Egypt - Multiple Indicator Cluster Survey - 2013

Publication date: 2013

Egypt MICS in the rural districts covered by the IPHN programme in Egypt Multiple Indicator Cluster Survey 2013-14 Final Report September 2015 The Egypt sub-national Multiple Indicator Cluster Survey (MICS) was carried out in 2013-14 by El-Zanaty & Associates in collaboration with the Ministry of Health and Population. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF) Egypt Country Office, Middle East and North Africa Regional Office, and UNICEF Headquarters. The global Multiple Indicator Cluster Survey (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 measures 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. This MICS aims at providing data for monitoring system of the ‘Integrated Perinatal Health and Child Nutrition Programme’ (IPHN) implemented by the Ministry of Health and Population (MOHP) in Egypt with the support of UNICEF. The IPHN covers selected rural districts in 6 governorates, 4 in Upper Egypt and 2 in Lower Egypt. Suggested citation: MOHP, UNICEF, and El-Zanaty & Associates, 2015.Egypt Multiple Indicator Cluster Survey in the rural districts covered by the IPHN programme, 2013-2014, Final Report. Cairo, Egypt: MOHP, UNICEF, and El-Zanaty & Associates iii Summary Tables of Survey Implementation and the Survey Population Survey implementation Sample frame: MoHP 2013: FHUs Catchment areas Updated October – November 2013 Questionnaires: Household Ever-married Women (15-49)1 Children under five Interviewer training 17 Nov - 3 Dec 2013 Fieldwork 3 Dec 2013 – 2 Jan 2014 Survey sample Households Children under-5 - Selected 7067 - Eligible for interviews 5096 - Occupied 7050 - Mothers/ caretakers interviewed 5090 - Interviewed 7046 - Response rate (per cent) 99.8 - Response rate (per cent) 99.9 Ever-married Women2 - Eligible for interviews 5859 - Interviewed 5847 - Response rate (per cent) 99.7 Survey population Average household size 4.6 Percentage of population living in - Pilot Upper Egypt - Expansion Upper Egypt - Expansion Lower Egypt 12.7 71.4 15.8 Percentage of population under: - Age 5 - Age 18 16.0 44.9 Ever-married Women aged 15-49 with live births in the last 5 years2 - Percent - Number 61.7 3605 Percentage of under-5s with - Height/Length measured - Weight measured 98.8 96.8 Housing characteristics Household or personal assets Percentage of households with Percentage of households that own a - Electricity 99.7 - A television 93.1 - Finished floor 83.2 - A refrigerator 90.8 - Finished roofing 88.4 - Agricultural land 21.4 - Finished walls 99.1 - Farm animals/livestock 40.2 Percentage of households where at least a member has or owns a Mean number of persons per room used for sleeping 2.51 - Mobile phone 86.0 - Car or truck 4.1 1This MICS specifically identified its target group as ever-married women age 15-49. The MDG and MICS indicators calculated for women in this sub-national survey are thus not fully comparable to the standard MDG and MICS indicators. 2This MICS applied the modules on maternal and newborn health to ever-married women age 15-49 with a live birth in the last 5 years, instead of in the last 2 years. The MDG and MICS indicators calculated for women in this sub-national survey are thus not fully comparable to the standard MDG and MICS indicators. iv Summary Table of Findings3 MULTIPLE INDICATOR CLUSTER SURVEYS (MICS) AND MILLENNIUM DEVELOPMENT GOALS (MDG) INDICATORS, EGYPT SUB-NATIONAL MICS, 2013-14 MICS Indicator Indicator Description Value NUTRITION Nutritional status 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and Severe (-2 SD) (b) Severe (-3 SD) 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 5.4 2.1 2.2a 2.2b Stunting prevalence (a) Moderate and Severe (-2 SD) (b) Severe (-3 SD) 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 21.7 8.8 2.3a 2.3b Wasting prevalence (a) Moderate and Severe (-2 SD) (b) Severe (-3 SD) 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 2.7 1.3 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 17.1 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of ever-married women with a live birth in the last 5 years who breastfed their last live-born child at any time4 96.9 2.6 Early initiation of breastfeeding Percentage of ever-married women with a live birth in the last 5 years who put their last new-born to the breast within one hour of birth3 35.8 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfedi 45.4 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishmentii during the previous day 67.1 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 79.6 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 20.4 3 See Appendix E for a detailed description of MICS indicators 4This MICS applied the modules on maternal and newborn health to ever-married women with a live birth in the last 5 years, instead of in the las 2 years. The MICS indicators 2.5 and 2.6 are thus not fully comparable to the standard MICS indicators. v MICS Indicator Indicator Description Value 2.11 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 18.2 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fediii during the previous day 56.6 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 78.6 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 31.7 Nutritional status 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 timesiv or more during the previous day 61.6 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groupsv during the previous day 53.6 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 34.6 19.9 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 15.8 Low-birth weight 2.20 Low-birth weight infants Percentage of most recent live births in the last 5 years weighing below 2,500 grams at birth5 23.0 2.21 Infants weighed at birth Percentage of most recent live births in the last 5 years who were weighed at birth4 62.6 CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 91.1 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 97.3 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 96.1 5This MICS applied the modules on maternal and newborn health to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The MICS indicators 2.20 and 2.21 are thus not fully comparable to the standard MICS indicators. vi MICS Indicator Indicator Description Value 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 24-35 months who received measles vaccine by their second birthday 95.5 3.5 Hepatitis B immunization coverage Percentage of children age 12-23 months who received the third dose of Hepatitis B vaccine (HepB3) by their first birthday 95.1 3.8 Full immunization coverage Percentage of children age 24-35 months who received allvi vaccinations recommended in the national immunization schedule by their first birthday (measles by their second birthday) 82.0 Tetanus toxoid6 3.9 Neonatal tetanus protection Percentage of ever-married women age 15-49 years with a live birth in the last 5 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 84.8 Diarrhoea 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 49.7 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 4.1 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre- packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 17.2 Acute Respiratory Infection (ARI) symptoms 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 64.4 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 59.6 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 0.4 WATER AND SANITATION 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 99.8 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 0.0 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 90.4 6This MICS applied the modules on maternal and newborn health to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The MICS indicator 3.9 is thus not fully comparable to the standard MICS indicator. vii MICS Indicator Indicator Description Value 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 64.2 4.5 Place for hand washing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 88.7 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 87.0 REPRODUCTIVE HEALTH7 Early childbearing 5.2 Early childbearing Percentage of ever-married women age 20-24 years who had at least one live birth before age 18 5.8 Maternal and new-born health 5.5a 5.5b MDG 5.5 Antenatal care coverage Percentage of ever-married women age 15-49 years with a live birth in the last 5 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 90.5 80.7 5.6 Content of antenatal care Percentage of ever-married women age 15-49 years with a live birth in the last 5 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 50.7 5.7 MDG 5.2 Skilled attendant at delivery Percentage of ever-married women age 15-49 years with a live birth in the last 5 years who were attended by skilled health personnel during their most recent live birth 89.0 5.8 Institutional deliveries Percentage of ever-married women age 15-49 years with a live birth in the last 5 years whose most recent live birth was delivered in a health facility 82.1 5.9 Caesarean section Percentage of ever-married women age 15-49 years whose most recent live birth in the last 5 years was delivered by caesarean section 39.8 Post-natal health checks8 5.10 Post-partum stay in health facility Percentage of ever-married 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 5 years 45.9 5.11 Post-natal health check for the new-born Percentage of last live births in the last 5 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 80.0 7This MICS applied the modules on maternal and newborn health, to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The MICS indicators 5.2-5.9, and the MDG indicators 5.2 and 5.5, are thus not fully comparable to the standard MICS and MDG indicators. 8This MICS applied the modules on maternal and newborn health, and post-natal health checks, to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The MICS indicators 5.10-5.12 are thus not fully comparable to the standard MICS indicators. viii MICS Indicator Indicator Description Value 5.12 Post-natal health check for the mother Percentage of ever-married 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 5 years 77.8 LITERACY AND EDUCATION 7.1 MDG 2.3 Literacy rate among young women9 Percentage of ever-married 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 81.5 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 36.5 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 85.8 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 95.0 7.5 Preparatory school net attendance ratio (adjusted) Percentage of children of Preparatory10 school age currently attending Preparatory school or higher 71.9 7.6 MDG 2.2 Children reaching last grade of primary Proportion of children entering the first grade of primary school who eventually reach last grade 97.7 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) 103.5 7.8 Transition rate to preparatory 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 92.3 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 (preparatory school) Preparatory school net attendance ratio (adjusted) for girls divided by preparatory school net attendance ratio (adjusted) for boys 1.01 CHILD PROTECTION Birth registration 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 99.4 9This MICS specifically identified its target group as ever-married women age 15-49. The MDG indicator 2.3, and the MICS indicator7.1 in this sub-national survey are thus not fully comparable to the standard MDG and MICS indicators. 10Preparatory level corresponds to Lower Secondary Education (ISCED 2) according to the international standard classification. ix MICS Indicator Indicator Description Value Early marriage and polygyny 8.4 Marriage before age 15 Percentage of ever-married women age 15-49 years who were first married before age 15 5.8 8.5 Marriage before age 18 Percentage of ever-married women age 20-49 years who were first married before age 18 29.8 8.6 Young women age 15-19 years currently married Percentage of young women age 15-19 years who are married 15.3 8.7 Polygyny Percentage of ever-married women age 15-49 years who are in a polygynous marriage 1.9 8.8a 8.8b Spousal age difference Percentage of currently married women whose spouse is 10 or more years older, (a) among ever-married women age 15-19 years, (b) among ever- married women age 20-24 years 31.5 20.7 ACCESS TO MASS MEDIA AND ICT Access to mass media 10.1 Exposure to all three forms of mass media Percentage of ever-married women age 15-49 years who, at least once a week, read a newspaper/ magazine, or listen to the radio, and watch television 1.4 Use of information/communication technology 10.2 Use of computers Percentage of ever-married young women age 15-24 years who used a computer during the last 12 months 17.0 10.3 Use of internet Percentage of ever-married young women age 15-24 who used the internet during the last 12 months 10.7 x Summary Table of Findings for Selected MoRES Indicators MoRES Indicator Description Value NUTRITION Breastfeeding and infant feeding Receiving no advice on breastfeeding Percentage of ever-married women age 15-49 with a live birth in the last 5 years who received no breastfeeding advice during pregnancy 67.1 Acceptance of immediate breastfeeding after delivery Percentage of ever-married women age 15-49 with a live birth in the last 5 years who were accepting of immediate breastfeeding after delivery 85.9 Acceptance of no pre-lacteal feeds Percentage of ever-married women age 15-49 with a live birth in the last 5 years who were accepting of no pre-lacteal feeds 77.7 Acceptance of exclusive breastfeeding for 6 months Percentage of ever-married women age 15-49 with a live birth in the last 5 years who were accepting of exclusive breastfeeding for 6 months 66.0 REPRODUCTIVE HEALTH Maternal and new-born health Received/ bought iron tablets Percentage of ever-married women age 15-49 with a live birth in the last 5 years who received/ bought iron tablets during pregnancy 61.0 Told about danger signs of pregnancy, delivery and puerperium Percentage of ever-married women age 15-49 with a live birth in the last 5 years who were told about danger signs of pregnancy, delivery and puerperium 22.5 Counselling for side-effects of iron supplementation during pregnancy Percentage of ever-married women age 15-49 with a live birth in the last 5 years and who received or bought iron supplements during pregnancy, who were counselled for side effects of iron supplementation 30.8 Compliance with iron supplementation during pregnancy Percentage of ever-married women age 15-49 with a live birth in the last 5 years who received or bought iron supplements during pregnancy, and who were compliant with iron supplementation 56.8 Presence of at least 3 elements of a birth preparedness plan Percentage of ever-married women age 15-49 with a live birth in the last 5 years who had at least 3 elements of a birth preparedness plan 56.0 Caesarean section planned in advance Percentage of ever-married women age 15-49 with a live birth in the last 5 years, who reported that the Caesarian section was scheduled in advance 20.7 Heel sample taken from infant within 7 days of birth Number of infants born within the last 5 years, who had a heel sample taken within 7 days of birth 94.0 Post-natal health checks Adequate number of PNC visits Percentage of ever-married women age 15-49 with a live birth in the last 5 years who received at least 3 post-natal care visits 3.0 Post-natal home visit within 48 hours Percentage of ever-married women age 15-49 with a live birth in the last 5 years who received a post-natal home visit within 48 hours of birth 1.7 Content of post-natal care visits Percentage of ever-married women age 15-49 with a live birth in the last 5 years, by content of post-natal care: (a) Blood pressure measured (b) Pulse measured (c) Temperature measured (d) Breast examined (e) Lower limbs examined 29.5 20.0 21.9 13.6 13.7 xi MoRES Indicator Description Value Knowledge of danger signs of pregnancy, delivery and puerperum Percentage of ever-married women age 15-49 with a live birth in the last 5 years, by knowledge of at least 3 danger signs of: (a) Pregnancy (b) Delivery (c) Puerperium 9.6 2.4 4.6 Decision making ability Decision-making ability for ANC Total number of ever-married women age 15-49 with a live birth in the last 5 years who participated in decision to have antenatal care 94.6 Decision-making ability for SBA Total number of ever-married women age 15-49 with a live birth in the last 5 years who participated in decision to have a skilled birth attendant 93.4 ACCESS TO MASS MEDIA AND ICT Access to mass media Exposure to any11 form of mass media Percentage of ever-married women age 15-49 years who, at least once a week, read a newspaper/ magazine, or listen to the radio, or watch television 97.0 11 This modified indicator reflects access and use of at least one of the listed mass media. xiii Table of Contents Summary Tables of Survey Implementation and the Survey Population . iii Summary Table of Findings . iv Summary Table of Findings for Selected MoRES Indicators . x Table of Contents . xiii List of Tables . xv List of Figures .xx List of Abbreviations . xxi Acknowledgements . xxiii Executive Summary . xxv I. Introduction . 1 Background . 1 Survey Objectives . 2 II. Sample and Survey Methodology . 3 Sample Design . 3 Questionnaires . 3 Training and Fieldwork . 4 Data Processing . 5 III. Sample Coverage and the Characteristics of Households and Respondents . 7 Sample Coverage . 7 Characteristics of Households . 7 Characteristics of women Respondents 15-49 Years of Age and Children Under-5 . 10 Housing Characteristics and asset ownership . 14 V. Nutrition . 17 Low Birth Weight . 17 Nutritional Status . 19 Breastfeeding and Infant and Young Child Feeding . 26 Children’s Vitamin A Supplementation . 47 Acceptance of Good Breastfeeding Practices . 49 1V. Child Health . 51 Vaccinations . 51 Neonatal Tetanus Protection . 55 Care of Illness. 57 Solid Fuel Use. 71 VII. Water and Sanitation . 73 Use of Improved Water Sources . 73 xiv Use of Improved Sanitation . 78 Hand washing . 81 VIII. Reproductive Health . 85 Early Childbearing . 85 Antenatal Care . 86 Assistance at Delivery . 101 Place of Delivery . 105 Post-natal Health Checks . 107 Danger Signs during Pregnancy/Delivery . 121 X. Literacy and Education . 137 Literacy among Young Ever-married Women . 137 School Readiness . 137 Primary and Preparatory School Participation . 138 XI. Child Protection . 147 Birth Registration . 147 Early Marriage and Polygyny . 148 Children’s Living Arrangements . 152 XIII. Access to Mass Media and Use of Information/Communication Technology . 155 Access to Mass Media . 155 Use of Information/Communication Technology . 157 Appendix A. Sample Design . 161 Appendix B. List of Personnel Involved in the Survey . 165 Appendix C. Estimates of Sampling Errors . 167 Appendix D. Data Quality Tables . 171 Appendix E. MICS5 Indicators: Numerators and Denominators. 185 Appendix F. Questionnaires . 197 xv List of Tables Table HH.1: Results of household, ever-married women's and under-5 interviews . 7 Table HH.2: Household age distribution by sex . 8 Table HH.3: Household composition . 10 Table HH.4: Ever-married women's background characteristics . 11 Table HH.MoRES1: Ever-married women's background characteristics (women with a birth in the past 5 years) . 12 Table HH.5: Under-5's background characteristics . 13 Table HH.6: Housing characteristics . 14 Table HH.7: Household and personal assets . 15 Table NU.1: Low birth weight infants . 18 Table NU.2: Nutritional status of children . 20 Table NU.MoRES1: Nutritional status of children (among last live-born children) . 22 Table NU.MoRES2: Attendance of last scheduled growth monitoring visits; recording of results of growth monitoring and anaemia screening in health card . 24 Table NU.MoRES3: Reasons for not attending last scheduled growth monitoring visit . 26 Table NU.3: Initial breastfeeding . 28 Table NU.MoRES4: Reasons for giving prelacteal feeds . 30 Table NU.4: Breastfeeding. 31 Table NU.MoRES5: Breastfeeding (among last live-born children) . 32 Table NU.MoRES6: Receiving a sample of a breast milk substitute; place of receiving breast milk substitute . 34 Table NU.5: Duration of breastfeeding . 35 Table NU.MoRES7: Duration of breastfeeding (among last live-born children) . 36 Table NU.MoRES8: Person giving advice on breastfeeding; breastfeeding advice received . 38 Table NU.6: Age-appropriate breastfeeding . 40 Table NU.MoRES9: Age-appropriate breastfeeding (among last live-born children). 41 Table NU.7: Introduction of solid, semi-solid, or soft foods . 42 Table NU.8: Infant and young child feeding (IYCF) practices . 43 Table NU.MoRES10: Infant and young child feeding (IYCF) practices (among last live-born children) 44 Table NU.9: Bottle feeding . 46 Table NU.MoRES11: Bottle feeding (among last live-born children) . 47 Table NU.MoRES12: Children's vitamin A supplementation; mother's Vitamin A supplementation . 48 Table NU.MoRES13: Mother's acceptance of good breastfeeding practices . 49 xvi Table NU.MoRES14: Ever-married women of reproductive age’s acceptance of good breastfeeding practices . 50 Table CH.1: Vaccinations in the first years of life . 52 Table CH.2: Vaccinations by background characteristics . 54 Table CH.3: Neonatal tetanus protection . 56 Table CH.4: Reported disease episodes . 58 Table CH.5: Care-seeking during diarrhoea . 60 Table CH.6: Feeding practices during diarrhoea . 61 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 62 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 64 Table CH.9: Source of ORS and zinc . 66 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 68 Table CH.11: Knowledge of the two danger signs of pneumonia . 70 Table CH.12: Solid fuel use. 72 Table CH.13: Solid fuel use by place of cooking. 72 Table WS.1: Use of improved water sources . 74 Table WS.2: Household water treatment . 76 Table WS.3: Time to source of drinking water . 77 Table WS.4: Person collecting water . 77 Table WS.5: Types of sanitation facilities . 78 Table WS.6: Use and sharing of sanitation facilities . 79 Table WS.7: Drinking water and sanitation ladders . 80 Table WS.8: Disposal of child's faeces . 81 Table WS.9: Water and soap at place for hand washing . 82 Table WS.10: Availability of soap or other cleansing agent . 83 Table RH.3: Early childbearing . 85 Table RH.4: Trends in early childbearing . 86 Table RH.7: Antenatal care coverage . 87 Table RH.MoRES1: Reasons for preference for private antenatal care provider. 88 Table RH.8: Number of antenatal care visits and timing of first visit . 90 Table RH.MoRES2: Reasons for late attendance of antenatal care . 91 Table RH.MoRES3: Reasons for insufficient antenatal care (less than 4 visits) . 92 xvii Table RH.9: Content of antenatal care. 94 Table RH.MoRES4: Counselling for side-effects of iron supplementation and compliance during pregnancy . 96 Table RH.MoRES5: Reasons for non-compliance with iron supplementation during pregnancy . 97 Table RH.MoRES6: Reasons for not attending health education sessions at family health unit . 99 Table RH.MoRES7: Presence of a birth preparedness plan . 100 Table RH.10: Assistance during delivery and caesarean section . 101 Table RH.MoRES8: Reasons for Caesarean delivery. 104 Table RH.11: Place of delivery . 105 Table RH.MoRES9: Reasons for not delivering in a health facility . 106 Table RH.12: Post-partum stay in health facility. 109 Table RH.13: Post-natal health checks for new-borns . 111 Table RH.14: Post-natal care visits for new-borns within one week of birth . 113 Table RH.15: Post-natal health checks for mothers . 115 Table RH.MoRES10: Content of post-natal care visits. 117 Table RH.16: Post-natal care visits for mothers within one week of birth . 118 Table RH.17: Post-natal health checks for mothers and new-borns . 120 Table RH.MoRES11: Knowledge of danger signs of pregnancy/delivery/puerperium . 122 Table RH.MoRES12: Persons providing information on danger signs of pregnancy . 124 Table RH.MoRES13: Source of knowledge of danger signs of delivery . 125 Table RH.MoRES14: Source of knowledge of danger signs of puerperium . 126 Table RH.MoRES15: Knowledge and reported occurrence of danger signs in pregnancy, delivery and puerperium . 127 Table RH.MoRES16: Person consulted after occurrence of danger signs. . 127 Table RH.MoRES17: Reasons for not consulting a physician after occurrence of danger sign(s) of pregnancy . 129 Table RH.MoRES18: Reasons for not consulting a physician after occurrence of danger sign(s) of puerperium . 131 Table RH.MoRES19: Decision-making ability for antenatal care and skilled birth attendant . 132 Table RH.MoRES20: Awareness of different services provided at the family health units . 134 Table RH.MoRES21: Client satisfaction with services provided at the family health units, among ever-married women age 15-49 who attended there in the last 12 months. 135 Table ED.1: Literacy (young ever-married women) . 137 Table ED.2: School readiness . 138 Table ED.3: Primary school entry. 139 Table ED.4: Primary school attendance and out of school children . 140 xviii Table ED.5: Preparatory school attendance and out of school children . 141 Table ED.6: Children reaching last grade of primary school . 142 Table ED.7: Primary school completion and transition to preparatory school . 143 Table ED.8: Education gender parity . 144 Table ED.9: Out of school gender parity . 145 Table CP.1: Birth registration . 147 Table CP.7: Early marriage and polygyny (ever-married women) . 149 Table CP.8: Trends in early marriage (ever-married women) . 150 Table CP.9: Spousal age difference . 152 Table CP.14: Children's living arrangements and orphan hood . 153 Table CP.15: Children with parents living abroad . 153 Table MT.1: Exposure to mass media (ever-married women) . 155 Table MT.MoRES1: Exposure to mass media (among ever-married women with a birth in the 5 years preceding the survey) . 157 Table MT.2: Use of computers and internet (ever-married women) . 158 Table MT.MoRES2: Use of computers and internet (among ever-married women with a birth in the 5 years preceding the survey) . 158 Table SE.1: Indicators selected for sampling error calculations . 168 Table SE.2: Sampling errors: Total sample . 169 Table SE.5: Sampling errors: Pilot Phase, Upper Egypt . 169 Table SE.6: Sampling errors: Expansion Phase, Upper Egypt . 170 Table SE.7: Sampling errors: Expansion Phase, Lower Egypt . 170 Table DQ.1: Age distribution of household population . 171 Table DQ.2: Age distribution of eligible and interviewed ever-married women . 172 Table DQ.4: Age distribution of children in household and under-5 questionnaires . 173 Table DQ.5: Birth date reporting: Household population . 173 Table DQ.6: Birth date and age reporting: Ever-married women . 174 Table DQ.8: Birth date and age reporting: Under-5s . 174 Table DQ.9: Birth date reporting: Children, adolescents and young people . 175 Table DQ.10: Birth date reporting: First and last births . 175 Table DQ.11: Completeness of reporting . 176 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . 176 xix Table DQ.13: Completeness of information for anthropometric indicators: Stunting . 177 Table DQ.14: Completeness of information for anthropometric indicators: Wasting . 177 Table DQ.15: Heaping in anthropometric measurement . 177 Table DQ.16: Observation of birth certificates . 178 Table DQ.17: Observation of vaccination cards . 179 Table DQ.18: Observation of ever-married women's health card . 179 Table DQ. 19: Observation of places for hand washing . 180 Table DQ.20: Presence of mother in the household and the person interviewed for the under-5 questionnaire . 180 Table DQ.22: School attendance by single age . 181 Table DQ.23: Sex ratio at birth among children ever born and living . 182 Table DQ.24: Births by calendar years . 182 Table DQ.25: Reporting of age at death in days . 183 Table DQ.26: Reporting of age at death in months . 184 xx List of Figures Figure HH.1: Age and sex distribution of household population, Egypt Sub-National MICS, 2013-14 . 9 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Egypt Sub-National MICS, 2013-14 . 23 Figure NU.2: Initiation of breastfeeding, Egypt Sub-National MICS, 2013-14. 29 Figure NU.MoRES1: Percent exclusively breastfed among children 0-5 months, by region, Egypt Sub-National MICS, 2013-14 . 33 Figure CH.1: Vaccinations by age 12 months (Measles 12+ months), Egypt Sub-National MICS, 2013-14 . 53 Figure CH.MoRES1: Percentage of ever-married women with a live birth in the last 12 months who are protected against neonatal tetanus, Egypt Sub-National MICS, 2013-14 . 57 Figure CH.2: Percentage of children under age 5 with diarrhoea who received ORS, Egypt Sub-National MICS, 2013-14 . 63 Figure CH.3: Percentage of children under age 5 with diarrhoea who received ORT (ORS, or increased fluids) and continued feeding, Egypt Sub-National MICS, 2013-14 . 65 Figure WS.1: Percent distribution of household members by source of drinking water, Egypt Sub-National MICS, 2013-14 . 75 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities, Egypt Sub-National MICS, 2013-14 . 79 Figure RH.3: Person assisting at delivery, Egypt Sub-National MICS, 2013-14 . 103 Figure ED.1: Education indicators by sex, Egypt Sub-National MICS, 2013-14 . 145 Figure CP.1: Children under age five whose births are registered, Egypt Sub-National MICS, 2013-14 . 148 Figure CP.3: Early marriage, Egypt Sub-National MICS, 2013-14 . 151 Figure DQ.1: Household population by single ages, Egypt Sub-National MICS, 2013-14 . 172 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points, Egypt Sub-National MICS, 2013-14 . 178 xxi List of Abbreviations ANC Antenatal Care BCG Bacillus-Calmette-Guerin (Tuberculosis) CHWs Community Health Workers CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization FHU Family Health Unit GPI Gender Parity Index IPHN Integrated Perinatal Health and Child Nutrition Programme HIV Human Immunodeficiency Virus MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Cluster Surveys programme MoHP Ministry of Health and Population MoRES Monitoring Results for Equity Systems NAR Net Attendance Rate ORT Oral rehydration treatment PNC Post Natal Care SBA Skilled Birth Attendant SPSS Statistical Package for Social Sciences TBA Traditional Birth Attendant UNICEF United Nations Children’s Fund WHO World Health Organization xxiii Acknowledgements This MICS was implemented within the collaboration between Egypt Ministry of Health and Population and UNICEF Egypt Country Office, with the aim to provide key data for the monitoring system of the Integrated Perinatal Care and Nutrition (IHPN) programme, active in selected rural districts of 4 Upper Egypt governorates and 2 Lower Egypt governorates. The survey was designed by UNICEF ECO and conducted by El-Zanaty and Associates led by Dr Fatma El-Zanaty and supported by the UNICEF Regional Office for Middle East and North Africa and the global MICS team at UNICEF Headquarters in all phases of the preparation and implementation of the survey. Acknowledgments go to the following persons who contributed to the implementation of different parts of the survey: Ministry of Health and Population: Dr Mohamed Nour El-Din, the head of Mother Child Health Unit Dr Osama Shawkat, the MCH Specialist El-Zanaty and Associates for their dedication and skill in implementing this survey: Dr Fatma El-Zanaty, President of El-Zanaty &Associates and Technical Director of the survey Dr Rashad Hamed, Assistant Director for Data Processing Mr. Mohamed El-Ghazaly, Assistant Survey Director UNICEF Egypt Country Office: Dr Leonardo Menchini, Chief of Social Policy, Monitoring and Evaluation Section Ms Manar Soliman, Knowledge Management and Statistics Officer Dr Naglaa Arafa, MoRES Consultant Dr Magdy El-Sanady, Chief of the Young Child Survival and Development Section Dr Samy Isaac, Health Officer UNICEF Regional Office for Middle East and North Africa: Ms Sarah Ahmad Mirza, Regional MICS Coordinator Dr Mohamed Mahmoudi, Regional MICS sampling consultant Mr. Housni El Arabi, Regional MICS consultant UNICEF headquarters for their continuous and valuable technical support and feedback on sampling, questionnaire design, and review of syntaxes and results. Dr Attila Hancioglu, Senior Adviser and Global MICS Coordinator Mr. Turgay Unalan, Statistics and Household Surveys Specialist Ms Ivana Bjelic, Statistics and Data Processing Specialist Lastly and not least, acknowledgments and sincere thanks and appreciation are extended to all the households and participants who responded in the survey; they opened their homes and gave their time and hospitality to respond to this survey. xxv Executive Summary The MICS in the rural districts cover by the IPHN programme in Egypt was conducted as part of the fifth global round of MICS Surveys (MICS5). The IPHN programme is implemented by the Ministry of Health and Population (MoHP) in collaboration with UNICEF in selected disadvantaged rural areas of Upper and Lower Egypt. The survey has been specifically designed to respond to the data needs of the IPHN program and of its monitoring system (which adopts the model of the Monitoring Results for Equity System, developed by UNICEF). The specific focus of this MICS is on perinatal care. In the MoRES framework developed for the IPHN program, this survey complements the data provided by the routine administrative data collection system and by evidence provided by a qualitative study on perinatal care and nutrition. The IPHN programme has been initially conducted, since 2008, as a pilot in selected rural village/Family Health Units (FHUs) in 3 Upper Egypt governorates, and then – starting in 2012, it has been expanded in new FHUs in Upper Egypt and Lower Egypt, covering a total of 6 governorates at the time of the survey. A total of 2.5 million people were living in the areas of intervention at the time of the survey. Consistently with the focus of the survey on perinatal care, this household survey considered as eligible for the interviews ever-married women age 15-49 and children under five. A total of 7046 households were successfully interviewed with response rate of 99.9 percent. A total of 5847 ever-married women age 15-49 were successfully interviewed and 5090 questionnaires were completed for children under-5. The results of the survey are representative of the full area covered by the IPHN and for three sub- domains, namely the pilots FHUs in Upper Egypt, the FHUs of Upper Egypt expansion phase, and the FHUs of the Lower Egypt expansion phase. Following is a summary of the main survey results. Household Characteristics The mean number of household members is 4.6. Twelve percent of the interviewed households were headed by a female. Almost all households have electricity and over 90 percent of households in all areas own: TV, refrigerator, satellite dish, and washing machine as well as mobile phones. Nutrition The height and weight measurements were taken for all children under-5 years using anthropometric equipment recommended by UNICEF. The survey indicates that 5 percent of children under-5 were classified as underweight, while 2 percent of children were severely underweight. Data show that 22 percent of children of this age were too short for their age (stunting). The data show also that wasting was present amongst 3 percent of children. More than one in six children under-5 years of age (17 percent) were overweight. The lowest percentage of underweight children was observed in expansion phase Lower Egypt (3 percent), while it was 6 percent in both pilot phase area and expansion phase Upper Egypt. No significant differences were observed between areas in the level of stunting where it ranges from 22 percent in expansion phase Upper Egypt to 19 percent in pilot phase area. Also, the highest percentage of wasted children was found in expansion phase Lower Egypt (3 percent). The highest percentage of overweight children was found in expansion phase Lower Egypt where almost one in three children is xxvi overweight. The proportion of overweight children increases with the mother’s education level and was highest amongst children whose mothers had higher education (23 percent). Despite the importance of early start of breastfeeding and establishment of a physical and emotional relationship between the baby and the mother, only 36 percent of babies are breastfed for the first time within one hour of birth, while 79 percent of new-borns started breastfeeding within one day of birth. The percentage of children who received a prelacteal feed was 61 percent. There were no clear differences between the three subdomains (regions) in the percentage of children who were first breastfed within one hour of birth (between 35 to 37 percent) or who were first breastfed within one day of birth (between 79 to 82 percent). Percentage of children who received a prelacteal feed was highest in pilot phase area (64 percent) and lowest in expansion phase Lower Egypt (49 percent). Exclusive breastfeeding is found in expansion phase Lower Egypt (50 percent) more often than in pilot phase or in expansion phase Upper Egypt (46 and 44 percent respectively). In older age groups, expansion phase Upper Egypt children continue receiving breast milk more often than children of other regions. Children of mothers with higher education are less likely to be exclusively breastfed than children of women with primary/preparatory education or no education levels (41 percent compared to 51 percent and 49 percent respectively). Less than one third of the children age 6-23 months (31 percent) were receiving the minimum acceptable diet (solid, semi-solid and soft foods with the recommended minimum number of times). Slightly less than two thirds of infants (63 percent) were weighed at birth. The data indicated that significant variation by region; the highest percentage of infants weighed at birth was observed in expansion phase Lower Egypt (84 percent), while the lowest was found in expansion phase of Upper Egypt (58 percent). Approximately 23 percent of infants are estimated by their mothers to be very small or smaller than average, which match with the figure for infants weigh less than 2,500 grams at birth (23 percent). Child Health According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a measles vaccination by the age of 12 months. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. The vaccination schedule followed by the Egypt National Immunization Programme provides all the above- mentioned vaccinations as well as three doses of vaccine against Hepatitis B. All those vaccinations should be received during the first year of life except for the MMR (measles) which should be received at age 12 months and 18 months. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the Egypt MICS are based on children age 24-35 months. Approximately 91 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 99 percent, which is almost the same percent for the second dose. However, the percentage of children age 12-23 months who received the DPT third dose drops to 96 percent. Similarly, virtually all children received Polio 1 by age 12 months and this declines to 97 percent by the third dose. Looking at older children (24-35 months), 96 percent received the measles vaccine by age 24 months. There is also a slight decrease in the Hepatitis B vaccination from 99 percent for the first dose to 98 percent for the second dose, and then a decline to 95 percent for the third dose, reflecting a small dropout rate of less than 3 percent. Overall, 82 percent of children in the age 24-35 months were fully immunized. xxvii Nineteen percent of under-five children had diarrhoea in the two weeks preceding the survey. No advice or treatment was sought for more than one-third of these children (37 percent of those who had diarrhoea), while treatment from a health facility or provider was sought for half of the children with diarrhoea. During the episode of diarrhoea, only 8 percent of children under-five with diarrhoea drank more than usual, almost one-third of children (34 percent) drank the same, while more than half of children (51 percent) drank less or much less. It is also worth noting that 7 percent of children who had diarrhoea were not given anything to drink. With respect to food intake, a quarter of the children were given the same amount to eat, 37 percent were given somewhat less and 20 percent of children were given much less than usual to eat. In 16 percent of cases children stopped food altogether. Only 2 percent of children were given more than usual food to eat with no significant regional differences. Four percent of children received fluids from ORS packets and pre-packaged ORS fluids with zinc. Children of mothers living in the pilot phase were less likely to receive ORS and zinc (3 percent) than children of mothers living in the expansion phase Upper Egypt (4 percent) and in the expansion phase Lower Egypt (6 percent). Overall, 13 percent of children had symptoms of ARI; however, prevalence of ARI was highest in expansion phase of Lower Egypt (17 percent), lower in Expansion Upper Egypt (13 percent) and least in pilot phase, Upper Egypt (11 percent). Around two-third of those children treatment or advice was sought from a health facility or provider. Sixty percent of children with ARI in the two weeks preceding the survey were given antibiotics. Water and Sanitation Almost the entire population in the IPHN areas uses an improved source of drinking water with minimal variation across regions. The majority of the population uses drinking water that is piped into their dwelling or into their yard or plot (90 percent). Piped water (including water piped to a neighbour or a public tap) was used by the vast majority of the population (97 percent). Five percent of households in the areas covered by the survey had no water sources on the premises (less than 2 percent in pilot phase and expansion phase Upper Egypt, while it was 24 percent in expansion phase Lower Egypt) and that the percentage of households with no sources of drinking water on the premises surprisingly increased with increased education level of household heads. More than 95 percent of household population used improved sanitation facilities. The highest percentage was reported among households in expansion phase and pilot phase Upper Egypt (99 percent) and lowest percentage among those in expansion phase Lower Egypt (72 percent). Three- quarters of the improved sanitation facilities were flush toilets connected to pit latrines (bayara), or septic tank (14 percent) and less likely to pipe sewer system (7 percent). Also, 90 percent of the population used improved sanitation that is not shared. The percentage of children aged 0-2 years whose last stools were disposed of safely was 64 percent: 69 percent in expansion phase Upper Egypt, 63 percent in pilot phase areas and 41 percent in in expansion phase Lower Egypt. For almost one third of children aged 0-2 years, the last stool was thrown into garbage. Surprisingly, the percentage of children aged 0-2 years whose last stools were disposed of safely is inversely proportional with mothers’ education. It is the lowest among mothers who had higher education (48 percent), whereas it is the highest among mothers who had no education (75 percent). Hand washing with water and soap is the most cost effective health intervention to reduce the incidence of both diarrhoea and pneumonia in children under five. The place used for hand washing xxviii was observed in 89 percent of households in Egypt MICS.In89 percent of cases these places had both water and soap present. Soap or other cleansing agent was available in 81 percent of households and in 2 percent of households the soap was subsequently shown to the interviewer. Soap or other cleansing agent was available in 92 percent of households in expansion phase Lower Egypt, 81 percent of households in pilot phase and 78 percent of households in expansion phase Upper Egypt. Reproductive Health This Sub-National MICS specifically applied the modules on maternal and new-born health only to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The indicators presented are thus not fully comparable to the standard MICS indicators. Sexual activity and childbearing early in life carry significant risks for young people all around the world. Forty-seven percent of ever-married women age 15-19 have already had a birth and among those women no live births before the age of 15 were observed. About 6 percent of ever-married women age 20 - 24 have had a live birth before age 18, mostly among mothers who had no education. More than 90 percent of women receive antenatal care and the majority (90 percent) of antenatal care is provided by medical doctors with preference for private antenatal care provider. Medical doctors provided antenatal care to almost all women of the expansion phase Lower Egypt and to 89 percent of women in pilot phase and to 88 percent of women in the expansion phase Upper Egypt. Only a minority of women receive care from a nurse/midwife. UNICEF and WHO recommend a minimum of four antenatal care visits during pregnancy. Almost nine in ten mothers (89 percent) receive antenatal care more than once, and four in five mothers received antenatal care at least four times (81 percent). Mothers living in the expansion phase Upper Egypt, mothers with high number of children and those with no education are less likely than more advantaged mothers to receive ANC four or more times. About 89 percent of births occurring in the five years preceding the MICS survey were delivered by skilled personnel. This percentage is highest in the expansion phase Lower Egypt (98 percent) and lowest in the expansion phase Upper Egypt (87 percent). More than four in five births (82 percent) in the IPHN areas are delivered in a health facility; 26 percent of deliveries occur in public sector facilities and 56 percent occur in private sector facilities. Less than one in five births (18 percent) occur at home. Women in expansion phase Lower Egypt are more likely to deliver in a health facility (96 percent) compared with women living in the pilot phase (81 percent) and women living in expansion phase Upper Egypt (79 percent). Less than half (46 percent) of ever-married women who gave birth in a health facility stay 12 hours or more in the facility after delivery with no much regional differences .There are no clear patterns with regards to background characteristics of women. Slightly more than three in four new-borns (76 percent) receive a health check following birth whether in a facility or at home. This percentage is the highest in the expansion phase Lower Egypt (96 percent) and lower in the pilot phase (76 percent) and the lowest in expansion phase Upper Egypt (72 percent). More than two-thirds (68 percent) of the first postnatal care (PNC) visits for new-borns occur in a private facility, only 17 percent in public facility and 16 percent at home. Around 95 percent of the first PNC visits for new-borns are provided by either a doctor/nurse/midwife or an auxiliary midwife, 2 percent by community health worker (CHW) mainly in the expansion phase Lower Egypt (7 percent), and 3 percent by traditional birth attendants (TBA). xxix Seventy-seven percent of mothers receive a health check following birth whether in a facility or at home. This percentage is the highest in the expansion phase Lower Egypt (96 percent) and lower in the pilot phase (78percent) and the lowest in expansion phase Upper Egypt (73 percent). Overall, 78 percent of women in the age 15-49 years who have a live birth in the last five years received any postnatal care (i.e. any health check while in health facility or at home, as well as PNC visits within 2 days of delivery). This percentage was highest in expansion phase Lower Egypt (96 percent) and lowest in expansion phase Upper Egypt (73 percent). More than half (51 percent) of the first PNC visits for mothers occur in a private facility, while only 12 percent in public facility and 37 percent at home. Around 93 percent of the first PNC visits for mothers are provided by either a doctor/nurse/midwife or an auxiliary midwife in Egypt, 2 percent by community health worker (CHW) mainly in the expansion phase Lower Egypt (6 percent), and 4 percent by traditional birth attendants (TBA) mainly in the expansion phase Upper Egypt (6 percent). This MICS shows that for slightly less than three quarter (74 percent) of live births, both the mothers and their new-borns received either a health check following birth or a timely (within 2 days of delivery) PNC visit, whereas for 16 percent of births both the mother and the new-born did not receive any health checks. There are large discrepancies by background characteristics. Proportion of births served with health checks or timely visits is highest in expansion phase Lower Egypt (95 percent), followed by the pilot phase (74 percent) and it is lowest in the expansion phase Upper Egypt (69 percent). More than half of women (52 percent) did not know any of the danger signs of pregnancy, 38 percent knew 1-2 signs and only 10 percent knew 3 or more signs. While 70 percent did not know any of the danger signs of delivery, 28 percent knew 1-2 signs and only 2 percent knew 3 or more danger signs of delivery. In addition, more than half of women (56 percent) did not know any of the danger signs of puerperium, 39 percent knew 1-2 signs and only 5 percent knew at least 3 signs. Proportion of the women who did not know any of the danger signs of pregnancy was the highest among women living in expansion phase Upper Egypt (57 percent), followed by women living in the pilot phase (50 percent), and it was the lowest among women living in expansion phase Lower Egypt (34 percent). Proportion of the women who did not know any of the danger signs of delivery was higher in both expansion phase Upper Egypt and the pilot phase (73 percent), and it was lower among women living in expansion phase Lower Egypt (54 percent). Proportion of the women who did not know any of the danger signs of puerperium also show similar pattern which was the highest among women living in expansion phase Upper Egypt (60 percent), followed by women living in the pilot phase (51 percent), and it was lowest among women living in expansion phase Lower Egypt (44 percent). The source of knowledge of at least one danger sign of pregnancy was a health provider (physician or nurse) in 37 percent of women; relatives (other than husbands or friends/neighbours) were the source in another 35 percent, friends/neighbours in 29 percent, television/radio in 10 percent, and CHW in 9 percent of women. Health provider (physician or nurse) was the source of knowledge in 56 percent of women living in the expansion phase Lower Egypt, 37 percent of women living in the pilot phase, and only 30 percent of women living in the expansion phase Upper Egypt. The source of knowledge of at least one danger sign of delivery was friends/neighbours and relatives (other than husbands or friends/neighbours) in 36 and 35 percent respectively, the source of knowledge in 30 percent of women was a health provider (physician or nurse), CHW in 7 percent, and xxx television/radio in 6percent of women. There was significant difference by region where, health provider (physician or nurse) was the source of knowledge in 50 percent of women living in the expansion phase Lower Egypt, 33 percent of women living in the pilot phase, and only 22 percent of women living in the expansion phase Upper Egypt. The source of knowledge of at least one danger sign of puerperium was relatives other than the husband in 48 percent of cases, friends/neighbours in 45 percent, health provider in 24 percent and for 8 percent their source of knowledge was television/radio. When women age 15-49 who gave birth in the last five years were asked about the decision-making ability for antenatal care and skilled birth attendance, results indicate that there were little regional differences in decision-making for both antenatal care and skilled birth attendance. The joint decision for ANC in expansion phase Lower Egypt (77 percent) was slightly higher than in both expansion phase Upper Egypt and pilot phase (75 percent). The joint decision for SBA in both pilot phase and expansion phase Lower Egypt (77 percent) was slightly higher than in expansion phase Upper Egypt (75 percent). The decision-making was mainly by respondent for both ANC & SBA was higher in the pilot phase, while the decision-making was mainly by the husband for both ANC & SBA was higher in the expansion phase Upper Egypt. Child Protection The survey shows that 99 percent of children under five years in Egypt have been registered. There are no significant variations in birth registration across sex, region, or education categories. The survey shows that 6 percent of women ages 15-49 years were first married before 15 years of age. As for women age 20-49 years, 7 percent of them were first married before 15 years of age and 30 percent were first married before the age of 18. Fifteen percent all of the women among the age group 15-19 were currently married. The survey shows that the percentages of married women before the age of 15 and before the age of 18 were the highest in the expansion phase Upper Egypt (10 percent and 39 percent respectively). In the pilot phase the proportions were 7 percent and 30 percent, while the percentages were the lowest in the expansion phase Lower Egypt (2 percent and 16 percent). Literacy and Education Eighty-two percent of women aged 15-24 in Egypt are literate. Interestingly, 94 percent of women age 15-24 in expansion phase Lower Egypt were literate, 85 percent in pilot phase Upper Egypt were literate while slightly more than three-quarters of women were literate in expansion phase Upper Egypt. Of the women that stated that primary or preparatory school was their highest level of education, only 73 percent were able to successfully read the statement shown to them. There is improvement over time in percentage of literacy among women where the percent of literate women among the age group 15-19 is 79 percent compared with 82 percent among the age group 20-24. Thirty-seven percent of children in Egypt who were currently attending the first grade of primary school had attended preschool the previous year: 45 percent in the pilot phase areas, 44 percent in expansion phase Lower Egypt and only 34 percent in expansion phase Upper Egypt. The proportion was slightly higher amongst male (38 percent) than female children (35 percent). xxxi Out of the total number of children of primary school entry age in Egypt, 86 percent were attending the first grade (94 percent in expansion phase Lower Egypt, 91 percent in pilot phase and 83 percent in expansion phase Upper Egypt). The majority of children of primary school age are attending school (95 percent). However, 2 percent of the children are out of school when they are expected to be participating in school. In expansion phase Lower Egypt and pilot phase, the net attendance ratio was 98 percent, while in expansion phase Upper Egypt attendance ratio is 94 percent. Net attendance ratio decreased as the level of school increases. 72 percent attend preparatory school, which is lower compared to primary school. Ten percent of children of preparatory school age were attending primary school when they should be attending preparatory school, while 16 percent were not attending school at all. Only 92 percent of the children that completed successfully the last grade of primary school were found at the moment the survey to be attending the first grade of preparatory school. This transition rate to preparatory schools was higher among female children (97 percent) than male children (89 percent). The rate is the highest in the expansion phase Lower Egypt (98 percent) followed by pilot phase areas (95 percent), and it was 91 percent in expansion phase Upper Egypt. Proportion of girls in the total out of school population of primary school age was 42 percent, which indicated more drop out among boys than girls. Access to Mass Media and Use of Information/Communication Technology The survey findings show that in Egypt only 3 percent of ever-married women age 15-49read a newspaper, 14 percent listened to the radio and 96 percent of women watched television at least once a week. In the expansion phase Lower Egypt, nearly all women watched television (98 percent), 35 percent listen to the radio, 11 percent read a newspaper at least once a week, and 1 percent of women do not have regular exposure to any of the three types of media. On the other hand, in the pilot phase, 97 percent of women watched television, 12 percent listen to the radio, 3 percent read a newspaper at least once a week, and 3 percent of women do not have regular exposure to any of the three types of media. In the expansion phase Upper Egypt, 96 percent of women watched television, 9 percent listen to the radio, 2 percent read a newspaper at least once a week, and 4 percent of women do not have regular exposure to any of the three types of media. The findings show that 30 percent of ever-married women aged 15-24 ever used a computer, 17 percent used a computer in the 12 months preceding the survey and 11 percent had used a computer at least once a week during the last one month. Overall 13 percent of women aged 15-24 had used the Internet during their lifetime, while 11 percent had used the Internet during the 12 months preceding the survey. The proportion of women aged 15- 24 who had used the Internet more frequently, at least once a week during the last one month, was smaller (7 percent). The computer had been used in the last 12 months by 41 percent of women in the expansion phase Lower Egypt, 21 percent of women in the pilot phase and 12 percent of women in the expansion phase Upper Egypt. Use of the Internet in the last 12 months is more common among women in the expansion phase Lower Egypt (28 percent), followed by women in the pilot phase (14 percent) and the least was among women in the expansion phase Upper Egypt (7 percent). 1 I. Introduction Background Since early 2008, the MoHP, with the support of UNICEF have piloted an initiative to accelerate the national efforts to address neonatal mortality, originally named the Peri-natal Care Programme of Excellence (PCPE), and now called the Integrated Perinatal Health and Child Nutrition (IPHN) Programme. The programme is implemented in selected disadvantaged rural areas. The model seeks to strengthen performance at the primary and secondary levels of care; to strengthen the referral system; and to provide family and community support through training community health workers (CHWs). At the primary and community level, the model is implemented at Family Health Units (FHUs) and their corresponding catchment areas. The model has four components: antenatal care (ANC), skilled birth attendants (SBA), postnatal care (PNC), and nutrition. The pilot phase of the programme was implemented in 14 selected FHUs in 4 districts in rural Upper Egypt. In 2012, the programme was expanded to include all the remaining FHUs of these 4 districts; all FHUs of an additional district in rural Upper Egypt were also added to the IPHN. In addition, other 21 FHUs of 2 districts of rural Lower Egypt were added. At the time of the survey, the programme covers a total of 160 FHUs, located in 7 districts in 6 governorates (Menia, Assiut, Sohag and Qena in Upper Egypt; and Gharbia and Qalyoubiya, in Lower Egypt). The total population living in the areas covered by the programme is approximately 2.5 million people. The monitoring system for this programme adopts the concepts and formats of the ‘Monitoring Results for Equity Systems’ (MoRES) promoted by UNICEF. MoRES is a conceptual framework for effective planning, programming, monitoring and managing for results to achieve desired outcomes for the most disadvantaged children. One of the key approaches which characterises MoRES is the Bottlenecks and Barrier Analysis, focusing on the critical factors or determinants which may constrain the achievement of the program’s results. The preliminary work conducted by the MoRES task force comprising of MoHP and UNICEF staff, with the support of the other national experts, identified a series of indicators reflecting potential bottlenecks existing in the system and which need to be monitored and analysed to improve the programme interventions. The indicators identified for assessing and monitoring bottlenecks to the programme implementation have different natures and require a mix of data collection tools (routinely collected administrative data, household surveys, and qualitative tools). An adaptation of the Multiple Indicator Cluster Survey (MICS) was decided for providing the survey data for the MoRES data system. The Multiple Indicator Cluster Survey (MICS) is an international household survey programme developed by UNICEF. MICS is designed to collect statistically sound, internationally comparable estimates of key indicators that are used to assess the situation of children and women in the areas of health, education, and child protection. MICS also provides a tool to monitor progress towards national goals and global commitments aimed at promoting the welfare of children, including the Millennium Development Goals (MDGs). This report is based on the Egypt sub-national Multiple Indicator Cluster Survey, conducted in 2013- 2014 by the El-Zanaty & Associates. The survey provides valuable information on the situation of children and women in the IPHN project areas, and was based, in large part, on the needs to monitor progress towards goals and targets emanating in the project. This MICS survey has been designed to be representative for the areas covered by the IPHN programme, including three geographical domains, i.e. the original pilot FHUs in Upper Egypt, the 2 expansion FHUs in Upper Egypt and the expansion FHUs in Lower Egypt. This MICS survey has been designed and tailored to respond to the data needs of the IPHN programme and its monitoring system (MoRES) and it has a specific focus on perinatal care and child health and nutrition. The results of this MICS, along with other implemented MoRES data tools (regular administrative data collection and a qualitative study) are providing MoHP and UNICEF with comprehensive data on key indicators of maternal and child health, nutrition behaviours, and use of perinatal care services. Thus, it will enhance the understanding of the factors preventing or enabling the success of the IPHN programme, assess geographic inequalities between rural areas in Upper and Lower Egypt, and will contribute to the assessment of the impact of the interventions. The survey results also compare all indicators between FHUs catchment areas in the pilot-phase and the expansion-phase in Upper and Lower Egypt, which are reported separately in Annex (G). Accordingly, the purpose of the assignment is to implement the household survey (using the Multiple Indicator Cluster Survey, MICS, and format) component of the new data system associated with Perinatal Care Programme of MOHP, to provide quantitative data, analysis on young child health and nutrition, on bottlenecks and barriers to effective perinatal care and nutrition interventions in rural Egypt. Survey Objectives This MICS has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women in in the areas where the IPHN is implemented, for the indicators included in the survey (focusing on child health, child and maternal health care, and nutrition).  To provide data disaggregated by domain for the pilot phase villages in Upper Egypt, expansion phase villages in Upper Egypt, and expansion phase villages in Lower Egypt.  To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable and contribute to more effective interventions of the IPHN interventions;  To validate data from other sources and the results of focused interventions. 3 II. Sample and Survey Methodology Sample Design The sample for the survey was designed to provide estimates for a large number of indicators on the situation of children and women in IPHN areas, and for the three domains: Upper Egypt pilot area, Upper Egypt expansion area, and Lower Egypt expansion area. The Family Health Unit (FHU) catchment areas in the villages of the IPHN within each region were identified as the main primary sampling units (PSUs) and the sample was selected in three stages. Within each stratum, a specified number of FHUs were selected systematically with probability proportional to size, where 10 FHUs were selected from Upper Egypt Pilot phase, and 17 FHUs from Upper Egypt Expansion phase, and 11 FHUs from Lower Egypt Expansion phase. Then a number of enumeration areas were selected systematically with probability proportional to size from each FHU catchment area. A total of 234 EAs in the selected FHUs were thus selected, 60 from Upper Egypt pilot, 108 from Upper Egypt expansion, and 66 from Lower Egypt Expansion. After a household listing was carried out within the selected enumeration areas, a systematic sample of 30-31 households with women age 15 to 49 and/or with children under-5 years was drawn in each sample enumeration area for a total of 7067 sample households. The sample was stratified by the three domains, and is not self-weighting. For reporting results for the entire IPHN area, sample weights are used. A more detailed description of the sample design can be found in Appendix A, Sample Design. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members (usual residents), the household, and the dwelling; 2) a women’s questionnaire administered in each household to all ever-married women age 15-49 years; 3) an under-5 questionnaire, administered to mothers or caretakers for all children under- 5 living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules:  List of Household Members  Education  Household Characteristics  Water and Sanitation  Hand Washing The standard MICS individual woman questionnaire is applied to all women. However, in this sub-national MICS, the UNICEF Egypt Country Office specifically identified the target group of women as ever-married women age 15-49, as beneficiaries of the perinatal health services offered by IPHN. In addition, this sub- national MICS also deviated from the standard MICS by applying the modules on maternal and new-born health, and post-natal health checks, to women with a live birth in the last 5 years, instead of in the last 2 years, so as to ensure an adequate number of responses. The MDG and MICS indicators calculated for women in this sub-national survey are thus not fully comparable to the standard MDG and MICS indicators. The Questionnaire for Individual Women included the following modules:  Women’s Background  Access to Mass Media and Use of Information/Communication Technology  Marriage  Birth History 4  Desire for Last Birth  Maternal and New-born Health  Post-natal Health Checks  Illness Symptoms  Attitude Module  Woman and Husband’s work status The Questionnaire for Children under Five was administered to mothers or caretakers of children under-5 years of age12living 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  Breastfeeding and Dietary Intake  Immunization  Growth Monitoring  Care of Illness  Anthropometry The questionnaires were based on the MICS5 model questionnaire13. The previous mentioned sections were taken from the MICS5 model Arabic version questionnaires and customized, then translated into Egyptian Arabic. Additional questions were added to respond to the data needs of the monitoring system (MoRES) of the IPHN, especially in antenatal and postnatal sections. A pre-test of the questionnaires was conducted in November 2013. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Egypt sub-national MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams observed the place of hand washing and measured the weights and heights for 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 two weeks in November. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent two days in practice interviewing in Manial Sheha FHU/ Abo El-Nomrous district in Giza and El-Kateba FHU/ Belbis district Sharkia. The data were collected by nine teams; each was comprised of one supervisor, one field editor and 4 interviewers. As a dedicated measurer was not included, the supervisor and field editor were mainly responsible of height and weight measurement. In addition one interviewer per team was trained on 12 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. 13 The model MICS5 questionnaires can be found at www.childinfo.org/mics5_questionnaire.html 5 height and weight to assist them during fieldwork. Fieldwork began on 3rd of December 2013 and concluded on 2nd of January 2014. Data Processing Data were entered using the CSPro software. The data were entered on eight microcomputers and carried out by 8 data entry operators, one data entry supervisor and one assistant. In order to ensure quality control, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS5 programme were used and adapted to the Egypt questionnaire in the survey. Data processing began simultaneously with data collection in mid-December 2013 and was completed with the clean data set in late January 2014. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 18, and the model syntax and tabulation plans developed by UNICEF were used for this purpose. In addition the country specific tables that were designed for the survey specific questions were developed using SPSS by the data processing expert of El-Zanaty and reviewed by UNICEF experts at the regional office as well as headquarters. 7 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Out of the 7,067 households selected for the survey, 7,050 were found to be occupied. Of these, 7,046 were successfully interviewed for a household response rate of 99.9 percent. In the interviewed households, 5,859 ever-married women (age 15-49 years) were identified. Of these, 5,847 ever-married women were successfully interviewed, yielding a response rate of 99.8 percent. In addition, 5,096 children under-5 were listed in the household questionnaire. Questionnaires were completed for 5,090 of these children, which corresponds to a response rate of 99.9 percent. Overall response rates of 99.7 and 99.8 percent are calculated for individual interviews of ever-married 15-49 year-old women and under-5s respectively. Table HH.1: Results of household, ever-married women's and under-5 interviews Number of households, ever-married women, and children under-5 by results of the household, ever-married women's and under-5's interviews, and household, ever-married women's and under-5's response rates, Egypt, subnational MICS, 2013-2014 Total Region Pilot Phase, Upper Egypt Expansion Phase, Upper Egypt Expansion Phase, Lower Egypt Households Sampled 7067 1813 3274 1980 Occupied 7050 1809 3272 1969 Interviewed 7046 1809 3271 1966 Household response rate 99.9 100.0 100.0 99.8 Ever-married women Eligible 5859 1497 2739 1623 Interviewed 5847 1493 2733 1621 Response rate 99.8 99.7 99.8 99.9 Overall response rate 99.7 99.7 99.8 99.7 Children under-5 Eligible 5096 1320 2436 1340 Mothers/caretakers interviewed 5090 1319 2431 1340 Response rate 99.9 99.9 99.8 100.0 Overall response rate 99.8 99.9 99.8 99.8 It should be noted that household, women and children under-5 response rates throughout the country were high with no significant differences between the pilot phase, expansion phase Upper Egypt and expansion phase Lower Egypt. 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 7,046 households successfully interviewed in the survey, a total of 32,452 people aged 0 to 85 years and older were surveyed in these households, of these 51 percent are males and 49 percent are females. 8 Table HH.2: Household age distribution 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, Egypt Sub-National MICS, 2013-14 Total Males Females Number Percent Number Percent Number Percent Total 32452 100.0 16436 100.0 16016 100.0 Age 0-4 5206 16.0 2580 15.7 2626 16.4 5-9 3765 11.6 1885 11.5 1880 11.7 10-14 3621 11.2 1869 11.4 1752 10.9 15-19 3223 9.9 1613 9.8 1610 10.1 20-24 2928 9.0 1443 8.8 1485 9.3 25-29 3099 9.6 1469 8.9 1630 10.2 30-34 2274 7.0 1224 7.4 1049 6.6 35-39 1923 5.9 1030 6.3 893 5.6 40-44 1502 4.6 778 4.7 724 4.5 45-49 1302 4.0 672 4.1 630 3.9 50-54 1055 3.3 556 3.4 500 3.1 55-59 799 2.5 426 2.6 373 2.3 60-64 724 2.2 385 2.3 340 2.1 65-69 412 1.3 207 1.3 205 1.3 70-74 284 0.9 135 0.8 149 0.9 75-79 171 0.5 81 0.5 89 0.6 80-84 107 0.3 54 0.3 53 0.3 85+ 54 0.2 30 0.2 25 0.2 Missing/DK 2 0.0 - - 2 0.0 Dependency age groups 0-14 12592 38.8 6334 38.5 6258 39.1 15-64 18829 58.0 9595 58.4 9234 57.7 65+ 1028 3.2 507 3.1 522 3.2 Missing/DK 2 0.0 - - 2 0.0 Children and adult populations Children age 0-17 years 14559 44.9 7335 44.6 7225 45.1 Adults age 18+ years 17890 55.1 9101 55.4 8789 54.9 Missing/DK 2 0.0 - - 2 0.0 Overall, 39 percent of the surveyed population are in the age group 0-14, 58 percent fall in the age group 15-64 and only 3 percent are of older ages- distributed almost equally among males and females There are 14,559 children aged 0-17 accounting for 45 percent of all surveyed household members. Forty-five percent of all males fall in this age group and 45 of all females also fall in this age category. The information on sex and age distribution is used to construct a population pyramid describing the population in interviewed households (Figure 1) in the IPHN areas. It has to be clear that this pyramid cannot be compared with the Egypt pyramid since the population of the survey covered selected rural districts only and does not represent all rural areas of Egypt. The pyramid has a wide base, with a large concentration (39 percent) of population under age 15 years. This pattern is typical of areas that have 9 experienced relatively high fertility in the recent past. The effect of recent high fertility is evident in the fact that the proportion of children under age 5 is significantly higher than the population in the age group 5-9 years. Only 2 percent of the population are 70 years or more. Figure HH.1: Age and sex distribution of household population, Egypt Sub-National MICS, 2013-14 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15- 49, and children under-5. Both un-weighted 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.14 Table HH.3 provide basic information on the interviewed households, including the sex of the head of the household, number of household members, region, as well as education of household head. The data is presented weighted and un-weighted. The total weighted and un-weighted numbers of households are equal, since sample weights were normalized. The table also shows the weighted mean household size estimated in the survey. 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. Also, these background characteristics are important because they are often associated with socioeconomic differences between households. 14See Appendix A: Sample Design, for more details on sample weights. 10 8 6 4 2 0 2 4 6 8 10 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Per cent Age Males Females Note: 2 household members with missing age and/or sex are excluded 10 Table HH.3: Household composition Percent distribution of households by selected characteristics, Egypt Sub-National MICS, 2013-14 Selected background characteristics Weighted percent Number of households Weighted Unweighted Total 100.0 7046 7046 Sex of household head Male 87.7 6179 6191 Female 12.3 867 855 Region Pilot Phase, Upper Egypt 12.7 898 1809 Expansion Phase, Upper Egypt 71.4 5034 3271 Expansion Phase, Lower Egypt 15.8 1114 1966 Number of household members 1 4.3 301 293 2 12.1 852 855 3 15.5 1089 1134 4 18.4 1294 1395 5 19.4 1363 1413 6 14.6 1027 1006 7 8.0 566 491 8 4.1 292 250 9 1.9 134 109 10+ 1.8 129 100 Education of household head No Education 27.1 1913 1707 Primary/Preparatory 26.6 1872 1847 Secondary 34.8 2453 2573 Higher 11.3 794 908 Missing/DK 0.2 15 11 Mean household size 4.6 7046 7046 Female headed households correspond to 12 percent of interviewed households. The table shows that 71 percent of interviewed households are located in the expansion phase Upper Egypt, while 13 percent are located in pilot phase Upper Egypt, and 16 percent of interviewed households are located in expansion phase Lower Egypt. Forty-six percent of household heads have secondary education or higher, while 27 percent have no education. The table indicated that the mean number of household members is 4.6, however, 30 percent of interviewed households have 6 members or more. Almost one-third of the households had 3 or less members, and 2 percent had 10 or more members. Characteristics of women Respondents 15-49 Years of Age and Children Under-5 Tables HH.4, HH.MoRES1 and HH.5 provide information on the background characteristics of ever- married women aged 15-49 interviewed and of children under age 5 interviewed in the survey. In all three tables, the total number of weighted and un-weighted observations is 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 number of observations in each background category. These categories are used in the subsequent tabulation of this report. 11 Table HH.4: Ever-married women's background characteristics Percent distribution and frequency distribution of ever-married women age 15-49 years by selected background characteristics, Egypt Sub-National MICS, 2013-14 Weighted percent Number of women Weighted Unweighted Total 100.0 5847 5847 Region Pilot Phase, Upper Egypt 12.6 736 1493 Expansion Phase, Upper Egypt 71.9 4203 2733 Expansion Phase, Lower Egypt 15.5 907 1621 Age 15-19 4.2 247 208 20-24 17.1 1002 968 25-29 24.7 1447 1460 30-34 16.9 986 1043 35-39 14.6 853 869 40-44 11.9 698 699 45-49 10.5 613 600 Marital status Currently married 94.7 5535 5544 Widowed 3.0 175 177 Divorced 1.8 105 92 Separated 0.6 33 34 Motherhood and recent births Never gave birth 9.9 579 530 Ever gave birth 90.1 5268 5317 Gave birth in last five years 61.7 3605 3620 No birth in last five years 28.5 1669 1701 Woman's education No Education 31.2 1825 1530 Primary/Preparatory 24.0 1401 1289 Secondary 34.8 2032 2246 Higher 10.1 589 782 Table HH.4 provides background characteristics of ever-married women 15-49 years of age who responded in the survey, including the distribution by region, age, marital status, motherhood status and education. Key findings from Table HH.4 are as follows. In the weighted sample, 72 percent of women aged 15- 49 lived in expansion phase Upper Egypt, 16 percent lived in expansion phase Lower Egypt and 13 percent lived in the pilot phase area. The age distribution of women by 5 year categories shows that the highest proportion of women of reproductive age was 25 percent in the 25-29 age group, followed by women aged 20-24 (17 percent) and women aged 30-34 (17 percent). The lowest proportion of women of reproductive age was 4 percent in the 15-19 age group. At the time of the survey, 95 percent of women age 15 to 49 years were married, the rest were divorced/separated or widowed. In terms of the motherhood status, 90 percent of women had given birth at least once, and 62 percent gave birth in the last five years. For educational attainment, the distribution shows that 35 percent of ever-married women have completed secondary education, 31 percent have no education, 24 percent have completed primary/preparatory education and 10 percent have completed higher education. 12 Table HH.MoRES1: Ever-married women's background characteristics (women with a birth in the past 5 years) Percent distribution and frequency distribution of ever-married women age 15-49 years with a birth in the past 5 years, by selected background characteristics, Egypt Sub-National MICS, 2013-14 Weighted percent Number of women Weighted Unweighted Total 100.0 3605 3620 Region Pilot Phase, Upper Egypt 12.9 464 939 Expansion Phase, Upper Egypt 71.6 2582 1673 Expansion Phase, Lower Egypt 15.5 560 1008 Age 15-19 3.2 116 100 20-24 21.9 790 775 25-29 34.5 1245 1269 30-34 21.2 766 788 35-39 13.5 486 491 40-44 4.8 173 172 45-49 0.8 29 25 Marital/Union status Currently married 98.4 3546 3559 Widowed 0.8 30 30 Divorced 0.6 23 22 Separated 0.2 7 9 Woman's education No Education 24.1 868 710 Primary/Preparatory 22.7 817 729 Secondary 41.4 1491 1606 Higher 11.9 429 575 Table HH.MoRES1 provides background characteristics of female respondents 15-49 years of age with a birth in the past 5 years (i.e. the focus of this survey implemented to respond to the MoRES data needs). The table includes information on the distribution of ever-married women 15-49 years of age with a birth in the past 5 years according to region, age, marital status, motherhood status, and education. The data indicated that 72 percent of ever-married women aged 15-49 with a birth in the past 5 years lived in expansion phase Upper Egypt, 16 percent lived in expansion phase Lower Egypt and 13 percent lived in the pilot phase area. The age distribution of women with a birth in the past 5 years shows that the highest proportion was among the 25-29 age group (35 percent), followed by women aged 20-24 (22 percent) and women aged 30-34 (21 percent). 3 percent were aged 15-19, 5 percent were aged 40-44, and only 1 percent were aged 45-49. At the time of the survey, 98 percent of the interviewed ever-married women were currently married, and the remaining 2 percent were divorced/separated or widowed. The data indicated that 41 percent have completed secondary education, 24 percent have no education, 23 percent have completed primary/preparatory education and 12 percent have completed higher than secondary education. Table HH.5 presents the background characteristics of children under-5 whose mother/caretaker was interviewed. These include the distribution of children by various background characteristics: sex, region, age, education level and work status of the mother, education level and work status of the father. The overall sex distribution of children was almost even (49.5 percent boys and 50.5 percent girls). Slightly less than three-quarters of the children under age 5 years lived in expansion phase Upper 13 Egypt, 14 percent in expansion phase Lower Egypt and 13 percent lived in the pilot phase area. Children under 6 months represent 11 percent of the total number of children under-five whose mother/caretaker was interviewed. This percentage increases to 21 percent among children 12-23 months and decreases to reach 17 percent among children 48-59 months. Almost all the respondents to the under-5 questionnaire were the mothers (99.8 percent). The majority of mothers with children under-5 years of age had secondary education or higher (54 percent), while around one-quarter had no education (24 percent). More fathers with children under-5 years of age had higher education than mothers. Sixty-one percent of fathers had secondary education or higher, while 10 percent of fathers had no education. Almost 93 percent of fathers are working for cash while the percentage is only 9 percent for the mothers. Table HH.5: Under-5's background characteristics Percent distribution and frequency distribution of children under five years of age by selected characteristics Egypt, subnational MICS, 2013-2014 Weighted percent Number of children Weighted Unweighted Total 100.0 5090 5090 Sex Male 49.5 2521 2546 Female 50.5 2569 2544 Region Pilot Phase, Upper Egypt 12.6 643 1319 Expansion Phase, Upper Egypt 73.0 3715 2431 Expansion Phase, Lower Egypt 14.4 732 1340 Age 0-5 months 11.4 582 584 6-11 months 10.8 552 563 12-23 months 21.4 1092 1071 24-35 months 19.9 1015 1018 36-47 months 19.2 977 980 48-59 months 17.1 873 874 Respondent to the under-5 questionnaire Mother 99.8 5071 5069 Other primary caretaker 0.2 10 9 Mother’s education* No Education 24.3 1236 1013 Primary/Preparatory 21.9 1116 986 Secondary 41.6 2116 2260 Higher 12.2 622 831 Father's education No Education 10.1 515 445 Primary/Preparatory 25.0 1275 1199 Secondary 46.6 2371 2383 Higher 14.3 730 862 Father not in household 3.9 198 199 Missing/DK 0.0 1 2 Mother's Work Status Working for cash 8.5 430 524 Not working for cash 91.4 4651 4556 Missing/DK 0.1 8 10 Father's Work Status Working for cash 92.9 4729 4732 Not working for cash 2.2 114 107 Missing/DK 4.9 247 251 *.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. 14 Housing Characteristics and asset ownership Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. Table HH.6 shows percent distribution of households by selected housing characteristics like availability of electricity, nature of floors, roofs and exterior walls, number of rooms used for sleeping and mean number of persons per room used for sleeping. HH 6 shows similarities of the housing characteristics across the regions. Electricity and finished exterior walls were available in almost all households (99.7 percent) with no variations across regions. Finished floors were found in 83 percent of households and finished roofing in 88 percent of the households. The percentage is the highest in the expansion phase Lower Egypt (99 percent for the floors and 97 percent for the roofs) while it is the lowest in the expansion phase Upper Egypt where the finished floors were found in 79 percent of the households and the finished roofs in 86 percent. Fifty-eight percent of the households have 2 rooms for sleeping. About two-thirds of the households (69 percent) in the expansion phase Lower Egypt used 2 rooms for sleeping, while only 56 percent of the households in the pilot phase and expansion phase Upper Egypt used 2 rooms for sleeping. Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Egypt Sub-National MICS, 2013-14 Total Region Pilot Phase, Upper Egypt Expansion Phase, Upper Egypt Expansion Phase, Lower Egypt Total 100.0 100.0 100.0 100.0 Electricity 99.7 99.8 99.7 99.9 Flooring Natural floor 16.6 11.8 20.8 1.4 Rudimentary floor 0.1 0.0 0.1 0.1 Finished floor 83.2 88.1 79.0 98.5 Other 0.0 0.1 0.0 0.0 Roof Natural roofing 5.0 3.9 6.3 0.1 Rudimentary roofing 6.5 6.0 7.4 3.1 Finished roofing 88.4 90.0 86.2 96.8 Other 0.0 0.0 0.1 0.0 Exterior walls Natural walls 0.4 0.2 0.5 0.2 Rudimentary walls 0.5 0.5 0.6 0.0 Finished walls 99.1 99.2 98.9 99.8 Other 0.0 0.0 0.0 0.0 Rooms used for sleeping 1 26.0 25.7 28.4 15.4 2 58.1 55.7 56.2 68.9 3 or more 15.8 18.5 15.3 15.6 Mean no. of persons per sleeping room 2.51 2.44 2.62 2.08 The mean number of persons per room used for sleeping is 2.5. It is highest in expansion phase Upper Egypt (2.6) and lowest in expansion phase Lower Egypt (2.1), while it is 2.4 in the pilot phase Upper Egypt. 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. Only 21 percent of households or its members owned a radio, with significant differences between regions: 52 percent of households 15 in expansion phase Lower Egypt own a radio, 18 percent in pilot phase and 14 percent in expansion phase Upper Egypt. More than 9 in 10 of interviewed households have a TV, only 10 percent have non- mobile telephones and 91 percent have refrigerators. Households in the expansion phase Upper Egypt were the least likely to have a non-mobile phone or refrigerator (3 percent and 89 percent respectively). Only one-fifth of the households have agricultural land and 40 percent have farm animals/livestock. Ownership was lowest in Expansion phase, Lower Egypt and highest in expansion phase Upper Egypt. The patterns of ownership are very similar to those noted in the latest Egypt Demographic and Health Survey (EDHS 2014).This reflects the changing lifestyle in rural Egypt, and especially rural Lower Egypt, where smaller proportions of the population are engaged in agricultural practices. In more than half of the households at least one of its members owned a watch, 86 percent owned a mobile telephone, 11 percent owned a bicycle, 11 percent owned a motorcycle or scooter, 3 percent have an animal-drawn cart, 4 percent have a car or truck and only 4 percent have a bank account. Around seven in ten households own their house, with significant differences between regions. Almost three-quarters of households in both expansion phase and pilot phase Upper Egypt have the dwelling owned by a household member, while the percentage of ownership decreases to 60 percent in expansion phase Lower Egypt. 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, Egypt Sub-National MICS, 2013-14 Total Region Pilot Phase, Upper Egypt Expansion Phase, Upper Egypt Expansion Phase, Lower Egypt Total 100.0 100.0 100.0 100.0 Percentage of households that own a Radio 20.7 18.2 14.2 52.4 Television 93.1 95.6 91.7 97.4 Non-mobile phone 10.0 10.6 3.3 39.8 Video / DVD player 1.3 1.9 1.2 1.1 Sewing machine 3.6 4.7 3.3 4.1 Electric fan 93.0 94.4 91.8 97.2 Air conditioner 2.6 3.9 2.3 2.6 Satellite dish / connection 90.3 92.7 88.6 96.0 Refrigerator 90.8 94.6 88.7 97.2 Freezer 2.7 2.4 1.8 6.9 Water heater 32.3 40.8 24.2 62.4 Automatic washing machine 11.4 15.1 6.9 28.5 Other washing machine 87.4 86.6 88.1 85.1 Bed 97.1 97.8 96.3 99.9 Sofa 96.5 97.7 95.7 99.2 Hanging lamp (yellow with no cover) 80.2 74.8 83.4 70.1 Table 87.6 90.5 85.6 94.5 Tablia (very low round table) 76.9 76.8 80.5 60.6 Chair 87.2 90.1 84.4 97.6 Kolla / Zeer (container for storing water) 35.2 31.6 41.5 9.6 Percentage of households that own Agricultural land 21.4 21.4 22.4 16.9 Farm animals/Livestock 40.2 36.9 43.9 26.1 Percentage of households where at least one member owns or has a Mobile phone 86.0 89.0 84.3 91.6 Personal home computer 16.7 22.0 10.6 39.8 Watch 52.6 57.0 45.7 80.2 Bicycle 10.6 11.2 9.1 17.0 Motorcycle or scooter 10.8 9.7 9.3 18.5 Animal-drawn cart 3.1 4.2 3.1 2.2 Car or truck 4.1 4.4 3.3 7.0 Bank account 3.5 5.3 2.3 7.6 Ownership of dwelling Owned by a household member 72.0 74.6 74.1 60.1 Not owned 28.0 25.4 25.9 39.9 Rented 2.3 3.2 1.5 5.1 Other 25.7 22.2 24.3 34.8 17 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 new-born’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of new-borns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. 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.15 15 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , (1996) ‘Data on Birth Weight in Developing Countries: Can Surveys Help?’ Bulletin of the World Health Organization, 74(2), 209-16 18 Table NU.1: Low birth weight infants Percentage of last live-born children in the last five years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Egypt Sub-National MICS, 2013-14a 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 five years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams [1] Weighed at birth [2] Total 10.1 12.4 70.9 6.3 0.3 100.0 23.0 62.6 3605 Mother's age at birth Less than 20 years 11.4 11.3 69.0 8.2 0.1 100.0 23.2 56.7 1284 20-34 years 9.3 13.0 72.1 5.3 0.4 100.0 22.9 65.9 2300 35-49 years * * * * * 100.0 * * 16 Birth order 1 12.2 13.8 68.3 5.6 0.2 100.0 25.0 68.2 773 2-3 9.0 12.4 73.0 5.3 0.2 100.0 22.5 64.7 1674 4-5 9.2 11.3 71.6 7.8 0.2 100.0 21.8 57.5 791 6+ 12.6 12.1 65.3 9.0 1.0 100.0 24.2 52.5 367 Region Pilot Phase, Upper Egypt 8.3 9.9 76.6 5.0 0.2 100.0 20.8 60.5 464 Expansion Phase, Upper Egypt 11.3 12.4 68.7 7.3 0.3 100.0 23.7 58.4 2582 Expansion Phase, Lower Egypt 5.9 14.7 76.3 2.9 0.2 100.0 21.8 83.9 560 Type of birth attendant SBA (physician) 10.6 12.5 70.3 6.4 0.3 100.0 23.3 69.2 3019 SBA (certified midwife) 6.3 13.7 75.5 4.4 0.0 100.0 21.5 35.3 190 Daya/other 8.5 11.5 73.2 6.6 0.1 100.0 21.6 25.5 380 None * * * * * 100.0 * * 15 Missing/DK * * * * * 100.0 * * 2 Woman's education No Education 11.5 12.7 67.5 8.0 0.3 100.0 23.9 56.0 868 Primary/Preparatory 12.9 12.7 68.2 5.7 0.5 100.0 25.0 53.5 817 Secondary 9.0 12.5 72.7 5.8 0.1 100.0 22.4 64.9 1491 Higher 5.8 11.3 76.7 5.8 0.4 100.0 19.9 85.2 429 Husband's education No Education 12.3 11.9 66.5 8.8 0.5 100.0 23.9 50.3 400 Primary/Preparatory 12.6 13.2 68.3 5.3 0.5 100.0 25.1 59.3 902 Secondary 8.9 11.7 72.9 6.2 0.2 100.0 22.0 63.5 1702 Higher 6.3 13.5 75.1 5.1 0.0 100.0 21.3 73.5 509 Husband not in household 18.5 14.1 52.9 14.5 0.0 100.0 28.3 71.3 91 Missing/DK * * * * * 100.0 * * 2 Woman's Work Status Working for cash 4.9 7.2 81.3 6.1 0.6 100.0 17.3 78.0 307 Not working for cash 10.6 12.9 69.9 6.3 0.3 100.0 23.6 61.2 3299 Husband's Work Status Working for cash 9.8 12.7 71.4 5.9 0.3 100.0 23.0 62.4 3368 Not working for cash 10.5 6.2 72.0 10.8 0.6 100.0 19.9 66.3 91 Husband not in household 18.5 14.1 52.9 14.5 0.0 100.0 28.3 71.3 91 Missing/DK 16.7 3.4 68.7 11.3 0.0 100.0 22.4 53.9 55 a- This sub-national MICS applied the modules on maternal and new-born health to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The MICS indicators 2.20 and 2.21 are thus not fully comparable to the standard MICS indicators. [1] MICS indicator 2.20 - Low-birth weight infants [2] MICS indicator 2.21 - Infants weighed at birth *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Overall, 63 percent of last live-born children in the last five years preceding the survey were weighed at birth and approximately 23 percent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.1). The data indicated significant variation by region; the highest percentage of infants weighed at birth was observed in expansion phase Lower Egypt (84 percent), while the lowest was found in expansion phase of Upper Egypt (58 percent). Also, the percentage of infants weighed at 19 birth was highest among parents who had higher than secondary education and in case where the birth attendants were physicians. Approximately 23 percent of infants are estimated by their mothers to be very small or smaller than average, which match with the figure for infants weighing less than 2,500 grams at birth (23 percent). The prevalence of low birth weight infants is lowest among mothers who had higher education (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 of, 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 standards16. 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. Low 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 moderately or severely stunted. Children 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 i.e., they are falling behind in developing their body weight relative to their height. Children whose weight-for-height is more than three standard deviations below the median are classified as severely wasted i.e., they are severely falling behind in developing their body weight relative to their height. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. 16http://www.who.int/childgrowth/standards/technical_report 20 In sub-national MICS Survey the height and weight measurements were taken for all children under-5 years using anthropometric equipment recommended 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. 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, Egypt Sub-National MICS, 2013-14 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 Above - 2 SD [1] - 3 SD [2] - 2 SD [3] - 3 SD [4] - 2 SD [5] - 3 SD [6] + 2 SD [7] Total 5.4 2.1 0.0 5016 21.7 8.8 -0.8 4912 2.7 1.3 17.1 0.8 4919 Sex Male 5.4 2.3 0.0 2480 22.5 9.1 -0.9 2433 3.0 1.3 17.4 0.8 2435 Female 5.4 1.8 0.0 2536 21.0 8.6 -0.8 2479 2.5 1.2 16.8 0.8 2484 Region Pilot Phase, Upper Egypt 5.8 2.0 0.1 636 18.9 7.3 -0.7 624 2.8 1.2 16.2 0.7 614 Expansion Phase, Upper Egypt 5.8 2.3 -0.1 3651 22.4 9.1 -0.9 3573 2.6 1.2 14.2 0.7 3603 Expansion Phase, Lower Egypt 2.9 1.1 0.5 729 20.5 9.1 -0.7 715 3.3 1.6 32.7 1.2 702 Age 0-5 13.4 5.7 -0.1 570 20.7 11.5 -0.5 544 7.4 3.8 22.1 0.7 520 6-11 8.3 5.9 -0.1 543 21.2 12.2 -0.8 524 3.6 2.0 15.7 0.7 540 12-23 4.5 1.4 0.1 1078 25.7 10.0 -0.9 1043 3.2 0.9 19.1 0.8 1065 24-35 4.6 1.3 -0.1 1005 31.8 12.7 -1.3 990 2.4 1.6 18.0 0.8 990 36-47 2.5 0.2 0.1 961 16.3 6.0 -0.8 957 1.2 0.3 14.0 0.9 950 48-59 3.6 1.0 0.1 859 12.2 2.5 -0.7 854 0.8 0.5 14.8 0.8 854 Mother's education No Education 6.8 3.0 -0.1 1218 22.8 10.6 -1.0 1190 2.7 1.5 14.3 0.7 1208 Primary/Preparatory 5.9 2.5 0.0 1096 22.5 10.2 -0.9 1075 2.3 1.3 16.2 0.8 1082 Secondary 4.4 1.5 0.1 2092 21.2 7.4 -0.8 2059 2.8 1.1 17.6 0.8 2042 Higher 4.9 1.4 0.2 609 20.3 8.1 -0.7 588 3.5 1.4 22.7 1.0 587 Father's education No Education 6.3 2.4 -0.1 508 27.2 13.0 -1.2 494 2.7 1.8 17.9 0.8 505 Primary/Preparatory 6.8 2.9 0.0 1266 21.0 8.7 -0.8 1238 2.6 1.4 16.3 0.8 1235 Secondary 4.8 1.7 0.1 2323 21.3 7.8 -0.8 2278 2.7 1.3 17.4 0.8 2283 Higher 4.0 1.1 0.1 725 20.7 8.0 -0.8 712 2.9 0.9 17.3 0.8 704 Father not in household 6.1 3.9 -0.2 192 20.7 15.0 -1.0 189 3.3 0.8 15.0 0.7 191 Missing/DK * * * 1 * * * 1 * * * * 1 Mother's Work Status Working for cash 4.4 0.8 0.2 423 21.9 9.5 -0.7 411 3.0 1.1 20.3 0.9 412 Not working for cash 5.5 2.2 0.0 4584 21.7 8.8 -0.9 4492 2.7 1.3 16.8 0.8 4498 Missing/DK * * * 8 * * * 8 * * * * 8 Father's Work Status Working for cash 5.3 1.9 0.0 4660 22.0 8.7 -0.8 4566 2.7 1.3 17.0 0.8 4569 Not working for cash 4.7 2.8 0.2 114 10.1 5.1 -0.8 109 2.3 0.4 21.4 1.0 111 Missing/DK 7.1 4.5 -0.2 241 21.5 13.2 -1.0 237 4.1 1.4 16.8 0.7 239 [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 *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. 21 Children whose full birth date (month and year) were not obtained, and children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.12, DQ.13, and DQ.14 in Appendix D. The tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, one percent of children have been excluded from calculations of the weight-for-age indicator, 3 percent from the height-for- age indicator, and 4 percent for the weight-for-height indicator. Almost one in twenty children under age five in Egypt are moderately underweight (5 percent) and 2 percent are classified as severely underweight (Table NU.2). More than one in five children (22 percent) are moderately stunted or too short for their age and 3 percent are moderately wasted or too thin for their height. More than one in six of children (17 percent) under age 5 were overweight or too heavy for their height. Children in expansion phase Upper Egypt are more likely to be underweight and stunted than other children. In contrast, the percentage wasted is highest in expansion phase Lower Egypt. Those children whose mothers have secondary or higher education are the least likely to be underweight and stunted compared to children of mothers with no education. Boys appear to be slightly more likely to be stunted than girls. Unexpectedly, the age pattern shows that a higher percentage of children age 24- 35 months are stunted, while for the other two indicators children 0-5 months showed the highest level of underweighted and wasting. This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. The lowest percentage of underweight children was in expansion phase Lower Egypt (3 percent), while it was 6 percent in both pilot phase area and expansion phase Upper Egypt. The highest percentages of underweight children were among children of age group 0-5 months, and among mothers who are not educated, and among mothers who are not working. About one in five children was stunted and/or severely stunted in expansion phase of both, Upper and Lower Egypt, while the percentage in the pilot phase area was 19 percent. The highest percentage of stunted children (32 percent) was found amongst children aged 24-35 months. Also, this percentage is the highest among fathers who had no education. The highest percentage of wasted children was found in expansion phase Lower Egypt (3.3 percent) and amongst children aged 0-5 months (7.4 percent). The highest percentage of overweight children was found in expansion phase Lower Egypt where almost one in three children is overweight. Overweight children were present across all age groups: the percentage peaked highest amongst children aged 0-5 months (22 percent). The proportion of overweight children increased markedly with the mother’s education level and was highest amongst children whose mothers had higher than secondary education (22 percent) and among mothers who are working for cash (20 percent). 22 Table NU.MoRES1: Nutritional status of children (among last live-born children) Percentage of last live-born children in the last five years by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Egypt Sub-National MICS, 2013-14a Weight for age Number of last child under age 5 Height for age Number of last child under age 5 Weight for height Number of last child under age 5 Underweight Percent below Mean Z-Score (SD) Stunted Percent below Mean Z- Score (SD) Wasted Percent below Overweight Above Mean Z- Score (SD) - 2 SD - 3 SD - 2 SD - 3 SD - 2 SD - 3 SD + 2 SD Total 5.8 2.5 0.0 3454 22.6 9.6 -0.8 3377 3.2 1.5 17.8 0.8 3376 Sex Male 5.6 2.7 0.0 1772 24.3 10.0 -0.9 1737 3.3 1.5 17.9 0.8 1735 Female 6.0 2.3 0.1 1682 20.9 9.2 -0.8 1641 3.1 1.4 17.6 0.8 1641 Region Pilot Phase, Upper Egypt 6.5 2.5 0.1 440 19.2 7.7 -0.6 430 3.0 1.4 16.8 0.7 425 Expansion Phase, Upper Egypt 6.3 2.7 -0.1 2470 23.2 9.9 -0.9 2416 3.3 1.6 15.0 0.7 2429 Expansion Phase, Lower Egypt 3.0 1.2 0.4 544 22.7 10.1 -0.8 532 2.9 1.1 31.6 1.2 522 Age 0-5 13.1 5.5 -0.1 555 20.3 11.1 -0.5 530 6.9 3.8 22.0 0.7 508 6-11 8.2 5.8 -0.1 532 21.4 12.3 -0.8 515 3.7 2.1 15.8 0.7 529 12-23 4.4 1.3 0.2 967 24.8 9.7 -0.9 942 3.3 0.9 18.3 0.8 956 24-35 4.4 1.4 0.0 658 31.8 12.4 -1.3 651 2.2 1.6 19.5 0.9 650 36-47 2.3 0.1 0.2 453 16.2 5.8 -0.7 450 1.1 0.1 15.6 0.8 447 48-59 0.8 0.3 0.2 289 11.2 1.6 -0.6 290 0.7 0.4 12.1 0.8 285 Attendance of Health education sessions during pregnancy Did not attend any sessions 5.8 2.5 0.0 3171 22.1 9.5 -0.8 3101 3.3 1.6 17.2 0.8 3105 Attended 1-3 sessions 5.1 1.3 0.2 228 25.4 8.8 -0.9 222 1.6 0.2 24.0 1.0 219 Attended at least 4 sessions 8.0 3.0 0.0 53 40.5 21.5 -1.4 53 2.2 2.2 27.2 1.3 51 Missing/DK * * * 2 * * * 2 * * * * 2 Received home visit from health provider Received at least 1 visit 4.9 1.7 0.1 900 21.5 8.5 -0.8 882 2.3 0.7 19.4 0.8 884 Did not receive any visits 6.0 2.7 0.0 2550 23.0 9.9 -0.8 2491 3.5 1.8 17.2 0.8 2489 Missing/DK * * * 4 * * * 4 * * * * 4 Mother's education No Education 7.5 3.4 -0.1 839 24.4 12.3 -1.0 819 3.2 1.8 14.3 0.7 826 Primary/Preparatory 6.0 3.0 0.0 781 24.7 11.0 -0.9 764 2.5 1.2 16.8 0.8 767 Secondary 4.7 1.8 0.1 1423 20.8 7.5 -0.7 1397 3.2 1.5 19.3 0.8 1383 Higher 5.6 2.0 0.2 411 21.6 9.0 -0.7 397 4.4 1.5 21.9 0.9 400 Father's education No Education 7.4 2.9 -0.2 358 31.3 16.0 -1.3 350 3.7 2.5 17.4 0.8 354 Primary/Preparatory 7.1 3.6 0.0 869 21.2 9.7 -0.8 847 3.1 1.6 18.0 0.8 844 Secondary 4.9 1.8 0.1 1603 21.3 7.9 -0.7 1569 2.8 1.4 18.1 0.8 1574 Higher 4.7 1.5 0.1 483 23.4 8.7 -0.8 474 3.9 1.2 18.1 0.7 466 Father not in household 7.2 5.1 -0.3 140 21.5 14.6 -1.1 137 3.8 0.3 13.0 0.6 138 Mother's Work Status Working for cash 4.4 1.1 0.2 295 24.5 11.6 -0.7 285 3.3 1.0 20.1 0.9 286 Not working for cash 5.9 2.6 0.0 3159 22.5 9.4 -0.8 3093 3.2 1.5 17.6 0.8 3090 Father's Work Status Working for cash 5.6 2.2 0.1 3199 22.9 9.5 -0.8 3131 3.1 1.5 17.8 0.8 3127 Not working for cash 5.7 3.7 0.1 88 9.5 5.4 -0.9 83 2.4 0.0 24.5 1.1 86 Missing/DK 9.3 6.2 -0.3 168 23.8 14.2 -1.1 163 4.3 1.4 14.8 0.6 164 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. 23 The Table NU.MoRES1 reports data on the nutrition status of the last live-born child in the last five years, and includes information on stunting, wasting and underweight according to the attendance of health education sessions. The data do not show a strong association between attendance of health education sessions and lower levels of malnutrition in the different forms. Similar lack of trend is observed when comparing the anthropometric results for children whose mothers received a home visit from health providers and those whose mothers did not. Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Egypt Sub-National MICS, 2013-14 Attendance of last scheduled growth monitoring visits; recording of results of growth monitoring and anaemia screening in health card This information was collected for assessing the continuity in child growth monitoring and anaemia screening in the FHUs, reflecting both the quality of the services, their demand and their access. These data were also collected to complement the information derived from administrative sources that points to widespread problems in the quality of growth monitoring and anaemia testing recording. Underweight Stunted Wasted Overweight 0 5 10 15 20 25 30 35 0 12 24 36 48 60 P e r ce n t Age in months 24 Table NU.MoRES2: Attendance of last scheduled growth monitoring visits; recording of results of growth monitoring and anaemia screening in health card Percentage of living children who attended last scheduled growth monitoring visits; or were screened for anaemia , and who had results recorded in health card, by age, Egypt Sub-National MICS, 2013-14a Children age 0-11 monthsb,c Children age 12-23 months Children age 24-59 months Last scheduled growth monitoring: Number of children Last scheduled growth monitoring Number of children Last scheduled growth monitoring: Number of children Attended Height Weight Attended Height Weight Haemoglobin recorded Attended Height Weight Haemoglobin recorded Total 75.5 61.2 61.1 708 69.5 52.7 55.6 45.4 700 10.6 47.8 47.8 60.1 1309 Sex Male 79.4 59.6 60.0 378 66.0 58.1 60.7 49.2 331 8.2 44.6 44.6 58.0 647 Female 71.1 63.2 62.5 330 72.7 48.4 51.4 42.2 369 13.0 49.8 49.8 61.4 661 Region Pilot Phase, Upper Egypt 79.1 59.5 60.0 106 73.3 66.5 67.2 56.0 102 12.7 60.2 60.2 69.9 214 Expansion Phase, Upper Egypt 72.2 56.4 56.0 510 66.5 45.6 49.4 37.3 532 8.6 34.7 34.7 49.8 917 Expansion Phase, Lower Egypt 90.3 84.3 85.0 91 88.2 78.1 78.1 80.4 67 18.3 69.4 69.4 77.0 178 Mother's Age at birth Less than 20 80.3 59.6 59.6 59 74.7 36.9 44.9 42.4 55 12.8 61.3 61.3 81.9 98 20-34 76.4 63.4 63.7 562 68.4 54.4 56.9 45.9 588 10.3 46.4 46.4 57.7 1113 35-49 67.3 46.3 42.9 87 75.2 50.3 51.5 45.0 56 12.2 47.1 47.1 59.7 94 Birth order 1 82.0 59.8 60.1 184 70.0 47.9 53.9 44.3 217 11.1 58.5 58.5 51.5 383 2-3 75.5 63.4 62.9 300 70.3 55.6 57.7 45.4 309 10.7 47.5 47.5 62.5 598 4-5 73.0 65.9 66.1 152 65.7 58.9 58.9 45.3 124 11.1 35.8 35.8 77.8 228 6+ 64.1 43.4 43.4 72 72.3 42.2 42.2 50.0 50 7.0 28.7 28.7 25.6 99 Attendance of Health education sessions during pregnancy Did not attend any sessions 74.7 60.4 60.0 631 70.2 50.4 53.1 45.4 573 12.6 45.4 45.4 62.9 568 Attended 1-3 sessions (86.5) (67.0) (70.5) 47 (78.7) (67.5) (73.0) (41.6) 49 (20.5) (60.0) (60.0) (48.4) 40 Attended at least 4 sessions * * * 13 * * * * 6 * * * * 13 Received home visit from health provider Received at least 1 visit 75.8 59.9 59.5 210 69.4 57.9 61.8 41.8 167 18.1 56.8 56.8 66.8 151 Did not receive any visits 76.0 61.5 61.5 481 71.3 50.2 52.8 46.2 460 11.8 43.4 43.4 60.2 471 Mother's education No Education 66.3 47.5 49.7 149 60.0 56.4 57.9 36.1 179 11.9 49.9 49.9 56.5 318 Primary/Preparatory 69.9 56.2 55.0 173 71.1 38.8 42.4 46.2 151 8.2 37.2 37.2 69.2 263 Secondary 81.6 67.8 67.3 301 73.0 54.3 57.4 49.3 295 11.4 45.2 45.2 55.6 555 Higher 81.5 66.1 66.1 85 75.6 66.2 69.0 46.8 75 9.3 67.7 67.7 74.2 172 Mother's Work Status Working for cash (83.1) (58.1) (59.6) 45 (69.3) (59.0) (59.0) (41.0) 39 5.9 59.2 59.2 48.8 97 Not working for cash 75.0 61.4 61.2 663 69.5 52.4 55.4 45.6 661 11.0 47.3 47.3 60.6 1209 Missing/DK * * * * * * * * * * * * * 4 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. b- Anaemia screening is performed only from the age of 12 months onwards c- For children < 2 months of age, the initial visit (before 15 days) will be considered a growth monitoring visit (this is currently not included in the MoHP indicator, although weight and height are measured and recorded in the health card) *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases 25 In Egypt, growth monitoring of children under five is done routinely at the FHUs. This is timed to coincide with the routine EPI visits (at the age of 2, 4, 6, 9, 12, and 18 months); the child then attends yearly until the age of five. The child’s weight and height are measured and plotted on his growth chart in his health card, and screening for anaemia takes place yearly. Nurses and community health workers encourage mothers to bring their children to these growth monitoring visits. Table NU.MoRES2 shows the percentage of living children who attended their last scheduled growth monitoring visits; or were screened for anaemia, and who had results recorded in health card, by age of children. The purpose of this question was to assess the demand for these services among the community, and to assess the completeness of documentation of the measurements in the child’s health card. For children age 0-11 months, three-quarters (76 percent) attended the last scheduled growth monitoring visits and the values for both height and weight were recorded in 61 percent of children. Last scheduled growth monitoring visits were attended by 90 percent of children in expansion phase Lower Egypt, 79 percent of children in the pilot phase and only 72 percent of children in expansion phase Upper Egypt. The percentage of attendance is the highest among younger mothers (less than 20), among first babies, among mothers who attended 1-3 health education sessions and mothers who had higher than secondary education. As for children age 12–23 months, the table shows lower level of visits; 70 percent attended the last scheduled growth monitoring visits and the values for height were recorded in 53 percent of children, while weight was recorded in 56 percent of children and haemoglobin was recorded in 45 percent of children. Last scheduled growth monitoring visits were attended by 88 percent of children in expansion phase Lower Egypt, 73 percent of children in the pilot phase and only 67 percent of children in Expansion phase Upper Egypt. The percentage of attendance is highest among younger mothers (less than 20), among first babies, among mothers who attended 1-3 health education sessions, and mothers who had higher than secondary education. The percentage of children age 24-59 months who attended the last growth monitoring visits is substantially lower, probably since the last routine EPI vaccination is at 18 months. Without this motivation to attend, only a small proportion of children are brought to the FHU for growth monitoring visits. Only 11 percent attended the last scheduled growth monitoring visits and the measurements for both height and weight were recorded in 48 percent of these children, and haemoglobin was recorded in 60 percent of children. Last scheduled growth monitoring visits were attended by 18 percent of children in expansion phase Lower Egypt, 13 percent of children in the pilot phase and only 9 percent of children in Expansion phase, Upper Egypt. The percentage of attendance is the highest among younger mothers (less than 20), among first babies, among mothers who attended 1-3 health education sessions and, surprisingly, among mothers who had no education. The tables shows that much effort must be directed to improving attendance of these routine visits at the FHU, as a measure for early detected of malnutrition; furthermore, all nurses must be trained to completely document all measurements within the child’s health card. Reasons for not attending last scheduled growth monitoring visit were shown in Table NU.MoRES3. The table shows the percent distribution of mothers or caretakers of children under-5 who did not attend the last scheduled growth monitoring visit, by reason. Being not aware that growth monitoring is required was the main reason in slightly less than one-third of cases (32 percent), while in 16 percent of cases, the mothers were not aware of timings of scheduled visits, in 8 percent mothers thought that growth monitoring visits were not necessary, and poor quality service was the reason in 6 percent of the mothers. Other reasons like child illness, facility too far / no transportation available, husband did not allow and the visit is too expensive were all minimal and insignificant. 26 Table NU.MoRES3: Reasons for not attending last scheduled growth monitoring visit Percentage of mothers or caretakers of children under-5 who did not attend the last scheduled growth monitoring visit, by reason, Egypt Sub-National MICS, 2013-14 Too expensive Facility too far/ no transport available Poor quality service Husband/ family did not allow Not necessary Child ill Not aware that growth monitoring is required Not aware of timings of schedule d visits Other Number of children Total* 0.0 0.6 10.7 0.3 13.6 1.1 55.3 28.5 3.0 1584 Region Pilot Phase, Upper Egypt 0.2 0.6 9.4 0.5 13.0 0.4 59.7 25.6 2.7 239 Expansion Phase, Upper Egypt 0.0 0.7 11.8 0.2 11.9 1.2 55.4 28.6 2.9 1178 Expansion Phase, Lower Egypt 0.0 0.0 5.2 0.3 26.8 1.6 47.5 32.2 4.8 167 Mother's education No Education 0.1 0.9 7.7 0.4 8.9 2.4 60.4 29.9 1.5 405 Primary/Preparatory 0.0 0.5 14.4 0.0 11.3 0.4 53.8 29.3 4.1 340 Secondary 0.0 0.6 11.0 0.5 14.5 0.8 53.4 29.7 2.9 646 Higher 0.0 0.3 9.6 0.0 24.8 0.6 53.1 20.5 4.8 193 Mother's Work Status Working for cash 0.0 0.4 7.2 0.0 23.5 0.5 59.6 20.2 4.2 113 Not working for cash 0.0 0.6 11.0 0.3 12.9 1.2 54.8 29.2 3.0 1468 Missing/DK * * * * * * * * * 4 Note: Multiple response was allowed and thus the percentage adds up to more than 100%. *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Some variations exist by region. Lack of awareness that growth monitoring is required was the reason in one-third of cases (33 percent) in both pilot phase and expansion phase Upper Egypt, while it was 23 percent in expansion phase Lower Egypt. This reason was also more frequently reported by mothers with no education. Mothers not aware of timings of scheduled visits was the cause of 17 percent of cases in expansion phase Upper Egypt, 16 percent in expansion phase Lower Egypt and 14 percent in the pilot phase. Also, the proportion for this reason is highest among mothers with no education. Thirteen percent of mothers in the expansion phase Lower Egypt thought that growth- monitoring visits are not necessary, while this percentage declines to 7 percent in both pilot phase and expansion phase Upper Egypt. Mothers with higher than a secondary education were the most likely to report that they did not attend the last growth monitoring visit because it is not necessary. 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 do not 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.17 17Bhuta 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. 27 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.18 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods19. A summary of key guiding principles20, 21 for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey, consistent with the protocols adopted by the IPHN. The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Diet diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For diet 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).22 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; (ii) food items form at least 4 food groups; and (iii) breast milk or at least 2 milk feeds (for non-breastfed children). Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups23 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 18WHO (2003). ‘Implementing the Global Strategy for Infant and Young Child Feeding’. Meeting Report, Geneva, 3-5 February 2003. 19WHO (2003). Global Strategy for Infant and Young Child Feeding. 20PAHO (2003). Guiding principles for complementary feeding of the breastfed child. 21WHO (2005). Guiding principles for feeding non-breastfed children 6-24 months of age 22WHO (2008). Indicators for assessing infant and young child feeding practices. Part 1: Definitions. 23 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. 28 Table NU.3: Initial breastfeeding Percentage of last-born children in the 5 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Egypt Sub- National MICS, 2013-14a Percentage ever breastfed [1] Percentage who were first breastfed: Percentage who received a prelacteal feed Percentage receiving a breast milk substitute Number of last live- born children in the last five years Within one hour of birth [2] Within one day of birth Total 96.9 35.8 79.4 60.7 6.7 3605 Region Pilot Phase, Upper Egypt 96.8 34.5 79.7 63.9 7.4 464 Expansion Phase, Upper Egypt 97.0 35.8 78.7 62.6 7.0 2582 Expansion Phase, Lower Egypt 96.7 36.8 82.3 49.4 4.8 560 Months since last birth 0-11 months 98.9 21.7 66.0 80.2 11.6 304 12-23 months 97.0 26.1 69.5 71.9 10.7 328 Type of ANC provider Public sector 97.7 42.2 80.3 60.3 7.3 312 Private sector 96.3 32.5 78.2 61.0 7.3 1934 Both 97.6 38.2 80.5 61.2 6.3 1016 No care/missing 97.2 40.9 82.5 58.4 4.5 343 Attendance of Health education sessions during pregnancy Did not attend any sessions 96.9 35.2 79.1 61.5 7.0 3310 Attended 1-3 sessions 98.3 42.5 83.8 51.2 3.8 236 Attended at least 4 sessions 93.5 44.8 81.5 56.8 2.1 56 Missing/DK * * * * * 3 Received home visit from health provider Received at least 1 visit 97.1 34.9 78.4 59.2 6.9 944 Did not receive any visits 96.9 36.1 79.8 61.4 6.7 2656 Missing/DK * * * * * 6 Assistance at delivery Skilled attendant 96.6 32.9 78.2 62.2 7.1 3209 Traditional birth attendant 99.7 59.4 89.1 48.5 3.8 336 Other (100.0) (60.7) (93.1) (45.3) (0.0) 44 No one/Missing * * * * * 16 Place of delivery Public sector health facility 96.5 32.8 77.5 59.7 8.5 949 Private sector health facility 96.3 30.8 77.1 65.4 6.8 1992 Home 99.4 55.5 89.4 47.7 3.7 641 Other/Missing * * * * * 23 Mother's education No Education 97.2 44.0 82.2 55.1 5.9 868 Primary/Preparatory 98.2 33.5 77.1 65.8 6.8 817 Secondary 96.1 33.3 78.5 60.8 6.6 1491 Higher 96.4 31.8 81.4 62.3 8.6 429 Husband's education No Education 96.7 40.7 77.6 52.7 4.7 400 Primary/Preparatory 97.0 36.9 79.5 58.7 5.5 902 Secondary 97.3 34.8 80.3 63.8 6.9 1702 Higher 96.4 32.8 78.4 59.1 8.8 509 Husband not in household 93.2 38.2 77.8 68.6 12.1 91 Missing/DK * * * * * 2 Woman's Work Status Working for cash 97.6 33.6 80.3 58.0 6.5 307 Not working for cash 96.8 36.0 79.3 61.0 6.7 3299 Husband's Work Status Working for cash 97.0 35.6 79.6 60.7 6.5 3368 Not working for cash 94.8 35.2 73.6 54.8 8.1 91 Husband not in household 93.2 38.2 77.8 68.6 12.1 91 Missing/DK 100.0 40.3 79.1 60.2 10.6 55 a- This sub-national MICS applied the modules on maternal and new-born health to ever-married women with a live birth in the last 5 years, instead of in the last 2 years. The MICS indicators 2.5 and 2.6 are thus not fully comparable to the standard MICS indicators. [1] MICS indicator 2.5 - Children ever breastfed [2] MICS indicator 2.6 - Early initiation of breastfeeding *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. 29 The IPHN, through the FHU nurses and CHWs, encourages women to breastfeed their children immediately after birth. Table NU.3 is based on mothers’ reports of what their last-born child was fed in the first few days of life. It indicates the proportion of children born in the five years preceding the survey who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed. Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 36 percent of babies are breastfed for the first time within one hour of birth, while 79 percent of new- borns in the IPHN areas start breastfeeding within one day of birth. The percentage of children who received a prelacteal feed was 61 percent. There are no clear differences between the regions in the percentage of children who were ever breastfed (around 97 percent) or in the percentage of children who were first breastfed within one hour of birth (between 35 to 37 percent) or in the percentage of children who were first breastfed within one day of birth (between 79 to 82 percent). Percentage of children who received a prelacteal feed was highest in pilot phase area (64 percent) and lowest in expansion phase Lower Egypt (49 percent). Figure NU.2 shows the initiation of breastfeeding by region. The figure shows limited differences between regions with highest level of initiation of breastfeeding within one hour or one day is observed in expansion phase Lower Egypt. Figure NU.2: Initiation of breastfeeding, Egypt Sub-National MICS, 2013-14 The percentage of children who were first breastfed within one hour of birth was 10 percent higher among mothers who received ANC in the public sector than in the private sector. Also this percentage was somewhat higher among mothers who attended health education sessions during pregnancy, which may indicate the success of these sessions in achieving IPHN objectives. The percentage of children who were first breastfed within one hour of birth was higher when the delivery was attended by traditional birth attendants (TBAs) or others rather than deliveries attended by skilled birth attendants (SBAs). Also this percentage was higher in home deliveries and among mothers and fathers who had no education. Table NU.MoRES4 shows reasons for giving prelacteal feeds. 80 79 82 79 35 36 37 36 0 20 40 60 80 100 Pilot Phase, Upper Egypt Expansion Phase, Upper Egypt Expansion Phase, Lower Egypt Total P er c en t Within one day Within one hour 30 Table NU.MoRES4: Reasons for giving prelacteal feeds Percentage of children age 0-5 months by mothers/caretakers reported reasons for giving prelacteal feeds, Egypt Sub- National MICS, 2013-14 M o th er 's m ilk n o t n u tr it io u s in b eg in n in g M o th er 's m ilk n o t su ff ic ie n t in b eg in n in g M o th er is s ic k/ w ea k N o t n ec es sa ry / n o t cu st o m ar y to g iv e b re as t m ilk im m ed ia te ly M o th er d id n o t kn o w h o w t o b re as tf ee d / fo u n d b re as tf ee d in g d if fi cu lt N o b re as t m ilk In fa n t w as il l/ in n eo n at al in te n si ve u n it M u lt ip le b ir th s C ae sa ri an d el iv e ry O th er To ta l n u m b er o f ch ild re n a ge 0 -5 m o n th s w h o r ec ei ve d p re la ct ea l f ee d s Total 10.1 47.4 29.2 0.5 0.4 27.5 12.9 0.8 9.9 0.1 2190 Region Pilot Phase, Upper Egypt 9.6 46.1 32.3 0.6 0.3 27.5 12.1 0.4 7.8 0.0 297 Expansion Phase, Upper Egypt 10.3 46.6 28.6 0.5 0.3 30.2 13.0 0.9 8.5 0.1 1617 Expansion Phase, Lower Egypt 9.7 53.7 29.4 0.2 0.9 11.2 12.9 1.1 20.3 0.0 277 Mother's Age at birth Less than 20 8.9 35.3 26.3 0.8 1.6 35.3 16.9 1.3 8.7 0.9 176 20-34 10.5 49.1 29.6 0.5 0.3 26.3 12.3 0.8 10.0 0.0 1778 35-49 8.2 43.8 28.5 0.2 0.0 30.5 13.7 0.2 9.9 0.0 234 Birth order 1 11.1 41.1 29.7 0.5 1.0 31.9 15.3 0.0 14.3 0.3 580 2-3 9.9 48.7 29.2 0.5 0.0 25.1 12.5 1.2 8.9 0.0 977 4-5 10.3 53.8 30.6 0.8 0.1 25.7 9.5 0.6 7.9 0.0 423 6+ 7.9 46.4 25.1 0.0 1.0 29.9 14.4 1.6 6.4 0.0 210 Woman's education No Education 7.4 47.5 30.3 0.5 0.3 30.3 9.5 0.8 10.5 0.0 478 Primary/Preparatory 11.2 45.9 26.7 0.4 0.8 29.7 14.7 0.5 8.3 0.3 538 Secondary 10.4 46.1 29.0 0.7 0.0 27.3 13.5 0.7 10.0 0.0 907 Higher 11.7 54.9 32.8 0.4 0.9 18.5 12.8 1.9 11.7 0.0 267 Woman's Work Status Working for cash 7.7 48.6 29.3 0.8 0.4 20.8 17.0 1.3 9.1 0.0 178 Not working for cash 10.3 47.3 29.2 0.5 0.4 28.1 12.5 0.8 10.0 0.1 2012 Note: Multiple response was allowed and thus the percentage adds up to more than 100%. The table NU.MoRES4 reports data on the reasons stated by mothers or caregivers for giving prelacteal feeds to the new-born, and shows that 47 percent of respondents thought that mother's milk was not sufficient at the beginning and about 3 in 10 reported that there was no breast milk or because mother was sick/weak. In 13 percent of cases, the reason was because the infant was ill/in neonatal intensive care unit and in 10 percent of cases, the reason was because the mother had a caesarean delivery. Other reasons like multiple births, mothers thought that it is not necessary/not customary to give breast milk immediately; mother did not know how to breastfeed/found breastfeeding difficult and other causes were all minimal and insignificant. In all the three regions, and irrespective from the level of education and the age of the mother, the perceived insufficiency of mother’s milk at the beginning is reported as the main justification for providing prelacteal feeds. The highest percentage is found in the expansion villages in Lower Egypt at 54 percent, while in Upper Egypt, the percentages are respectively 46 percent in the pilot villages and 47 percent in the expansion villages. No major variation is observed between mothers with different levels of education. Having no breast milk was the reason reported by 30 percent of mothers or caretakers in expansion phase Upper Egypt, 28 percent in pilot phase, and only 11 percent in expansion phase Lower Egypt. Mother was sick/weak was the reason in 32 percent of cases in the pilot phase, and 29 percent in both expansion phase Upper Egypt and in expansion phase Lower Egypt. The Caesarean delivery was reported as the reasons for giving children prelacteal feeds by 20 percent of the respondents in Lower 31 Egypt expansion phase and by around 8 percent of the responds in the Upper Egypt villages covered by the IPHN. 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 and NU.MoRES5, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids during the previous day or night prior to the interview Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). Table NU.MoRES5 shows exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12-15 and 20-23 months of age. Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Egypt Sub-National MICS, 2013-14 Children 0-5 months Children 12-15 months Children 20-23 months Percent exclusively breastfed [1] Percent predominantly breastfed [2] Number of children Percent breastfed (Continued breastfeeding at 1 year) [3] Number of children Percent breastfed (Continued breastfeeding at 2 years) [4] Number of children Total 45.4 67.1 582 79.6 358 20.4 378 Sex Male 43.1 65.2 308 84.8 181 29.9 177 Female 48.1 69.2 274 74.1 176 12.0 200 Region Pilot Phase, Upper Egypt 45.8 63.8 80 93.2 50 (17.3) 41 Expansion Phase, Upper Egypt 44.4 67.9 423 77.1 256 22.3 289 Expansion Phase, Lower Egypt 50.4 66.3 79 78.5 52 (11.0) 48 Mother's education No Education 49.1 70.6 111 84.4 70 30.5 108 Primary/Preparatory 50.5 75.1 125 80.1 100 22.9 86 Secondary 42.9 63.8 270 79.0 143 14.0 141 Higher 40.7 60.4 75 (72.6) 44 10.5 43 Father's education No Education 49.2 70.8 54 (88.0) 35 17.2 61 Primary/Preparatory 52.6 70.6 136 72.7 89 24.9 95 Secondary 43.2 67.5 281 84.1 170 19.6 162 Higher 45.1 62.0 95 71.6 54 (19.9) 47 Father not in household * * 17 * 11 * 12 Mother's Work Status Working for cash (44.1) (57.3) 42 (76.4) 32 (12.7) 27 Not working for cash 45.5 67.9 540 79.9 326 21.0 350 Father's Work Status Working for cash 46.2 67.8 557 80.0 337 20.7 352 Not working for cash * * 4 * 4 * 12 Missing/DK * * 21 * 16 * 14 [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 *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. Approximately 45 percent of children age less than six months are exclusively breastfed and two-thirds are predominantly breastfed. By age 12-15 months, 80 percent of children are still being breastfed and by age 20-23 months this percentage drops dramatically to only 20 percent. Girls were more likely to be exclusively breastfed than boys, and less likely to receive continued breastfeeding. 32 The practice of exclusive breastfeeding is more prevalent in expansion phase Lower Egypt (50 percent) than in pilot phase or in expansion phase Upper Egypt (46 and 44 percent respectively). The level of mothers’ education has a certain impact on the prevalence of breastfeeding. Children of mothers with higher than secondary education are less likely to be exclusively breastfed than children of women with primary/preparatory education or no education levels (41 percent compared to 51 percent and 49 percent respectively). Children of mothers who are working for cash are less likely to be breastfed (exclusively or continually) than children of women who are not working Table NU.MoRES5: Breastfeeding (among last live-born children) Percentage of last live-born children in the last five years according to breastfeeding status at selected age groups, Egypt Sub-National MICS, 2013-14a Children 0-5 months Children 12-15 months Children 20-23 months Percent exclusively breastfed [1] Percent predomina ntly breastfed [2] Number of last live- born children Percent breastfed (Continued breastfeeding at 1 year) [3] Number last live- born children Percent breastfed (Continued breastfeeding at 2 years) [4] Number of last live- born children Total 45.9 67.9 567 82.2 339 23.9 315 Sex Male 43.4 65.9 296 86.5 173 34.6 148 Female 48.6 70.0 271 77.7 167 14.3 167 Region Pilot Phase, Upper Egypt 46.1 64.3 78 (96.1) 47 (22.7) 31 Expansion Phase, Upper Egypt 44.7 68.4 413 79.4 245 26.1 242 Expansion Phase, Lower Egypt 52.0 68.6 76 (82.5) 47 (12.2) 43 Type of ANC provider Public sector (45.6) (77.8) 47 (88.1) 23 (31.5) 27 Private sector 42.6 64.9 339 82.4 182 27.0 152 Both 52.1 71.7 154 82.1 102 18.8 102 No care/missing (51.5) (66.1) 28 (76.9) 32 (19.0) 34 Attendance of Health education sessions during pregnancy Did not attend any sessions 46.2 68.1 511 81.2 305 24.4 295 Attended 1-3 sessions (46.9) (65.8) 40 (89.9) 30 * 18 Attended at least 4 sessions * * 16 * 3 * 3 Received home visit from health provider Received at least 1 visit 37.8 62.0 155 86.4 83 25.9 79 Did not receive any visits 48.9 70.1 412 80.8 256 23.2 236 Mother's education No Education 48.4 70.2 110 83.9 68 31.7 99 Primary/Preparatory 49.9 75.0 123 82.0 96 26.9 73 Secondary 44.1 65.1 262 84.4 133 17.5 113 Higher 42.1 62.4 73 (72.7) 42 (14.7) 31 Father's education No Education 48.2 70.6 52 (91.5) 31 (21.4) 49 Primary/Preparatory 52.5 70.5 135 74.6 84 27.1 87 Secondary 44.1 68.8 270 87.4 162 22.2 136 Higher 45.9 63.0 93 73.3 51 (26.7) 35 Father not in household * * 17 * 11 * 8 Mother's Work Status Working for cash (45.4) (59.0) 41 (75.7) 31 * 22 Not working for cash 45.9 68.5 527 82.8 308 24.5 293 Father's Work Status Working for cash 46.7 68.6 543 82.4 321 24.0 297 Not working for cash * * 4 * 4 * 8 Missing/DK * * 21 * 15 * 10 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. 33 The Table NU.MoRES5 provides information on breastfeeding status according to some characteristics of antenatal care. The data are limited to the last born child, and show that those children under 6 months whose mothers attended both private and public antenatal care are more likely to be exclusively breastfed or predominantly breastfed than those attending exclusively private ANC. In addition, home visits from health provider does not seem associated with higher probability of breastfeeding the child, since the percentages of exclusive breastfeeding and predominant breastfeeding are higher among those who did not receive any visit. Figure NU.MoRES1 shows the difference in exclusive breastfeeding by region. In the Expansion phase areas of Lower Egypt women are more likely to exclusively breastfeed their children 0-5 (50 percent) compared with the other two regions, the Pilot areas in Upper Egypt (44 percent) and the Expansion areas in Upper Egypt (44 percent). Figure NU.MoRES1: Percent exclusively breastfed among children 0-5 months, by region, Egypt Sub- National MICS, 2013-14 Egypt has adopted the International Code of Marketing of Breast-milk Substitutes which prohibits the distribution of breast-milk substitute samples among recently-delivered mothers in hospitals. However, women who have a medical condition which makes them unable to breastfeed are legible to receive breast-milk substitutes at selected public medical facilities. Table NU.MoRES6 shows the percentage of women receiving a sample of a breast milk substitute and place of receiving this sample. Only a very small proportion of women received a substitute, and of these, the majority received it from a public facility. 50 44 46 41 42 43 44 45 46 47 48 49 50 51 Expansion Phase, Lower Egypt Expansion Phase, Upper Egypt Pilot Phase, Upper Egypt 34 Table NU.MoRES6: Receiving a sample of a breast milk substitute; place of receiving breast milk substitute Percentage distribution of ever-married women age 15-49 with a live birth in the last 5 years by receiving a breast milk substitute sample; and place of receiving this sample, Egypt Sub-National MICS, 2013-14 Received a sample Number of women who gave birth in the last five years Place where sample was received Number of women who received a breast milk sample after birth Y es , r ec ei ve d a f re e sa m p le Ye s, r ec ei ve d a su b si d iz ed s am p le N o D K To ta l P ri va te c lin ic / h o sp it al G o ve rn m en t h o sp it al P ri m ar y h ea lt h c ar e ce n tr e Fa m ily h ea lt h u n it A t h o m e O th er / M is si n g To ta l Total 0.6 2.2 97.1 0.0 100.0 5847 15.9 20.3 28.6 29.3 0.6 5.3 100.0 104 Region Pilot Phase, Upper Egypt 0.4 2.0 97.6 0.0 100.0 736 * * * * * * 100.0 11 Expansion Phase, Upper Egypt 0.8 1.9 97.3 0.1 100.0 4203 22.9 20.1 24.3 29.4 0.0 3.3 100.0 67 Expansion Phase, Lower Egypt 0.2 4.2 95.5 0.0 100.0 907 (2.1) (19.8) (34.8) (30.2) (0.0) (13.2) 100.0 25 Mother's Age at birth Less than 20 0.4 0.6 98.9 0.0 100.0 240 * * * * * * 100.0 3 20-34 0.7 2.4 96.9 0.0 100.0 2938 17.6 18.8 26.4 30.5 .6 6.1 100.0 91 35-49 0.5 1.9 97.2 0.4 100.0 422 * * * * * * 100.0 10 Birth order 1 0.4 2.0 97.6 0.0 100.0 769 * * * * * * 100.0 18 2-3 0.9 2.2 96.8 0.0 100.0 1672 21.8 15.3 28.9 27.9 1.1 5.0 100.0 53 4-5 0.3 2.6 97.1 0.0 100.0 791 * * * * * * 100.0 23 6+ 0.5 2.0 97.1 0.4 100.0 367 * * * * * * 100.0 9 Woman's education No Education 0.5 2.1 97.4 0.0 100.0 1825 * * * * * * 100.0 23 Primary/Preparatory 0.8 1.4 97.6 0.2 100.0 1401 * * * * * * 100.0 18 Secondary 0.7 2.2 97.2 0.0 100.0 2032 (17.7) (20.0) (37.0) (20.9) (0.0) (4.5) 100.0 42 Higher 0.4 4.3 95.2 0.0 100.0 589 * * * * * * 100.0 20 Woman's Work Status Working for cash 1.2 5.0 93.8 0.0 100.0 527 * * * * * * 100.0 19 Not working for cash 0.6 2.0 97.4 0.0 100.0 5320 19.5 20.6 27.5 28.7 .7 3.1 100.0 85 *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. Table NU.5 shows the median duration of breastfeeding among children at 0-35 months of age by selected background characteristics. Among children under age 3, the median duration is 18months for any breastfeeding (19 months for boys and 17months for girls). The median duration of exclusive breastfeeding was 2 months (1.9 months for boys and 2.3 months for girls), while the median duration of predominant breastfeeding was 4. (4.0 months amongst boys and 4.3 amongst girls). The median duration of any breastfeeding was somewhat longer in the expansion phase of Upper Egypt (18.3) and expansion phase Lower Egypt (18.2) compared with pilot phase of Upper Egypt (17.7 months). The median durations of both exclusive and predominant breastfeeding were almost equal in both pilot phase and expansion phase Upper Egypt, while in expansion phase Lower Egypt the median durations of exclusive breastfeeding is longer (2.5) and predominant breastfeeding is shorter (3.9). The median durations of both exclusive and predominant breastfeeding were shorter amongst children whose mothers had higher education (2.0 and 3.4 months respectively) compared to children whose mothers had no education (2.3 and 4.7 months) or had primary/preparatory education (2.5 and 4.2 months). 35 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Egypt Sub-National MICS, 2013-14 Median duration (in months) of Number of children age 0-35 months Any breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Median 18.2 2.1 4.1 3241 Mean for all children (0-35 months) 17.7 2.7 4.5 3241 Sex Male 19.3 1.9 4.0 1609 Female 17.3 2.3 4.3 1632 Region Pilot Phase, Upper Egypt 17.7 2.1 4.1 412 Expansion Phase, Upper Egypt 18.3 2.0 4.1 2369 Expansion Phase, Lower Egypt 18.2 2.5 3.9 459 Mother's education No Education 18.8 2.4 4.7 719 Primary/Preparatory 17.8 2.5 4.2 731 Secondary 17.8 1.8 4.1 1387 Higher 19.0 2.0 3.3 404 Father's education No Education 18.1 2.4 5.6 305 Primary/Preparatory 17.5 2.7 4.1 799 Secondary 18.4 1.8 4.3 1540 Higher 19.0 2.2 3.4 468 Father not in household 17.5 0.4 2.5 128 Women's work status Working for cash 18.3 2.2 3.3 258 Not working for cash 18.2 2.1 4.2 2977 Husband's work status Working for cash 18.3 2.2 4.2 3017 Not working for cash 15.3 2.2 2.2 63 Missing/DK 17.7 0.5 2.9 161 [1] MICS indicator 2.11 - Duration of breastfeeding The Table NU.MoRES7 below, limited to last live-born children, reports data on the duration of breastfeeding (in months) by the type of ANC received by the mothers, the attendance of the education sessions during pregnancy and by the benefit of home visit from health providers. 36 Table NU.MoRES7: Duration of breastfeeding (among last live-born children) Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among last live-born children in last five years age 0-35 months, Egypt Sub-National MICS, 2013-14a Median duration (in months) of Number of children age 0-35 months Any breastfeeding Exclusive breastfeeding Predominant breastfeeding Median 18.7 2.2 4.1 2752 Mean for all children (0-35 months) 18.3 2.7 4.6 2752 Sex Male 19.7 1.9 4.0 1382 Female 17.9 2.4 4.3 1370 Region Pilot Phase, Upper Egypt 18.2 2.1 4.1 348 Expansion Phase, Upper Egypt 18.9 2.0 4.2 2000 Expansion Phase, Lower Egypt 18.4 2.7 4.0 403 Type of ANC provider Public sector 19.4 2.0 5.0 222 Private sector 18.8 1.9 4.0 1485 Both 18.5 2.7 4.2 801 No care/missing 19.0 2.6 3.7 243 Attendance of Health education sessions during pregnancy Did not attend any sessions 18.6 2.2 4.1 2515 Attended 1-3 sessions 19.4 1.9 4.1 191 Attended at least 4 sessions (18.2) (1.6) (5.3) 45 Received home visit from health provider Received at least 1 visit 18.6 1.0 4.0 744 Did not receive any visits 18.8 2.4 4.2 2005 Mother's education No Education 19.0 2.3 4.7 616 Primary/Preparatory 18.4 2.5 4.2 637 Secondary 18.4 1.9 4.2 1159 Higher 19.4 2.0 3.4 340 Father's education No Education 18.4 2.3 5.7 264 Primary/Preparatory 18.2 2.7 4.1 679 Secondary 18.8 2.0 4.4 1304 Higher 19.5 2.2 3.5 395 Father not in household 18.2 0.4 2.5 109 Women's work status Working for cash 18.3 2.2 3.4 216 Not working for cash 18.8 2.1 4.2 2536 Husband's work status Working for cash 18.8 2.2 4.3 2561 Not working for cash 15.3 2.2 2.2 58 Missing/DK 18.2 0.5 2.9 133 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. There is little difference in duration of any breastfeeding according place of antenatal care, attending health education sessions in pregnancy, or receiving home visits from health provider. The duration of exclusive breastfeeding is slightly higher among women who attended both private and public antenatal care, and among women who attended neither. The median durations of exclusive breastfeeding were higher among mothers who did not attend any health education sessions during pregnancy, and among mothers who did not receive any home visits from health providers. 37 The IPHN provides breastfeeding advice to pregnant and recently delivered mothers, through health education sessions held at the FHU and via home visits by CHWs. Table NU.MoRES8 shows persons giving advice to mothers on breastfeeding and the nature of the breastfeeding advice which was provided. 38 Table NU.MoRES8: Person giving advice on breastfeeding; breastfeeding advice received Percentage distribution of ever-married women age 15-49 with a live birth in the last 5 years by person giving advice on breastfeeding; and breastfeeding advice received, Egypt Sub-National MICS, 2013-14 Person giving advice on breastfeeding Number of women who gave birth in the last five years Breastfeeding advice received Number of women who received advice on breastfeeding Physician/ nurse CHW TBA Friends/ neighbors Family member/ Relative Other No one Immediate breast- feeding Breast- feeding on demand Exclusive breast- feeding for 6 months Breast- feeding position shown Other Total 11.4 7.1 0.1 3.8 17.2 0.9 67.1 3605 49.1 34.7 24.9 41.0 15.0 1186 Region Pilot Phase, Upper Egypt 12.7 14.3 0.1 3.1 15.8 0.3 62.2 464 40.8 28.1 26.4 42.2 20.0 175 Expansion Phase, Upper Egypt 7.9 4.7 0.1 4.2 17.1 0.9 71.5 2582 46.7 37.0 19.9 37.7 16.3 734 Expansion Phase, Lower Egypt 26.7 12.2 0.1 2.5 18.8 1.5 50.6 560 61.0 32.9 37.3 49.0 8.2 277 Mother's Age at birth Less than 20 12.1 4.7 0.6 4.7 40.2 0.0 47.8 240 48.9 35.7 26.1 45.6 12.4 125 20-34 12.2 7.6 0.0 3.9 16.6 0.9 66.8 2938 50.4 35.4 24.8 41.1 15.0 976 35-49 5.7 5.1 0.5 2.3 8.3 1.2 80.3 422 33.4 26.6 25.7 33.1 18.4 83 Birth order 1 16.5 8.2 0.0 6.0 39.8 0.7 42.8 769 50.5 41.4 24.0 46.9 11.1 440 2-3 12.5 7.6 0.1 3.3 13.1 0.8 69.8 1672 51.0 30.3 27.3 40.0 15.8 505 4-5 7.5 6.8 0.1 3.5 9.7 1.5 76.2 791 42.9 34.5 23.0 33.3 20.5 188 6+ 4.3 3.0 0.5 1.9 4.6 0.4 86.1 367 40.0 24.1 16.8 29.3 20.2 51 Woman's education No Education 7.6 6.2 0.4 2.3 10.8 0.6 77.1 868 53.7 39.1 17.5 41.9 8.0 199 Primary/Preparatory 8.0 4.6 0.1 4.2 16.0 0.4 71.8 817 47.1 37.8 23.6 40.7 10.9 230 Secondary 12.9 8.1 0.0 4.5 18.9 0.8 63.7 1491 48.1 31.2 26.8 41.1 18.9 541 Higher 20.8 9.9 0.0 3.4 26.2 2.7 49.6 429 49.7 36.4 28.6 40.4 15.8 216 Woman's Work Status Working for cash 15.4 8.1 0.0 3.0 13.3 1.9 65.8 307 44.1 26.2 28.3 39.6 20.8 105 Not working for cash 11.1 7.0 0.1 3.9 17.5 0.8 67.2 3299 49.6 35.6 24.6 41.1 14.4 1082 Note: for the type of breastfeeding advice, multiple response was allowed. 39 The table shows that around two thirds of the mothers did not receive specific advice on breastfeeding (percentage ranging between 51 percent in the Expansion phase areas of Lower Egypt to 72 percent of Expansion phase areas in Upper Egypt). Relatives and family members are mentioned as source of advices on breastfeeding by 17 percent of the mothers, followed by physician and nurses, mentioned by 11 percent of the mothers. In the Expansion phase areas of Lower Egypt, the share of mothers that have received advice on breastfeeding from physicians or nurses grows to 27 percent (in comparison with 8 percent in Expansion phase areas in Upper Egypt). The younger the mother, the highest the probability that she receive advice on breastfeeding, especially by a family member (40 percent). As for the kind of advice provided, the most common category mentioned was immediate breastfeeding (49 percent of those who received the advice), followed by advice on breastfeeding positions (41 percent) and breastfeeding on demand (35 percent). Only one-quarter of women who received advice on breastfeeding reported that they were advised to exclusively breastfeed their child for the first 6 months after birth. 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 breast milk and solid, semi-solid or soft food. As a result of feeding patterns, only 61 percent of children ages 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children ages 0-23 months drops to 57 percent. Furthermore, age-appropriate feeding among all infants age 0-5 months drops to 45 percent. Appropriate feeding is higher among boys (60 percent) than girls (53 percent). Also, appropriate feeding among children 0-23 months in highest among those whose mother attained a primary or preparatory education (61 percent).Among infants age 0-5 months, 45 percent are exclusively breastfed with some differences between regions. The highest percentage of children age 0-5 who are exclusively breastfed was found in expansion phase Lower Egypt areas (50 percent). Among infants age 6-23 months, boys are more likely to be adequately fed (67 percent) than girls (54 percent). Pilot phase infants (64 percent) are more likely to be adequately fed than their expansion phase Upper Egypt peers (60 percent) and children in expansion phase Lower Egypt (61 percent). Exclusive breastfeeding and age-appropriate feeding are inversely associated with mother’s educational level, while it increases with father’s education. 40 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Egypt Sub-National MICS, 2013-14 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Total 45.4 582 60.5 1643 56.6 2225 Sex Male 43.1 308 67.1 801 60.4 1109 Female 48.1 274 54.3 842 52.7 1116 Region Pilot Phase, Upper Egypt 45.8 80 64.0 201 58.9 281 Expansion Phase, Upper Egypt 44.4 423 59.9 1211 55.9 1634 Expansion Phase, Lower Egypt 50.4 79 60.8 231 58.1 310 Mother's education No Education 49.1 111 57.8 378 55.9 490 Primary/Preparatory 50.5 125 63.9 392 60.6 517 Secondary 42.9 270 59.3 668 54.5 939 Higher 40.7 75 63.2 205 57.2 280 Father's education No Education 49.2 54 51.4 157 50.8 210 Primary/Preparatory 52.6 136 56.4 411 55.4 547 Secondary 43.2 281 64.0 781 58.5 1062 Higher 45.1 95 62.4 239 57.5 333 Father not in household * 17 60.3 56 50.1 72 Mother's Work Status Working for cash 44.1 42 60.4 127 56.4 168 Not working for cash 45.5 540 60.5 1516 56.6 2056 Missing/DK - - * 1 * 1 Father's Work Status Working for cash 46.2 557 60.9 1534 57.0 2091 Not working for cash * 4 (49.2) 40 (48.2) 44 Missing/DK * 21 59.1 69 51.4 90 [1] MICS indicator 2.7 - Exclusive breastfeeding under 6 months [2] MICS indicator 2.12 - Age-appropriate breastfeeding *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. Table NU.MoRES9 shows the same data but for last live born children, adding information on breastfeeding by ANC attendance, participation to health education session during pregnancy and .home visits from health providers. 41 Table NU.MoRES9: Age-appropriate breastfeeding (among last live-born children) Percentage of last live-born children in last five years age 0-23 months who were appropriately breastfed during the previous day, Egypt Sub-National MICS, 2013-14a Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed Number of children Total 45.9 567 64.1 1522 59.2 2089 Sex Male 43.4 296 69.7 747 62.2 1043 Female 48.6 271 58.7 774 56.1 1046 Region Pilot Phase, Upper Egypt 46.1 78 68.5 185 61.9 263 Expansion Phase, Upper Egypt 44.7 413 63.5 1120 58.4 1533 Expansion Phase, Lower Egypt 52.0 76 63.6 217 60.6 292 Type of ANC provider Public sector 45.6 47 69.0 116 62.3 163 Private sector 42.6 339 63.6 809 57.4 1147 Both 52.1 154 65.7 461 62.3 616 No care/missing 51.5 28 57.9 135 56.8 163 Attendance of Health education sessions during pregnancy Did not attend any sessions 46.2 511 63.4 1395 58.8 1905 Attended 1-3 sessions 46.9 40 71.9 111 65.3 152 Attended at least 4 sessions 33.3 16 72.1 16 52.7 32 Received home visit from health provider Received at least 1 visit 37.8 155 65.6 420 58.1 575 Did not receive any visits 48.9 412 63.6 1101 59.6 1513 Mother's education No Education 48.4 110 58.9 357 56.4 467 Primary/Preparatory 49.9 123 68.4 363 63.7 486 Secondary 44.1 262 63.4 616 57.6 878 Higher 42.1 73 68.0 185 60.7 258 Father's education No Education 48.2 52 56.0 141 53.9 193 Primary/Preparatory 52.5 135 59.2 389 57.4 524 Secondary 44.1 270 67.4 726 61.1 996 Higher 45.9 93 66.1 218 60.1 311 Father not in household 15.6 17 68.4 48 55.0 65 Mother's Work Status Working for cash 45.4 41 63.2 116 58.6 157 Not working for cash 45.9 527 64.2 1405 59.2 1932 Father's Work Status Working for cash 46.7 543 64.3 1426 59.5 1969 Not working for cash 39.4 4 53.3 37 51.9 41 Missing/DK 25.2 21 66.4 59 55.7 79 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. The table shows that appropriate breast feeding is higher among children whose mothers received ANC in the public sector than those who received ANC in the private sector. The practice of appropriate breast feeding is also higher among mothers who attended 1-3 health education sessions during pregnancy but is not associated with receiving a home visit or the work status of the mother. Appropriate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and the prevention of under nutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. This requires that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more meals of solid, 42 semi-solid or soft foods or milk feeds are needed. These information was collected in the survey and presented in Table NU.7 Overall, 79 percent of infants age 6-8 received solid, semi-solid, or soft foods (Table NU.7). The proportion of boys receiving solid, semi-solid or soft foods among currently breastfeeding children is higher than that of girls in both groups (82 percent versus 76 percent). The percentage of children receiving solid, semi-solid or soft foods in expansion phase Lower Egypt areas is also higher than in expansion phase Upper Egypt and in pilot phase areas. 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, Egypt Sub- National MICS, 2013-14 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods [1] Number of children age 6-8 months Total 79.1 280 * 14 78.6 293 Sex Male 82.1 149 * 8 81.8 157 Female 75.6 131 * 5 74.8 136 Region Pilot Phase, Upper Egypt (77.8) 36 * 2 (77.6) 38 Expansion Phase, Upper Egypt 78.7 205 * 9 78.0 214 Expansion Phase, Lower Egypt (82.2) 39 * 3 (82.1) 42 [1] MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. Table NU.8 presents the proportion of children age 6-23 months who received semi-solid or soft foods the minimum number of times or more during the day or night preceding the interview by breastfeeding status (see the note in Table NU.8 for a definition of minimum number of times for different age groups). Overall, less than one-third of the children age 6-23 months (30 percent) were receiving solid, semi-solid and soft foods with the recommended minimum dietary diversity and the minimum meal frequency. There is almost no difference between males and females in achieving the minimum meal frequency. Among currently breastfeeding children age 6-23 months, slightly more than one-third of them (35percent) were receiving solid, semi-solid and soft foods with the recommended minimum dietary diversity and the minimum meal frequency. This proportion was higher among females (36percent) compared to males (34 percent). Among non-breastfeeding children, only one in five children were meeting the minimum acceptable diet; this proportion was higher among females (22 percent) compared to males (18 percent). The percentage of children who were receiving appropriate feeds the recommended minimum acceptable diet is highest among children of age group 12-17 months (43 percent) and lowest among the age group 6- 8 months (17 percent). This percentage is highest among children of the pilot phase area (34 percent), then the expansion phase Lower Egypt (32 percent) and lowest in expansion phase Upper Egypt (29 percent). The percentage of children who were receiving the minimum acceptable diet increased with the mother’s education level (from 21percent for children whose mothers had no education to 38percent for children whose mothers had higher education). This proportion is also higher among children whose mothers were working for cash (38 percent) than among children whose mothers were not working (30 percent). Table NU.MoRES10 present the proportion of last live born children age 6-23 received appropriate feeding by additional background characteristics. The table shows same pattern as Table NU.8 but higher percentages. A higher proportion of infants whose mothers attended health education sessions during pregnancy received the minimum acceptable diet, as compared to mothers who had not attended any sessions. 43 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, Egypt Sub-National MICS, 2013-14 Currently breastfeeding Number of children age 6-23 months Currently not breastfeeding Number of children age 6-23 months All Percent of children who received: Percent of children who received: Percent of children who received: Number of children age 6-23 months Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [1], [c] Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [2], [c] At least 2 milk feeds [3] Minimum dietary diversity [4], [a] Minimum meal frequency [5], [b] Minimum acceptable diet [c] Total 46.2 63.1 34.6 1085 69.7 58.2 19.9 31.7 495 53.6 61.6 30.0 1643 Sex Male 44.6 65.8 33.7 582 67.1 55.0 17.5 29.2 195 50.4 63.1 29.7 801 Female 48.1 59.9 35.6 503 71.4 60.3 21.5 33.2 300 56.7 60.1 30.3 842 Age 6-8 months 18.5 65.7 17.2 280 * * * * 8 18.1 65.6 17.1 293 9-11 months 45.8 52.6 29.1 233 * * * * 16 45.4 54.7 28.8 258 12-17 months 62.6 64.0 47.2 425 70.6 58.0 27.6 39.6 122 63.5 62.7 42.8 571 18-23 months 52.4 72.1 40.2 148 72.5 56.9 17.2 25.8 350 66.8 61.4 24.0 521 Region Pilot Phase, Upper Egypt 48.1 64.5 40.0 139 68.4 60.7 19.7 37.5 54 53.9 63.4 34.3 201 Expansion Phase, Upper Egypt 44.6 64.0 33.7 794 68.7 57.1 18.3 27.4 369 52.3 61.8 28.8 1211 Expansion Phase, Lower Egypt 52.7 57.0 34.3 152 75.9 61.9 28.1 49.0 72 60.0 58.6 32.3 231 Mother's education No Education 36.3 55.4 25.6 253 57.4 54.6 9.8 20.8 109 42.4 55.1 20.8 378 Primary/Preparatory 48.1 67.4 39.3 262 75.1 53.6 16.7 27.3 114 57.5 63.2 32.5 392 Secondary 48.8 65.7 37.3 433 70.5 58.2 19.4 30.8 214 55.7 63.2 31.4 668 Higher 52.6 60.9 33.7 137 79.3 73.9 46.7 63.1 59 59.8 64.8 37.6 205 Father's education No Education 42.7 66.3 36.4 90 58.6 41.1 12.6 21.8 61 48.2 56.1 26.8 157 Primary/Preparatory 49.2 62.8 38.4 259 67.3 65.0 18.4 30.3 127 56.1 63.5 31.8 411 Secondary 45.1 63.7 33.2 541 73.0 57.6 18.1 30.9 220 53.1 61.9 28.8 781 Higher 49.4 57.7 31.8 160 74.9 61.9 33.6 43.7 71 56.6 58.9 32.4 239 Father not in household (36.5) (71.9) (36.5) 36 * * * * 16 44.7 69.0 32.7 56 Mother's Work Status Working for cash 56.0 57.4 37.3 83 (75.8) (66.1) (35.6) (50.4) 43 61.9 60.4 36.7 127 Not working for cash 45.4 63.5 34.4 1002 69.1 57.5 18.4 29.9 453 52.9 61.6 29.4 1516 Missing/DK * * * 1 * * * * * * * * 1 Father's Work Status Working for cash 46.3 62.6 34.2 1021 70.0 58.1 20.2 32.1 457 53.7 61.2 29.9 1534 Not working for cash * * * 22 * * * * 17 (48.2) (56.3) (25.7) 40 Missing/DK (45.5) (74.3) (43.8) 43 * * * * 21 53.9 72.5 35.1 69 [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 *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. 44 Table NU.MoRES10: Infant and young child feeding (IYCF) practices (among last live-born children) Percentage of last live-born 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, Egypt Sub-National MICS, 2013-14a Currently breastfeeding Number of last child age 6-23 months Currently not breastfeeding Number of last child age 6-23 months All Percent of children who received: Percent of children who received: Percent of children who received: Number of last child age 6-23 months Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [c] Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [c] At least 2 milk feeds Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [c] Total 46.4 62.9 34.9 1064 69.6 59.5 20.1 32.7 412 52.7 62.0 30.8 1522 Sex Male 44.6 65.6 34.0 565 66.3 54.9 17.6 29.4 163 49.3 63.2 30.3 747 Female 48.4 59.9 35.9 499 71.8 62.5 21.8 34.9 249 55.9 60.8 31.2 774 Age 6-8 months 18.7 65.3 17.3 277 15.4 57.1 15.4 57.1 7 18.3 65.1 17.3 290 9-11 months 46.5 52.2 29.5 228 28.1 85.9 24.3 85.1 16 45.6 54.4 29.1 251 12-17 months 62.5 64.2 47.4 414 73.3 64.9 30.4 44.5 100 63.6 64.3 44.1 532 18-23 months 53.2 71.7 40.8 145 72.0 56.2 16.5 25.2 290 65.8 61.4 24.6 449 Region Pilot Phase, Upper Egypt 48.4 64.0 40.3 138 65.3 62.0 18.7 36.6 42 52.4 63.6 35.2 185 Expansion Phase, Upper Egypt 44.8 63.9 34.0 778 69.1 58.9 19.1 29.4 308 51.5 62.5 29.8 1120 Expansion Phase, Lower Egypt 52.8 56.6 34.5 149 75.0 60.6 26.3 46.6 62 58.9 57.8 32.1 217 Type of ANC provider Public sector 48.3 70.0 43.6 84 65.8 58.6 14.8 18.2 32 53.1 66.8 35.7 116 Private sector 45.4 62.0 33.2 571 71.4 60.1 21.6 37.2 213 52.4 61.5 30.1 809 Both 46.8 62.8 35.0 321 68.5 59.8 18.3 30.0 127 52.8 61.9 30.3 461 No care/missing 50.1 62.8 36.9 88 67.1 55.8 22.3 28.7 40 53.6 60.6 32.3 135 Attendance of Health education sessions during pregnancy Did not attend any sessions 45.6 62.6 34.2 970 70.1 59.1 20.4 32.3 382 52.3 61.6 30.3 1395 Attended 1-3 sessions 55.8 61.8 40.6 83 69.3 71.4 20.4 42.0 26 59.0 64.1 35.8 111 Attended at least 4 sessions 50.0 95.4 50.0 11 28.6 28.0 0.0 14.0 4 44.0 76.6 36.0 16 Received home visit from health provider Received at least 1 visit 45.0 59.6 33.9 301 71.0 61.1 22.2 35.0 110 52.5 60.0 30.8 420 Did not receive any visits 47.0 64.2 35.2 763 69.1 58.9 19.3 31.8 302 52.7 62.7 30.7 1101 Missing/DK 0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Mother's education No Education 36.1 53.9 25.0 245 57.8 57.0 10.7 22.3 99 41.6 54.8 20.9 357 Primary/Preparatory 48.4 67.8 39.6 261 76.4 53.7 16.1 27.9 94 56.3 64.0 33.3 363 Secondary 49.4 65.6 37.9 426 70.1 59.7 19.9 32.1 173 55.1 63.9 32.7 616 Higher 51.9 61.4 34.2 133 79.9 76.1 50.0 67.8 45 58.7 65.1 38.2 185 45 Currently breastfeeding Number of last child age 6-23 months Currently not breastfeeding Number of last child age 6-23 months All Percent of children who received: Percent of children who received: Percent of children who received: Number of last child age 6-23 months Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [c] Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [c] At least 2 milk feeds Minimum dietary diversity [a] Minimum meal frequency [b] Minimum acceptable diet [c] Father's education No Education 42.0 65.6 35.6 88 53.2 33.0 5.7 17.2 49 45.1 54.0 24.9 141 Primary/Preparatory 49.5 63.2 38.7 257 67.5 67.2 19.5 32.2 114 55.1 64.4 32.8 389 Secondary 45.5 63.3 33.5 529 72.6 60.4 19.7 32.7 181 52.3 62.6 30.0 726 Higher 49.0 57.8 32.4 155 78.9 62.9 33.2 44.8 57 56.7 59.2 32.6 218 Father not in household 37.2 71.3 37.2 35 68.5 64.3 31.6 44.1 10 42.7 69.7 35.9 48 Mother's Work Status Working for cash 56.4 60.1 39.6 78 74.6 64.5 37.0 51.5 37 61.4 61.5 38.7 116 Not working for cash 45.6 63.2 34.5 986 69.1 59.0 18.5 30.9 375 51.9 62.0 30.1 1405 Father's Work Status Working for cash 46.5 62.5 34.5 1001 69.9 59.9 20.7 33.4 384 52.9 61.8 30.7 1426 Not working for cash 43.2 63.6 34.0 22 53.3 38.4 3.4 15.3 14 45.3 53.8 22.1 37 Missing/DK 45.9 73.0 44.1 41 77.4 69.3 22.6 31.6 14 52.2 72.0 38.5 59 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. 46 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 16 percent of children age 0- 23 months was fed with a bottle with a nipple. This percentage is high in Lower Egypt (23 percent), while it is only 14 percent in expansion phase Upper Egypt and 21 percent in pilot phase of Upper Egypt. More than one-quarter of children less than 6 months are fed using a bottle with a nipple; this percentage decreases to 10 percent among children 12-23 months. The percentage of children fed with a bottle with a nipple increases with the level of education of the parents and bottle feeding is more prevalent among mothers working for cash. 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, Egypt Sub- National MICS, 2013-14 Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months Total 15.8 2225 Sex Male 15.8 1109 Female 15.7 1116 Age 0-5 months 26.2 582 6-11 months 16.2 552 12-23 months 10.0 1092 Region Pilot Phase, Upper Egypt 21.0 281 Expansion Phase, Upper Egypt 13.5 1634 Expansion Phase, Lower Egypt 22.9 310 Mother's education No Education 10.1 490 Primary/Preparatory 13.2 517 Secondary 17.9 939 Higher 23.1 280 Father's education No Education 7.2 210 Primary/Preparatory 14.9 547 Secondary 16.4 1062 Higher 19.3 333 Father not in household 20.1 72 Mother's Work Status Working for cash 25.4 168 Not working for cash 14.9 2056 Missing/DK * 1 Father's Work Status Working for cash 15.5 2091 Not working for cash (16.4) 44 Missing/DK 21.0 90 [1] MICS indicator 2.18 - Bottle feeding *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. Table NU.MoRES11 reports data on bottle feeding for the last live born children aged 0-23, including information by ANC attendance, type of ANC provider and attendance of health education sessions during pregnancy. Overall 15 percent of last live born children age 0-23 months were fed with a bottle with a nipple. 47 Table NU.MoRES11: Bottle feeding (among last live-born children) Percentage of last live-born children age 0-23 months who were fed with a bottle with a nipple during the previous day, Egypt Sub-National MICS, 2013-14a Percentage of last child age 0-23 months fed with a bottle with a nipple Number of last child age 0-23 months Total 15.0 2089 Sex Male 15.2 1043 Female 14.8 1046 Age 0-5 months 25.0 567 6-11 months 15.3 541 12-23 months 9.0 981 Region Pilot Phase, Upper Egypt 20.8 263 Expansion Phase, Upper Egypt 12.9 1533 Expansion Phase, Lower Egypt 20.7 292 Type of ANC provider Public sector 9.3 163 Private sector 16.0 1147 Both 15.3 616 No care/missing 11.9 163 Attendance of Health education sessions during pregnancy Did not attend any sessions 14.8 1905 Attended 1-3 sessions 15.7 152 Attended at least 4 sessions 20.9 32 Received home visit from health provider Received at least 1 visit 15.5 575 Did not receive any visits 14.8 1513 Mother's education No Education 10.3 467 Primary/Preparatory 12.6 486 Secondary 16.7 878 Higher 22.1 258 Father's education No Education 7.1 193 Primary/Preparatory 14.3 524 Secondary 15.4 996 Higher 18.5 311 Father not in household 20.5 65 Mother's Work Status Working for cash 23.4 157 Not working for cash 14.3 1932 Father's Work Status Working for cash 14.7 1969 Not working for cash 16.5 41 Missing/DK 20.4 79 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. Note: Figures in parentheses are based on 25-49 unweighted cases. The percentage of last live born children age 0-23 months who were fed with a bottle with a nipple was the highest among children whose mothers received ANC from a private service provider and who attended at least 4 health education sessions during pregnancy. Children’s Vitamin A Supplementation Table NU.MoRES12 shows percentage of children age 6-59 months who received a high dose of vitamin A supplement in the last 6 months. The table shows that only 43 percent of children age 6-59 months received vitamin A in the last 6 months with no gender difference. The table indicates that children who received vitamin A in expansion phase Upper Egypt (44 percent) were slightly more than children in the pilot phase (43 percent) followed by children in expansion phase Lower Egypt (40 percent). The percentage is higher among children age 12–23 months, when birth order is 6 or more, among mothers who attended 1–3 health education sessions and received home visit from health provider. Surprisingly, the proportion was lowest among mothers with higher than secondary education. 48 Table NU.MoRES12: Children's vitamin A supplementation; mother's Vitamin A supplementation Percentage of children age 6-59 months receiving a high dose vitamin A supplement in the last 6 months, and percentage of women who delivered in the last five years who received Vitamin A within 2 months of, Egypt Sub-National MICS, 2013-14a Percentage of children who received Vitamin A in the last 6 months Number of children age 6-59 months Percentage of women who delivered in the last five years who received Vitamin A within 2 months of delivery Number of women who delivered in the past five years Total 43.4 4508 40.8 3017 Sex Male 43.4 2214 40.7 1554 Female 43.3 2294 40.9 1462 Region Pilot Phase, Upper Egypt 43.1 564 42.0 384 Expansion Phase, Upper Egypt 44.0 3292 38.9 2151 Expansion Phase, Lower Egypt 40.2 653 48.5 481 Age 6-11 32.0 552 43.6 553 12-23 47.5 1092 42.6 1014 24-35 45.6 1015 32.9 680 36-47 42.5 977 44.3 472 48-59 43.7 873 41.9 297 Mother's Age at birth Less than 20 43.4 359 32.8 182 20-34 43.3 3722 41.3 2476 35-49 43.5 407 41.8 359 Birth order 1 39.5 1253 32.8 624 2-3 44.4 2003 42.7 1386 4-5 44.8 853 46.2 683 6+ 47.0 399 36.5 323 Attendance of Health education sessions during pregnancy Did not attend any sessions 43.7 2704 39.6 2778 Attended 1-3 sessions 47.1 190 54.0 195 Attended at least 4 sessions (36.9) 39 (57.1) 40 Missing/DK * 2 * 3 Received home visit from health provider Received at least 1 visit 46.8 760 47.8 787 Did not receive any visits 42.7 2171 38.4 2224 Missing/DK * 4 * 6 Mother's education No Education 43.6 1124 38.9 755 Primary/Preparatory 45.1 991 40.3 690 Secondary 43.7 1846 42.2 1217 Higher 38.6 547 41.0 354 Father's education No Education 48.1 461 36.1 342 Primary/Preparatory 43.0 1139 41.6 763 Secondary 42.7 2090 42.1 1422 Higher 40.8 635 41.6 415 Father/Husband not in household 50.3 181 26.3 74 Mother's Work Status Working for cash 42.9 388 43.7 266 Not working for cash 43.4 4111 40.5 2751 Missing/DK * 8 - - Father's Work Status Working for cash 42.8 4172 41.7 2803 Not working for cash 51.4 110 30.2 86 Husband not in household 49.7 227 26.3 74 Missing/DK 49.7 227 32.4 54 a- The data in this table is disaggregated by selected explanatory variables obtained from the reproductive health modules, which were applied only for the last birth in the past 5 years. The totals in this table thus do not represent all the under-5 children who participated in the child questionnaire. *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. Note: Figures in parentheses are based on 25-49 unweighted cases. 49 Acceptance of Good Breastfeeding Practices A set of questions were asked in the survey to address ever-married women’s acceptance of good breastfeeding practices. The results are presented in Tables NU.MoRES13, and NU.MoRES14. Table NU.MoRES13: Mother's acceptance of good breastfeeding practices Percentage distribution of ever-married women age 15-49 with a live birth in the last 5 years preceding the survey by acceptance of immediate breastfeeding after delivery, acceptance of no pre-lacteal feeds, and acceptance of exclusive breastfeeding for 6 months, Egypt Sub-National MICS, 2013-14 Acceptance of breastfeeding immediately after delivery Acceptance of breastfeeding only in the first 3 days of life Acceptance of exclusive breastfeeding for the first 6 months of life Number of women who delivered in the past five years Total 85.9 77.7 66.0 3605 Sex of child Male 86.9 78.5 65.9 1860 Female 84.9 76.8 66.1 1742 Region Pilot Phase, Upper Egypt 83.4 70.8 58.9 464 Expansion Phase, Upper Egypt 84.8 76.7 68.0 2582 Expansion Phase, Lower Egypt 93.5 88.1 62.6 560 Mother's Age at birth Less than 20 86.7 79.9 64.1 240 20-34 85.7 77.5 66.0 2938 35-49 87.1 77.8 67.6 422 Birth order 1 84.8 75.1 63.3 769 2-3 85.9 78.3 66.4 1672 4-5 86.2 80.0 68.2 791 6+ 87.6 75.5 65.6 367 Type of ANC provider Public sector 83.7 71.4 62.2 312 Private sector 86.3 78.5 65.4 1934 Both 86.5 79.1 67.5 1016 No care/missing 84.1 74.7 68.7 343 Attendance of Health education sessions during pregnancy Did not attend any sessions 85.6 77.0 65.9 3310 Attended 1-3 sessions 90.4 85.4 68.8 236 Attended at least 4 sessions 85.0 85.3 62.9 56 Missing/DK * * * 3 Received home visit from health provider Received at least 1 visit 88.9 80.1 69.0 944 Did not receive any visits 84.9 76.8 64.9 2656 Missing/DK * * * 6 Woman's education No Education 86.8 79.8 70.3 868 Primary/Preparatory 84.4 77.1 65.6 817 Secondary 85.4 75.5 64.2 1491 Higher 88.9 82.4 64.3 429 Woman's Work Status Working for cash 87.6 82.7 66.7 307 Not working for cash 85.8 77.2 65.9 3299 *Indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. In general, among women with a live birth in the past five years, there is high acceptance of initiating breastfeeding immediately after delivery by women and community (around 86 percent). Also, the acceptance of breastfeeding only in the first 3 days of life was high but less than acceptance of immediately after delivery (78 percent). Two-third of women and community accept exclusive breastfeeding for the first 6 months. Women of the expansion phase, Lower Egypt had higher acceptance of breastfeeding immediately after birth, and of not providing prelacteal feeds. Variations by background characteristics are limited; however, non-educated mothers are more likely to accept exclusive breastfeeding for the first 6 months than educated women. There was slightly 50 higher acceptance of good breastfeeding practices among women who had attended 1-3 health education sessions during pregnancy, and women who had received at least 1 visit from a health provider during pregnancy. Table NU.MoRES14 shows the acceptance of ever-married women in the reproductive age of various breastfeeding practices. Table NU.MoRES14: Ever-married women of reproductive age’s acceptance of good breastfeeding practices Percentage of ever-married women aged 15-49 by acceptance of immediate breastfeeding after delivery, acceptance of no pre-lacteal feeds, and acceptance of exclusive breastfeeding for 6 months,, Egypt Sub-National MICS, 2013-14 Acceptance of breastfeeding immediately after delivery Acceptance of breastfeeding only in the first 3 days of life Acceptance of exclusive breastfeeding for the first 6 months of life Number of ever- married women aged 15-49who delivered in the past five years Total 85.6 77.8 65.0 5847 Region Pilot Phase, Upper Egypt 83.9 72.3 58.2 736 Expansion Phase, Upper Egypt 84.5 76.8 66.8 4203 Expansion Phase, Lower Egypt 92.1 87.0 62.3 907 Mother's Age at birth Less than 20 78.9 78.0 69.6 247 20-34 85.8 77.7 65.2 3435 35-49 86.1 78.0 64.2 2165 Woman's education No Education 85.6 78.7 67.3 1825 Primary/Preparatory 84.0 77.0 63.6 1401 Secondary 86.0 76.8 64.8 2032 Higher 88.5 81.0 61.9 589 Woman's Work Status Working for cash 89.0 81.7 65.1 527 Not working for cash 85.3 77.5 65.0 5320 Overall, acceptance of women in this group of good breastfeeding practices are very similar to that of women with a live birth in the past 5 years i.e. the attitudes of women are similar overall and do not differ according to whether they had a recent birth or not. 51 1V. 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 achieving this goal. 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 Children24 recommends all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenza type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. The vaccination schedule followed by the Egypt National Immunization Programme provides most of the above mentioned vaccinations with birth doses of Bacillus-Calmette-Guerin (BCG) and polio vaccines, three doses of diphtheria, pertussis and tetanus (DPT), Hepatitis B, and polio vaccines, and two doses of the MMR vaccine containing measles, mumps, and rubella antigens. All vaccinations should be received during the first year of life with the exception of MMR vaccine which is currently received at age 12 months and 18 months. Taking into considerati

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