Malawi - Multiple Indicator Cluster Survey - 2014

Publication date: 2014

Monitoring the situation of children and women Malawi Malawi MDG Endline Survey 2014 National Statistical Office of Malawi Administrator Sticky Note Updated on 23 July 2015 Update includes: - Clarification on the differences in the calculation of education indicators using the national system versus calculation of indicators using the International Standard Classification of Education (ISCED). - Corrections in tables CH.18, CH.19 and CH.24 Malawi MDG Endline Survey 2014 Main Report June 2015 The Malawi MDG Endline Survey (MES) was carried out in 2013-14 by National Statistical Office as part of the global MICS programme. Technical support was provided by the United Nations Children’s Fund (UNICEF). UNICEF and John Hopkins University-World Health Organization (JHU- WHO), United Nations Development Programme (UNDP), UN Women, United Nations Population Fund (UNFPA), United States Agency for International Development (USAID), Norwegian Ministry of Foreign Affairs (MFA), SAVE the Children Malawi and the Government of Malawi provided financial support. The global MICS programme which the MES is part of was developed by UNICEF in the 1990s as an international household survey programme to collect internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The basic objective of the MES 2014 is to provide information on indicators for monitoring progress of attainment of the Millennium Development Goals and Malawi Growth and Development Strategy and other development programmes. Through collection and calculation of status of indicators of the Millennium Development Goals and other key social statistics indicators, the MES data will also be used to update the socio-economic database for policy and research. Suggested citation: National Statistical Office. 2015. Malawi MDG Endline Survey 2014. Zomba, Malawi: National Statistical Office P a g e | iv Summary Table of Survey Implementation and the Survey Population, Malawi MDG Endline Survey, 2014 Survey implementation Sample frame - Updated 2008 Malawi Population and Housing Census September 2013 Questionnaires Household Women (age 15-49) Men (age 15-49) Children under five Interviewer training November 2013 Fieldwork Nov 2013 – Apr 2014 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Per cent) 28,479 27,030 26,713 98.8 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Per cent) 19,285 18,981 98.4 Women - Eligible for interviews - Interviewed - Response rate (Per cent) 25,430 24,230 95.3 Men - Eligible for interviews - Interviewed - Response rate (Per cent) 7,818 6,842 87.5 Survey population Average household size 4.5 Percentage of population living in - Urban areas - Rural areas - Northern Region - Central Region - Southern Region 13.8 86.2 12.2 39.5 48.3 Percentage of population under: - Age 5 - Age 18 16.0 54.0 Percentage of women age 15-49 years with at least one live birth in the last 2 years 30.9 Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 9.5 25.4 41.5 66.6 Percentage of households that own - A television - A refrigerator - Agricultural land - Farm animals/livestock 11.1 5.1 85.4 55.6 Mean number of persons per room used for sleeping 2.4 Percentage of households where at least a member has or owns a - Mobile phone - Car or truck 48.6 2.0 P a g e | v Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Malawi MDG Endline Survey, 2014 CHILD MORTALITY Early childhood mortalitya MICS Indicator Indicator Description Value 1.1 Neonatal mortality rate Probability of dying within the first month of life 29 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 53 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 24 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 33 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 85 a Rates refer to the 5-year period preceding the survey. NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 16.7 3.7 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 42.4 16.3 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 3.8 1.1 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 5.1 1 See Appendix E for a detailed description of MICS indicators P a g e | vi Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 97.8 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 74.5 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 70.2 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 80.1 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 97.2 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 75.4 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 24.1 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 84.1 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 88.6 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 12.5 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day 46.8 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 26.6 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 15.0 5.2 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 4.2 Salt iodization 2.19 2.S1 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate Percentage of households with salt testing with any iodate 43.0 77.9 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 12.9 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 87.5 P a g e | vii CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 96.4 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 87.5 3.3 3.5 3.6 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 90.5 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 85.1 3.S1 PCV immunization coverage Percentage of children age 12-23 months who received the third dose of PCV vaccine (PCV3) by their first birthday 87.4 3.S2 ROTA immunization coverage Percentage of children age 12-23 months who received the second dose of ROTA vaccine (ROTA2) by their first birthday 60.3 3.8 3.S3 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday (excluding recently introduced ROTA and PCV) Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday (including recently introduced ROTA and PCV) 71.5 38.5 Tetanus toxoid 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 89.7 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 24.1 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 67.0 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 23.0 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 48.5 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 7.8 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 68.2 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 45.7 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 98.3 P a g e | viii Malaria / Fever MICS Indicator Indicator Description Value - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 37.2 3.16a 3.16b Household availability of insecticide-treated nets (ITNs) Percentage of households with (a) at least one ITN (b) at least one ITN for every two people 80.2 33.9 3.17a 3.17b Household vector control Percentage of households (a) with at least one ITN or that have been sprayed by IRS in the last 12 months (b) with at least one ITN for every two people or that have been sprayed by IRS in the last 12 months 81.9 39.9 3.18 MDG 6.7 Children under age 5 who slept under an ITN Percentage of children under age 5 who slept under an ITN the previous night 65.5 3.19 Population that slept under an ITN Percentage of household members who slept under an ITN the previous night 53.3 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 74.9 3.21 Malaria diagnostics usage Percentage of children under age 5 with fever in the last 2 weeks who had a finger or heel stick for malaria testing 41.5 3.22 MDG 6.8 Anti-malarial treatment of children under age 5 Percentage of children under age 5 with fever in the last 2 weeks who received any antimalarial treatment 39.1 3.23 Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti- malarial treatment Percentage of children under age 5 with fever in the last 2 weeks who received ACT (or other first-line treatment according to national policy) 88.3 3.24 Pregnant women who slept under an ITN Percentage of pregnant women who slept under an ITN the previous night 60.8 3.25 Intermittent preventive treatment for malaria during pregnancy Percentage of women age 15-49 years who received three or more doses of SP/Fansidar, at least one of which was received during an ANC visit, to prevent malaria during their last pregnancy that led to a live birth in the last 2 years 19.3 WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 86.2 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 27.8 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 40.6 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 88.2 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 4.2 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 56.2 P a g e | ix REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women age 15-49 years 5.0 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 143 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 31.3 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 58.6 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 19.4 Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 96.1 44.7 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 29.0 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 87.4 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 88.9 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 5.1 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 94.3 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 81.3 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 75.0 Maternal mortality 5.13 MDG 5.1 Maternal mortality ratio Deaths during pregnancy, childbirth, or within two months after delivery or termination of pregnancy, per 100,000 births within the 7-year period preceding the survey 574 P a g e | x CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 39.2 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 29.3 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 3.0 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 9.6 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 1.2 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 45.2 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 37.1 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning 59.8 LITERACY AND EDUCATIONA MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young people Percentage of young people age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education (a) women (b) men 72.4 77.8 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 17.7 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first class of primary school 79.5 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) ISCED Percentage of children of primary school age (6-11) currently attending primary (Standard 1-6) or secondary school (Standard 7-8 + Form 1-4) 93.2 7.S1 Primary school net attendance ratio (adjusted) National Percentage of children of primary school age (6-13) currently attending primary (Standard 1-8) or secondary school (Form 1-4) 93.6 7.5 Secondary school net attendance ratio (adjusted) ISCED Percentage of children of secondary school age (12-17) currently attending secondary school or higher (Standard 7 or higher) 33.1 7.S2 Secondary school net attendance ratio (adjusted) National Percentage of children of secondary school age (14-17) currently attending secondary school or higher (Form 1 or higher) 15.9 7.6 MDG 2.2 Children reaching last class of primary ISCED Percentage of children entering the first class of primary school who eventually reach last class (Standard 6) 87.8 7.S3 Children reaching last class of primary National Percentage of children entering the first class of primary school who eventually reach last class (Standard 8) 75.8 7.7 Primary completion rate (Standard 1-6) ISCED Number of children attending the last class of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final class of primary school) 86.5 P a g e | xi LITERACY AND EDUCATIONA MICS Indicator Indicator Description Value 7.S4 Primary completion rate (Standard 1-8) National Number of children attending the last class of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final class of primary school) 45.7 7.8 Transition rate to secondary school (Standard 6 to Standard 7) ISCED Number of children attending the last class of primary school during the previous school year who are in the first class of secondary school during the current school year divided by number of children attending the class of primary school during the previous school year 93.4 7.S5 Transition rate to secondary school (Standard 8 to Form 1) National Number of children attending the last class of primary school during the previous school year who are in the first class of secondary school during the current school year divided by number of children attending the last class of primary school during the previous school year 57.8 7.9 MDG 3.1 Gender parity index (primary school) (Standard 1-6) ISCED Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 1.01 7.S6 Gender parity index (primary school) (Standard 1-8) National Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 1.01 7.10 MDG 3.1 Gender parity index (secondary school) (Standard 7-8 + Form 1-4) ISCED Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.04 7.S7 Gender parity index (secondary school) (Form 1-4) National Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.22 A In Malawi, children enter primary school at age 6 and secondary school at age 14. Primary school comprises 8 classes (Standard 1-8) and secondary school comprises 4 (Form 1-4). The International Standard Classification of Education (ISCED) comprises the following three levels: (i) Primary (ISCED 1): age 6-11, Standard 1-6; (ii) Lower Secondary (ISCED 2): age 12-15, Standard 7-8 + Form 1-2; (iii) Higher Secondary (ISCED 3): age 16-17, Form 3-4. Indicators labelled “ISCED” calculate Primary school indicators based on Primary 1-6, whereas Primary 7 and 8 and included in secondary school. Indicators labelled national and marked with “S” are based on the national education system, which includes Primary 7-8 in primary school indicators. P a g e | xii CHILD PROTECTION MICS Indicator Indicator Description Value Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 39.3 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 72.4 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of people age 15-49 years who were first married or in union before age 15 (a) Women (b) Men 10.3 1.5 8.5 Marriage before age 18 Percentage of people age 20-49 years who were first married or in union before age 18 (a) Women (b) Men 49.9 9.1 8.6 Young people age 15-19 years currently married or in union Percentage of young people age 15-19 years who are married or in union (a) Women (b) Men 28.4 2.6 8.7 Polygyny Percentage of people age 15-49 years who are in a polygynous union (a) Women (b) Men 13.8 8.3 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 7.8 10.4 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of people age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food (a) Women (b) Men 12.9 8.0 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 16.7 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 11.6 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 3.8 P a g e | xiii HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of people age 15-49 years who have heard of AIDS (a) Women (b) Men 99.0 99.4 9.1 MDG 6.3 Knowledge about HIV prevention among young people Percentage of young people age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission (a) Women (b) Men 44.2 51.1 9.2 Knowledge of mother-to- child transmission of HIV Percentage of people age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV (a) Women (b) Men 68.4 61.2 9.3 Accepting attitudes towards people living with HIV Percentage of people age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV (a) Women (b) Men 13.5 24.9 HIV testing 9.4 People who know where to be tested for HIV Percentage of people age 15-49 years who state knowledge of a place to be tested for HIV (a) Women (b) Men 94.7 95.2 9.5 People who have been tested for HIV and know the results Percentage of people age 15-49 years who have been tested for HIV in the last 12 months and who know their results (a) Women (b) Men 43.3 40.0 9.6 Sexually active young people who have been tested for HIV and know the results Percentage of young people age 15-24 years who have had sex in the last 12 months, who have been tested for HIV in the last 12 months and who know their results (a) Women (b) Men 54.5 44.8 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 88.7 9.8 HIV testing during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 91.2 P a g e | xiv Sexual behaviour 9.9 Young people who have never had sex Percentage of never married young people age 15-24 years who have never had sex (a) Women (b) Men 63.2 40.8 9.10 Sex before age 15 among young people Percentage of young people age 15-24 years who had sexual intercourse before age 15 (a) Women (b) Men 14.7 18.2 9.11 Age-mixing among sexual partners Percentage of women age 15-24 years who had sex in the last 12 months with a partner who was 10 or more years older 8.9 9.12 Multiple sexual partnerships Percentage of people age 15-49 years who had sexual intercourse with more than one partner in the last 12 months (a) Women (b) Men 0.9 10.7 9.13 Condom use at last sex among people with multiple sexual partnerships Percentage of people age 15-49 years who report having had more than one sexual partner in the last 12 months who also reported that a condom was used the last time they had sex (a) Women (b) Men 35.4 35.4 9.14 Sex with non-regular partners Percentage of sexually active young people age 15-24 years who had sex with a non-marital, non-cohabitating partner in the last 12 months (a) Women (b) Men 14.0 39.0 9.15 MDG 6.2 Condom use with non- regular partners Percentage of young people age 15-24 years reporting the use of a condom during the last sexual intercourse with a non-marital, non-cohabiting sex partner in the last 12 months (a) Women (b) Men 57.2 69.9 Orphans 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non- orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents 0.96 Male circumcision 9.17 Male circumcision Percentage of men age 15-49 years who report having been circumcised 27.5 P a g e | xv ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 10.S1 Exposure to mass media Percentage of people age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television (a) Women (b) Men Percentage of people age 15-49 years who, at least once a week, read a newspaper or magazine or listen to the radio or watch television (ANY MEDIA) (a) Women (b) Men 3.8 10.7 49.8 73.1 Use of information/communication technology 10.2 Use of computers Percentage of young people age 15-24 years who used a computer during the last 12 months (a) Women (b) Men 3.4 9.3 10.3 Use of internet Percentage of young people age 15-24 years who used the internet during the last 12 months (a) Women (b) Men 3.9 12.1 SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.1 Life satisfaction Percentage of young people age 15-24 years who are very or somewhat satisfied with their life, overall (a) Women (b) Men 88.7 89.4 11.2 Happiness Percentage of young people age 15-24 years who are very or somewhat happy (a) Women (b) Men 89.2 86.9 11.3 Perception of a better life Percentage of young people age 15-24 years whose life improved during the last one year, and who expect that their life will be better after one year (a) Women (b) Men 50.2 52.1 P a g e | xvi TOBACCO AND ALCOHOL USE Tobacco use MICS Indicator Indicator Description Value 12.1 Tobacco use Percentage of people age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month (a) Women (b) Men 0.5 11.7 12.2 Smoking before age 15 Percentage of people age 15-49 years who smoked a whole cigarette before age 15 (a) Women (b) Men 0.1 2.7 Alcohol use 12.3 Use of alcohol Percentage of people age 15-49 years who had at least one alcoholic drink at any time during the last one month (a) Women (b) Men 1.3 22.7 12.4 Use of alcohol before age 15 Percentage of people age 15-49 years who had at least one alcoholic drink before age 15 (a) Women (b) Men 0.4 2.9 P a g e | xvii Table of Contents Summary Table of Survey Implementation and the Survey Population, Malawi MDG Endline Survey, 2014 . iv Summary Table of Findings . v Table of Contents . xvii List of Tables xx List of Figures . xxvii List of Abbreviations . xxviii Acknowledgements . xxx Executive Summary . xxxi I. Introduction . 1 Background . 1 Survey Objectives . 2 II. Sample and Survey Methodology . 3 Sample Design . 3 Questionnaires . 3 Training and Fieldwork . 5 Data Processing . 5 III. Sample Coverage and the Characteristics of Households and Respondents . 6 Sample Coverage . 6 Characteristics of Households . 7 Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under 5 . 11 Housing characteristics, asset ownership, and wealth quintiles . 18 IV. Child Mortality . 22 V. Nutrition 28 Low Birth Weight . 28 Nutrition Status of Children . 30 Breastfeeding and Infant and Young Child Feeding . 34 Salt Iodization . 45 VI. Child Health . 48 Vaccinations . 48 Neonatal Tetanus Protection . 54 Care of Illness . 55 P a g e | xviii Diarrhoea. 57 Acute Respiratory Infections . 67 Solid Fuel Use . 71 Malaria/Fever . 74 VII. Water and Sanitation . 92 Use of Improved Water Sources . 92 Use of Improved Sanitation . 101 Handwashing . 110 VIII. Reproductive Health . 113 Fertility . 113 Contraception . 118 Unmet Need . 121 Antenatal Care. 123 Assistance at Delivery . 128 Place of Delivery . 130 Post-natal Health Checks . 132 Adult Mortality Rates . 143 Maternal Mortality . 145 IX. Early Childhood Development . 152 Early Childhood Care and Education . 152 Quality of Care. 153 Developmental Status of Children . 159 X. Literacy and Education. 163 Literacy among Young Women and Men . 163 School Readiness . 165 Primary and Secondary School Participation . 166 XI. Child Protection . 180 Birth Registration . 180 Child Labour . 182 Child Discipline . 186 Early Marriage and Polygyny . 190 Attitudes toward Domestic Violence . 199 Children’s Living Arrangements . 201 XII. HIV/AIDS and Sexual Behaviour . 205 Knowledge about HIV Transmission and Misconceptions about HIV . 205 Accepting Attitudes toward People Living with HIV . 214 P a g e | xix Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 217 Sexual Behaviour Related to HIV Transmission . 221 HIV Indicators for Young Women and Young Men . 224 Orphans . 230 Male circumcision . 232 XIII. Access to Mass Media and Use of Information/Communication Technology . 239 Access to Mass Media . 239 Use of Information/Communication Technology . 241 XIV. Subjective well-being . 245 XV. Tobacco and Alcohol Use . 254 Tobacco Use . 254 Alcohol Use . 259 Appendix A. District Tables . 263 Appendix B. Sample Design . 442 Appendix C. List of Personnel Involved in the Survey . 449 Appendix D. Estimates of Sampling Errors . 456 Appendix E. Data Quality Tables . 495 Appendix F. Malawi MDG Endline Survey Indicators: Numerators and Denominators . 521 Appendix G. Education tables according to the International Standard Classification (ISCED) . 534 Appendix H. Questionnaires. 541 P a g e | xx List of Tables Table HH.1: Results of household, women's, men's and under-5 interviews. 6 Table HH.2: Age distribution of household population by sex . 7 Table HH.2A: Population distribution by sex . 8 Table HH.3: Household composition . 10 Table HH.4: Women's background characteristics . 12 Table HH.4M: Men's background characteristics . 15 Table HH.5: Under-5's background characteristics . 17 Table HH.6: Housing characteristics . 19 Table HH.7: Household and personal assets . 20 Table HH.8: Wealth quintiles . 21 Table CM.1: Early childhood mortality rates . 23 Table CM.2: Early childhood mortality rates by socioeconomic characteristics . 24 Table CM.3: Early childhood mortality rates by demographic characteristics . 26 Table NU.1: Low birth weight infants . 29 Table NU.2: Nutritional status of children . 32 Table NU.3: Initial breastfeeding . 37 Table NU.4: Breastfeeding . 39 Table NU.5: Duration of breastfeeding . 41 Table NU.6: Age-appropriate breastfeeding . 42 Table NU.7: Introduction of solid, semi-solid, or soft foods . 43 Table NU.8: Infant and young child feeding (IYCF) practices . 44 Table NU.9: Bottle feeding . 45 Table NU.10: Iodized salt consumption . 46 Table CH.1A. Malawi Childhood Immunization schedule . 48 Table CH.1: Vaccinations in the first years of life . 50 Table CH.2: Vaccinations by background characteristics . 53 Table CH.3: Neonatal tetanus protection . 55 Table CH.4: Reported disease episodes . 57 Table CH.5: Care-seeking during diarrhoea . 59 Table CH.6: Feeding practices during diarrhoea . 60 Table CH.7: Oral rehydration solutions and zinc. 61 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 63 Table CH.9A: Source of ORS . 65 Table CH.9B: Source of 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 . 73 Table CH.14: Household availability of insecticide treated nets and protection by a vector control method . 76 Table CH.15: Access to an insecticide treated net (ITN) - number of household members . 78 Table CH.16: Access to an insecticide treated net (ITN) - background characteristics . 79 Table CH.17: Use of ITNs . 80 Table CH.18: Children sleeping under mosquito nets . 81 Table CH.19: Use of mosquito nets by the household population . 82 Table CH.20: Care-seeking during fever . 83 Table CH.21: Treatment of children with fever . 85 Table CH.22: Diagnostics and anti-malarial treatment of children . 86 Table CH.23: Source of anti-malarial . 87 Table CH.24: Pregnant women sleeping under mosquito nets . 89 Table CH.25: Intermittent preventive treatment for malaria . 91 Table WS.1: Use of improved water sources . 94 Table WS.2: Household water treatment . 97 Table WS.3: Time to source of drinking water . 99 Table WS.4: Person collecting water . 100 P a g e | xxi Table WS.5: Types of sanitation facilities . 102 Table WS.6: Use and sharing of sanitation facilities . 104 Table WS.7: Drinking water and sanitation ladders . 107 Table WS.8: Disposal of child's faeces . 109 Table WS.9: Water and soap at place for handwashing . 111 Table WS.10: Availability of soap or other cleansing agent . 112 Table RH.1: Fertility rates . 113 Table RH.2: Adolescent birth rate and total fertility rate . 115 Table RH.3: Early childbearing . 116 Table RH.4: Trends in early childbearing . 117 Table RH.5: Use of contraception . 119 Table RH.6: Unmet need for contraception . 122 Table RH.7: Antenatal care coverage . 124 Table RH.8: Number of antenatal care visits and timing of first visit . 126 Table RH.9: Content of antenatal care. 127 Table RH.10: Assistance during delivery and caesarian section . 129 Table RH.11: Place of delivery . 131 Table RH.12: Post-partum stay in health facility. 133 Table RH.13: Post-natal health checks for newborns . 135 Table RH.14: Post-natal care visits for newborns within one week of birth . 137 Table RH.15: Post-natal health checks for mothers . 139 Table RH.16: Post-natal care visits for mothers within one week of birth . 141 Table RH.17: Post-natal health checks for mothers and newborns . 143 Table RH.18: Adult mortality rates . 144 Table RH.19: Adult mortality probabilities . 145 Table RH.20: Maternal mortality . 146 Table RH.21: Thermal care for newborns . 148 Table RH.22: Cord cutting . 149 Table RH.23: Cord care . 151 Table CD.1: Early childhood education . 153 Table CD.2: Support for learning . 155 Table CD.3: Learning materials . 157 Table CD.4: Inadequate care . 159 Table CD.5: Early child development index . 161 Table ED.1: Literacy (young women) . 164 Table ED.1M: Literacy (young men) . 165 Table ED.2: School readiness . 166 Table ED.3: Primary school entry . 167 Table ED.4: Primary school attendance and out of school children . 169 Table ED.5: Secondary school attendance and out of school children . 171 Table ED.6: Children reaching last class of primary school . 173 Table ED.7: Primary school completion and transition to secondary school . 175 Table ED.8: Education gender parity . 176 Table ED.9: Out of school gender parity . 177 Table ED.10: Summary of education indicators (ISCEDa) . 179 Table CP.1: Birth Certificate . 181 Table CP.2: Children's involvement in economic activities . 183 Table CP.3: Children's involvement in household chores . 184 Table CP.4: Child labour . 186 Table CP.5: Child discipline . 187 Table CP.6: Attitudes toward physical punishment . 189 Table CP.7: Early marriage and polygyny (women) . 192 Table CP.7M: Early marriage and polygyny (men) . 194 Table CP.8: Trends in early marriage (women) . 196 Table CP.8M: Trends in early marriage (men) . 196 Table CP.9: Spousal age difference . 198 Table CP.13: Attitudes toward domestic violence (women) . 200 P a g e | xxii Table CP.13M: Attitudes toward domestic violence (men) . 201 Table CP.14: Children's living arrangements and orphanhood . 203 Table CP.15: Children with parents living abroad . 204 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women) . 206 Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (men) . 208 Table HA.2: Knowledge of mother-to-child HIV transmission (women) . 212 Table HA.2M: Knowledge of mother-to-child HIV transmission (men) . 213 Table HA.3: Accepting attitudes toward people living with HIV (women) . 215 Table HA.3M: Accepting attitudes toward people living with HIV (men) . 216 Table HA.4: Knowledge of a place for HIV testing (women) . 218 Table HA.4M: Knowledge of a place for HIV testing (men) . 219 Table HA.5: HIV counselling and testing during antenatal care. 220 Table HA.6: Sex with multiple partners (women) . 222 Table HA.6M: Sex with multiple partners (men) . 223 Table HA.7: Key HIV and AIDS indicators (young women) . 225 Table HA.7M: Key HIV and AIDS indicators (young men) . 226 Table HA.8: Key sexual behaviour indicators (young women). 228 Table HA.8M: Key sexual behaviour indicators (young men) . 229 Table HA.9: School attendance of orphans and non-orphans . 231 Table HA.10: Male circumcision . 233 Table HA.11: Provider and location of circumcision . 236 Table MT.1: Exposure to mass media (women). 240 Table MT.1M: Exposure to mass media (men) . 241 Table MT.2: Use of computers and internet (women) . 243 Table MT.2M: Use of computers and internet (men) . 244 Table SW.1: Domains of life satisfaction (women) . 247 Table SW.1M: Domains of life satisfaction (men) . 248 Table SW.2: Overall life satisfaction and happiness (women) . 250 Table SW.2M: Overall life satisfaction and happiness (men) . 251 Table SW.3: Perception of a better life (women) . 252 Table SW.3M: Perception of a better life (men) . 253 Table TA.1: Current and ever use of tobacco (women) . 255 Table TA.1M: Current and ever use of tobacco (men) . 256 Table TA.2M: Age at first use of cigarettes and frequency of use (men) . 258 Table TA.3: Use of alcohol (women) . 260 Table TA.3M: Use of alcohol (men) . 261 Table HH.1: Results of household interviews: Districts . 263 Table HH.3: Household composition: Districts . 265 Table HH.4: Distribution of Women 15-49: Districts . 266 Table HH.4M: Distribution of men 15-49: Districts . 267 Table HH.5: Distribution of Under-5 Children: Districts. 268 Table HH.6: Housing characteristics: Districts . 269 Table HH.7: Household and personal assets: Districts. 272 Table HH.8: Wealth quintiles: Districts . 274 Table CM.2: Early childhood mortality rates by district . 275 Table NU.1: Low birth weight infants: Districts . 276 Table NU.2: Nutritional status of children: Districts . 277 Table NU.3: Initial breastfeeding: Districts . 279 Table NU.4: Breastfeeding: Districts . 280 Table NU.5: Duration of breastfeeding: Districts . 281 Table NU.6: Age-appropriate breastfeeding: Districts . 282 Table NU.8: Infant and young child feeding (IYCF) practices: Districts . 283 Table NU.9: Bottle feeding: Districts. 285 Table NU.10: Iodized salt consumption: Districts . 286 Table CH.2: Vaccinations: Districts . 287 P a g e | xxiii Table CH.3: Neonatal tetanus protection: Districts . 289 Table CH.4: Reported disease episodes: Districts . 290 Table CH.5: Care-seeking during diarrhoea: Districts . 291 Table CH.6: Feeding practices during diarrhoea: Districts . 292 Table CH.7: Oral rehydration solutions and zinc: Districts . 294 Table CH.8: Oral rehydration therapy with continued feeding and other treatments: Districts . 295 Table CH.9A: Source of ORS: Districts . 297 Table CH.9B: Source of Zinc: Districts . 299 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI): Districts . 301 Table CH.11: Knowledge of the two danger signs of pneumonia: Districts . 303 Table CH.12: Solid fuel use: Districts . 304 Table CH.13: Solid fuel use by place of cooking: Districts. 306 Table CH.14: Household availability of insecticide treated nets and protection by a vector control method: Districts . 307 Table CH.16: Access to an insecticide treated net (ITN): Districts . 309 Table CH.17: Use of ITNs: Districts . 310 Table CH.18: Children sleeping under mosquito nets: Districts . 311 Table CH.19: Use of mosquito nets by the household population: Districts . 312 Table CH.20: Care-seeking during fever: Districts. 314 Table CH.21: Treatment of children with fever: Districts . 315 Table CH.22: Diagnostics and anti-malarial treatment of children: Districts . 317 Table CH.23: Source of anti-malarial: Districts . 318 Table CH.24: Pregnant women sleeping under mosquito nets: Districts . 319 Table CH.25: Intermittent preventive treatment for malaria: Districts . 321 Table WS.1: Use of improved water sources: Districts . 323 Table WS.2: Household water treatment: Districts . 325 Table WS.3: Time to source of drinking water: Districts . 327 Table WS.4: Person collecting water: Districts . 328 Table WS.5: Types of sanitation facilities: Districts . 329 Table WS.6: Use and sharing of sanitation facilities: Districts . 331 Table WS.7: Drinking water and sanitation ladders: Districts. 333 Table WS.8: Disposal of child's faeces: Districts . 335 Table WS.9: Water and soap at place for handwashing: Districts . 337 Table WS.10: Availability of soap or other cleansing agent: Districts . 339 Table RH.2: Adolescent birth rate and total fertility rate: Districts . 340 Table RH.3: Early childbearing: Districts . 341 Table RH.5: Use of contraception: Districts . 342 Table RH.6: Unmet need for contraception: Districts . 344 Table RH.7: Antenatal care coverage: Districts . 345 Table RH.8: Number of antenatal care visits and timing of first visit: Districts . 347 Table RH.9: Content of antenatal care: Districts . 349 Table RH.10: Assistance during delivery and caesarian section: Districts . 350 Table RH.11: Place of delivery: Districts . 352 Table RH.12: Post-partum stay in health facility: Districts . 353 Table RH.13: Post-natal health checks for newborns: Districts . 354 Table RH.14: Post-natal care visits for newborns within one week of birth: Districts . 355 Table RH.15: Post-natal health checks for mothers: Districts . 357 Table RH.16: Post-natal care visits for mothers within one week of birth: Districts . 358 Table RH.17: Post-natal health checks for mothers and newborns: Districts . 360 Table RH.21: Thermal care for newborns: Districts . 361 Table RH.22: Cord cutting: Districts . 362 Table RH.23: Cord care: Districts . 363 Table CD.1: Early childhood education: Districts . 364 Table CD.2: Support for learning: Districts . 365 Table CD.3: Learning materials: Districts . 367 Table CD.4: Inadequate care: Districts . 368 Table CD.5: Early child development index: Districts . 369 Table ED.1M: Literacy (young women): Districts . 370 P a g e | xxiv Table ED.1M: Literacy (young men): Districts . 371 Table ED.2: School readiness: Districts . 372 Table ED.3: Primary school entry: Districts . 373 Table ED.4: Primary school attendance and out of school children: Districts . 374 Table ED.5: Secondary school attendance and out of school children: Districts . 376 Table ED.6: Children reaching last grade of primary school: Districts . 378 Table ED.7: Primary school completion and transition to secondary school: Districts . 380 Table ED.8: Education gender parity: Districts . 382 Table ED.9: Out of school gender parity: Districts . 383 Table CP.1: Birth certificates: Districts . 385 Table CP.2: Children's involvement in economic activities: Districts . 386 Table CP.3: Children's involvement in household chores: Districts . 387 Table CP.4: Child labour: Districts . 388 Table CP.5: Child discipline . 389 Table CP.6: Attitudes toward physical punishment: Districts . 390 Table CP.7: Early marriage and polygyny (women): Districts . 391 Table CP.7M: Early marriage and polygyny (men): Districts . 392 Table CP.9: Spousal age difference: Districts . 393 Table CP.13: Attitudes toward domestic violence (women): Districts . 394 Table CP.13M: Attitudes toward domestic violence (men): Districts . 395 Table CP.14: Children's living arrangements and orphanhood: Districts. 396 Table CP.15: Children with parents living abroad: Districts . 397 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women): Districts . 398 Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (men): Districts . 400 Table HA.2: Knowledge of mother-to-child HIV transmission (women): Districts . 402 Table HA.2M: Knowledge of mother-to-child HIV transmission (men): Districts . 403 Table HA.3: Accepting attitudes toward people living with HIV (women): Districts . 404 Table HA.3M: Accepting attitudes toward people living with HIV (men): Districts . 405 Table HA.4: Knowledge of a place for HIV testing (women): Districts . 406 Table HA.4M: Knowledge of a place for HIV testing (men): Districts . 407 Table HA.5: HIV counselling and testing during antenatal care: Districts . 408 Table HA.6: Sex with multiple partners (women): Districts . 409 Table HA.6M: Sex with multiple partners (men): Districts . 411 Table HA.7: Key HIV and AIDS indicators (young women): Districts . 413 Table HA.7M: Key HIV and AIDS indicators (young men): Districts . 415 Table HA.8: Key sexual behaviour indicators (young women): Districts . 417 Table HA.8M: Key sexual behaviour indicators (young men): Districts . 419 Table HA.10: Male circumcision: Districts . 421 Table HA.11: Provider and location of circumcision: Districts . 423 Table MT.1: Exposure to mass media (women): Districts . 425 Table MT.1M: Exposure to mass media (men): Districts . 425 Table MT.2: Use of computers and internet (women): Districts . 427 Table MT.2M: Use of computers and internet (men): Districts . 428 Table SW.1: Domains of life satisfaction (women): Districts . 429 Table SW.1M: Domains of life satisfaction (men): Districts. 431 Table SW.2: Overall life satisfaction and happiness (women): Districts . 433 Table SW.2M: Overall life satisfaction and happiness (men): Districts . 434 Table SW.3: Perception of a better life (women): Districts . 435 Table SW.3M: Perception of a better life (men): Districts . 436 Table TA.1: Current and ever use of tobacco (women): Districts . 437 Table TA.1M: Current and ever use of tobacco (men): Districts . 438 Table TA.2M: Age at first use of cigarettes and frequency of use (men): Districts . 439 Table TA.3: Use of alcohol (women): Districts . 440 Table TA.3M: Use of alcohol (men): Districts . 441 Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata . 444 P a g e | xxv Table SE.1: Indicators selected for sampling error calculations . 457 Table SE.2: Sampling errors: Total sample . 458 Table SE.3: Sampling errors: Northern Region . 459 Table SE.4: Sampling errors: Central Region . 460 Table SE.5: Sampling errors: Southern Region. 461 Table SE.6: Sampling errors: Urban . 462 Table SE.7: Sampling errors: Rural . 463 Table SE.8: Sampling errors: Chitipa District. 464 Table SE.9: Sampling errors: Karonga District . 465 Table SE.10: Sampling errors: Nkhatabay District. 466 Table SE.11: Sampling errors: Rumphi District . 467 Table SE.12: Sampling errors: Mzimba District . 468 Table SE.13: Sampling errors: Mzuzu City . 469 Table SE.14: Sampling errors: Kasungu District . 470 Table SE.15: Sampling errors: Nkhotakota District . 471 Table SE.16: Sampling errors: Ntchisi District . 472 Table SE.17: Sampling errors: Dowa District . 473 Table SE.18: Sampling errors: Salima District . 474 Table SE.19: Sampling errors: Lilongwe District . 475 Table SE.20: Sampling errors: Mchinji District . 476 Table SE.21: Sampling errors: Dedza District . 477 Table SE.22: Sampling errors: Ntcheu District . 478 Table SE.23: Sampling errors: Lilongwe City . 479 Table SE.24: Sampling errors: Mangochi District . 480 Table SE.25: Sampling errors: Machinga District . 481 Table SE.26: Sampling errors: Zomba District . 482 Table SE.27: Sampling errors: Chiradzulu District . 483 Table SE.28: Sampling errors: Blantyre District . 484 Table SE.29: Sampling errors: Mwanza District . 485 Table SE.30: Sampling errors: Thyolo District . 486 Table SE.31: Sampling errors: Mulanje District . 487 Table SE.32: Sampling errors: Phalombe District . 488 Table SE.33: Sampling errors: Chikwawa District. 489 Table SE.34: Sampling errors: Nsanje District . 490 Table SE.35: Sampling errors: Balaka District . 491 Table SE.36: Sampling errors: Neno District . 492 Table SE.37: Sampling errors: Zomba City . 493 Table SE.38: Sampling errors: Blantyre City . 494 Table DQ.1: Age distribution of household population . 495 Table DQ.2: Age distribution of eligible and interviewed women . 497 Table DQ.3: Age distribution of eligible and interviewed men . 497 Table DQ.4: Age distribution of children in household and under-5 questionnaires . 498 Table DQ.5: Birth date reporting: Household population. 499 Table DQ.6: Birth date and age reporting: Women . 500 Table DQ.7: Birth date and age reporting: Men . 501 Table DQ.8: Birth date and age reporting: Under-5s . 502 Table DQ.9: Birth date reporting: Children, adolescents and young people . 503 Table DQ.10: Birth date reporting: First and last births. 504 Table DQ.11: Completeness of reporting . 505 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . 506 Table DQ.13: Completeness of information for anthropometric indicators: Stunting . 507 Table DQ.14: Completeness of information for anthropometric indicators: Wasting . 508 Table DQ.15: Heaping in anthropometric measurements . 509 Table DQ. 16: Observation of birth certificates . 510 Table DQ.17: Observation of vaccination cards . 511 Table DQ.18: Observation of women's health cards . 512 Table DQ.19: Observation of bednets and places for handwashing . 513 P a g e | xxvi Table DQ.20: Respondent to the under-5 questionnaire . 514 Table DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 515 Table DQ.22: School attendance by single age . 516 Table DQ.23: Sex ratio at birth among children ever born and living. 517 Table DQ.24: Births by calendar years . 518 Table DQ.26: Reporting of age at death in months . 519 Table DQ.27: Completeness of information on siblings . 520 Table DQ.28: Sibship size and sex ratio of siblings . 520 Table ED.4: Primary school attendance and out of school children . 534 Table ED.5: Secondary school attendance and out of school children . 535 Table ED.6: Children reaching last class of primary school . 536 Table ED.7: Primary school completion and transition to secondary school . 537 Table ED.8: Education gender parity . 538 Table ED.9: Out of school gender parity . 540 P a g e | xxvii List of Figures Figure HH.1: Age and sex distribution of household population, Malawi, 2014 . 9 Figure CM.1: Early childhood mortality rates, Malawi, 2014 . 23 Figure CM.2: Under-5 mortality rates by area and regions, Malawi, 2014 . 25 Figure CM.3: Trend in under-5 mortality rates, MES 2014, 2010 MDHS, 2006 MICS and 2004 MDHS . 27 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Malawi, 2014 . 34 Figure NU.2: Initiation of breastfeeding, Malawi, 2014 . 38 Figure NU.3: Infant feeding patterns by age, Malawi 2014 . 40 Figure NU.4: Consumption of iodized salt, Malawi, 2014. 47 Figure CH.1: Vaccinations by age 12 months, Malawi, 2014 . 52 Figure CH.2: Children under-5 with diarrhea who received ORS, Malawi, 2014 . 62 Figure CH.3: Children under-5 with diarrhea receiving oral rehydration therapy (ORT) and continued feeding, Malawi, 2014 . 64 Figure CH.4: Percentage of household population with access to an ITN in the household, Malawi, 2014 . 79 Figure WS.1: Percent distribution of household members by source of drinking water, Malawi, 2014 . 95 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities, Malawi, 2014 . 105 Figure WS.3: Use of improved drinking water sources and improved . 108 sanitation facilities by household members, Malawi, 2014 . 108 Figure RH.1: Age-specific fertility rates by area, Malawi, 2014 . 114 Figure RH.2: Differentials in modern contraceptive use, Malawi 2014 . 120 Figure RH.3: Person assisting at delivery, Malawi, 2014 . 130 Figure ED.1: Education indicators by sex (national system), Malawi, 2014. 178 Figure CP.2: Child disciplining methods, children age 1-14 years, Malawi, 2014 . 188 Figure CP.3: Early marriage among women, Malawi, 2014 . 197 Figure HA.1: Women and men with comprehensive knowledge of HIV transmission, Malawi, 2014 . 211 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS, Malawi, 2014 . 217 Figure HA.3: Sexual behavior that increases the risk of HIV infection, young people age 15-24, Malawi, 2014 . 230 Figure TA.1: Ever and current smokers, Malawi, 2014 . 257 Figure DQ.1: Household population by single ages, Malawi, 2014 . 496 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points, Malawi, 2014 . 509 P a g e | xxviii List of Abbreviations ACT Artemisinin-based combination therapy AIDS Acquired Immune Deficiency Syndrome AL Artemether-Lumefantrine ANC Antenatal care ARI Acute Respiratory Infection ASAQ Amodiaquine and Artesunate ASFRs Age Specific Fertility Rates BCG Bacillus Calmette-Guérin (Tuberculosis) CBR Crude Birth Rate CHAM Christian Health Association of Malawi CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EA Enumeration Area ECDI Early Child Development Index EMTC Elimination of Mother to child Transmission EPI Expanded Programme on Immunization GAPPD Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea GARPR Global Aids Response Progress Reporting GFR General Fertility Rate GMAP Global Malaria Action Plan GPI Gender Parity Index GVAP Global Vaccination Action Plan HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IRS indoor residual spraying ITN Insecticide Treated Net IUD Intrauterine Device IYCF Infant and Young Child Feeding JHU Johns Hopkins University JMP Joint Monitoring Programme LLIN Long Lasting Insecticide Treated Nets MDG Millennium Development Goals MDHS Malawi Demographic Health Survey MDHS Malawi Demographic and Healthy Survey MES Malawi MDG Endline Survey MFA Norwegian Ministry of Foreign Affairs MGDS Malawi Growth and Development Strategy MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MMR Maternal Mortality Rate MoH Ministry of Health MPRS Malawi Poverty Reduction Strategy NAR Net Attendance Rate NITWG New Born Indicators Technical Working Group NMCP National Malaria Control Program NMSP National Malaria Strategic Plan OPV Oral Polio Vaccine ORS Oral Rehydration Salts ORT Oral rehydration treatment PNC Post Natal Health Checks PPM Parts Per Million P a g e | xxix PCV Pneumococcal Conjugate Vaccine RHF Recommended Home Fluid ROTA Rotavirus SP Sulfadoxide-pyrimethamine SPSS Statistical Package for Social Sciences STIs Sexually Transmitted Infections TFR Total Fertility Rate UN United Nations UN WOMEN United Nations Entity for Gender Equality and the Empowerment of Women UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund USAID United States Agency for International Development WFFC World Fit for Children WHO World Health Organization Acknowledgements On behalf of the National Statistical Office (NSO), I would particularly like to acknowledge the technical and financial assistance received from the United Nations Children’s Fund (UNICEF) at various stages of this survey. UNICEF staff from the Malawi Country Office, Regional Office and Headquarters, as well as UNICEF consultants, supported the Malawi MDG Endline Survey 2014 (MES 2014) from the planning stage to the sample design, training, data collection, and the data processing phases to ensure that the final report was of high quality. The United States Agency for International Development (USAID), John Hopkins University-World Health Organization (JHU-WHO), Norwegian Ministry of Foreign Affairs (MFA), United Nations Population Fund (UNFPA), United Nations Development Programme (UNDP), UN Women, United Nations Population Fund (UNFPA), SAVE the Children International and the Government of Malawi also deserve a special mention. Without their financial support, the objective of this survey would not have been achieved. I would also like to express my sincere gratitude to experts from relevant government ministries and agencies, other UN agencies, and international partners who were part of the Steering and Technical Committees for the MES survey. The invaluable advice, comments and inputs received from them during the organization of the survey, questionnaire development and report writing has helped to improve the quality of the final output derived from the survey. Further I would like to commend the hard work and dedication of the National Statistical Office staff for successfully completing this survey and making the results available to users on timely basis. Special thanks also go to all the interviewers, measurers, editors, supervisors, data processing staff and other individuals in the survey for their hard work and the long working hours they committed towards the completion of the survey. The names of those who supported the survey in various ways are included in Appendix C of this report. Finally, the data collection would have not been possible without the respondents in the selected households in different parts of Malawi who generously gave their time to the realization this survey. P a g e | xxx Mercy Kanyuka (Mrs.) COMMISSIONER OF STATISTICS P a g e | xxxi Executive Summary The MES 2014 is a nationally representative sample survey encompassing a total of 28,479 households and involving women age 15-49 years, men age 15-49 years and children 0-5 years in 1,140 clusters. One third of the households in the sample were selected for male survey. The survey used a two-stage sample based on the 2008 Census of Population and Housing and has been designed to provide estimates of key indicators for the rural and urban areas in Malawi, the three Regions, and the 27 districts (except Likoma). The objective of the survey is to provide information on indicators for monitoring progress of attainment of the Millennium Development Goals and Malawi Growth and Development Strategy and other development programmes. The survey was carried out in 2013-14 by the National Statistical Office (NSO) with financial support from United States Agency for International Development (USAID), John Hopkins University-World Health Organization (JHU-WHO), Norwegian Ministry of Foreign Affairs (MFA), United Nations Population Fund (UNFPA), United Nations Development Programme (UNDP), UN Women, United Nations Population Fund (UNFPA), SAVE the Children International and the Government of Malawi. Technical support was provided by UNICEF. Fieldwork was carried out by 32 mobile interviewing teams. The results pertain to the period between December 2013 and April 2014, when the field work was conducted. SAMPLE COVERAGE AND CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Of the 28,479 households selected for the sample, 27,030 were occupied. Of these, 26,713 were interviewed, giving a response rate of 98.8 percent. In the households interviewed, 25,430 women age 15-49 years were eligible for interviews and of these 24,230 were interviewed producing a response rate of 95.3 percent. For the male survey, 7,818 men age 15-49 years were identified, and 6,842 successfully interviewed, yielding a response rate of 87.5 percent. Concerning children under the age of 5 years, 19,285 were eligible, for whom responses were obtained from their mother or caregiver in 18,981 complete interviews, giving a response rate of 98 percent. Overall, 86 percent of the household population resides in rural areas, while 14 percent lives in urban areas. The average household size is 4.5 persons. Twenty-seven percent of households in Malawi are headed by women. The age structure of the population indicates that a larger proportion of the population falls into the younger age groups for each sex. Children under age 15 years constitute 48 percent of the total population. In Malawi, 31 percent of women age 15-49 years have given birth at least once in the last 2 years preceding the survey. With respect to education level, the results show that 12 percent of female household members in Malawi have never been to school, the proportion among males is 5 percent. In Malawi, only 10 percent of households have electricity with the proportion of households with electricity much higher in urban areas (46 percent) than in rural area (3 percent). According to area of residence, rural areas have a higher proportion of people in the poorest, second, middle and fourth quintiles compared with urban areas. Seventy-eight percent of the population in urban areas is in the highest quintile compared with only 11 percent of the population in rural areas. P a g e | xxxii CHILD MORTALITY Identifying groups of children with the highest risk of dying enables policy makers and programme planners to better channel resources and efforts to improve child survival and lower the exposure of infants and young children to risk. In the MES 2014, infant and under-five mortality rates were calculated from mother’s birth history information using the direct method of estimation. Data from the MES 2014 show that in the five-years before the survey, neonatal mortality was at 29 per 1,000 live births, while post-neonatal mortality rate was at 24 per 1,000 live births. With an under-five mortality of 85 deaths per 1,000 live births and infant mortality of 53 deaths per 1,000 live births occurring before they reach their first birthday. During the last 15 years there has been some improvement for infant, child and under-five mortality. For example during the 10-14 year period preceding the survey, under-five mortality was at 146 deaths per 1,000, and 85 per 1,000 live births during the recent five-year period. While there is improvement in the general infant and under-five mortality, the rate of improvement in neonatal and post-neonatal mortality is slower. NUTRITION Nutritional status of children The MES 2014 collected data on nutritional status of children by measuring height and weight of children under 5 in sampled households. These measurements were compared against the World Health Organization (WHO) growth standard for children under 5. The four anthropometric indices of nutritional status used to assess the nutritional status of children in this report are weight-for-age (underweight); height-for-age (stunting); weight-for-height (wasting) and overweight. At national level, 17 percent of children under five years old in Malawi are moderately or severely underweight and four percent are severely underweight. Forty-two percent of children are severely or moderately stunted (or too short for their age) and 16 percent are severely stunted. Four percent of children are severely or moderately wasted (or too thin for their height) and one percent are severely wasted. Five percent of children are overweight (or too heavy for their height). Low birth weight Eighty-eight percent of last live-born children in the last 2 years preceding the survey were weighed at birth. Out of those weighed, about 13 percent are estimated to weigh less than 2,500 grams. The percentage of children with a low birth weight is slightly higher among children whose birth order is 1, younger mothers (those less than 20 years), mothers with no education as well as in households in poorest wealth quintile. Breastfeeding practices Breastfeeding is nearly universal in Malawi, with 98 percent of women with a live birth in the last 2 years preceding the survey reporting having breastfed their last live-born child at any time. Exclusive breastfeeding of babies under the age of 6 months is recommended. Seventy percent of children aged 0-5 months are exclusively breastfed and 80 percent predominantly breastfed. Among children under age 3, the median duration for any breastfeeding is 24 months, 4 months for exclusive breastfeeding, and 5 months for predominant breastfeeding. Bottle-feeding in uncommon in Malawi. Use of feeding bottles in children age 0-23 months is at four percent. Salt iodization In 83 percent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate content. In 43 percent of households, salt was P a g e | xxxiii found to contain 15ppm or more of iodine while proportion of households with salt testing with any iodate (i.e. greater than 0 ppm) was 78 percent. Eight-eight percent of urban households were found to be using adequately iodized salt as compared with 76 percent of households in rural areas. CHILD HEALTH Vaccinations The percentage of children age 12-23 months who had all the recommended vaccinations including ROTA and PCV by first birthday is 39 percent and the percentage of children age 12-23 months who had all the recommended vaccinations excluding ROTA and PCV by first birthday is 71 percent. Approximately 96 percent of children age 12-23 months received a BCG vaccination by the age of 12 months. The coverage of the first dose of DPT-HepB-Hib vaccine was 97 percent, for the second dose was 96 percent and for the third dose was 90 percent. Ninety-six percent of children received Polio 1 by age 12 months and this declines to 88 percent by the third dose. The coverage of the PCV ranges from 95 percent for the first dose, 93 percent for the second, and 87 percent for the third dose. The coverage of ROTA vaccine is 64 percent for the first dose and 60 percent for the second dose. Neonatal tetanus protection The MES 2014 results indicate that the protection against tetanus among women who have had a live birth within the last 2 years is relatively high in Malawi, at 90 percent. Care of child illness Overall, 24 percent of children aged 0-59 months were reported to have had diarrhoea in the two weeks preceding the survey, 8 percent symptoms of ARI, and 37 percent an episode of fever. Of those children aged 0-59 months who had diarrhoea, 49 percent received ORT (ORS packet, increased fluid) and continued feeding during the episode of diarrhoea. Of those with ARI symptoms, 46 percent were treated with antibiotics. Solid fuel use Use of solid fuel increases the risk of other illnesses including ARI and pneumonia. In Malawi, 98 percent of all the households use solid fuels for cooking, consisting mainly of wood (84 percent). Use of solid fuels is higher in rural areas, where they are used by almost all of the household members (99 percent) compared to urban areas (90 percent). Although use of solid fuel in rural areas is higher than in urban areas still, a large majority of the population uses solid fuels for cooking in both urban and rural areas. The main difference though is in the type of fuel used: while in rural areas 93 percent of household members use wood as cooking fuel, in urban areas the main cooking fuel used is charcoal (60 percent of households). Malaria The use of insecticide-treated nets (ITNs) is a primary health intervention proven to reduce malaria transmission. Nearly four in every five (78 percent) households in Malawi own at least one ITN, and about one-third (34 percent) households have at least one ITN for every two household members. Slightly more than half (53 percent) of the household members slept under an ITN the night preceding the survey. The percentage of children under age 5 who slept under an ITN the night preceding the survey was 66 percent while the percentage of pregnant mothers who slept under an ITN the night preceding the survey was 61 percent. P a g e | xxxiv Approximately one-fifth (19 percent) of pregnant women age 15-49 received three or more doses of SP/Fansidar (Intermittent preventive treatment), at least one of which during antenatal care visits. WATER AND SANITATION Use of Improved water sources Eighty-six percent of the population in Malawi use improved water sources (piped water, tube well or borehole, protected well, protected spring). The main improved source of drinking water in Malawi is tube-well/borehole (63 percent) followed by public tap/stand-pipe (11 percent). The situation in rural areas, with 84 percent having access to improved water sources, differs markedly from urban areas where almost all (99 percent) of the household members use improved drinking water source. Twenty-eight percent of household members in households using an unimproved source of drinking water use appropriate water treatment methodologies. The main water treatment methods used by household members in households using unimproved drinking water sources are adding bleach or chlorine (15 percent) and boiling (6 percent). Eighty percent of the household members in households using unimproved drinking water sources do not use any water treatment method. Use of improved sanitation Only 41 percent of the household members in Malawi are using improved sanitation facilities which are not shared. In rural areas the percentage is 39 percent compared to 49 percent in urban areas. Fifteen percent of households from the poorest wealth index quintile have no sanitary facility but use the bush or fields to dispose of excreta. Handwashing A specific place for handwashing was observed in only 11 percent of the households, and in only four percent of them there was water and soap available for appropriate handwashing. REPRODUCTIVE HEALTH Fertility The fertility rate among women 15-49 years in Malawi for the three years before the survey is estimated at 5 children per woman. Specific fertility arrives at its peak among women 20-24 years old. Among adolescents 15-19 years old, the age-specific fertility rate (adolescent birth rate) is 143. As expected, fertility is strongly associated with education and wealth status. The total fertility rate (TFR) decreases dramatically from 6.1 for women with no education to 3.5 for women with secondary education. The TFR for women in the poorest quintile is 6.4 births per woman, compared with 3.3 births for women in the richest quintile. Early childbearing Regarding early child bearing, 24 percent of women aged 15-19 years already had one birth; 6 percent are pregnant with their first child, and 30 percent begun childbearing. Early childbearing is more prevalent among rural women than urban women and young women with no education. P a g e | xxxv Contraception Over half of the women 15-49 years who are currently married use any contraception method (59 percent). The most popular method are the Injectables which are used by 32 percent of currently married women in Malawi followed by the female sterilization which is used by one in married women (10 percent). Adolescents are far less likely to use modern contraception than older women. About 39 percent of women age 15-19 married or in union currently use a modern method of contraception compared to 57 percent of 20-24 year olds, while the use of modern contraception among older women age 45-49 years is 49 percent. Unmet need The overall unmet need for contraception, or the proportion of married women 15-49 years willing to stop having children though not using contraceptives, is 19 percent. Unmet need for spacing and limiting among currently married women is 12 percent and 7 percent respectively. Antenatal care Coverage of antenatal care by skilled personnel (doctor, nurse or midwife) is at 96 percent of women receiving antenatal care at least once during the pregnancy, and at 45 percent of women receiving antenatal care at least four times by any provider. Assistance at delivery Most of the births (87 percent) occurring in the two years preceding the survey were assisted by a skilled attendant. Deliveries by traditional birth attendants were more common among women with no education (4 percent) and among women in the lower wealth quintiles. Delivery by Caesarean- section occurred in 5 percent of births. Maternal mortality Data on the survival of respondents’ sisters were used to calculate a maternal mortality ratio for the7-year period before the survey, cantered in md-2007. Using direct estimation procedures, the maternal mortality ratio (MMR) is estimated to be 574. CHILD DEVELOPMENT Early childhood care and education Thirty-nine percent of children age 36-59 months are attending an organized early childhood education programme with attendance as high as 66 percent in urban areas, compared to 36 percent in rural areas. Developmental status of children Young children’s development in four key domains was assessed in the survey: literacy-numeracy, physical development, social-emotional development and learning (ability to follow simple instructions, ability to occupy herself/himself independently). The Early Child Development Index (ECDI) is the percentage of children who are developmentally on track in at least three of these four domains. In Malawi, 60 percent of children aged 36-59 months are found to be developmentally on track. LITERACY AND EDUCATION Literacy among young people The Youth Literacy Rate reflects the outcomes of primary education over the previous 10 years or so. As a measure of the effectiveness of the primary education system, it is often seen as a proxy P a g e | xxxvi measure of social progress and economic achievement. The MES 2014 results show that 72 percent of young women 15-24 years and 78 percent of young men 15-24 in Malawi are literate. School attendance The primary school net attendance ratio (adjusted) is 94 percent. In urban areas, the net attendance ratio (adjusted) is 98 percent compared to 93 percent in rural areas. The secondary school net attendance ratio (adjusted) is only 16 percent, which is 44 percent in urban areas compared to 11 percent in rural areas. Primary and secondary school participation Seventy-six percent of children entering first class of primary school (Standard 1) reach the last class (Standard 8). The primary school completion rate is 46 percent. While the transition rate to secondary school is 58 percent. The gender parity index is 1.01 in primary school and 1.22 in secondary school. CHILD PROTECTION Child labour About 39 percent of children age 5-17 years are involved in child labour while 35 percent were working under hazardous conditions. More male children (42 percent) compared with female children (37 percent) were engaged in child labour. Forty-six percent of children whose mothers’ have no education as compared with nine percent of children whose mothers’ have higher education were engaged in child labour. Child discipline Seventy-two percent of children aged 1-14 years were subjected to at least one form of psychological or physical punishment by household members during the past month preceding the survey, and of these six percent were subjected to severe physical punishment. Early marriage and polygyny About one in four (28 percent) young women age 15-19 years are currently married. The proportion of currently married young women ranges from 24 percent in the Central Region to 33 percent in the Southern Region. Young women in rural areas (21 percent) are more likely to be currently married than their urban counterparts (30 percent). Overall, 14 percent of all currently married women are in polygynous unions. In general, women in older age groups, living in rural areas or the Northern Region, with no education and in the poorest wealth quintile are also more likely to be in polygynous union. Data on polygynous unions among currently married men show that 8 percent report being in polygynous unions. Attitudes toward domestic violence Overall, 13 percent of women in Malawi feel that a husband/partner is justified in hitting or beating his wife in at least one of the five situations: 1) if she goes out without telling him, 2) she neglects the children, 3) she argues with him, 4) she refuses sex with him and 5) she burns the food. The justification of wife-beating is more present among rural dwellers (14 percent) compared with urban dwellers (9 percent). Children’s living arrangements Fifty-nine percent of children aged 0-17 years live with both their parents while 22 percent live with their mothers only and two percent live with their fathers only. Nearly 11 percent of children whose parents are alive live with neither of their biological parents. About 12 percent of children have at P a g e | xxxvii least one or both parents dead (orphanhood). Four percent of children have one or both parents living abroad. The percentage of at least one parent abroad is much higher in Northern Region (eight percent) and among children in the richest household population (five percent). HIV AND AIDS AND SEXUAL BEHAVIOUR Knowledge about HIV transmission and misconceptions about HIV In Malawi, the knowledge of HIV and AIDS by men and women is almost universal (99 percent). However, the percentage of men and women that know both of the main ways of preventing HIV transmission – having only one faithful uninfected partner and using a condom every time – is only 65 percent for women and 71 percent for men. Further, about 87 percent of women and 89 percent of men know of having one faithful uninfected sex partner and 70 percent of women and 77 percent of men know of using a condom every time as main ways of preventing HIV transmission. About 44 percent of women age 15-24 years and slightly more than half of men (51 percent) age 15- 24 years have comprehensive knowledge on HIV and AIDS. HIV testing Ninety-five percent of both women and men age 15-49 know where to be tested for HIV. Slightly more women (43 percent) than men (40 percent) of age 15-49 have been tested for HIV in the last 12 months preceding the survey and know the results of their most recent test. Results on HIV testing and counselling indicate that 89 percent of women age 15-49 who had a live birth in the last 2 years preceding the survey received counselling on HIV during ANC for their most recent birth. About 91 percent of the women were offered an HIV test and were tested for HIV during antenatal care and received the results. Sexual behaviour related to HIV transmission Men age 15-49 years were reported more likely to have multiple sexual partners in the last 12 months preceding the survey with 11 percent compared to 0.9 percent for women of the same age. Nine percent of women age 15-24 years reported having had sex in the last 12 months with a partner who was 10 or more years older. The percentage of sexually active young people age 15-24 years who reported having had sex with a non-marital, non-cohabiting partner in the last 12 months preceding the survey was 14 percent for women and 39 percent for men. About 57 percent of young women and 70 percent of young men reported condom use with non-regular partners in the last 12 months preceding the survey. Male circumcision The Malawi government has included and is actively promoting male medical circumcision as one of the strategies to prevent the further spread of HIV infection. About 28 percent of men age 15-49 are circumcised. There are marked differences in prevalence according to regions, ethnicity of household head and religion. Circumcision is prevalent in the Southern Region (45 percent) and lowest in the Northern Region (6 percent). ACCESS TO MASS MEDIA AND USE OF INFORMATION/COMMUNICATION TECHNOLOGY Access to mass media About 4 percent of women age 15-49 years and 11 percent of men age 15-49 years are exposed to all three media (newspaper, radio and Television) at least once a week. The percentage of women P a g e | xxxviii and men age 15-49 years who are exposed to any of the three media (newspaper, radio and Television) is 50 percent and 73 percent respectively. For both sexes, radio is the most predominant media (45 percent of women and 68 percent of men listen to the radio at least once a week). Use of information/communication technology Three percent of young women age 15-24 years and 9 percent of young men age 15-24 years used a computer during the 12 months prior to the survey while about 4 percent of young women and 12 percent of young men age 15-24 years had used the internet in the last 12 months prior to the survey. For both sexes, the use of computer and internet are strongly correlated with educational level, wealth quintiles and urban residence. SUBJECTIVE WELL-BEING Overall, 89 percent of young women age 15-24 years and 89 percent of young men age 15-24 years in Malawi are satisfied with life. The proportion of young women and young men who are satisfied with life is higher in urban areas (93 percent each) than in rural areas (88 percent). TOBACCO AND ALCOHOL USE Tobacco use Use of tobacco products is more common among men than among women in Malawi. Twelve percent of men and less than one percent of women smoked cigarettes, or used smoked or smokeless tobacco products on one or more days during the last one month before the survey. Three percent of men smoked a whole cigarette before age 15. The highest proportion of tobacco use among women is found in the Southern Region (2 percent), while the highest proportion of tobacco use among men is found in the Central Region (29 percent). Alcohol use Nearly one-quarter (23 percent) of men age 15-49 years and one percent of women age 15-49 years had at least one alcoholic drink at any time during the last one month. In addition, three percent of men and less than one percent of women had at least one alcoholic drink before the age of 15. On the other hand, 95 percent of women and 56 percent of men reported that they had never had an alcoholic drink. P a g e | 1 I. Introduction Background This report is based on the Malawi MDG Endline Survey 2014, conducted in 2013-2014 by the National Statistical Office. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also comitted themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child- focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” For almost one and half decades now, Malawi has been implementing medium term strategies whose objective is to reduce poverty through sustainable economic growth and infrastructure development. All the medium term strategies including the current one, the Malawi Growth and Development Strategy (MGDS), have incorporated the Millennium Development Goals (MDGs). In this respect, implementation of the MGDS simultaneously addresses the MDGs given that they are localized in the national development plans. P a g e | 2 The MES 2014 is expected to contribute to the evidence base of several other important initiatives, including ‘Committing to Child Survival: A Promise Renewed,’ a global movement to end child deaths from preventable causes, and ‘the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health.’ This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2014 MES has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women in Malawi  To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention;  To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally and nationally agreed upon goals and to serve as a basis for future action;  To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable;  To contribute to the generation of baseline data for the post-2015 agenda;  To validate data from other sources and the results of focused interventions. http://www.apromiserenewed.org/ http://www.who.int/woman_child_accountability/en/ http://www.who.int/woman_child_accountability/en/ P a g e | 3 II. Sample and Survey Methodology Sample Design The sample for the 2014 MES was designed to provide estimates for a large number of indicators on the situation of children and women at the national level; for urban and rural areas; the three regions (Northern Region, Central Region and Southern Region); and the 27 districts of Malawi excluding Likoma2. The urban and rural areas within each region were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size. After a household listing was carried out within the selected enumeration areas (EAs), a systematic sample of 25 households was drawn in each sample cluster. A total of 1,140 sample EAs and 28,479 households were selected for the 2014 MES. One of the selected clusters (Cluster 0152) in Rumphi district was not visited because it was inaccessible due to heavy rains and poor road network during the fieldwork period. The sample is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix B, Sample Design. Questionnaires Four sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; 3) a questionnaire for individual men administered in every third household to all men age 15-49 years; and 4) 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: o List of Household Members o Education o Child Labour o Child Discipline o Household Characteristics o Insecticide Treated Nets o Indoor Residual Spraying o Water and Sanitation  Country-specific questions on how much time is spent waiting at the source (in queue) and distance to the main source of drinking water were added o Handwashing  Country-specific questions on location where household members most often wash their hands and use of soap were added o Salt Iodization 2 Likoma district, an island on Lake Malawi, was excluded in the survey because of logistical challenges. P a g e | 4 The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility/Birth History o Desire for Last Birth o Maternal and Newborn Health  Country-specific questions on instrument used to cut the umbilical cord; whether anything was applied to the cord after the cord was cut; whether name was dried or wiped after delivery and how soon after name was dried or wiped after delivery were added o Post-natal Health Checks o Illness Symptoms o Contraception o Unmet Need o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Maternal Mortality o Tobacco and Alcohol Use o Life Satisfaction  Country-specific question on the use of soap in the house was added. The Questionnaire for Individual Men was administered to all men age 15-49 years living in the one- third of households, and included the following modules: o Man’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Circumcision o Tobacco and Alcohol Use o Life Satisfaction  Country-specific question on the use of soap in the house was added. The Questionnaire for Children under five was administered to mothers (or caretakers) of children under 5 years of age3 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age 3 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report P a g e | 5 o Birth Registration o Early Childhood Development o Breastfeeding and Dietary Intake o Immunization o Care of Illness o Anthropometry The questionnaires are based on the MICS5 model questionnaire4. From the MICS5 model English version, the questionnaires were customised and translated into Chichewa and Tumbuka and were pre-tested in Kasungu district during October 2013. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the 2014 MES English version questionnaires is provided in Appendix H and the translated version (Chichewa or Tumbuka) can be obtained from the NSO on request. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for handwashing, and measured the weights and heights of children age under 5 years. Details and findings of these observations and measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 28 days in November 2013. 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 4 days in practice interviewing in rural communities around the training site in Chiradzulu district. The data were collected by 32 teams; each was comprised of 4 interviewers, one driver, one editor, one measurer and a supervisor. Fieldwork began in November 2013 and finished in April 2014. Data Processing Data were entered using the CSPro software, Version 5.0. The data were entered on 30 desktop computers and carried out by 30 data entry operators and 4 data entry supervisors. For quality assurance purposes, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS programme and adapted to the MES questionnaire were used throughout. Data processing began simultaneously with data collection in December 2013 and was completed in May 2014. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version 21. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. 4 The model MICS5 questionnaires can be found at http://www.childinfo.org/mics5_questionnaire.html http://www.childinfo.org/mics5_questionnaire.html P a g e | 6 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage This chapter summarises characteristics of households and respondents sampled during the MES 2014. The information in this chapter is intended to facilitate interpretation of key demographic and socioeconomic indices presented later in the report. It will also assist in the assessment of the representativeness of the survey sample. The survey results in this report are presented for the country as whole and for population subgroups such as those defined by sex, region, area (rural- urban residence), age, education and wealth quintile. All district-level results are available in Appendix A. Of the 28,479 households selected for the sample, 27,030 were found to be occupied. Of these, 26,713 were successfully interviewed for a household response rate of 99 percent. In the interviewed households, 25,430 women (age 15-49 years) were identified. Of these, 24,230 were successfully interviewed, yielding a response rate of 95 percent within the interviewed households. The survey also sampled men (age 15-49 years), but required only a subsample. All men (age 15-49 years) were identified in every third sample household. In these households, a total of 7,818 men (age 15-49 years) were listed in the household questionnaires. Questionnaires were completed for 6,842 eligible men, which corresponds to a response rate of 88 percent within eligible interviewed households. Table HH.1: Results of household, women's, men's and under-5 interviews Number of households, women, men, and children under 5 by interview results, and household, women's, men's and under-5's response rates, Malawi, 2014 Total Area Region Urban Rural Northern Central Southern Households Sampled 28,479 4,076 24,403 5,225 9,530 13,724 Occupied 27,030 3,889 23,141 4,968 9,068 12,994 Interviewed 26,713 3,821 22,892 4,886 9,003 12,824 Household response rate 98.8 98.3 98.9 98.3 99.3 98.7 Women Eligible 25,430 4,002 21,428 4,683 8,597 12,150 Interviewed 24,230 3,784 20,446 4,352 8,271 11,607 Women's response rate 95.3 94.6 95.4 92.9 96.2 95.5 Women's overall response rate 94.2 92.9 94.4 91.4 95.5 94.3 Men Eligible 7,818 1,356 6,462 1,511 2,712 3,595 Interviewed 6,842 1,196 5,646 1,277 2,451 3,114 Men's response rate 87.5 88.2 87.4 84.5 90.4 86.6 Men's overall response rate 86.5 86.7 86.4 83.1 89.7 85.5 Children under 5 Eligible 19,285 2,170 17,115 3,407 6,536 9,342 Mothers/caretakers interviewed 18,981 2,125 16,856 3,320 6,451 9,210 Under-5's response rate 98.4 97.9 98.5 97.4 98.7 98.6 Under-5's overall response rate 97.3 96.2 97.4 95.8 98.0 97.3 P a g e | 7 There were 19,285 children under age five listed in the household questionnaires. Questionnaires were completed for 18,981 of these children, which corresponds to a response rate of 98 percent within interviewed households. Overall response rates of 94 percent, 87 percent and 97 percent are calculated for the individual interviews of women, men, and under-5s, respectively (Table HH.1). Generally, household response rates were high (98 percent or higher) within urban and rural areas and across the three regions. The response rates for eligible women, men and under 5s within rural and urban areas do not differ much. 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 26,713 households successfully interviewed in the survey, 120,695 household members were listed. Of these 58,908 were males, and 61,787 were females. Table HH.2: Age distribution of household population by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Malawi, 2014 Total Males Females Number Percent Number Percent Number Percent Total 120,695 100.0 58,908 100.0 61,787 100.0 Age 0-4 19,258 16.0 9,725 16.5 9,533 15.4 5-9 20,737 17.2 10,320 17.5 10,417 16.9 10-14 18,222 15.1 8,852 15.0 9,370 15.2 15-19 11,644 9.6 6,173 10.5 5,471 8.9 20-24 9,118 7.6 4,297 7.3 4,821 7.8 25-29 8,171 6.8 3,697 6.3 4,474 7.2 30-34 7,783 6.4 3,689 6.3 4,094 6.6 35-39 5,942 4.9 2,993 5.1 2,949 4.8 40-44 4,288 3.6 2,256 3.8 2,032 3.3 45-49 3,082 2.6 1,557 2.6 1,525 2.5 50-54 3,210 2.7 1,399 2.4 1,811 2.9 55-59 2,274 1.9 1,001 1.7 1,273 2.1 60-64 2,333 1.9 1,032 1.8 1,302 2.1 65-69 1,452 1.2 700 1.2 752 1.2 70-74 1,282 1.1 505 0.9 777 1.3 75-79 805 0.7 297 0.5 508 0.8 80-84 683 0.6 257 0.4 426 0.7 85+ 413 0.3 161 0.3 252 0.4 Dependency age groups 0-14 58,216 48.2 28,896 49.1 29,320 47.5 15-64 57,844 47.9 28,092 47.7 29,752 48.2 65+ 4,634 3.8 1,919 3.3 2,715 4.4 Child and adult populations Children age 0-17 years 65,166 54.0 32,728 55.6 32,438 52.5 Adults age 18+ years 55,529 46.0 26,180 44.4 29,349 47.5 P a g e | 8 The age structure of Malawi shows a larger proportion of its population in the younger age groups than in the older age groups. About 48 percent of the population is under the age of 15 years while 4 percent of the population is age 65 years or older. Children 0-17 years constitute over half (54 percent) of the population. In general, the broad age structure of the 2014 MES compares well with the 2008 Malawi Population Housing Census which has 46 percent, 50 percent and 3.8 percent for the age groups 0-14, 15-64 and 65+ respectively (see Table HH.2A). Table HH.2A: Population distribution by sex Percent of population by broad age groups and sex, Malawi 2008 and 2014 Malawi MDG Endline 2014 Malawi Census 2008 Total Male Female Total Male Female Total 100.0 100.0 100.0 100.0 100.0 100.0 Age group 0-14 48.2 49.1 47.5 45.9 46.7 45.3 15-64 47.9 47.7 48.2 50.2 49.9 50.5 65+ 3.8 3.3 4.4 3.8 3.4 4.2 Note: The MDG Endline population distribution is based on the population living in households, whereas the Census distribution is based on the entire population, i.e. including the institutional population and other negligible non-household populations. Figure HH.1 illustrates the age structure of the Malawi household population in a population pyramid. The broad base of the pyramid indicates that Malawi’s population is young. This scenario is typical of countries with high fertility rates. However, the figure also shows deficits of children under age 5 comparing with age group 5-9. Examining the Table DQ.1 in Appendix E, Data Quality Tables shows the single year age distribution and from Table DQ.1 it is noted that there is a gradual increase in the number of children from the age 0 years to 3 years where we would normally expect the contrary due to child mortality. This can reflect under-recording of small children, which is a phenomenon found in many surveys and may be attributed to out-transference that may have happened from particularly age 4 to ages 5+ to reduce workload of individual Under 5 questionnaires or the tendency on the part of the respondents to forget to mention the small children of the household. It could also be that some of the interviewers were not probing enough to get small children listed. P a g e | 9 Figure HH.1: Age and sex distribution of household population, Malawi, 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49, male respondents 15-49, and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.5 Table HH.3 provides basic background information on the households, including the sex of the household head, region, area, number of household members, education of household head, ethnicity of the household head6 and religion of the household head are shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. 5 See Appendix B: Sample Design, for more details on sample weights. 6 This was determined by asking: To what ethnic group does the head of this household belong? 10 8 6 4 2 0 2 4 6 8 10 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Per cent Age Males Females P a g e | 10 Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Malawi, 2014 Weighted percent Number of households Weighted Unweighted Total 100.0 26,713 26,713 Sex of household head Male 72.6 19,388 19,487 Female 27.4 7,325 7,226 Region Northern 11.4 3,050 4,886 Central 39.7 10,598 9,003 Southern 48.9 13,065 12,824 Area Urban 15.0 4,016 3,821 Rural 85.0 22,697 22,892 Number of household members 1 7.4 1,970 1,928 2 10.2 2,738 2,727 3 17.0 4,529 4,411 4 17.5 4,681 4,745 5 17.4 4,645 4,500 6 13.3 3,565 3,519 7 8.7 2,314 2,435 8 4.6 1,219 1,318 9 2.2 596 648 10+ 1.7 455 482 Education of household head None 16.2 4,330 4,215 Primary 59.0 15,762 15,906 Secondary 21.0 5,607 5,570 Higher 3.5 925 941 Missing/DK 0.3 89 81 Ethnicity of household head Chewa 32.7 8,739 7,644 Tumbuka 8.1 2,166 2,689 Lomwe 19.5 5,210 4,745 Tonga 1.7 449 842 Yao 14.1 3,777 3,169 Sena 4.2 1,131 1,405 Nkhonde 0.9 242 469 Ngoni 11.8 3,163 3,446 Other 6.6 1,767 2,220 Religion of household head Catholic 18.5 4,955 4,988 CCAP 15.5 4,149 4,009 Anglican 1.9 499 696 Seventh Day Adventist 5.6 1,507 1,545 Other Christian 39.9 10,653 11,257 Muslim 13.3 3,562 3,148 No religion 4.4 1,186 900 Other religion 0.8 202 170 Mean household size 4.5 26,713 26,713 P a g e | 11 The weighted and unweighted total number of households are equal, since sample weights were normalized5. The table also shows the weighted mean household size estimated by the survey. Table HH.3 shows that only 27 percent of households are headed by females indicating that in Malawi households are predominantly headed by men. This figure (female headed households) has remained relatively constant in Malawi in last 20 years. For example it was 28 percent in 2010 Malawi DHS, 25 percent in 2004 MDHS, 27 percent in 2000 MDHS and 25 percent in 1992 MDHS. The Southern Region has the highest proportion of sampled households at 49 percent followed by the central region at 40 percent and Northern Region at 11 percent. Eighty-five percent of households reside in rural areas while 15 percent in urban areas. The table also shows that seven percent of households have only one member while only two percent have 10 or more members. Sixteen percent of households are headed by persons with no education. The majority of household heads have primary education (59 percent) followed by secondary education (21 percent). Only four percent have higher education. Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under 5 Tables HH.4, HH.4M and HH.5 provide information on the background characteristics of female and male respondents 15-49 years of age and of children under age 5 years. In all three tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized)5. In addition to providing useful information on the background characteristics of women, men, and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. P a g e | 12 Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Malawi, 2014 Weighted percent Number of women Weighted Unweighted Total 100.0 24,230 24,230 Region Northern 11.6 2,800 4,352 Central 40.3 9,769 8,271 Southern 48.1 11,660 11,607 Area Urban 16.5 3,995 3,784 Rural 83.5 20,235 20,446 Age 15-19 21.3 5,152 5,248 20-24 18.9 4,582 4,555 25-29 17.7 4,278 4,319 30-34 16.4 3,985 3,895 35-39 11.8 2,853 2,863 40-44 8.0 1,933 1,963 45-49 6.0 1,448 1,387 Marital/Union status Currently married/in union 66.8 16,176 15,998 Widowed 3.4 831 870 Divorced 5.8 1,397 1,465 Separated 4.1 1,003 981 Never married/in union 19.9 4,817 4,908 Missing 0.0 6 8 Motherhood and recent births Never gave birth 21.5 5,213 5,279 Ever gave birth 78.5 19,017 18,951 Gave birth in last two years 30.9 7,490 7,576 No birth in last two years 47.6 11,532 11,379 Education None 11.5 2,795 2,721 Primary 65.7 15,914 15,937 Secondary 20.7 5,012 5,118 Higher 2.1 502 445 Missing/ DK 0.0 7 9 Wealth index quintile Poorest 19.0 4,599 4,528 Second 19.4 4,696 4,635 Middle 19.2 4,656 4,870 Fourth 19.1 4,632 4,850 Richest 23.3 5,648 5,347 Ethnicity of household head Chewa 32.0 7,763 6,895 Tumbuka 9.1 2,197 2,510 Lomwe 19.0 4,599 4,280 Tonga 1.9 462 833 Yao 14.5 3,518 2,944 Sena 4.2 1,014 1,244 Nkhonde 0.9 213 391 Ngoni 11.8 2,864 3,172 Other 6.4 1,545 1,895 Religion of household head Catholic 17.9 4,344 4,426 CCAP 15.8 3,838 3,671 Anglican 2.0 493 671 Seventh Day Adventist 6.0 1,459 1,490 Other Christian 39.6 9,588 10,145 Muslim 13.6 3,302 2,924 No religion 4.5 1,084 781 Other religion 0.5 121 122 P a g e | 13 Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to region, area, age, marital/union status, motherhood status, births in last two years, education7, wealth index quintiles8,9, ethnicity and religion of the household head. The 2014 MES sampled all women of reproductive age. The results in Table HH.4 reveal that almost half (48 percent) of female respondent 15-49 years live in the Southern Region and about 40 percent live in the Central Region while the remaining live in the Northern Region (12 percent). In terms of urban versus rural residency, about 16 percent of women reside in urban areas compared with about 84 percent in rural areas. The table shows that 21 percent of women are in 15-19 age category and the proportion is declining over the ages with 45-49 age group having six percent. Of the 24,230 successfully interviewed women, about two-thirds (67 percent) were currently married or in a union, about 13 percent were formerly married and about one-fifth (20 percent) were never married. Almost 4 in every 5 (78 percent) of those women who were ever married gave birth while 22 percent never did. Thirty one percent of women age 15 – 49 years gave birth in the last two years before the survey. To assess their education, women were asked about the highest level of school they reached. About 12 percent of all women never attended any form of education. The majority of women (66 percent) have attended some primary level education and 23 percent reached secondary education or higher. This is consistent with the 2010 Malawi DHS, which has the same proportions on primary 7 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 8 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In MES 2014 the following assets were used in these calculations: electricity, solar panel, radio, television, non-mobile telephone, refrigerator, paraffin lamp, bed with, mattress, table and chairs, Koloboyi, torch/ battery lamp, computer/laptop, watch, mobile telephone, bicycle, motorcycle/scooter, animal drawn cart, car/truck, boat with motor, canoe boat without motor, and fishing nets. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D and Pritchett, L. 2001. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India. Demography 38(1): 115-132; Rutstein, SO and Johnson, K. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6; and Rutstein, SO. 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. 9 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest population quintile”, which is used interchangeably with “women in the wealthiest survey population”, “women living in households in the richest population wealth quintile and similar. P a g e | 14 and higher education attendance. Regarding wealth index, slightly less than a quarter (23 percent) of women are in the richest wealth quintile while less than one-fifth (19 percent) of women are in each of the other wealth quintiles. P a g e | 15 Table HH.4M: Men's background characteristics Percent and frequency distribution of men age 15-49 years by selected background characteristics, Malawi, 2014 Weighted percent Number of Men Weighted Unweighted Total 100.0 6,842 6,842 Region Northern 12.3 840 1,277 Central 40.5 2,770 2,451 Southern 47.2 3,232 3,114 Area Urban 19.5 1,335 1,196 Rural 80.4 5,507 5,646 Age 15-19 24.2 1,654 1,685 20-24 17.2 1,177 1,179 25-29 15.8 1,080 1,062 30-34 15.4 1,057 1,029 35-39 12.1 829 830 40-44 8.9 609 614 45-49 6.4 436 443 Marital/Union status Currently married/in union 57.4 3,928 3,905 Widowed 0.3 19 22 Divorced 1.5 102 104 Separated 1.8 125 144 Never married/in union 39.0 2,666 2,664 Missing 0.0 2 3 Fatherhood status Has at least one living child 58.7 4,016 4,008 Has no living children 41.0 2,807 2,806 Missing/DK 0.3 19 28 Education None 5.0 340 323 Primary 58.8 4,021 4,100 Secondary 32.1 2,196 2,161 Higher 4.0 274 250 Missing/ DK 0.2 11 8 Wealth index quintile Poorest 15.2 1,039 1,058 Second 18.1 1,240 1,289 Middle 18.1 1,238 1,343 Fourth 21.3 1,461 1,481 Richest 27.2 1,864 1,671 Ethnicity of household head 32.3 2,207 2,057 Chewa 9.0 615 743 Tumbuka 18.7 1,280 1,142 Lomwe 1.8 120 217 Tonga 13.8 947 778 Yao 4.1 281 335 Sena 1.0 68 115 Nkhonde 12.3 840 884 Ngoni 6.9 475 557 Other 0.1 10 14 Religion of household head Catholic 18.8 1,287 1,274 CCAP 17.0 1,162 1,108 Anglican 1.9 128 204 Seventh Day Adventist 5.9 401 412 Other Christian 38.5 2,632 2,788 Muslim 13.1 899 791 No religion 4.6 311 239 Other religion 0.3 22 26 P a g e | 16 Similarly, Table HH.4M provides background characteristics of male respondents 15-49 years of age. The table shows information on the distribution of men according to region, area, age, marital status, fatherhood status, education, and wealth index quintiles, ethnicity of the household head and religion of the household head. In the MES 2014, one third of the households in the total sample were selected for male survey. Twelve percent of men live in the Northern Region, 41 percent in the Central Region and the remaining 47 percent in the Southern Region. The distribution of respondents by residence shows that about 20 of male live in the urban areas while 80 percent live in rural areas. According to the distribution by age groups, 24 percent of men are aged 15-19 years compared to only six percent in the oldest age group 45-49 years. Over half (57 percent) of all men in this sample are currently married or are in union, while 39 percent have never been married/in union. To assess their education, men were asked about highest level of school they attended. The data shows that only five percent of men never attended any form of education. About 59 percent reached primary education and 36 percent reached secondary education or higher. Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age in months, respondent type, mother’s (or caretaker’s) education, wealth, ethnicity of the household head and religion of the household head. P a g e | 17 Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Malawi, 2014 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 18,981 18,981 Sex Male 50.4 9,567 9,490 Female 49.6 9,414 9,491 Region Northern 11.4 2,163 3,320 Central 39.3 7,452 6,451 Southern 49.3 9,366 9,210 Area Urban 11.8 2,247 2,125 Rural 88.2 16,734 16,856 Age 0-5 months 9.4 1,780 1,686 6-11 months 9.2 1,746 1,791 12-23 months 19.8 3,755 3,870 24-35 months 20.7 3,936 3,795 36-47 months 21.3 4,045 4,099 48-59 months 19.6 3,719 3,740 Respondent to the under-5 questionnaire Mother 94.9 17,819 17,860 Other primary caretaker 5.1 958 909 Mother’s educationa None 13.6 2,589 2,528 Primary 69.8 13,254 13,330 Secondary 15.3 2,904 2,921 Higher 1.2 223 188 Missing/DK 0.1 12 14 Wealth index quintile Poorest 23.0 4,360 4,290 Second 22.2 4,213 4,190 Middle 20.9 3,965 4,082 Fourth 17.6 3,335 3,538 Richest 16.4 3,108 2,881 Ethnicity of household head Chewa 31.9 6,059 5,414 Tumbuka 8.2 1,557 1,825 Lomwe 18.9 3,595 3,345 Tonga 1.6 308 616 Yao 16.6 3,151 2,587 Sena 4.6 870 1,066 Nkhonde 0.8 158 303 Ngoni 11.1 2,113 2,337 Other 6.0 1,132 1,437 Missing 0.2 38 51 Religion of household head Catholic 17.0 3,218 3,209 CCAP 13.5 2,566 2,428 Anglican 1.8 347 502 Seventh Day Adventist 5.5 1,042 1,058 Other Christian 40.6 7,708 8,257 Muslim 16.3 3,096 2,708 No religion 4.7 898 705 Other religion 0.6 105.8 114.0 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. P a g e | 18 The results show that there is equality in proportion (50 percent) for female and male children. Eighty-eight percent of children live in rural areas with only 12 percent residing in urban areas. The largest proportion of children under five is found in the Southern Region (49 percent), followed by the Central and the Northern Regions (39 percent and 11 percent respectively). The age distribution of children of children age 0-59 months is lower for children from 0-5 months and 6-11 months (9 percent each), the distribution is quite balanced for the remaining one-year age groups. Fourteen percent of children’s mothers or care takers are uneducated, 70 percent reached primary education while about 17 percent reached secondary education or higher. Furthermore, only 16 percent of children under age five live in households in the richest population quintile, while 34 percent come from the poorest (23 percent) and the second (22 percent) wealth quintiles. Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. Only 1 in 10 households (10 percent) in Malawi have electricity. The proportion is higher among urban households (46 percent) than in rural areas (3 percent). At regional level, the Northern Region has the highest proportion of households that have electricity (11 percent) followed by the Southern Region (10 percent) while the Central Region has the lowest (8 percent). Regarding flooring, 25 percent of households have finished floor. In rural areas this percentage is lower (16 percent) compared to urban areas (76 percent). As regards roofing, 42 percent have a finished roof. Similarly, in rural areas the percentage is lower (33 percent) compared to urban areas (88 percent). Overall, 31 percent of households have 1 room used for sleeping. There are no differences by rural/urban residency. At regional level 25 percent of households in the Northern Region have only one room used for sleeping compared to 33 percent in the Central Region and 31 percent in the Southern Region respectively. P a g e | 19 Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Malawi, 2014 Total Area Region Urban Rural Northern Central Southern Electricity Yes 9.5 46.4 2.9 10.8 8.0 10.3 No 90.5 53.6 97.1 89.1 92.0 89.7 Missing/DK 0.0 0.0 0.0 0.1 0.0 0.0 Flooring Natural floor 74.5 23.6 83.5 67.2 77.1 74.1 Rudimentary floor 0.0 0.0 0.0 0.0 0.0 0.0 Finished floor 25.4 76.2 16.4 32.7 22.7 25.8 Other 0.1 0.1 0.1 0.0 0.1 0.0 Missing/DK 0.1 0.1 0.1 0.0 0.1 0.0 Roof Natural roofing 58.3 12.2 66.5 51.1 65.4 54.3 Rudimentary roofing 0.1 0.1 0.1 0.0 0.0 0.1 Finished roofing 41.5 87.6 33.4 48.8 34.5 45.5 Other 0.1 0.1 0.1 0.0 0.1 0.1 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 Exterior walls Natural walls 2.6 0.2 3.0 1.7 3.0 2.5 Rudimentary walls 30.7 18.1 33.0 11.9 31.1 34.8 Finished walls 66.6 81.7 63.9 86.3 65.9 62.5 Other 0.1 0.1 0.1 0.0 0.0 0.1 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.1 Rooms used for sleeping 1 30.9 31.2 30.8 24.8 32.7 30.8 2 42.1 39.2 42.6 40.2 42.6 42.1 3 or more 24.9 27.7 24.4 34.3 24.4 23.2 Missing/DK 2.2 1.9 2.2 0.7 0.4 3.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 26,713 4,016 22,697 3,050 10,598 13,065 Mean number of persons per room used for sleeping 2.4 2.2 2.5 2.3 2.5 2.4 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. The table shows the percentage of households that own a torch or battery lamp is 76 percent followed by radio, which is owned by 48 percent of households. Torch or battery lamp is mostly owned in the rural area (80 percent) whereas radio is mostly owned in urban area (68 percent). Across regions, ownership of torch or battery lamp and radio is almost the same. Owning agricultural land or farm animal or livestock is a symbol of wealth. Eighty-five percent of the households own agricultural land while 56 percent own farm animals or livestock. As expected most ownership of the two is in the rural areas while the Northern Region has high ownership rate compared to the Central and Southern Regions. Specially in farm animals/livestock (the difference in land ownership across regions only ranges from 85 percent in Southern Region to 91 percent in the Northern Region, compared to difference in livestock ownership, which ranges from 49 percent in Southern Region to 71 percent in the Northern Region). The table also shows percentage of households where at least one member owns or has a number of assets. The percentage of households with at least one member owning a mobile phone is 49 P a g e | 20 percent. Mobile phone ownership is higher in urban areas (84 percent) than in rural areas (43 percent) and at regional level the Northern Region has a higher rate (63 percent). 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, Malawi, 2014 Total Area Region Urban Rural Northern Central Southern Percentage of households that own a Radio 47.8 67.6 44.3 51.8 47.1 47.4 Television 11.1 42.7 5.6 15.7 10.5 10.6 Non-mobile phone 1.4 5.6 0.7 3.2 1.0 1.4 Refrigerator 5.1 24.8 1.6 6.1 5.0 4.9 Solar panel 4.6 2.2 5.0 13.1 4.4 2.6 Paraffin lamp 15.1 15.5 15.0 16.9 11.1 17.9 Bed with mattress 27.9 69.5 20.5 49.3 24.1 25.9 A table and chairs 34.8 70.9 28.4 53.3 32.4 32.3 Koloboyi 14.4 11.9 14.9 9.3 8.3 20.7 Torch/ Battery lamp 75.9 52.7 80.0 82.3 80.3 70.8 Computer/ Laptop 2.8 13.4 0.9 3.5 2.4 2.9 Percentage of households that own Agricultural land 85.4 54.2 90.9 91.0 84.9 84.5 Farm animals/Livestock 55.6 29.8 60.2 70.9 59.2 49.1 Percentage of households where at least one member owns or has a A watch 14.4 33.5 11.0 21.3 12.3 14.4 Mobile phone 48.6 83.5 42.5 63.1 46.9 46.6 Bicycle 44.2 28.7 46.9 44.3 44.3 44.0 Motorcycle or scooter 1.8 1.8 1.8 1.9 1.6 1.8 Animal-drawn cart 2.2 0.6 2.5 6.6 3.0 0.5 Car or truck 2.0 9.5 0.7 2.4 2.2 1.8 Boat with motor 0.1 0.1 0.1 0.3 0.1 0.1 Canoe/ Boat without motor 0.5 0.2 0.5 0.8 0.2 0.6 Fishing nets 1.2 0.4 1.4 1.7 0.9 1.4 Bank account 19.4 55.3 13.1 28.2 20.3 16.6 Ownership of dwelling Owned by a household member 82.3 40.0 89.8 85.6 82.7 81.3 Not owned 17.6 60.0 10.2 14.4 17.3 18.7 Rented 12.9 56.7 5.1 10.1 13.3 13.3 Other 4.7 3.2 5.0 4.3 4.1 5.4 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 26,713 4,016 22,697 3,050 10,598 13,065 Overall, 44 percent of households have one member owning a bicycle. The percentage is higher in the rural area (47 percent) compared to the urban areas (29 percent) but it is the same across all three regions (44 percent). The table also shows ownership of dwelling. Eighty-two percent of the households are owned by a household member with home ownership being higher in the rural area (90 percent) compared to urban areas (40 percent). Across the regions it is almost the same. Overall, 17 percent of dwellings are not owned, out of which 13 percent are rented. The percentage of rented dwellings is much higher in the urban areas (57 percent) than in the rural areas (5 percent), however the proportion of rented dwellings across the three regions is almost the same. P a g e | 21 The availability of durable consumer goods is a good indicator of a household’s socioeconomic status. Moreover, particular goods have specific benefits. For instance, having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs food storage; and a means of transport allows greater access to many services away from the local area. Table HH.8 shows the distribution of household population across areas of residence (urban or rural) and regions, by wealth quintiles. According to area of residence, rural areas have a higher proportion of people in the poorest, second, middle and fourth quintiles compared with urban areas. On the other hand urban areas have a higher proportion of people in the highest quintile (78 percent) compared with rural areas (11 percent). Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintile, according to area of residence and regions, Malawi, 2014 Wealth index quintile Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 120,695 Area Urban 3.3 2.0 4.2 12.2 78.2 100.0 16,600 Rural 22.7 22.9 22.5 21.3 10.7 100.0 104,095 Region Northern 9.1 12.8 21.5 28.2 28.4 100.0 14,729 Central 22.6 22.2 18.2 17.4 19.5 100.0 47,633 Southern 20.6 20.0 21.1 20.0 18.3 100.0 58,332 The Northern Region has the highest proportion of persons in the fourth and richest quintiles while the Central and Southern Regions have a lower proportion of the population in these quintiles. The proportion of households in the poorest and second quintiles is highest in the Central Region followed by the Southern Region. This is consistent with the wealth quintiles for the 2010 Malawi DHS. P a g e | 22 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction of under-five mortality by two- thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions such as, “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. However, the indirect methods cannot provide estimates of the age at death distribution beyond infant and child mortality and do not provide the richness of data available from collecting birth histories. As child mortality drops across the world, due to commitment and action, evidence shows that reductions are predominantly made in deaths occurring past infancy and increasingly there is a demand for precision in and analysis of the period where most deaths occur. The Malawi MDG End-line Survey employed birth histories in Women’s Questionnaires to collect information on childhood mortality. Mortality rates presented in this chapter are calculated from information collected in the birth histories. All interviewed women were asked whether they had ever given birth, and if yes, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): probability of dying within the first month of life • Post-neonatal mortality (PNN): difference between infant and neonatal mortality rates • Infant mortality (1q0): probability of dying between birth and the first birthday • Child mortality (4q1): probability of dying between the first and the fifth birthday • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday Rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one, and post-neonatal mortality, which is the difference between infant and neonatal mortality rates. All estimates in the chapter here are based on five years whereas the district estimates in the appendix are based on 10 years. P a g e | 23 Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Malawi, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total Years preceding the survey 0-4 29 24 53 33 85 5-9 30 30 60 42 100 10-14 40 46 86 66 146 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-five mortality rates for the three most recent five-year periods before the survey. Neonatal mortality in the most recent 5-year period is estimated at 29 deaths per 1,000 live births, while the post-neonatal mortality rate is estimated at 24 deaths per 1,000 live births. Figure CM.1: Early childhood mortality rates, Malawi, 2014 40 46 86 66 146 30 30 60 42 100 29 24 53 33 85 Neonatal mortality rate Post-neonatal mortality rate Infant mortality rate Child mortality rate Under-five mortality rate Years preceding the survey Note: Indicator values are per 1,000 live births 10-14 5-9 0-4 P a g e | 24 The infant mortality rate in the five years preceding the survey is 53 deaths per 1,000 live births and under-five mortality rate is estimated at 85 deaths per 1,000 live births for the same period indicating that 62 percent of under-five deaths are infant deaths. However, as shown in data quality Table DQ.26, there is some heaping on deaths at age 12 months resulting in underestimation of infant mortality rate and overestimation of child mortality rate. Table CM.1 and Figure CM.1 also show a declining trend at the national level, during the last 15 years, with under-five mortality at 146 deaths per 1,000 live births during the 10-14 year period preceding the survey, and 85 deaths per 1,000 live births during the most recent 5-year period, roughly referring to the years 2009 to 2014. A similar pattern is observed in all other indicators. Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the five year period preceding the survey, by socioeconomic characteristics, Malawi, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 29 24 53 33 85 Region Northern 28 17 45 23 67 Central 23 26 49 34 81 Southern 34 25 59 36 92 Area Urban 31 30 61 20 80 Rural 29 23 52 35 86 Mother's education None 26 22 48 35 81 Primary 31 24 54 35 88 Secondary + 26 30 57 25 80 Wealth index quintile Poorest 31 25 56 44 98 Second 26 23 49 35 82 Middle 34 21 55 35 88 Fourth 30 24 54 31 83 Richest 24 28 52 19 70 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.2 provides estimates of child mortality by socioeconomic characteristics such as region, area, mother’s education and wealth index for the five years preceding the survey (approximately (2009 to 2014). Generally all mortality rates (except post-neonatal mortality) are somewhat higher in the Southern Region compared with the Central and the Northern Region whereas the Northern Region has generally lower mortality rates (except neonatal mortality) compared with the Central and Southern Region. Figure CM.2 provides a graphical presentation of these differences. P a g e | 25 Mortality risk among children under five in rural areas is higher (86 deaths per 1,000 live births) than in urban areas (80 deaths per 1,000 live births). Child mortality is also higher in rural areas at 35 deaths per 1,000 compared with 20 deaths per 1,000 children in urban areas. Although we normally expect better mortality experience in urban areas than in rural areas, the results show that neonatal, post-neonatal and infant mortality rates among children in urban areas are higher than in rural areas. The results in Table CM.2 further show a clearer pattern on the relationship between childhood mortality rates (child and under-five mortality rates only), mother’s education and household wealth. Higher levels of mother’s education are generally associated with lower mortality rates, however the results from MES 2014 appear to not correlate with education. While there appears to be no significant difference in under-five mortality rates between children born to mothers with no education (81 deaths per 1,000 live births) and children born to mothers with secondary and higher education (80 deaths per 1,000 live births), the rate is higher for children born to mothers with primary education (88 deaths per 1,000 live births). Under-five mortality rates are lowest for children in the richest wealth quintile (70 deaths per 1,000 live births) and highest for children in the poorest wealth quintile (98 deaths per 1,000 live births). However the pattern is not clear for infant, post-neonatal and neonatal mortality rates. Further differentials in under-five mortality rates by region and area of residence are shown in Figure CM.2. Figure CM.2: Under-5 mortality rates by area and regions, Malawi, 2014 Early childhood mortality rates were also estimated by demographic characteristics of the mother and the child that are known to play an important role in the mortality risks children are exposed to: mother’s age at birth, birth order and birth intervals. Table CM.3 shows that children from mothers age less than 20 years have higher neonatal mortality rates while children from mothers age 35-49 years have higher post-neonatal, child and under-five mortality rates. Further, Table CM.3 shows that mortality rates of children whose birth order is seventh or higher are generally higher (except during the neonatal period). Regarding the previous birth interval, the results show that when the interval with the previous birth is less than 2 years, mortality rates are about twice as high as when the interval is 2 years or more, suggesting that shorter birth intervals are associated with higher risks of mortality at any age of the children under-five. 85 67 81 92 80 86 0 20 40 60 80 100 Total Northern Central Southern Urban Rural Under-5 Mortality Rates per 1,000 Births P a g e | 26 Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the five year period preceding the survey, by demographic characteristics, Malawi, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 29 24 53 33 85 Sex of child Male 33 25 58 35 91 Female 25 24 49 32 79 Mother's age at birth Less than 20 42 25 67 33 98 20-34 25 23 48 30 76 35-49 32 34 66 55 117 Birth order 1 41 24 66 34 98 2-3 25 23 48 29 75 4-6 23 23 47 33 78 7+ 35 33 68 48 113 Previous birth interval b < 2 years 50 51 101 57 152 2 years 27 23 49 33 80 3 years 17 18 34 22 56 4+ years 21 20 41 29 68 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates b Excludes first order births Figure CM.3 compares the 2014 MES findings on under-five mortality with those from other data sources. The graph fits the previous surveys nicely confirming the constant decline in mortality rates in Malawi over the past 15 years. Further qualification of these apparent declines and differences as well as its determinants should be taken up in a more detailed and separate analysis. P a g e | 27 Figure CM.3: Trend in under-5 mortality rates, MES 2014, 2010 MDHS, 2006 MICS and 2004 MDHS 0 20 40 60 80 100 120 140 160 180 200 1990 1994 1998 2002 2006 2010 2014 Per 1,000 live births Year MDHS 2010 MICS 2006 MDHS 2004 MES 2014 P a g e | 28 V. Nutrition Malnutrition remains the world’s most prevalent health problem and the single biggest contributor to child mortality. Almost one-third of children in the developing world are either underweight or stunted and over 30 percent of the population in the developing world suffers from micronutrients deficiencies. Malnutrition contributes to more than half of all child deaths from all causes and is increasing in the sub-Saharan Africa. Nutrition status is the result of complex interaction between food consumption and the overall health status and care practices. Several socioeconomic and cultural factors influence decisions on patterns of feeding and nutritional status. Unless policies and priorities are changed, malnutrition will prevent many countries from achieving the MDGs. Low Birth Weight Weight at birth is a proxy indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy, accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 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 P a g e | 29 recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.10 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Malawi, 2014 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live-born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 3.8 8.7 51.0 33.8 2.8 100.0 12.9 87.5 7,490 Mother's age at birth Less than 20 years 4.2 12.0 50.6 30.5 2.7 100.0 14.4 89.0 1,453 20-34 years 3.6 7.9 51.0 34.9 2.6 100.0 12.4 88.4 5,095 35-49 years 4.3 7.9 51.7 32.3 3.7 100.0 13.1 80.9 943 Birth order 1 5.0 11.0 51.7 29.4 2.9 100.0 14.5 90.9 1,691 2-3 3.6 7.6 49.3 36.6 2.9 100.0 12.2 90.2 2,683 4-5 3.1 8.7 51.2 34.5 2.4 100.0 12.5 84.5 1,832 6+ 3.6 7.8 53.3 32.5 2.9 100.0 12.7 81.8 1,284 Region Northern 3.4 6.4 66.8 20.8 2.6 100.0 13.1 91.9 839 Central 2.9 9.7 50.5 34.6 2.3 100.0 12.8 85.7 2,957 Southern 4.6 8.4 47.8 36.0 3.2 100.0 12.9 88.0 3,695 Area Urban 4.5 7.6 50.2 35.0 2.7 100.0 12.8 93.0 889 Rural 3.7 8.8 51.1 33.6 2.8 100.0 12.9 86.8 6,602 Mother’s education None 4.7 11.3 53.2 28.1 2.7 100.0 14.5 79.2 872 Primary 3.9 8.6 50.3 34.3 3.0 100.0 12.9 86.8 5,318 Secondary 2.6 7.5 52.6 35.5 1.8 100.0 11.7 95.8 1,203 Higher 6.4 5.4 50.1 32.2 5.8 100.0 13.1 99.3 96 Missing/DK (*) (*) (*) (*) (*) 100.0 (*) (*) 1 Wealth index quintile Poorest 4.0 11.1 50.6 31.8 2.4 100.0 14.0 82.2 1,853 Second 3.3 9.9 50.5 33.9 2.5 100.0 13.0 86.7 1,676 Middle 4.4 6.6 51.4 34.6 2.9 100.0 12.5 86.7 1,556 Fourth 3.5 7.2 51.6 34.0 3.7 100.0 12.2 90.4 1,242 Richest 3.6 7.6 51.0 35.2 2.7 100.0 12.2 95.3 1,163 1 MICS indicator 2.20 – Low –birth weight infants 2 MICS indicator 2.21 –Infants weighed at birth (*) Omitted: figures are based on less than 25 unweighted cases Table NU.1 presents data on the percentage of last live-born children in the last 2 years preceding the survey weighed at birth. Overall, 88 percent of births were weighed at birth. According to mother’s assessment of the size at birth, about half (51 percent) of those children were of the average size, 34 percent were larger than average or very large, while 4 percent were very small and 9 percent were smaller than average. Out of those live born infants weighed at birth, approximately 13 percent are estimated to weigh less than 2,500 grams. The percentage of children with a low 10 For a detailed description of the methodology, see Boerma, J. T. et al. 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2):209-16. P a g e | 30 birth weight is higher among children whose birth order is 1, younger mothers (those less than 20 years), mothers with no education as well as mothers in poorest wealth quintile. There was no large variation by region or area of residence (rural or urban). Nutrition Status of Children Children’s nutritional status is a reflection of their overall health and development. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Undernutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards11. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height can be used to assess wasting and overweight status. Children whose weight-for- height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. 11 http://www.who.int/childgrowth/standards/technical_report http://www.who.int/childgrowth/standards/technical_report P a g e | 31 In 2014 MES, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended12 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children under 5 years classified into each of these categories: weight-for-age, height-for-age, and weight-for-height based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight is above 2 standard deviations from the median of the reference population, and mean z-scores for all three anthropometric indicators. 12 See MICS Supply Procurement Instructions: http://www.childinfo.org/mics5_planning.html http://www.childinfo.org/mics5_planning.html P a g e | 32 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, Malawi, 2014 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Total 16.7 3.7 -1.0 18,530 42.4 16.3 -1.8 18,275 3.8 1.1 5.1 0.1 18,211 Sex Male 17.6 4.0 -1.0 9,313 45.7 18.7 -1.8 9,170 4.3 1.2 5.6 0.1 9,152 Female 15.8 3.4 -0.9 9,217 39.1 13.8 -1.7 9,105 3.3 0.9 4.5 0.0 9,059 Region Northern 11.7 2.3 -0.8 2,099 38.7 14.4 -1.6 2,057 3.1 1.0 7.1 0.2 2,059 Central 16.6 3.9 -1.0 7,300 44.2 17.0 -1.8 7,211 3.9 1.0 5.9 0.1 7,177 Southern 18.0 4.0 -1.0 9,131 41.8 16.1 -1.7 9,006 3.9 1.1 3.9 0.0 8,975 Area Urban 13.5 2.7 -0.8 2,204 36.2 12.9 -1.6 2,180 2.9 0.8 7.4 0.2 2,170 Rural 17.1 3.9 -1.0 16,326 43.2 16.7 -1.8 16,096 3.9 1.1 4.7 0.0 16,041 Age 0-5 months 10.0 2.0 -0.4 1,722 21.1 8.5 -.9 1,640 5.8 2.6 14.1 0.4 1,592 6-11 months 14.1 4.6 -0.8 1,703 29.9 10.5 -1.4 1,670 5.8 2.5 7.7 0.1 1,676 12-23 months 18.3 4.4 -1.0 3,689 44.1 16.5 -1.8 3,650 5.4 1.1 3.9 -0.1 3,650 24-35 months 20.7 4.5 -1.1 3,855 52.8 21.6 -2.1 3,813 3.9 0.8 4.1 0.0 3,812 36-47 months 16.6 4.1 -1.1 3,944 47.4 19.8 -1.9 3,909 2.2 0.7 4.5 0.1 3,905 48-49 months 15.3 2.2 -1.0 3,617 39.8 12.8 -1.7 3,593 2.0 0.3 2.6 0.0 3,576 Mother’s education None 21.2 5.0 -1.1 2,522 49.0 20.9 -1.9 2,479 4.6 1.5 4.6 0.0 2,477 Primary 17.0 3.9 -1.0 12,933 43.1 16.8 -1.8 12,755 3.8 1.0 4.9 0.1 12,710 Secondary 12.1 2.4 -0.8 2,843 34.7 10.7 -1.6 2,814 3.1 0.9 5.9 0.1 2,795 Higher 9.7 1.4 -0.4 219 23.7 6.3 -1.1 215 3.3 2.3 7.8 0.4 217 Missing/DK (*) (*) (*) 12 (*) (*) (*) 12 (*) (*) (*) (*) 12 Wealth index quintile Poorest 21.4 5.0 -1.1 4,266 48.7 20.6 -1.9 4,192 4.8 1.1 5.1 0.0 4,157 Second 17.1 4.3 -1.0 4,120 43.9 17.8 -1.8 4,060 4.4 1.3 4.7 0.0 4,046 Middle 16.6 3.4 -1.0 3,847 43.6 15.5 -1.8 3,791 3.4 1.0 4.4 0.0 3,781 Fourth 13.8 2.8 -0.9 3,256 39.1 13.6 -1.7 3,222 2.8 0.9 4.7 0.1 3,215 Richest 12.9 2.8 -0.7 3,041 33.6 11.8 -1.5 3,010 3.2 1.0 6.7 0.2 3,013 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 (*) Omitted: figures are based on less than 25 unweighted cases P a g e | 33 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. 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 E. The tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, 3 percent of children have been excluded from calculations of the weight-for-age indicator, 4 percent from the height-for-age indicator, and 4 percent for the weight-for-height indicator. Almost one in six children (17 percent) under age five in Malawi are moderately or severely underweight and close to four percent are severely underweight (Table NU.2). More than two in five (42 percent) children under the age of five are moderately or severely stunted or too short for their age and 16 are severely stunted. Severely or moderately wasted -or too thin for their height- stands at four percent with one percent severely wasted. It is also important to note that five in a hundred children under five (5 percent) are overweight or too heavy for their height. Results in Table NU.2 show variation in the nutrition indicators according to some background characteristics. Children in the Southern Region are more likely to be underweight while children in the Central Region are more likely to be stunted than children in the Northern Region. In contrast, the percentage of wasting is highest in both Central and Southern Regions. Those children whose mothers have attended secondary or higher education are the least likely to be underweight and stunted compared to children of mothers with no education. Nevertheless, children of these mothers are more likely to be overweight. Boys appear to be slightly more likely to be underweight, stunted, and wasted (malnourished) than girls. The age pattern shows that a higher percentage of children age 24-35 months are undernourished according to all three indices except wasting in comparison to children who are younger and older (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. Children in rural areas are more likely to be wasted, stunted and underweight than children in urban areas and the richest are more likely to be overweight. P a g e | 34 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Malawi, 2014 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.13 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.14 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.15 A summary of key guiding principles16, 17 for feeding 6-23 13 Bhuta, Z. et al. 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 14 WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February 2003. 15 WHO. 2003. Global Strategy for Infant and Young Child Feeding. 16 PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. 17 WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age Underweight Stunted Wasted Overweight 0 10 20 30 40 50 60 0 12 24 36 48 P e r c e n t Age in months P a g e | 35 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are: (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. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).18 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). 18 WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. P a g e | 36 Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups19 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 19 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. P a g e | 37 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a prelacteal feed, Malawi, 2014 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live- born children in the last two years Within one hour of birth2 Within one day of birth Total 97.8 74.5 94.4 1.5 7,490 Region Northern 98.0 73.6 95.0 1.2 839 Central 98.7 78.4 96.5 2.0 2,957 Southern 97.1 71.5 92.6 1.1 3,695 Area Urban 97.8 73.5 91.8 1.1 889 Rural 97.8 74.6 94.8 1.5 6,602 Months since last birth 0-11 months 98.3 75.0 94.8 1.9 3,559 12-23 months 97.9 74.5 94.5 1.1 3,669 Assistance at delivery Skilled attendant 99.0 76.3 95.6 1.3 6,545 Traditional birth attendant 98.7 73.1 95.3 4.2 223 Other 98.5 67.1 93.6 3.0 540 No one/Missing 53.7 30.8 52.9 0.0 183 Place of delivery Public sector health facility 99.0 76.1 95.6 1.3 5,728 Private sector health facility 97.4 74.1 94.8 0.7 216 CHAM/MISSION 98.9 77.3 95.3 1.7 717 Home 98.2 71.5 94.9 3.3 613 Other/DK/Missing 62.8 30.6 56.9 1.6 216 Mother’s education None 96.7 74.9 92.8 1.3 872 Primary 97.9 74.0 94.7 1.5 5,318 Secondary 98.5 76.4 95.1 1.1 1,203 Higher 98.1 71.8 86.2 3.7 96 Missing/DK (*) (*) (*) (*) 1 Wealth index quintile Poorest 98.2 75.0 95.6 2.2 1,853 Second 97.9 74.5 94.6 1.4 1,676 Middle 97.9 75.6 94.7 0.9 1,556 Fourth 97.7 73.1 93.7 1.5 1,242 Richest 97.3 73.4 92.6 1.0 1,163 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding (*) Omitted: figures are based on less than 25 unweighted cases P a g e | 38 Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.20 Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 75 percent of babies are breastfed within one hour of birth, while 94 percent of new-borns in Malawi start breastfeeding within one day of birth. Among children born in the last two years preceding the survey, 98 percent had ever breastfed and about only two percent of them received a prelacteal feed. Women differed in the timing of initial breastfeeding according to their education level. Women with more than secondary education are less likely to breastfeed within an hour or a day after delivery as opposed to women with secondary or less education. Also a baby is less likely to be breastfed within one hour or one day of birth if delivery takes place at home or if assistance at delivery is provided by other person rather than a skilled or traditional birth attendant. The proportions of women who initiated breastfeeding within one hour of birth is generally at low levels compared with those who initiated breastfeeding within one day of birth. The findings are presented in Figure NU.2 by region and area. Figure NU.2: Initiation of breastfeeding, Malawi, 2014 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. 20 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). 95 97 93 92 95 94 74 78 72 73 75 74 0 20 40 60 80 100 P e r c e n t Within one day Within one hour P a g e | 39 In Table NU.4, breastfeeding status is presented for both exclusively breastfed and predominantly breastfed; referring to infants’ age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Malawi, 2014 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed1 Percent predominantl y breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Total 70.2 80.1 1,780 97.2 1,372 75.4 1,076 Sex Male 68.0 77.0 958 96.9 658 75.5 516 Female 72.8 83.8 822 97.4 714 75.3 560 Region Northern 65.8 78.5 181 96.9 160 69.7 114 Central 68.9 80.7 735 98.0 495 77.5 422 Southern 72.2 79.9 863 96.6 718 75.0 540 Area Urban 71.2 75.6 243 92.6 123 60.0 134 Rural 70.1 80.8 1,537 97.6 1,249 77.6 942 Mother’s education None 71.3 78.1 211 97.1 171 79.3 111 Primary 69.0 79.7 1,251 97.9 959 79.5 754 Secondary 75.6 85.4 290 95.1 231 61.3 187 Higher (*) (*) 26 (*) 11 (*) 24 Missing/DK (*) (*) 2 (*) 1 - 0 Wealth index quintile Poorest 67.8 77.9 455 97.9 329 78.7 262 Second 68.1 83.0 374 97.7 328 78.1 238 Middle 70.1 77.2 355 98.2 319 77.5 195 Fourth 72.9 83.0 279 96.9 235 73.7 185 Richest 73.8 80.6 317 93.0 162 67.3 197 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 (*) Omitted: figures are based on less than 25 unweighted cases Seventy percent of children aged less than six months are exclusively breastfed. With 80 percent predominantly breastfed, it is evident that water-based liquids are displacing feeding of breast milk to a great extent. By age 12-15 months, 97 percent of children are breastfed and by age 20-23 months, 75 percent are breastfed. There is a direct relationship between exclusive breastfeeding and wealth index. About two in three (68 percent) women in the poorest household population breastfeed exclusively compared with 74 percent of women in the richest household population. However, there is no direct relationship between predominant breastfeeding and wealth index. P a g e | 40 Notable, also, is that predominant breastfeeding is higher in rural (81 percent) than urban (76 percent) areas and there is no difference in exclusive breastfeeding between the two areas. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, a large number of children are receiving liquids or foods other than breast milk, with other milk (tinned, powdered, or fresh animal milk) and infant formula being of highest prevalence, even at the early age of 0-1 months. At age 4-5 months old, the percentage of children exclusively breastfed is below 50 percent. Only about 10 percent of children are receiving breast milk at age 2 years. Figure NU.3: Infant feeding patterns by age, Malawi 2014 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 24 months for any breastfeeding, 4 months for exclusive breastfeeding, and 5 months for predominant breastfeeding. There is no difference in median duration of breastfeeding between male and female children while the median duration differs slightly between rural and urban areas. Median duration for breastfeeding differs with mother’s education. For example, the median duration for any breastfeeding is 24 months for women with no education and 21 months for women with more than secondary education. Exclusively breastfed Breastfed and complimentary foods Weaned (not breastfed) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age in months Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk / formula Breastfed and complimentary foods Weaned (not breastfed) P a g e | 41 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Malawi, 2014 Median duration (in months) of: Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median 24.1 4.1 4.9 11,217 Sex Male 24.2 4.0 4.8 5,642 Female 24.1 4.3 5.0 5,575 Region Northern 23.7 3.6 4.7 1,206 Central 25.0 4.0 4.9 4,461 Southern 23.6 4.4 5.0 5,550 Area Urban 22.2 4.4 4.8 1,369 Rural 24.4 4.1 4.9 9,848 Mother’s education None 24.3 4.4 5.0 1,343 Primary 24.4 4.0 4.9 7,888 Secondary 22.7 4.7 5.3 1,833 Higher 20.7 3.0 3.0 144 Wealth index quintile Poorest 24.7 3.9 5.0 2,699 Second 24.6 3.9 4.9 2,458 Middle 24.1 4.1 4.6 2,309 Fourth 24.0 4.5 5.0 1,922 Richest 23.1 4.5 5.1 1,829 Mean 24.2 4.2 5.2 11,217 1 MICS indicator 2.11 - Duration of breastfeeding 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, 87 percent of children age 6-23 months is being appropriately breastfed while age-appropriate breastfeeding among all children age 0-23 months is 84 percent. Slightly more female children age 0-23 were appropriately breastfed the day before the survey than their male counterparts (85 and 83 percent, respectively). Percentage of children age 0- 23 appropriately breastfed the day before the survey also differed by area of residence with 81 percent in urban areas compared to 85 percent in rural areas. P a g e | 42 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Malawi,2014 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Total 70.2 1,780 88.6 5,502 84.1 7,281 Sex Male 68.0 958 88.8 2,719 83.4 3,676 Female 72.8 822 88.4 2,783 84.9 3,605 Region Northern 65.8 181 89.3 631 84.1 812 Central 68.9 735 89.4 2,157 84.2 2,892 Southern 72.2 863 87.8 2,714 84.0 3,576 Area Urban 71.2 243 84.4 625 80.7 868 Rural 70.1 1,537 89.1 4,877 84.6 6,413 Mother’s education None 71.3 211 85.7 646 82.2 857 Primary 69.0 1,251 90.1 3,882 84.9 5,133 Secondary 75.6 290 85.6 886 83.2 1,176 Higher (*) 26 73.6 86 69.9 112 Missing/DK (*) 2 (*) 1 (*) 3 Wealth index quintile Poorest 67.8 455 88.2 1,367 83.1 1,822 Second 68.1 374 91.4 1,240 86.0 1,614 Middle 70.1 355 90.6 1,163 85.8 1,519 Fourth 72.9 279 86.7 927 83.5 1,206 Richest 73.8 317 84.3 804 81.4 1,120 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding (*) Omitted: figures are based on less than 25 unweighted cases Appropriate complementary feeding of children from six months to two years of age is particularly important for growth and development and prevention of malnutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate foods that help meet nutritional requirements when breastmilk 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 6-8 months old, and three or more meals if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk are needed. Table NU.7 presents information on the introduction of solid, semi-solid, or soft foods to infants age 6-8 months. Overall, 89 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day. It is the same proportion among currently breastfeeding infants (89 percent). Rural-urban differentials are more pronounced for all and currently breastfed who received solid, semi-solid, or soft foods at least once during the previous day. Proportion for urban areas is higher than rural areas. P a g e | 43 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, Malawi, 2014 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods1 Number of children age 6-8 months Total 88.5 853 (*) 12 88.6 865 Sex Male 86.9 429 (*) 6 87.1 435 Female 90.1 424 (*) 6 90.1 431 Area Urban 94.5 107 (*) 2 94.6 110 Rural 87.7 746 (*) 10 87.7 756 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods (*) Omitted: figures are based on less than 25 unweighted cases Table NU.8 presents the proportion of children age 6-23 months who received semi-solid or soft food at least the minimum number of times during the previous day according to their breastfeeding status. Overall, about half of the children age 6-23 months (47 percent) were receiving solid, semi-solid and soft foods the minimum number of times. The same proportion of males and females (47 percent each) were achieving the minimum meal frequency. However, for currently breastfed children, a slightly higher proportion of females (49 percent) were achieving the minimum meal frequency compared to males (48 percent). The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups, was much lower (27 percent) than that for minimum meal frequency, indicating the need to focus on improving diet quality and nutrient intake among this vulnerable group. A slightly higher proportion of older (18-23 month old) children (34 percent) were achieving the minimum dietary diversity compared to younger (6-8 month old) children (11 percent). The overall assessment using the indicator of minimum acceptable diet revealed that only 14 percent were benefitting from a diet sufficient in both diversity and frequency, ranging from 5 percent for currently not breastfeeding women to 15 percent for currently breastfeeding women. As expected, good infant and child feeding practices are better in urban than rural areas. P a g e | 44 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Malawi, 2014 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Total 25.1 48.3 15.0 5,081 44.1 28.0 5.2 12.5 384 26.6 46.8 14.3 5,502 Sex Male 26.2 47.9 15.3 2,523 42.6 28.0 3.6 9.8 177 27.3 46.6 14.5 2,719 Female 24.0 48.7 14.7 2,558 45.4 28.0 6.6 14.8 207 25.9 47.1 14.1 2,783 Age 6-8 months 11.1 65.2 9.5 853 (*) (*) (*) (*) 7 11.1 65.1 9.4 865 9-11 months 22.4 38.2 11.3 875 (*) (*) (*) (*) 5 22.7 38.5 11.4 881 12-17 months 28.1 46.7 17.4 2,012 52.2 30.6 6.8 18.4 73 29.2 46.2 17.0 2,100 18-23 months 31.2 46.4 17.3 1,340 42.3 25.6 4.3 9.1 298 33.5 42.6 15.0 1,655 Region Northern 30.0 61.6 23.3 582 58.4 22.4 1.8 5.2 46 32.0 58.7 21.8 631 Central 19.4 48.5 12.2 2,007 36.5 22.4 2.9 13.6 136 20.5 46.9 11.6 2,157 Southern 28.6 45.0 15.3 2,492 46.0 33.1 7.6 13.3 202 30.1 44.1 14.7 2,714 Area Urban 36.2 55.7 21.7 541 55.7 47.9 10.8 31.6 76 39.3 54.7 20.3 625 Rural 23.8 47.4 14.2 4,540 41.3 23.1 3.9 7.8 308 25.0 45.8 13.5 4,877 Mother’s education None 16.9 38.1 7.2 598 (30.0) (17.4) (3.7) (6.6) 45 17.8 36.6 7.0 646 Primary 23.2 48.2 13.9 3,641 34.2 23.5 2.1 6.4 221 23.9 46.8 13.2 3,882 Secondary 37.1 54.6 24.3 778 64.0 34.4 9.5 21.2 99 40.5 52.3 22.6 886 Higher 63.9 69.0 37.6 63 (*) (*) (*) (*) 20 70.3 69.2 33.9 86 Missing/DK (*) (*) (*) 1 (*) (*) (*) (*) 0 (*) (*) (*) 1 Wealth index quintile Poorest 15.6 41.4 9.3 1,287 27.8 25.8 0.0 1.7 74 16.4 40.5 8.8 1,367 Second 21.5 46.0 11.9 1,170 21.0 19.6 4.0 7.1 64 21.6 44.7 11.5 1,240 Middle 22.6 48.0 11.9 1,083 30.8 21.5 4.0 10.8 69 23.2 46.4 11.5 1,163 Fourth 31.9 54.6 19.1 842 59.0 22.8 2.6 7.0 83 34.3 51.8 17.6 927 Richest 44.3 57.5 30.5 698 69.3 44.7 13.4 30.6 94 47.7 56.0 28.5 804 1 MICS indicator 2.17a - Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 - Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 - Minimum dietary diversity 5 MICS indicator 2.15 - Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds ( ) Figures that are based on 25-49 unweighted cases (*) Omitted: figures are based on less than 25 unweighted cases P a g e | 45 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that bottle-feeding is not prevalent in Malawi. Only four percent of children under age six months are fed using a bottle with a nipple, with a much higher percentage in urban areas (15 percent) than in rural areas (3 percent). It is also observed that the percentage of bottle use is higher among mothers with higher education (38 percent) compared with mothers with no education (2 percent) or primary education (3 percent). Furthermore, bottle-feeding is also more common in richest households (16 percent) than in poorest ones (1 percent). 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, Malawi, 2014 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Total 4.2 7,281 Sex Male 4.4 3,676 Female 4.0 3,605 Age 0-5 months 2.2 1,780 6-11 months 4.8 1,746 12-23 months 4.9 3,755 Region Northern 4.7 812 Central 3.6 2,892 Southern 4.6 3,576 Area Urban 14.5 868 Rural 2.8 6,413 Mother’s education None 2.4 857 Primary 2.5 5,133 Secondary 9.8 1,176 Higher 37.7 112 Missing/DK (*) 3 Wealth index quintile Poorest 1.4 1,822 Second 1.5 1,614 Middle 2.7 1,519 Fourth 3.3 1,206 Richest 15.7 1,120 1 MICS indicator 2.18 - Bottle feeding (*) Omitted: figures are based on less than 25 unweighted cases Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). P a g e | 46 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Malawi, 2014 Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Total 83.0 26,713 16.2 5.9 34.9 43.0 100.0 26,464 Region Northern 89.9 3,050 9.6 5.4 32.5 52.5 100.0 3,033 Central 83.2 10,598 16.1 4.8 36.5 42.7 100.0 10,511 Southern 81.2 13,065 17.9 7.0 34.1 41.0 100.0 12,920 Area Urban 89.8 4,016 9.4 2.8 28.1 59.7 100.0 3,984 Rural 81.8 22,697 17.4 6.5 36.1 40.0 100.0 22,480 Wealth index quintile Poorest 71.3 5,851 27.9 6.5 33.4 32.2 100.0 5,781 Second 80.1 5,326 19.2 6.1 36.6 38.1 100.0 5,280 Middle 83.7 5,096 15.4 7.1 37.4 40.1 100.0 5,040 Fourth 88.0 5,048 11.3 6.9 36.8 45.0 100.0 5,010 Richest 93.2 5,391 6.1 3.2 30.6 60.0 100.0 5,352 1 MICS indicator 2.19 - Iodized salt consumption In 83 percent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate content. Table NU.10 shows that in 16 percent of households, there was no salt available. These households are included in the denominator of the indicator. The consumption of adequately iodized salt is graphically presented in Figure NU.4 together with the percentage of salt containing less than the 15 parts per million (ppm). In 43 percent of households, salt was found to contain 15 ppm or more of iodine while proportion of households with salt testing with any iodate (i.e. greater than 0 pm) was 78 percent. Use of iodized salt (any iodate) was lowest in the Southern Region (75 percent) and highest in the Northern Region (85 percent). Sixty percent of urban households were found to be using adequately iodized salt as compared with 40 percent of households in rural areas. P a g e | 47 Figure NU.4: Consumption of iodized salt, Malawi, 2014 P a g e | 48 VI. Child Health Vaccinations The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. The WHO Recommended Routine Immunisations for Children21 recommends all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenzae type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. The vaccination schedule followed by the Malawi National Immunization Programme provides all the above mentioned vaccinations with birth doses of BCG and Polio (within 2 weeks of birth), three doses of the Pentavalent vaccine containing DPT, Hepatitis B, and Haemophilus influenzae type b (Hib) antigens, three doses of Polio vaccine, three doses of Pneumococcal conjugate vaccine (PCV), two doses of rotavirus vaccine (ROTA) and one dose of measles. All vaccinations should be received during the first year of life. Table CH.1A shows Malawi’s Childhood Immunization schedule. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the 2014 MES are based on children age 12-23 months. Table CH.1A. Malawi Childhood Immunization schedule Age Vaccine At birth or first contact BCG At birth up to 2 weeks OPV 0 At 6 weeks OPV1, DPT-HepB-Hib1, PCV1 and Rota1 At 10 weeks OPV2, DPT-HepB-Hib2, PCV2 and Rota2 At 14 weeks OPV 3, DPT-HepB-Hib3, and PCV3 At 9 months Measles Note: Pneumococcal Conjugate Vaccine (PCV) was introduced in Malawi in November 2011 while Rotavirus Vaccine was introduced in October 2012. 21 http://www.who.int/immunization/diseases/en. Table 2 includes recommendations for all children and additional antigens recommended only for children residing in certain regions of the world or living in certain high-risk population groups. http://www.who.int/immunization/diseases/en P a g e | 49 Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MES questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, DPT-HEPB-HIB, PCV and ROTA, how many doses were received. The final vaccination coverage estimates are based on information obtained from the vaccination card and the mother’s report. P a g e | 50 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Malawi, 2014 Children age 12-23 months: Children age 24-35 months: Vaccinated at any time before the survey according to: Vaccinated by 12 months of agea Vaccinated at any time before the survey according to: Vaccinated by 12 months of age Vaccination card Mother's report Either Vaccination card Mother's report Either Antigen BCG1 82.8 15.3 98.2 96.4 60.1 36.3 96.4 93.4 Polio At birth 59.2 19.0 78.1 74.2 41.1 39.9 81.1 76.6 1 82.8 15.3 98.1 96.3 60.4 36.0 96.4 93.1 2 82.1 14.5 96.6 94.9 60.3 34.3 94.6 91.3 32 78.4 12.1 90.5 87.5 59.0 28.5 87.5 83.6 DPT-HepB-Hib 1 83.1 15.1 98.2 96.9 60.9 35.6 96.6 94.3 2 82.7 14.4 97.1 95.9 60.7 33.9 94.6 91.9 33 80.8 11.9 92.6 90.4 59.6 28.2 87.8 85.2 PCV 1 81.9 15.1 97.0 95.2 53.6 36.8 90.4 84.6 2 81.2 13.7 94.9 93.2 50.5 34.3 84.8 78.4 34 78.3 11.2 89.4 87.3 46.1 29.5 75.6 67.3 ROTA 1 48.6 18.9 67.5 63.8 3.3 27.2 30.5 16.5 25 47.3 16.1 63.4 60.3 2.9 23.1 26.0 11.7 Measles (MCV1) 6 75.2 16.9 92.0 85.1 55.7 36.7 92.4 82.0 Fully vaccinated including ROTA and PCV7 b 48.0 6.0 54.0 38.5 10.1 9.7 19.8 1.2 Fully vaccinated excluding ROTA and PCV8 c 73.9 9.8 83.6 71.4 54.9 23.9 78.7 63.4 No vaccinations 0.1 1.1 1.1 1.3 0.0 2.4 2.4 2.9 Number of children 3,755 3,755 3,755 3,755 3,936 3,936 3,936 3,936 1 MICS indicator 3.1 - Tuberculosis immunization coverage 2 MICS indicator 3.2 - Polio immunization coverage 3 MICS indicator 3.3, 3.5, 3.6 - Diphtheria, pertussis and tetanus (DPT), Hepatitis B, Haemophilus influenzae type B (Hib) immunization coverage 4 MES indicator 3.S1 – PCV immunization coverage 5 MES indicator 3.S2– ROTA immunization coverage 6 MICS indicator 3.4; MDG indicator 4.3 - Measles immunization coverage 7 MES indicator 3.S3 - Full immunization coverage including PCV and ROTA 8 MICS indicator 3.8 - Full immunization coverage excluding PCV and ROTA a All MICS indicators refer to results in this column b Includes: BCG, Polio3, DPT-HepB-Hib3 , Measles (MCV1), PCV, and ROTA as per the vaccination schedule in Malawi c Includes: BCG, Polio3, DPT-HepB-Hib3, and Measles (MCV1) as per the vaccination schedule in Malawi P a g e | 51 The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information (vaccination card and mother’s recall) is shown in Table CH.1 and Figure CH.1. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the last column in each panel, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Approximately 96 percent of children age 12-23 months received a BCG vaccination by the age of 12 months. By age of 12 months, 97 percent of children of 12-23 months had received the first dose of DPT-HepB-Hib, 96 percent had received the second dose of DPT-HepB-Hib, and 90 percent the third dose. Similarly, by age 12 months, 96 percent of children 12-23 months of age had received the first dose of the Polio vaccine, 95 percent had received the second dose, and 88 percent had received the third dose. Ninety-five percent of children age 12-23 months had received the first dose of the PCV by age 12 months, 93 percent had received the second, and 87 percent had received the third dose. Sixty four percent of the children 12-23 months of age had received the first dose of ROTA vaccine by age 12 months and 60 percent had received the second dose. ROTA vaccine is a new vaccine which was introduced in October 2012 and immunises children against diarrhoea caused by rotavirus. This gives a reason for the lower coverage compared to the other antigens. The coverage for measles vaccine by 12 months is at 85 percent. The percentage of children age 12-23 months who had all the recommended vaccinations by first birthday with recently included ROTA and PCV is 39 percent. The percentage of children age 12-23 months who had all the recommended vaccinations excluding ROTA and PCV by first birthday is 71 percent. The individual coverage figures for children age 24-35 months are generally lower to those for children age 12-23 months, suggesting that immunization coverage has been on average improving in Malawi between 2011 and 2014. P a g e | 52 Figure CH.1: Vaccinations by age 12 months, Malawi, 2014 Table CH.2 presents vaccination coverage estimates among children age 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. Vaccination cards have been seen by the interviewer for 84 percent of children age 12-23 months. A higher percentage of vaccination cards was observed for children in rural areas (85 percent) than in urban areas (79 percent). At regional level, full vaccination coverage does not vary much, ranging from 53 percent in the Southern Region to 56 percent in the Northern Region. About 61 percent of children whose mothers have secondary education are fully immunized compared with 52 percent of children whose mothers have no education. 96 74 96 95 88 97 96 90 85 64 60 95 93 87 39 71 1 BCG Polio at birth Polio1 Polio2 Polio3 DPT-HepB-Hib 1 DPT-HepB-Hib 2 DPT-HepB-Hib 3 Measles ROTA 1 ROTA 2 PCV 1 PCV 2 PCV 3 Fully vaccinated with ROTA and PCV Fully vaccinated without ROTA and PCV No vaccinations Per cent Children Age 12-23 months 93 77 93 91 84 94 92 85 82 17 12 85 78 67 1 63 3 BCG Polio at birth Polio1 Polio2 Polio3 DPT-HepB-Hib 1 DPT-HepB-Hib 2 DPT-HepB-Hib 3 Measles ROTA 1 ROTA 2 PCV 1 PCV 2 PCV 3 Fully vaccinated with ROTA and PCV Fully vaccinated without ROTA and PCV No vaccinations Children Age 24-35 months P a g e | 53 Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against vaccine preventable childhood diseases, Malawi, 2014 Percentage of children who received: Percentage with vaccination card seen Number of children age 12-23 months BCG Polio DPT-HepB-Hib PCV ROTA Measles (MCV1) Fulla None At birth 1 2 3 1 2 3 1 2 3 1 2 Total 98.2 78.1 98.1 96.6 90.5 98.2 97.1 92.6 97.0 94.9 89.4 67.5 63.4 92.0 54.0 1.1 83.8 3,755 Sex Male 97.8 77.3 97.8 96.2 89.8 97.8 96.6 92.3 96.7 95.3 89.4 67.3 63.0 91.6 54.4 1.5 82.8 1,841 Female 98.5 78.9 98.4 96.9 91.3 98.6 97.6 92.9 97.2 94.6 89.5 67.6 63.8 92.4 53.7 0.8 84.9 1,914 Region Northern 98.2 72.6 98.7 97.0 90.3 98.7 96.9 93.5 97.9 97.4 92.1 71.9 67.4 89.7 56.1 0.4 83.5 439 Central 98.0 77.9 97.7 95.8 89.6 98.0 97.2 92.0 96.8 94.8 89.6 67.9 64.6 90.9 54.7 1.3 82.5 1,466 Southern 98.3 79.6 98.3 97.1 91.3 98.3 97.1 93.0 96.8 94.4 88.7 66.0 61.5 93.5 53.0 1.2 85.0 1,850 Area Urban 98.0 90.1 97.9 96.8 90.0 98.3 97.1 95.2 97.7 96.5 92.4 68.4 62.0 93.2 54.6 1.7 78.7 401 Rural 98.2 76.7 98.1 96.5 90.6 98.2 97.2 92.3 96.9 94.7 89.1 67.4 63.5 91.9 54.0 1.1 84.5 3,355 Mother’s education None 98.2 72.2 98.9 97.4 90.3 98.1 97.7 93.1 97.4 95.4 90.3 66.7 63.4 89.5 52.4 0.7 84.4 445 Primary 98.1 77.4 98.0 96.3 90.0 98.2 96.9 91.9 96.8 94.5 88.5 66.8 62.6 91.7 52.8 1.2 83.6 2,653 Secondary 98.3 85.0 98.0 97.0 92.7 98.4 97.9 95.0 97.4 96.6 92.5 71.5 67.7 94.8 60.8 1.2 83.8 605 Higher (99.3) (86.0) (99.3) (99.3) (95.9) (99.3) (99.3) (99.3) (94.9) (94.9) (94.9) (60.1) (52.5) (99.3) (49.1) (0.7) (90.8) 52 Missing/DK (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 1 Wealth index quintile Poorest 97.6 72.4 97.1 95.4 89.9 97.2 96.6 91.7 96.0 93.8 88.2 67.7 65.3 91.3 55.3 1.6 83.0 930 Second 97.9 76.3 97.9 96.1 89.7 98.3 97.1 92.1 97.3 93.9 87.3 65.2 61.1 89.4 50.5 1.0 87.0 840 Middle 98.0 79.2 98.8 97.2 90.5 98.6 96.8 92.0 97.4 95.2 89.0 68.8 64.5 93.4 54.5 1.0 83.4 810 Fourth 99.0 79.4 98.7 96.9 90.4 98.6 97.7 93.4 96.9 95.6 91.1 69.7 65.1 92.2 56.0 1.0 82.3 652 Richest 98.7 88.0 98.5 97.9 93.1 98.8 98.1 95.4 97.5 97.3 93.7 65.7 59.9 94.9 54.3 1.0 82.9 524 a Includes: BCG, Polio3, DPT-HepB-Hib3 , Measles (MCV1) PCV and ROTA as per the vaccination schedule in Malawi ( ) Figures that are based on 25-49 unweighted case

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