles, Polio4 and DPT4 by 24 months)a Health facility record or vaccination card at home Mother's report Either Health facility record or vaccination card at home Mother's report Either Antigen BCG1 99.7 0.2 99.9 99.9 99.6 0.4 100.0 99.9 Polio At birth 99.7 0.2 99.9 99.9 99.4 0.4 99.8 99.7 1 99.2 0.6 99.8 98.9 98.9 1.1 100.0 98.6 2 98.4 1.0 99.4 98.8 98.7 1.2 99.9 98.0 32 98.1 0.8 98.8 97.9 98.6 1.3 99.9 97.6 4b 36.6 18.3 54.9 na 95.1 3.2 98.3 96.1 DPT 1 99.2 0.3 99.6 98.7 99.0 0.9 99.9 98.4 2 98.5 0.5 99.0 98.5 98.9 1.1 99.9 98.2 33 98.4 0.6 99.0 98.0 98.7 1.2 99.9 97.2 4b 38.8 11.7 50.5 na 96.7 1.4 98.2 96.1 HepBc At birth 99.6 0.3 99.9 99.8 99.6 0.4 100.0 99.8 1 99.1 0.4 99.5 98.6 99.1 0.8 99.9 98.4 2 98.4 0.6 99.0 98.5 98.9 1.0 99.9 98.2 34 98.2 0.7 99.0 98.0 98.5 1.4 99.9 97.2 Hib 1 99.2 0.2 99.5 98.6 98.9 1.0 99.9 98.4 2 98.5 0.5 99.0 98.5 98.7 1.0 99.7 98.0 35 98.4 0.6 99.0 98.0 98.1 1.6 99.7 97.0 Measles (MMR)6, d 90.5 4.7 95.2 na 99.0 0.8 99.8 99.3 Fully vaccinated7, e na na na na 99.5 0.1 99.6 95.3 No vaccinations 0.0 0.1 0.1 0.1 0.0 0.0 0.0 0.0 Number of children 778 778 778 778 746 746 746 746 1 MICS indicator 3.1 - Tuberculosis immunization coverage 2 MICS indicator 3.2 - Polio immunization coverage 3 MICS indicator 3.3 - Diphtheria, pertussis and tetanus (DPT) immunization coverage 4 MICS indicator 3.5 - Hepatitis B immunization coverage 5 MICS indicator 3.6 - Haemophilus influenzae type B (Hib) immunization coverage 6 MICS indicator 3.4; MDG indicator 4.3 - Measles immunization coverage 7 MICS indicator 3.8 - Full immunization coverage na: not applicable a MICS indicators 3.1, 3.2, 3.3, 3.5 and 3.6 refer to results of this column in the left panel; MICS indicators 3.4 and 3.8 refer to this column in the right panel. b Polio4 and DPT4 are booster doses that are not included in full vaccination coverage. c The way HepB doses are labelled in this table differs to the labelling in the vaccination schedule of Turkmenistan, where the birth dose (HepB0) is labelled as HepB1, HepB1 is labelled as HepB2, HepB2 as HepB3 and HepB3 as HepB4. d Measles is administered through the combined measles, mumps and rubella (MMR) vaccine in Turkmenistan. e Includes: BCG, Polio3, DPT3, HepB3, Hib3, and Measles (MMR) as per the vaccination schedule in Turkmenistan. P a g e | 51 The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information (vaccination card/passport or vaccination records at health facilities and mother’s recall) is shown in Table CH.1 and Figure CH.1. The denominators for the table are comprised of children age 12-23 months and 24-35 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card/passport or the vaccination records at health facilities or the mother’s report. In the last column in each panel, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards/passports/records, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards/passports/records. All children age 12-23 months received the birh dose of HepB as well as the BCG and Polio vaccines that are given during the first 2-3 days of life, while the third doses of Polio, DPT, HepB and Hib were received by 98 percent of children this age. The coverage for the first dose of measles vaccine by 24 months is 99 percent. As a result, the percentage of children who had all the recommended vaccinations by their first birthday (MMR by their second birthday) is very high at 95 percent. The individual coverage figures for children age 24-35 months are generally similar to those age 12-23 months suggesting that immunization coverage has been on average stable in Turkmenistan between 2013 and 2014. P a g e | 52 Figure CH.1: Vacc inat ions by age 12 months (measles by 24 months) , Turkmenistan , 2015 -2016 Table CH.2 presents vaccination coverage estimates among children age 12-23 and 24-35 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards/passport or health facility records and mothers’/caretakers’ reports. Vaccination cards/passports have been seen by the interviewer for almost all children age 12-23 and children age 24-35 months (Table DQ.15). P a g e | 53 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months and 24-35 months currently vaccinated against vaccine preventable childhood diseases, Turkmenistan, 2015-2016 Percentage of children age 12-23 months who received: Percentag e with health facility record or vaccinatio n card at home seen Numbe r of childre n age 12-23 months Percentage of children age 24-35 months who received: Percentag e with health facility record or vaccinatio n card at home seen Num ber of child ren age 24- 35 mon ths BCG Polio DPT HepBa Hib None At birth 1 2 3 1 2 3 At birth 1 2 3 1 2 3 Measle s (MMR)b Fullc Non e Polio4 d DPT4 d Total 99.9 99.9 99.8 99.4 98.8 99.6 99.0 99.0 99.9 99.5 99.0 99.0 99.5 99.0 99.0 0.1 99.7 778 99.8 99.6 0.0 98.3 98.2 99.6 746 Sex Male 99.9 99.9 99.9 99.7 99.5 99.7 99.3 99.1 99.9 99.5 99.3 99.1 99.5 99.3 99.1 0.1 99.5 397 99.8 99.8 0.0 98.3 97.6 99.5 418 Female 99.9 99.9 99.6 99.0 98.2 99.4 98.8 98.8 99.9 99.4 98.8 98.8 99.4 98.8 98.8 0.1 99.9 382 99.7 99.3 0.0 98.4 99.0 99.7 328 Region Ashgabat city 100.0 100.0 98.9 96.4 93.1 96.9 93.4 92.5 100.0 96.0 93.4 92.5 96.0 93.4 92.5 0.0 100.0 81 100.0 98.3 0.0 89.8 91.1 100.0 78 Ahal velayat 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 99.1 0.9 98.6 110 99.4 99.4 0.0 99.4 98.6 99.2 120 Balkan velayat 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 46 100.0 100.0 0.0 100.0 100.0 100.0 35 Dashoguz velayat 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 211 100.0 100.0 0.0 98.6 98.6 100.0 178 Lebap velayat 100.0 100.0 100.0 99.3 99.3 100.0 99.3 99.3 100.0 100.0 99.3 99.3 100.0 99.3 99.3 0.0 99.3 160 99.3 99.3 0.0 100.0 99.3 98.5 150 Mary velayat 100.0 100.0 100.0 100.0 99.2 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 171 100.0 100.0 0.0 99.3 99.3 100.0 184 Area Urban 99.6 99.6 99.3 98.2 97.2 98.7 97.3 97.0 99.6 98.5 97.3 97.1 98.5 97.3 97.0 0.4 99.0 276 100.0 99.5 0.0 96.7 97.0 99.2 276 Rural 100.0 100.0 100.0 100.0 99.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 502 99.6 99.6 0.0 99.3 98.9 99.8 470 Mother’s educatione Primary (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 2 (*) (*) (*) (*) (*) (*) 1 Secondary 99.9 99.9 99.7 99.3 98.7 99.5 98.9 98.8 99.9 99.4 98.9 98.8 99.4 98.9 98.8 0.1 99.6 679 99.7 99.5 0.0 98.4 98.3 99.7 648 Primary vocational 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 57 100.0 100.0 0.0 100.0 98.3 98.0 51 Secondary vocational (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 16 (*) (*) (*) (*) (*) (*) 21 Higher (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0 ) (100.0) 23 (100.0) (100.0 ) (0.0) (96.0) (96.0) (100.0) 24 Wealth index quintile Poorest 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 178 99.4 99.4 0.0 99.2 98.5 100.0 154 Second 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 161 99.5 99.5 0.0 98.8 98.8 100.0 153 Middle 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 162 100.0 100.0 0.0 99.2 98.5 99.4 162 Fourth 99.3 99.3 99.3 99.3 98.4 98.8 98.8 98.8 99.3 98.8 98.8 98.8 98.8 98.8 98.8 0.7 99.3 150 100.0 100.0 0.0 99.0 100.0 99.2 158 Richest 100.0 100.0 99.3 96.9 94.8 98.6 95.5 95.0 100.0 98.1 95.6 95.0 98.0 95.5 95.0 0.0 98.7 128 100.0 98.9 0.0 94.5 94.0 99.1 119 Language of household head Turkmen 99.9 99.9 99.7 99.3 98.7 99.5 98.9 98.8 99.9 99.4 98.9 98.8 99.4 98.9 98.8 0.1 99.6 682 99.7 99.5 0.0 98.2 98.0 99.5 647 Uzbek 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.0 100.0 65 (100.0) (100.0 ) (0.0) (100.0) (100.0) (100.0) 64 Russian (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 14 (*) (*) (*) (*) (*) (*) 20 Other (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 17 (*) (*) (*) (*) (*) (*) 15 a The way HepB doses are labelled in this table differs to the labelling in the vaccination schedule of Turkmenistan, where the birth dose (HepB0) is labelled as HepB1, HepB1 is labelled as HepB2, HepB2 as HepB3 and HepB3 as HepB4. b Measles is administered through the combined measles, mumps and rubella (MMR) vaccine in Turkmenistan. c Includes: BCG, Polio3, DPT3, HepB3, Hib3, and Measles (MMR) as per the vaccination schedule in Turkmenistan. d Polio4 and DPT4 are booster doses that are not included in full vaccination coverage. e Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 54 There are no differences in coverage with individual vaccines by background characteristics for children age 12-23 months with the exception of children from Ashgabat city and from the richest wealth index quintile. In Asghabat city, comparing with other regions, a higher percentage of children did not receive recommended doses or they did not receive it timely. In particular, the percentage of children age 12-23 months who received the first dose of HepB vaccine is 100 percent while the percentage for the third dose declines to 93 percent. The situation is almost the same for children from the richest wealth index quintile. Findings on coverage with the DPT-HepB-Hib combination vaccine for children age 12-23 months are presented in Table CH.2A. 99 percent of children age 12-23 months received all three doses of the vaccine against diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenzae type b through the DPT-HepB-Hib combination vaccine. The coverage is slightly lower for the children from Ashgabat city and from the richest wealth index quintile. Table CH.2A: Coverage of the DPT-HepB-Hib combination vaccine Percentage of children age 12-23 months vaccinated against diphtheria, pertussis, tetanus, hepatitis B and the Hib disease using the DPT-HepB-Hib combination vaccinea, Turkmenistan, 2015-2016 Percentage of children age 12-23 months who received: Number of children age 12-23 months Pentavalent1 DPT1-HepB1- Hib1 Pentavalent2 DPT2-HepB2-Hib2 Pentavalent3 DPT3-HepB3-Hib3 Total 99.5 99.0 99.0 778 Sex Male 99.5 99.3 99.1 397 Female 99.4 98.8 98.8 382 Region Ashgabat city 96.0 93.4 92.5 81 Ahal velayat 99.1 99.1 99.1 110 Balkan velayat 100.0 100.0 100.0 46 Dashoguz velayat 100.0 100.0 100.0 211 Lebap velayat 100.0 99.3 99.3 160 Mary velayat 100.0 100.0 100.0 171 Area Urban 98.5 97.3 97.0 276 Rural 100.0 100.0 100.0 502 Mother’s education Primary (*) (*) (*) 2 Secondary 99.4 98.9 98.8 679 Primary vocational 100.0 100.0 100.0 57 Secondary vocational (*) (*) (*) 16 Higher (100.0) (100.0) (100.0) 23 Wealth index quintile Poorest 100.0 100.0 100.0 178 Second 100.0 100.0 100.0 161 Middle 100.0 100.0 100.0 162 Fourth 98.8 98.8 98.8 150 Richest 98.0 95.5 95.0 128 Language of household head Turkmen 99.4 98.9 98.8 682 Uzbek 100.0 100.0 100.0 65 Russian (*) (*) (*) 14 Other (*) (*) (*) 17 a The way HepB doses are labelled in this table differs to the labelling in the vaccination schedule of Turkmenistan, where the birth dose (HepB0) is labelled as HepB1, HepB1 is labelled as HepB2, HepB2 as HepB3 and HepB3 as HepB4. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 55 Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 2025. From 2001, Turkmenistan has started the implementation of the program “Integrated Management of Childhood Illness” (IMCI) which focuses on improving primary health care, education and community outreach. One important component of this program is the rational use of medications in most common childhood diseases (use of oral rehydration salts (ORS) with diarrhoea and use of antibiotics for suspected pneumonia). Table CH.3 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the 2 weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of those illnesses over a two-week time window. The definition of a case of diarrhoea or fever, in this survey, was the mother’s (or caretaker’s) report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must consequently be interpreted with caution. For these reasons, although the period- prevalence over a two-week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. P a g e | 56 Table CH.3: Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea, symptoms of acute respiratory infection (ARI), and/or fever in the last two weeks, Turkmenistan, 2015-2016 Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhoea Symptoms of ARI An episode of fever Total 1.9 0.4 5.6 3765 Sex Male 2.1 0.5 5.7 1984 Female 1.6 0.4 5.4 1781 Region Ashgabat city 3.2 1.0 7.8 385 Ahal velayat 1.8 0.3 11.1 576 Balkan velayat 3.3 0.2 10.0 195 Dashoguz velayat 2.0 0.0 3.3 950 Lebap velayat 1.8 0.4 5.8 780 Mary velayat 1.0 0.9 2.1 879 Area Urban 2.0 0.4 6.4 1324 Rural 1.8 0.5 5.1 2441 Age 0-11 months 3.3 0.0 5.5 723 12-23 months 2.6 0.8 7.2 778 24-35 months 1.9 0.5 6.0 746 36-47 months 1.0 0.1 4.2 758 48-59 months 0.5 0.7 4.9 760 Mother’s educationa Primary (*) (*) (*) 8 Secondary 1.8 0.5 5.4 3252 Primary vocational 2.3 0.7 6.3 251 Secondary vocational 2.1 0.0 7.2 128 Higher 1.8 0.0 6.1 124 Wealth index quintile Poorest 2.1 0.3 4.7 826 Second 1.5 0.7 4.3 799 Middle 1.5 0.5 5.6 793 Fourth 2.2 0.2 6.2 737 Richest 2.1 0.7 7.5 610 Language of household head Turkmen 1.9 0.4 5.7 3291 Uzbek 1.1 0.3 4.0 333 Russian 3.6 0.0 8.5 74 Other 2.0 2.1 4.1 68 a Due to the low number of unweighted cases, the category "None" for the background characteristic "Mother's education" is not shown. (*) Figures that are based on fewer than 25 unweighted cases. Overall, 2 percent of under five children were reported to have had diarrhoea in the two weeks preceding the survey, less than 1 percent symptoms of ARI, and 6 percent an episode of fever (Table CH.3). There are major differences between regions in the case of fever. Diarrhoea Diarrhoea is a leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. In addition, provision of zinc supplements has been shown to reduce the duration and severity of the illness as well as the risk of P a g e | 57 future episodes within the next two or three months. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. In the MICS, mothers or caretakers were asked whether their child under age five years had an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness, including what the child had been given to drink and eat during the episode and whether this was more or less than what was usually given to the child. The overall period-prevalence of diarrhoea in children under 5 years of age is 2 percent (Table CH.3). With the increase of the age of child, the incidence of diarrhoea is gradually reduced from 3 percent for the children age 0-11 months to less than 1 percent for children age 48-59 months. Table CH.4: Care-seeking during diarrhoea Percentage of children age 0-59 months with diarrhoea in the last two weeks for whom advice or treatment was soughta, by source of advice or treatment, Turkmenistan, 2015-2016 Percentage of children with diarrhoea for whom: Number of children age 0-59 months with diarrhoea in the last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider1, d Publicb Private Mobile/Outreach clinicc Total 50.3 1.2 0.0 0.0 51.4 48.6 70 Sex Male (56.4) (0.0) (0.0) (0.0) (56.4) (43.6) 42 Female (40.8) (3.0) (0.0) (0.0) (43.8) (56.2) 28 Area Urban (41.2) (3.1) (0.0) (0.0) (44.3) (55.7) 26 Rural (55.7) (0.0) (0.0) (0.0) (55.7) (44.3) 44 1 MICS indicator 3.10 - Care-seeking for diarrhoea a Due to low numbers of denominators, the background characteristics “Region”, “Age”, “Mother’s education”, “Wealth index quintile” and “Language of household head” are not shown. b Public health facilities and providers include public pharmacies c Includes both public (Mobile/Outreach clinic) and private (Mobile clinic) health facilities d Includes all public and private health facilities and providers, but excludes public and private pharmacy ( ) Figures that are based on 25–49 unweighted cases. Table CH.4 shows the percentage of children with diarrhoea in the two weeks preceding the survey for whom advice or treatment was sought and where. Overall, a health facility or provider was seen in a half of the cases (51 percent), predominantly in the public sector (50 percent). P a g e | 58 Table CH.5: Feeding practices during diarrhoea Percent distribution of children age 0-59 months with diarrhoeaa in the last two weeks by amount of liquids and food given during episode of diarrhoea, Turkmenistan, 2015-2016 Drinking practices during diarrhoea Eating practices during diarrhoea Number of children age 0-59 months with diarrhoea in the last two weeks Child was given to drink: Total Child was given to eat: Total Much less Somewhat less About the same More Nothing Much less Somewhat less About the same More Nothing Total 10.1 24.3 36.5 26.5 2.6 100.0 13.2 47.0 35.7 1.2 2.9 100.0 70 Sex Male (10.4) (22.3) (37.5) (28.6) (1.2) 100.0 (15.2) (37.1) (44.9) (0.0) (2.8) 100.0 42 Female (9.6) (27.4) (34.9) (23.2) (4.8) 100.0 (10.0) (62.2) (21.7) (3.0) (3.1) 100.0 28 Area Urban (18.2) (12.7) (40.2) (21.9) (7.0) 100.0 (14.4) (54.2) (26.4) (3.1) (1.9) 100.0 26 Rural (5.2) (31.3) (34.3) (29.2) (0.0) 100.0 (12.5) (42.8) (41.3) (0.0) (3.5) 100.0 44 a Due to low numbers of denominators, the background characteristics “Region”, “Age”, “Mother’s education”, “Wealth index quintile” and “Language of household head” are not shown. ( ) Figures that are based on 25–49 unweighted cases. P a g e | 59 Table CH.5 provides statistics on drinking and feeding practices during diarrhoea. 27 percent of under five children with diarrhoea were given more than usual to drink while 71 percent were given the same or less. About 84 percent were given somewhat less, same or more (continued feeding), while 16 percent were given much less or almost nothing. Table CH.6: Oral rehydration solutions and zinc Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration salts (ORS) and zinca, Turkmenistan, 2015-2016 Percentage of children with diarrhoea who received: Number of children age 0-59 months with diarrhoea in the last two weeks Oral rehydration salts (ORS) Zinc ORS and zinc1 Tablet Syrup Any zinc Total 47.1 3.9 9.5 10.9 6.6 70 Sex Male (45.8) (4.3) (7.1) (8.6) (5.7) 42 Female (49.0) (3.2) (13.1) (14.4) (7.9) 28 Area Urban (68.6) (5.7) (6.0) (9.8) (8.0) 26 Rural (34.2) (2.8) (11.5) (11.5) (5.7) 44 1 MICS indicator 3.11 - Diarrhoea treatment with oral rehydration salts (ORS) and zinc a Due to low numbers of denominators, the background characteristics “Region”, “Age”, “Mother’s education”, “Wealth index quintile” and “Language of household head” are not shown. ( ) Figures that are based on 25–49 unweighted cases. Table CH.6 shows the percentage of children receiving ORS, various types of recommended homemade fluids and zinc during the episode of diarrhoea. Since children may have been given more than one type of liquid, the percentages do not necessarily add to 100. About 47 percent received fluids from ORS packets. Additionally, 11 percent received zinc in one form or another. Only 7 percent of children with diarrhoea received ORS and zinc. P a g e | 60 Table CH.7: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given oral rehydration therapy with continued feeding and percentage who were given other treatmentsa, Turkmenistan, 2015-2016 Children with diarrhoea who were given: Not given any treatmen t or drug Number of children age 0-59 months with diarrhoe a in the last two weeks Zinc ORS or increase d fluids ORT with continue d feeding1, b Other treatments Pill or syrup Injection Intra- venous Home remedy, herbal medicin e Other Anti- biotic Anti- motility Other Unknow n Anti- biotic Non- antibioti c Unknow n Total 10.9 66.7 39.4 36.2 6.5 15.6 9.0 7.0 0.0 3.0 7.7 0.6 6.4 1.9 70 Sex Male (8.6) (70.6) (38.0) (40.2) (1.9) (11.9) (13.7) (9.0) (0.0) (4.9) (8.6) (0.0) (7.5) (3.2) 42 Female (14.4) (60.8) (41.6) (30.0) (13.5) (21.2) (1.7) (4.0) (0.0) (0.0) (6.2) (1.6) (4.6) (0.0) 28 Area Urban (9.8) (77.5) (54.0) (23.6) (14.6) (16.1) (1.8) (11.0) (0.0) (0.0) (2.3) (1.7) (7.5) (0.0) 26 Rural (11.5) (60.3) (30.6) (43.7) (1.6) (15.3) (13.2) (4.6) (0.0) (4.7) (10.9) (0.0) (5.7) (3.1) 44 1 Survey-specific indicator 3.S1 - Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding a Due to the low number of unweighted cases, the categories "None" and "Primary" for the background characteristic "Mother's education" are not shown. Due to low numbers of denominators, the background characteristics “Region”, “Age”, “Mother’s education”, “Wealth index quintile” and “Language of household head” are not shown. b This is comparable to MICS Indicator 3.12 “Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding” with the exception that recommended homemade fluids are not included as part of the institutional approach in Turkmenistan. ( ) Figures that are based on 25–49 unweighted cases. P a g e | 61 Table CH.7 provides the proportion of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, 67 percent of children with diarrhoea received ORS or increased fluids. Combining the information in Table CH.5 with that of Table CH.6 on oral rehydration therapy, it is observed that 39 percent of children received ORT and, at the same time, feeding was continued, as is the recommendation. Table CH.7 also shows the percentage of children having had diarrhoea in the two weeks preceding the survey who were given various forms of treatment, leaving about 2 percent of them without any treatment or drug. P a g e | 62 Table CH.8: Source of ORS and zinc Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given ORS, and percentage given zinc, by the source of ORS and zincb, Turkmenistan, 2015- 2016 Percentage of children who were given as treatment for diarrhoea: Number of children age 0-59 months with diarrhoea in the last two weeks Percentage of children for whom the source of ORS was: Number of children age 0-59 months who were given ORS as treatment for diarrhoea in the last two weeks Percentage of children for whom the source of zinc was: Number of children age 0-59 months who were given zinc as treatment for diarrhoea in the last two weeks Health facilities or providers A health facility or providera Health facilities or providers Other source A health facility or providera ORS zinc Public Private Public Private Total 47.1 10.9 70 (93.5) (6.5) (100.0) 33 (*) (*) (*) (*) 8 Sex Male (45.8) (8.6) 42 (*) (*) (*) 19 (*) (*) (*) (*) 4 Female (49.0) (14.4) 28 (*) (*) (*) 14 (*) (*) (*) (*) 4 Area Urban (68.6) (9.8) 26 (95.4) (4.6) (100.0) 18 (*) (*) (*) (*) 3 Rural (34.2) (11.5) 44 (*) (*) (*) 15 (*) (*) (*) (*) 5 a Due to low numbers of denominators, the background characteristics “Region”, “Age”, “Mother’s education”, “Wealth index quintile” and “Language of household head” are not shown. b Includes all public and private health facilities and providers ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 63 Table CH.8 provides information on the source of ORS and zinc for children who benefitted from these treatments. The main source of ORS is the public sector (94 percent). Acute Respiratory Infections Symptoms of ARI are collected during the 2015-2016 Turkmenistan MICS to capture pneumonia disease, the leading cause of death in children under five. Once diagnosed, pneumonia is treated effectively with antibiotics. Studies have shown a limitation in the survey approach of measuring pneumonia because many of the suspected cases identified through surveys are in fact, not true pneumonia.34 While this limitation does not affect the level and patterns of care-seeking for suspected pneumonia, it limits the validity of the level of treatment of pneumonia with antibiotics, as reported through household surveys. MICS indicators 3.13 “Care-seeking for children with acute respiratory infection (ARI) symptoms” and 3.14 “Antibiotic treatment for children with ARI symptoms” are not shown in a table in this report because they are based on too few unweighted cases. 34 Campbell, H. et al. 2013. Measuring Coverage in MNCH: Challenges in Monitoring the Proportion of Young Children with Pneumonia Who Receive Antibiotic Treatment. PLoS Med 10(5): e1001421. doi:10.1371/journal.pmed.1001421 P a g e | 64 Table CH.9: Knowledge of the two danger signs of pneumonia Percentage of women age 15-49 years who are mothers or caretakers of children under age 5 by symptoms that would cause them to take a child under age 5 immediately to a health facility, and percentage of mothers who recognize fast or difficult breathing as signs for seeking care immediately, Turkmenistan, 2015-2016 Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/caretakers who recognize at least one of the two danger signs of pneumonia (fast and/or difficult breathing) Number of women age 15-49 years who are mothers/caretakers of children under age 5 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 Total 15.3 46.3 80.1 29.0 23.6 8.1 1.8 9.7 46.7 2580 Region Ashgabat city 17.2 53.9 88.6 20.5 17.9 3.3 4.0 21.5 34.7 280 Ahal velayat 30.2 48.6 75.5 34.9 23.1 8.1 4.6 17.0 49.4 375 Balkan velayat 8.9 32.1 94.0 39.5 19.3 2.3 1.0 0.3 48.0 150 Dashoguz velayat 1.3 33.5 82.6 41.8 24.1 3.3 0.0 0.2 56.6 620 Lebap velayat 17.1 54.4 82.7 19.5 28.6 23.1 2.9 22.2 44.3 543 Mary velayat 19.4 50.8 70.6 22.2 22.8 3.2 0.2 0.7 42.5 611 Area Urban 15.1 46.2 85.2 28.9 24.0 8.6 2.4 11.8 46.0 947 Rural 15.4 46.4 77.1 29.0 23.4 7.8 1.5 8.5 47.2 1634 Educationa Primary (*) (*) (*) (*) (*) (*) (*) (*) (*) 3 Secondary 15.1 45.7 79.0 29.5 23.5 7.6 2.0 9.0 47.1 2183 Primary vocational 16.6 47.3 85.9 25.2 29.4 12.0 0.0 13.5 48.1 186 Secondary vocational 22.0 50.2 86.9 28.8 20.2 11.6 1.7 10.4 43.3 108 Higher 10.7 55.2 86.6 25.6 20.4 8.3 1.3 17.2 41.4 99 Wealth index quintile Poorest 8.9 42.4 77.1 33.2 21.2 7.8 0.4 4.6 48.8 536 Second 15.8 44.0 75.2 25.9 27.8 7.0 1.2 10.2 48.4 536 Middle 21.0 49.1 77.7 27.2 21.4 9.5 2.8 10.0 43.5 541 Fourth 15.1 47.0 83.5 30.3 26.2 7.5 2.7 11.5 49.8 507 Richest 15.5 49.6 88.2 28.5 21.4 8.7 2.2 12.9 42.7 460 Language of household head Turkmen 16.5 47.5 79.5 28.0 23.7 8.6 2.1 10.5 46.2 2251 Uzbek 4.4 34.7 84.1 38.7 25.6 3.0 0.0 0.5 53.6 222 Russian 14.0 48.8 92.3 26.4 20.9 7.6 1.3 20.5 43.4 66 Other (10.8) (39.7) (73.1) (34.1) (14.4) (5.7) (0.0) (1.9) (44.3) 42 a Due to the low number of unweighted cases, the category "None" for the background characteristic "Education" is not shown. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 65 Mothers’ knowledge of danger signs is an important determinant of care-seeking behaviour. In the MICS, mothers or caretakers were asked to report symptoms that would cause them to take a child under-five for care immediately at a health facility. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.9. Overall, 47 percent of women know at least one of the two danger signs of pneumonia – fast and/or difficult breathing. The most commonly identified symptom for taking a child to a health facility is if the child develops a fever (80 percent). About 29 percent of mothers identified fast breathing and 24 percent difficult breathing as symptoms for taking children immediately to a health care provider. Notable differences are found between regions. Mothers or caretakers from Ashgabat city are less likely to recognise the two danger signs of pneumonia (35 percent) compared to those from velayats. Fever Table CH.10 provides information on care-seeking behaviour during an episode of fever in the past two weeks. As shown in Table CH.10, advice was sought from a health facility or a qualified health care provider for 59 percent of children with fever; these services were provided by the public sector. With the increase of household wealth, values for this indicator increase from 42 percent for children in the poorest quintile to 71 percent for children from the richest quintile (data are based on low numbers of unweighted cases and should be interpreted with caution). No advice or treatment was sought in 40 percent of the cases. P a g e | 66 Table CH.10: Care-seeking during fever Percentage of children age 0-59 months with fever in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, Turkmenistan, 2015-2016 Percentage of children for whom: Number of children with fever in last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider1, b Public Private Mobile/Outreach clinica Total 59.3 0.5 0.0 1.0 59.3 40.1 209 Sex Male 61.1 0.0 0.0 0.6 61.1 38.9 114 Female 57.0 1.1 0.0 1.4 57.0 41.6 95 Region Ashgabat city (40.0) (3.5) (0.0) (0.0) (40.0) (60.0) 30 Ahal velayat 62.8 0.0 0.0 1.0 62.8 37.2 64 Balkan velayat 88.0 0.0 0.0 0.0 88.0 12.0 20 Dashoguz velayat (*) (*) (*) (*) (*) (*) 32 Lebap velayat (57.3) (0.0) (0.0) (0.0) (57.3) (42.7) 45 Mary velayat (*) (*) (*) (*) (*) (*) 19 Area Urban 61.8 1.2 0.0 0.8 61.8 38.2 85 Rural 57.5 0.0 0.0 1.1 57.5 41.4 125 Age 0-11 months (45.5) (0.0) (0.0) (0.0) (45.5) (54.5) 40 12-23 months 71.5 0.0 0.0 1.1 71.5 28.5 56 24-35 months 60.4 2.3 0.0 3.0 60.4 36.6 45 36-47 months (44.7) (0.0) (0.0) (0.0) (44.7) (55.3) 32 48-59 months (66.8) (0.0) (0.0) (0.0) (66.8) (33.2) 37 Mother’s education Secondary 58.0 0.6 0.0 1.1 58.0 41.3 177 Primary vocational (*) (*) (*) (*) (*) (*) 16 Secondary vocational (*) (*) (*) (*) (*) (*) 9 Higher (*) (*) (*) (*) (*) (*) 8 Wealth index quintile Poorest (41.9) (0.0) (0.0) (3.5) (41.9) (54.7) 39 Second (56.3) (0.0) (0.0) (0.0) (56.3) (43.7) 34 Middle 60.3 0.0 0.0 0.0 60.3 39.7 45 Fourth 63.8 2.3 0.0 0.0 63.8 36.2 46 Richest 70.7 0.0 0.0 1.4 70.7 29.3 46 Language of household head Turkmen 61.5 0.6 0.0 0.3 61.5 38.5 187 Uzbek (*) (*) (*) (*) (*) (*) 13 Russian (*) (*) (*) (*) (*) (*) 6 Other (*) (*) (*) (*) (*) (*) 3 1 MICS indicator 3.20 - Care-seeking for fever a Includes both public (Mobile/Outreach clinic) and private (Mobile clinic) health facilities b Includes all public and private health facilities and providers as well as shops ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. Mothers were asked to report all of the medicines given to a child to treat the fever, including both medicines given at home and medicines given or prescribed at a health facility (Table CH.11). The majority of children (71 percent) who had a fever in the last two weeks received Paracetamol or Panadol, 38 percent received Ibuprofen or Ibufen and 34 percent received an antibiotic in the form of a pill or syrup. Antibiotic injections and other medicines are less common (13 percent and 12 percent respectively). P a g e | 67 Table CH.11: Treatment of children with fever Percentage of children age 0-59 months who had a fever in the last two weeks, by type of medicine given for the illness, Turkmenistan, 2015-2016 Children with a fever in the last two weeks who were given: Number of children with fever in last two weeks Medications Other Missing/DK Antibiotic pill or syrup Antibiotic injection Paracetamol/ Panadol Ibuprofen/Ibufen Total 34.0 12.6 70.6 38.0 11.7 0.0 209 Sex Male 37.5 13.0 79.4 35.7 11.0 0.0 114 Female 29.8 12.1 60.2 40.7 12.5 0.0 95 Region Ashgabat city (39.5) (11.8) (35.5) (31.7) (27.4) (0.0) 30 Ahal velayat 20.4 11.2 87.6 61.1 16.7 0.0 64 Balkan velayat 30.2 6.5 75.3 14.4 4.0 0.0 20 Dashoguz velayat (*) (*) (*) (*) (*) (*) 32 Lebap velayat (49.2) (10.4) (78.3) (18.2) (10.2) (0.0) 45 Mary velayat (*) (*) (*) (*) (*) (*) 19 Area Urban 34.3 19.1 61.8 32.5 15.0 0.0 85 Rural 33.8 8.2 76.6 41.6 9.4 0.0 125 Age 0-11 months (28.0) (9.0) (75.7) (28.7) (3.0) (0.0) 40 12-23 months 35.4 11.4 61.9 39.7 18.1 0.0 56 24-35 months 34.2 26.6 80.6 36.9 13.8 0.0 45 36-47 months (31.3) (7.4) (69.7) (37.2) (9.0) (0.0) 32 48-59 months (40.4) (6.0) (67.1) (47.1) (10.9) (0.0) 37 Mother’s education Secondary 34.9 9.7 73.7 38.5 11.3 0.0 177 Primary vocational (*) (*) (*) (*) (*) (*) 16 Secondary vocational (*) (*) (*) (*) (*) (*) 9 Higher (*) (*) (*) (*) (*) (*) 8 Wealth index quintile Poorest (35.2) (2.6) (70.6) (30.1) (2.6) (0.0) 39 Second (40.0) (17.4) (77.7) (38.2) (3.6) (0.0) 34 Middle 29.1 9.9 73.9 50.0 15.5 0.0 45 Fourth 35.8 13.7 71.5 37.4 13.7 0.0 46 Richest 31.5 19.0 61.3 33.2 19.5 0.0 46 Language of household head Turkmen 34.6 13.0 74.2 37.2 12.0 0.0 187 Uzbek (*) (*) (*) (*) (*) (*) 13 Russian (*) (*) (*) (*) (*) (*) 6 Other (*) (*) (*) (*) (*) (*) 3 ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. Solid Fuel Use More than 3 billion people around the world rely on solid fuels for their basic energy needs, including cooking and heating. Solid fuels include biomass fuels, such as wood, charcoal, crops or other agricultural waste, dung, shrubs and straw, and coal. Cooking and heating with solid fuels leads to high levels of indoor smoke which contains a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is their incomplete combustion, which produces toxic elements such as carbon monoxide, polyaromatic hydrocarbons, and sulphur dioxide (SO2), among others. Use of solid fuels increases the risks of incurring acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, asthma, or cataracts, and may contribute to low birth weight P a g e | 68 of babies born to pregnant women exposed to smoke. The primary indicator for monitoring use of solid fuels is the proportion of the population using solid fuels as the primary source of domestic energy for cooking, shown in Table CH.12. In Turkmenistan, solid fuels are not used for cooking. The vast majority of household members use natural gas for cooking (98 percent). A very small percentage of household members uses other fuels. It should be noted that natural gas and electricity (according to the established average norms) are free of charge for citizens of Turkmenistan since the beginning of 2013, which ensures high availability to the whole population. P a g e | 69 Table CH.12: Solid fuel use Percent distribution of household members according to type of cooking fuel mainly used by the household, and percentage of household members living in households using solid fuels for cooking, Turkmenistan, 2015-2016 Percentage of household members in households mainly using: Number of household members Electricity Liquefied Petroleum Gas (LPG) Natural Gas Kerosene Solid fuels Other fuel No food cooked in the household Total Solid fuels for cooking1 Coal/ Lignite Wood Total 1.7 0.3 98.0 0.0 - - - - 100.0 0.0 29871 Region Ashgabat city 10.4 0.0 89.5 0.1 - - - - 100.0 0.0 3613 Ahal velayat 0.4 0.2 99.5 0.0 - - - - 100.0 0.0 3967 Balkan velayat 0.4 0.0 99.6 0.0 - - - - 100.0 0.0 2013 Dashoguz velayat 0.6 0.4 99.0 0.0 - - - - 100.0 0.0 7058 Lebap velayat 0.6 0.2 99.3 0.0 - - - - 100.0 0.0 5799 Mary velayat 0.6 0.5 98.9 0.0 - - - - 100.0 0.0 7421 Area Urban 3.8 0.0 96.1 0.0 - - - - 100.0 0.0 11666 Rural 0.4 0.4 99.2 0.0 - - - - 100.0 0.0 18206 Education of household heada Primary 0.0 7.5 92.5 0.0 - - - - 100.0 0.0 159 Secondary 0.8 0.3 98.9 0.0 - - - - 100.0 0.0 18917 Primary vocational 1.1

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