Sao Tome and Principe - Multiple Indicator Cluster Survey - 2006

Publication date: 2006

1 Democratic Republic of São Tomé e Príncipe NATIONAL STATISTICS INSTITUTE Ministry of Planning and Finance UNICEF United Nations Children’s Fund 2006 Multiple Indicator Cluster Survey August 2007 2 Contributors to this report : We wish to acknowledge the major contribution of Ms. Teodora de Sousa, MICS Co-ordinator, and Mr. Raúl Jorge da Costa Cravid Oliveira, MICS IT Specialist, of the Institute of National Statistics, Ministry of Planning and Finance, São Tomé e Príncipe to the development of this report. Their work was also guided by the Institute’s director Ms. Elsa Cardoso to whom we are also grateful. The Institute of National Statistics, in collaboration with the United Nations Children’s Fund (UNICEF) whose financial and technical support was considerable, conducted the 2006 Multiple Indicator Cluster Survey (MICS3) for São Tomé e Príncipe. Our appreciation is also extended to the varied ministries, UN and other development partners that worked with the UNICEF Sao Tome team and the Minsitry of Planning and Finance to produce the MICS 3 report. The survey is part of the framework series of MICS surveys undertaken between 2005 and 2006 in more than 50 countries in the world, following those of 1995 and 2000. The survey instruments to evaluate the situation of children and women in the world are based on model types elaborated by the Coordinator of the Global MICS Project at UNICEF Headquarters in New York. Complementary information on the project is available at www.childinfo.org. Suggested citation : Institute of National Statistics (INE) of the Democratic Republic of São Tomé e Príncipe. The 2006 São Tomé e Príncipe Multiple Indicator Cluster Survey : Final Report. São Tomé, 2007. 3 Combined results table 2006 São Tomé e Príncipe Multiple Indicator Cluster Survey (MICS) and Millennium Development Goals (MDGs) Indicators Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Mortality 1 13 Under five mortality rate 66 Per thousand 2 14 Child mortality rate 45 Per thousand NUTRITION Nutritional status 6 4 Moderate weighted insufficiency prevalence 9.2 Percent 6 4 Low birth weight prevalence 1.2 Percent 7 Stunting prevalence 10.1 Percent 8 Wasting prevalence 1.4 Percent Breastfeeding 45 Timely initiation of breastfeeding 35.3 Percent 15 Exclusive breastfeeding rate < 0-3 months 70.2 Percent 15 Exclusive breastfeeding rate < 6 months 60.4 Percent 16 Continued breastfeeding rate to 12-15 months to 20-23 months 88.2 18.4 Percent Percent 17 Timely complementary feeding rate 60.0 Percent 18 Frequency of complementary feeding 44.3 Percent 19 Adequately-fed children 52.6 Percent Salt iodisation 41 Iodised salt consumption 36.6 Percent Vitamin A 42 Vitamin A supplemented (under 5s) 33.4 Percent 43 Vitamin A supplemented (postpartum mothers) 63.1 Percent Weighted insufficiency at birth 9 Low birth weight newborns 7.8 Percent 10 Newborns weighed at birth 82.4 Percent CHILD HEALTH Vaccination 25 Tuberculosis vaccination coverage 98.1 Percent 26 DPT vaccination coverage (3) 91.4 Percent 27 Polio vaccination coverage (3) 87.4 Percent 28 15 Measles vaccination coverage 83.4 Percent 31 Children completely vaccinated 76.0 Percent 29 Hepatitis B vaccination coverage 82.9 Percent 30 Yellow fever vaccination coverage 76.9 Percent Tetanus toxoid 32 Protection against neonatal tetanus 87.3 Percent Illnesses care 33 Utilisation of oral rehydration therapy (ORT) 47.1 Percent 34 Home care in the case of diarrhoea 49.2 Percent 35 ORT received with increase of fluid, followed by feeding 62.9 Percent 23 Care sought for presumed pneumonia 71.3 Percent 22 Antibiotic treatment for presumed pneumonia 56.0 Percent Solid fuels use 24 29 Solid fuels 75.5 Percent Malaria 36 Availability of impregnated mosquito nets (IMN), by household 36.0 Percent 37 22 Under fives sleeping under an IMN 41.7 Percent 38 Under fives sleeping under a mosquito net 52.8 Percent 4 Topic MICS Indicator Number MDG Indicator Number Indicator Value 39 22 Anti-malarial treatment (under five) 17.0 Percent 40 Intermittent preventive anti-malarial treatment (pregnant women) 0.0 Percent Supply source and cost 96 Supply source (public sources) Impregnated mosquito nets 57.6 Percent Anti-malarials 38.8 Percent Antibiotics 64.5 Percent Oral rehydration salts 95.9 Percent 97 Supply cost (average) Impregnated mosquito nets Public sources 27000 [STD] Private sources 27000 [STD] Anti-malarials Public sources 5000 [STD] Private sources 15064 [STD] Antibiotics Public sources 5000 [STD] Private sources 3000 [STD] Oral rehydration salts Public sources 3000 [STD] Private sources 5000 [STD] ENVIRONMENT Water and sanitation 11 30 Use of improved potable water sources 86.2 Percent 13 Water treatment 13.7 Percent 12 31 Use of improved sanitation facilities 28.0 Percent 14 Disposal of child faeces 19.0 Percent Security of tenure and housing durability 93 Security of tenure NA Percent 94 House durability NA Percent 95 32 Slum household NA Percent REPRODUCTIVE HEALTH Contraception needs 21 19c Prevalence of contraceptives 30.3 Percent 98 Family planning needs 15.2 Percent 99 Family planning needs covered 65.8 Percent Maternal and neo-natal health 20 Pre-natal care 97.3 Percent 44 Pre-natal care package 98.5 Percent 4 17 Care by qualified staff 80.7 Percent 5 Births in specialised clinics 77.8 Percent Maternal mortality 3 16 Maternal mortality rate 267 Per 100,000 CHILD DEVELOPMENT Child development 46 Study support NA Percent 47 Father’s support towards learning NA Percent 48 Study support : children’s books NA Percent 49 Study support : other books NA Percent 50 Study support : teaching materials NA Percent 51 Non adult tutor NA Percent 5 Topic MICS Indicator Number MDG Indicator Number Indicator Value EDUCATION Education 52 Pre-school attendance 27.4 Percent 53 School readiness 81.7 Percent 54 Net intake in primary education 74.0 Percent 55 6 Net primary school attendance rate 94.1 Percent 56 Net secondary school attendance rate 35.4 Percent 57 7 Children reaching grade 5 87.2 Percent 58 Transition rate to secondary school 77.7 Percent 59 7b Primary school completion rate 31.9 Percent 61 9 Gender parity index Primary school Secondary school 1.00 1.00 Ratio ratio Literacy 60 8 Adult literacy rate 69.9 Percent CHILD PROTECTION Birth registration 62 Registration at birth 68.7 Percent Child labour 71 Child labour 7.5 Percent 72 Labourer students 7.5 Percent 73 Student labourers 81.7 Percent Child punishment 74 Child punishment Any, psychological or physical NA Percent Early marriage and polygamy 67 Marriage before 15 years Marriage before 18 years 3.3 35.9 Percent Percent 68 Young women 15-19 married/in union 18.5 Percent 70 Polygamy NA Percent 69 Age difference in couples (women 15-19) 17.0 Percent Age difference in couples (women 20-24) 16.2 Percent Excision / female genital mutilation / cutting (E/FGM) 66 Approval for E/FGM NA Percent 63 Prevalence of E/FGM NA Percent 64 Prevalence of extreme E/FGM NA Percent 65 Prevalence of E/FGM in girls NA Percent Domestic violence 100 Domestic violence attitudes 32.0 Percent Handicap 101 Handicapped children 15.7 Percent HIV/AIDS, SEXUAL BEHAVIOUR, ORPHANED AND VULNERABLE CHILDREN Knowledge and behaviours related to HIV/AIDS 82 19b General knowledge on HIV prevention among the young 39.3 Percent 89 Knowledge on maternal-infant HIV transmission 76.4 Percent 86 Attitude towards HIV/AIDS infected people 23.8 Percent 87 Women aware of HIV testing centres 69.0 Percent 88 Women voluntarily tested for HIV 36.6 Percent 90 Psychological care for the prevention of mother-to- child transmission 70.5 Percent 91 Preventive mother-to-child HIV testing 53.8 Percent 6 Topic MICS Indicator Number MDG Indicator Number Indicator Value Sexual behaviour 84 Age of first sexual relation among the young (15- 19) 8.9 Percent 92 Age mixing among sexual partners 12.4 Percent 83 19a Condom use by non-regular partners 56.3 Percent 85 High risk sexual relations during the past year 33.5 Percent Support to orphaned and vulnerable children 75 Prevalence of orphans 6.2 Percent 78 Children’s living arrangements 15.5 Percent 76 Prevalence of vulnerable children 5.2 Percent 77 20 School attendance orphans/non-orphans 1.09 Ratio 81 External support to orphaned children or vulnerable children with HIV/AIDS 4.3 Percent 79 Malnutrition among orphaned and made vulnerable children by HIV/AIDS** 0.95 Ratio 80 Early sex among children orphaned and made vulnerable by HIV/AIDS 0.89 Ratio 7 Table of contents Combined results table . . 4 List of tables . . 11 List of figures . . 14 List of abbreviations . . 15 Acknowledgements . . 17 . . 17 Analytical summary . . 18 I. Introduction . . 27 Context . . . 27 Survey objectives . . 29 Sample concept . . 30 Questionnaires . . 30 Training and field work . . 32 Data treatment . . 32 III. Sample representativity and characteristics of surveyed households and persons . . 33 Sample représentativity . . 33 Household characteristics . . 33 Characteristics of persons surveyed . . 37 IV. Child mortality . . 39 Nutritional status . . 46 Breastfeeding. . 49 Salt iodisation . . 55 Vitamin A supplementation . . 57 Low birth weight . . 59 Vaccination coverage . . 62 Tetanus toxoid . . 65 Oral rehydration treatment . . 68 Care seeking and antibiotic treatment of pneumonia . . 73 Solid fuel use . . 74 Malaria . . 75 Supply sources and costs . . 77 VII. Environment . . 80 Water and sanitation . . 80 VIII. Reproductive health . . 85 Contraception . . 85 Prenatal consultations . . 87 Assistance during childbirth . . 88 Maternal mortality . . 89 IX. Education . . 91 Pre-school attendance and school readiness . . 91 Primary and secondary school attendance . . 91 Adult literacy . . 94 X. Child protection . . 96 Registration at birth . . 96 Child labour . . 96 Marriage and union . . 98 Domestic violence . . 100 8 Handicapped children . . 100 XI. HIV/AIDS, Sexual behaviour and orphans and vulnerable children . . 102 Knowledge of HIV transmission and condom utilisation . . 102 Sexual behaviours linked to HIV transmission . . 106 Orphans and vulnerable children . . 109 List of references . . 111 MICS 3 STP tables . . 112 Appendix A. Sample concept . . 112 Appendix B. List of surveyers . . 112 Appendix C. Sample errors estimate . . 112 Appendix D. Data quality tables . . 112 Appendix E. MICS indicators : numerators and denominators . . 112 Appendix F. Questionnaires . . 112 9 List of Tables Table HH.1 Results of household and individual interviews . Table HH.2 Household age distribution by sex . Table HH.3 Household composition . Table HH.4 Social specificities of women . Table HH.5 Social specificities of children . Table CM.1 Child mortality . Table CM.2 Live births and proportion of stillborn . Table NU.1 Child malnutrition . Table NU.2 Initial breastfeeding . Table NU.3 Breastfeeding . Table NU.3w Different forms of child nutrition, based on age . Table NU.4 Adequately fed children . Table NU.5 Consumption of iodised salt . Table NU.6 Vitamin A supplementation for children . Table NU.7 Vitamin A supplementation for post-partum women . Table NU.8 Low birth weight newborns . Table CH.1 Vaccinations during the first year of life . Table CH.1c Vaccinations during the first year of life (continued) . Table CH.2 Vaccinations, by social specificities . Table CH.2c Vaccinations, by social specificities (continued) . Table CH.3 Neo-natal tetanus protection . Table CH.4 ORT treatment . Table CH.5 Home management of diarrhoea . Table CH.6 Consultations for children with presumed pneumonia . Table CH.7 Antibiotic treatment for pneumonia . Table CH.7A Knowledge of two alert signals for pneumonia . Table CH.8 Solid fuel use . Table CH.9 Solid fuel use, by type of oven or hearth . Table CH.10 Availability of impregnated mosquito nets . Table CH.11 Children sleeping under a mosquito net . Table CH.12 Anti-malaria treatment of children . Table CH.13 Preventive intermittent malaria treatment . Table CH.14 Supply source and cost of impregnated mosquito nets . Table CH.15 Supply source and cost of anti-malaria drugs . Table CH.16 Supply source and cost of antibiotics . Table CH.17 Supply source and cost of ORT salts . Table EN.1 Utilisation of improved water sources . Table EN.2 Household water treatment . Table EN.3 Time needed to reach water source . Table EN.4 Person responsible for collecting water . Table EN.5 Utilisation of toilets for faeces disposal . Table EN.5w Utilisation of toilets for faeces disposal . Table EN.6 Disposal of child faeces, 0 to 2 . Table EN.7 Disposal of household faeces . Table RH.1 Utilisation of contraceptives . Table RH.2 Unsatisfied demand in means of contraception . Table RH.3 Consultant during pre-natal visits . Table RH.4 Pre-natal care . Table RH.4w Pre-natal care . Table RH.5 Assistance during childbirth . 10 Table RH.6 Maternal mortality rate . Table ED.1 Pre-school education . Table ED.2 Primary school enrolment . Table ED.3 Net primary school attendance rate . Table ED.4 Net secondary school attendance rate . Table ED.4W Secondary school-aged children attending primary school . Table ED.5 Children passing fifth grade . Table ED.6 Completion of primary school and passing to secondary school . Table ED.7 Gender parity in education . Table ED.8 Adult literacy . Table CP.1 Birth registration . Table CP.2 Child labour . Table CP.3 Labourer students and student labourers . Table CP.5 Early marriage and polygamy . Table CP.6 Age differences in couples . Table CP.9 Attitudes to domestic violence . Table CP.10 Percentage of children 2 to 9 with declared handicap . Table HA.1 Knowledge on HIV prevention and transmission . Table HA.2 Identification of false ideas about HIV/AIDS . Table HA.3 General knowledge on HIV/AIDS . Table HA.4 Knowledge on mother to child HIV transmission . Table HA.5 Attitudes towards people living with HIV/AIDS . Table HA.6 Knowledge about HIV testing centre . Table HA.7 HIV testing and psychological treatment during pre-natal visits . Table HA.8 Sexual behaviours facilitating the risk of HIV infection . Table HA.9 Utilisation of condoms during recent high-risk sexual relations . Table HA.10 Sleeping arrangements for children, and orphanage . Table HA.11 Prevalence of orphanages and child vulnerability . Table HA.12 School attendance by orphans and vulnerable children . Table HA.13 Support for orphaned and vulnerable children due to AIDS . Table HA.14 Malnutrition among orphans and vulnerable children . Table HA.15 Sexual behaviour in young women, orphaned and vulnerable due to AIDS . 11 List of figures Figure 1: HH1 Distribution (en percentage) of household population by gender, and by age and gender . . 36 Figure 2: CM1 Mortality rate of under fives, by socio-economic groups and by social specificities . . 42 Figure 3: CM.2 Tendency of mortality rates in under fives . . 45 Figure 4: NU.1 Percentage of malnutrition in under fives . . 48 Figure 5: NU.2 Percentage breastfeeding less than one hour or one day after childbirth . 52 Figure 6: NU.3 Feeding methods for infants, by age : Distribution (percentage) of children under 3 by feeding method and by age group . . 55 Figure 7: NU.4 Percentage of households consuming correctly iodised salt . . 57 Figure 8: CH.1 Percentage of children 12-23 months with recommended vaccinations before their 12th month . . 64 Figure 9: CH.2 Percentage of women protected against neo-natal tetanus having birthed a live infant during the last 12 months . . 67 Figure 10: CH.3 Percentage of children 0-59 months with diarrhoea during 2 weeks having received ORT treatment . . 69 Figure 11: CH.4 Percentage of children 0-59 months with diarrhoea during 2 weeks having received ORT treatment or increased amount of liquid foods followed by food . . 72 Figure 12: EN.1 Distribution (percentage) of household population, by source of drinking water supply . . 81 Figure 13: HA.1 Percentage of women 15-49 with complete knowledge on HIV/AIDS transmission . . 105 Figure 14: HA.2 Sexual behaviour favouring risk of HIV infection . . 107 12 Li st o f a bb re vi at io ns A ID S A cq ui re d Im m un e D ef ic ie nt S yn dr om e BC G Ba ci lle -C al m et te -G ué ri n (T ub er cu lo si s) C C A C om m on C ou nt ry A ss es sm en t C D C en su s D is tr ic t C ED A W C on ve nt io n on a ll Fo rm s o f D is cr im in at io n ag ai ns t W om en C O C ar bo n C RC C on ve nt io n on th e Ri gh ts o f C hi ld re n D PT D ip ht he ri a Pe rt us si s Te ta nu s EV P Ex te nd ed V ac ci na tio n Pr og ra m m e G PI G en de r P ar ity In de x H B H ep at iti s B H IV H um an Im m un od ef ic ie nc y V ir us ID D Io di ne D ef ic ie nc y D is or de rs IM N Im pr eg na te d M os qu ito N et (s ) IN E In st itu te o f N at io na l S ta tis tic s IP T In te rm itt en t P re ve nt iv e Tr ea tm en t IU D In tr au te ri ne D ev ic e LA M La ct at io na l A m en or rh ea M et ho d M D G M ill en ni um D ev el op m en t G oa ls M IC S M ul tip le In di ca to r C lu st er S ur ve y M oH M in is tr y of H ea lth N A R N et A tte nd an ce R at e N C H S N at io na l C en tr e fo r H ea lth S ta tis tic s ( U ni te d St at es ) N SI N at io na l S ta tis tic s I ns tit ut e (S TP ) N Y N ew Y or k O RS O ra l R eh yd ra tio n Sa lts O RT O ra l R eh yd ra tio n Tr ea tm en t O V C O rp ha n an d V ul ne ra bl e C hi ld re n PN C Pr e- na ta l C on su lta tio ns PN LP N at io na l P la n fo r t he F ig ht a ga in st M al ar ia P la n PP M Pa rt s p er m ill io n SO 2 D io xi de a zo te SP SS St at is tic al P ac ka ge fo r S oc ia l S ci en ce s ( so ftw ar e) U N A ID S U ni te d N at io ns P ro gr am m e on H IV /A ID S U N D A F U ni te d N at io ns D ev el op m en t A ss is ta nc e Fr am ew or k U N D P U ni te d N at io ns D ev el op m en t P ro gr am m e U N G A SS U ni te d N at io ns G en er al A ss em bl y Sp ec ia l S es si on fo r H IV /A ID S U N IC EF U ni te d N at io ns C hi ld re n’ s F un d W FF C W or ld F it fo r C hi ld re n W H O W or ld H ea lth O rg an is at io n 13 A ck no w le dg em en ts Th e M ul tip le In di ca to rs C lu st er S ur ve y (M IC S 3) , c ar ri ed o ut in 2 00 6 by th e In st itu te o f N at io na l S ta tis tic s, h as p ro vi de d in va lu ab le in fo rm at io n an d pe rt in en t in di ca to rs o n th e si tu at io n of c hi ld re n an d w om en in S ão T om é e Pr ín ci pe . Th e re su lt is th e pr es en t r ep or t, w hi ch a ls o re sp on ds , i n la rg e pa rt , t o fo llo w -u p re qu ir em en ts fo r pr oj ec t i m pl em en te d to w ar ds th e ac hi ev em en t o f o bj ec tiv es an d go al s i nc lu de d in in te rn at io na l a gr ee m en ts s uc h as th e M ill en ni um D ev el op m en t D ec la ra tio n, th e Pl an o f A ct io n of a W or ld F it fo r C hi ld re n as w el l a s th e Po ve rt y R ed uc tio n St ra te gi c Pl an . Th e su cc es s of t he M IC S3 , d em on st ra te d by t hi s re po rt ’s p ub lic at io n, w as p os si bl e th an ks t o th e co lla bo ra tio n an d su pp or t fr om t he I ns tit ut e of N at io na l St at is tic s , M in is tr y of P la nn in g an d Fi na nc e an d th e U N IC EF S ao T om e an d U N C EF A re a O ffi ce (G ab on ) t ea m s. C o- or di na tio n by t he N ew Y or k U N IC EF H ea dq ua rt er s an d th e D ak ar U N IC EF R eg io na l B ur ea u te ch ni ca l t ea m s ha s eq ua lly c on tr ib ut ed to t he p ro je ct ’s su cc es s. Th e hi gh ly t ec hn ic al in pu t ha s re su lte d in s ci en tif ic al ly a ss ur ed r es ul ts o f th e su rv ey p re se nt ed in t hi s fin al r ep or t. W e si nc er el y th an k a ll ou r ex te rn al p ar tn er s! O ur t ha nk s al so g o to t he v ar io us m in is tr ie s w ho , at a c ru ci al m om en t, w er e ab le t o co nt ri bu te i n an i m po rt an t m an ne r to w ar ds t he v al id at io n of t he qu es tio nn ai re . W e ad dr es s ou r th an ks a s w el l t o al l a dm in is tr at iv e an d lo ca l a ut ho ri tie s fo r th ei r tim el y as si st an ce to th e su rv ey , t o th e w om en a nd m en w ho r es po nd ed to th e su rv ey , f or th ei r a va ila bi lit y, th ei r co lla bo ra tio n an d th e qu al ity o f i nf or m at io n pr ov id ed to th e su rv ey . Fi na lly , t o th e ch ild re n, w ho e nd ur ed o ur m an ip ul at io n du ri ng th e an th ro po m et ri c (w ei gh t a nd h ei gh t) m ea su re m en ts in th e fie ld , w e se nd o ur a po lo gi es a nd w is h th em a w on de rf ul a nd ra di an t f ut ur e is li ke ly to b e gu ar an te ed th ro ug h th e go od u se o f s ur ve y re su lts . 14 A na ly tic al S um m ar y Th e M ul tip le In di ca to r C lu st er S ur ve y (M IC S 20 06 ) f or S ão T om é e Pr ín ci pe is th e se co nd s er ie s of it s ki nd , a fte r th at o f 1 99 5, to w hi ch th e co un tr y di d no t pa rt ic ip at e, a nd t ha t of 2 00 0. Th is s ur ve y is w ith in t he f ra m ew or k of c o- op er at io n be tw ee n Sã o To m é e Pr ín ci pe a nd U N IC EF , t he f ol lo w -u p of p ro gr es s ac hi ev ed to w ar ds th e at ta in m en t o f t he in te rn at io na lly a gr ee d ob je ct iv es a nd g oa ls s uc h as th e M ill en ni um D ev el op m en t D ec la ra tio n ad op te d by th e M em be r St at es o f t he U ni te d N at io ns in S ep te m be r 2 00 0 an d th e Pl an o f A ct io n fo r a W or ld F it fo r C hi ld re n ad op te d in M ay 2 00 2, a nd b as ed o n pr om is es m ad e by th e in te rn at io na l c om m un ity d ur in g th e G lo ba l C hi ld re n’ s S um m it of 1 99 0. Th e m ai n in te nt io n of th e 20 06 M IC S (M IC S3 ) i s to m ak e av ai la bl e to th e St at e an d its d ev el op m en t p ar tn er s pe rt in en t d at a, d is ag gr eg at ed a cc or di ng to s om e so ci al c at eg or ie s of in te re st th at c an a ss is t i t i n th e de fin iti on a nd im pl em en ta tio n of a ct io ns in b en ef it of th e po pu la tio n, o f c hi ld re n an d w om en in p ar tic ul ar . Th e su rv ey a ls o in te nd s to s tr en gt he n na tio na l an d in st itu tio na l ca pa ci tie s to i m pr ov e m on ito ri ng a nd e va lu at io n in t he t ar ge te d se ct or s th ro ug h th e co lle ct io n, tr ea tm en t a nd a na ly si s o f d at a. M IC S3 is a n at io na l p ro bi ng s ur ve y ba se d on t he g lo ba l s am pl e of 5 60 0 ho us eh ol ds r ep re se nt at iv e of h ou se ho ld s th ro ug ho ut t he c ou nt ry . Sp ec ifi ca lly , i ts ob je ct iv e is to e st im at e a gr ea t n um be r o f i nd ic at or s re la tiv e to th e si tu at io n of c hi ld re n an d w om en n at io na lly a nd in p ar tic ul ar th at o f s om e su b- po pu la tio ns (w om en b et w ee n 15 a nd 4 9, c hi ld re n un de r f iv e) . M IC S3 w as c ar ri ed o ut b et w ee n 12 M ay a nd 1 2 Ju ne 2 00 6. T he c ol le ct io n of d at a fo r M IC S3 h as a llo w ed th e m ea su re m en t a nd u pd at in g of in di ca to rs w ith re ga rd to c hi ld m or ta lit y, n ut ri tio n an d he al th o f t he c hi ld , t he e nv ir on m en t, re pr od uc tiv e he al th , t he d ev el op m en t o f t he c hi ld , e du ca tio n, c hi ld p ro te ct io n an d H IV /A ID S, in p ar tic ul ar w ith re ga rd to se xu al b eh av io ur a m on g or ph an ed c hi ld re n an d th os e m ad e vu ln er ab le b y A ID S. Pr in ci pa l S ur ve y R es ul ts In fa nt ile m or ta lit y C hi ld m or ta lit y is r el at iv e co m pa re d to s ub -r eg io na l l ev el s, w ith d iff er en ce s in th e ra te s be tw ee n so ci al c at eg or ie s. A t t he n at io na l l ev el , 4 5 of 10 00 c hi ld re n di e be fo re re ac hi ng o ne y ea r a nd 6 6 of 1 00 0 di e be fo re re ac hi ng 5 y ea rs . Pr ob ab ili ty o f d ea th p ri or to o ne y ea r i s sl ig ht ly h ig he r a m on g bo ys w hi le in fa nt -ju ve ni le m or ta lit y is s lig ht ly le ss fo r b oy s (6 5 of 1 00 0 ag ai ns t 6 6 to 1 00 0) . Th e di ffe re nc e be tw ee n di st ri ct s is g re at er , w ith r at es lo w er in M é- zo ch i a nd L ob at a (3 5 an d 39 o f 10 00 , r es pe ct iv el y) . Th e in fa nt - 15 ju ve ni le m or ta lit y ra te s fo llo w th e sa m e te nd en cy . W ha te ve r th e m or ta lit y ty pe , t he r is ks o f d ea th a re lo w er w ith th e ed uc at io n of th e m ot he r w hi le th ey re m ai n in se ns iti ve to th e ho us eh ol d’ s le ve l o f l ife . N ut ri tio n C lo se t o on e ch ild u nd er f iv e ou t of 1 0 (9 .2 % ) su ffe rs f ro m m od er at e w ei gh te d in su ffi ci en cy w hi le 1 .2 % s uf fe r fr om s ev er w ei gh te d in su ffi ci en cy . C lo se to o ne c hi ld o f e ve ry fo ur (2 3% ) s uf fe r fr om m od er at e gr ow th r et ar da tio n an d on e ch ild o ut o f 1 0 (1 0. 1% ) i s to o sh or t i n re la tio n to a ge . A bo ut 6 .0 % o f c hi ld re n ar e m od er at el y em ac ia te d an d 1. 4% is to o th in fo r th ei r he ig ht . M or e th an o ne c hi ld o ut o f t en s uf fe rs fr om e xc es si ve w ei gh t. M or e th an o ne th ir d (3 5. 3% ) o f w om en h av e be gu n ex cl us iv e br ea st fe ed in g th ei r c hi ld re n w ith in th e ho ur fo llo w in g bi rt h, a nd m or e th an e ig ht ou t o f t en (8 1. 0% ) l es s th an a d ay fo llo w in g bi rt h. Ex cl us iv e br ea st fe ed in g is re as on ab ly w id es pr ea d : 7 0. 2% o f c hi ld re n be tw ee n 0- 3 m on th s ar e ex cl us iv el y br ea st fe d an d 60 .4 % o f t ho se le ss th an si x m on th s. B et w ee n 6- 9 m on th s, si x ch ild re n ou t o f t en a re b re as tfe d as w el l a s fe d so lid s, s em i-s ol id s w hi le 8 8. 2% a nd 1 8. 4% o f c hi ld re n fr om 12 -1 5 m on th s, a nd 2 0- 23 m on th s, re sp ec tiv el y, c on tin ue to b e br ea st fe d. M or e th an s ix c hi ld re n ou t o f t en , a ge d 0- 5 m on th s, b en ef it fr om a de qu at e nu tr iti on o r ex cl us iv e br ea st fe ed in g co ns id er ed a de qu at e ac co rd in g to th e re co m m en da tio ns , w hi le fo ur c hi ld re n ou t o f t en a re n ot c or re ct ly n ou ri sh ed . U nd er h al f ( 44 .3 % ) o f c hi ld re n be tw ee n 6- 11 m on th s ha ve ac ce ss to m at er na l m ilk a nd c om pl em en ta ry fo od a t t he m in im um re co m m en de d da ily ti m es . Th e us e of a de qu at el y io di se d sa lt is n ot w id es pr ea d en ou gh i n Sã o To m é e Pr ín ci pe : le ss t ha n on e ho us eh ol d ou t of f ou r (3 6. 6% ) ut ili se co rr ec tly i od is ed s al t (i. e. , co nt ai ni ng > 15 p pm ), w hi ch m ea ns t ha t th e gr ea t m aj or ity o f ho us eh ol ds c on su m e in ad eq ua te ly i od is ed s al t. Fo llo w in g le ga l d is po si tio ns b as ed o n th e co nc lu si on s of t he N at io na l T ec hn ic al C om m is si on f or S al t Io di sa tio n in S ão T om é e Pr ín ci pe , t he bo dy th at s et s th e le ve l o f i od in e at 6 0 pp m o r m or e, th e pe rc en ta ge o f h ou se ho ld s co ns um in g io di se d sa lt at a n ad eq ua te le ve l f al ls to 1 7. 7% , o r tw ic e le ss th an th e pe rc en ta ge c al cu la te d ag ai ns t t he s ta nd ar d o f > 15 p pm . O ne th ir d of c hi ld re n 6- 59 m on th s re ce iv ed a h ig h do se o f V ita m in A s up pl em en ts d ur in g th e si x m on th s pr ec ed in g th e su rv ey . Th is s up po rt in V ita m in A is m or e fr eq ue nt in th e di st ri ct s of P rí nc ip e an d Le m bá (6 3. 4% a nd 4 2. 4% , r es pe ct iv el y) , a m on g th e yo un ge st c hi ld re n (0 -2 3 m on th s) w ith 4 4. 0% a nd a m on g ne w bo rn w ith m or e ed uc at ed m ot he rs ( 37 .0 % ). I t is l es s w id es pr ea d in t he d is tr ic ts o f Á gu a G ra nd e (2 5. 4% ) an d C an ta ga lo (2 5. 4% ) a nd a m on g ch ild re n w ith u ne du ca te d m ot he rs (2 1. 0% ) a nd a m on g ol de r c hi ld re n (2 0% fo r t ho se a ge d 48 -5 9 m on th s) . 16 A bo ut 6 3. 0% o f w om en h av in g gi ve n bi rt h du ri ng t he t w o ye ar s pr ec ed in g, t he s ur ve y re ce iv ed V ita m in A s up pl em en ts p ri or t o th e ei gh th m on th f ol lo w in g bi rt h. Th is p ro po rt io n is h ig he r in t he d is tr ic ts o f Pr ín ci pe ( 84 .0 % ) an d Le m bá ( 71 .0 % ) an d am on g w om en w ith m or e ed uc at io n (7 3. 0% ). M or e th an e ig ht c hi ld re n ou t of t en b or n w ith in t he t w o ye ar s pr ec ed in g th e su rv ey w er e w ei gh ed a t bi rt h. Le ss t ha n 8. 0% a m on g th em w ei gh ed le ss th an th e st an da rd b ir th w ei gh t o f 2 50 0 gr am s. A t w ha te ve r th e le ve l o f a na ly si s, w ea k bi rt h w ei gh ts v ar y ve ry li gh tly in r el at io n to th e co nt ex t’s so ci al c at eg or ie s ( 6. 0% to 9 .0 % ). H ea lth o f t he C hi ld In S ão T om é e Pr ín ci pe p ra ct ic al ly a ll ch ild re n (9 8. 0% ) a re v ac ci na te d ag ai ns t B C G b ef or e th e ag e of 1 2 m on th s, 91 .4 % r ec ei ve d th e 3 do se s of D PT , 8 7. 0% th e Po lio (P ol io 3) d os es a nd 8 3. 0% th e m ea sl es v ac ci ne . In g en er al , t hr ee q ua rt er s (7 6. 0% ) o f c hi ld re n w er e va cc in at ed a ga in st th e pr in ci pl e ch ild ho od il ln es se s. A bo ut 8 3. 0% a nd 7 7. 0% a re c om pl et el y va cc in at ed a ga in st H ep at iti s B an d Y el lo w F ev er , r es pe ct iv el y, b ef or e th e ag e of o ne . A lto ge th er , c lo se to e ig ht o ut o f t en c hi ld re n ag ed 1 2- 23 m on th s ha ve b ee n va cc in at ed a ga in st c hi ld ho od il ln es se s at o ne m om en t or a no th er . N ev er th el es s, v ac ci ne c ov er ag e ag ai ns t c hi ld ho od il ln es se s va ri es d ep en di ng u po n th e co nt ex t. T he p er ce nt ag e of v ac ci na te d ch ild re n ag ai ns t al l ill ne ss es i s hi gh er f or b oy s (8 4. 0% ) in t he D is tr ic ts o f M é- Zo ch i (9 2. 0% ), C au é an d Pr ín ci pe ( 86 .0 % ) an d am on g ch ild re n w ith e du ca te d m ot he rs a nd a m on g th e w el l-o ff (8 5. 0% , r es pe ct iv el y) . It is l ow er i n th e D is tr ic ts o f C an ta ga lo a nd L ob at a (6 6. 0% r es pe ct iv el y) a nd a m on g ch ild re n of w om en w ith ou t e du ca tio n (6 2. 0% ). C lo se to n in e w om en o ut o f t en (8 7. 0% ) a re p ro te ct ed a ga in st te ta nu s of w hi ch tw o th ir ds h av e re ce iv ed a t l ea st tw o do se s du ri ng p re gn an cy , on e w om an o ut o f f iv e at le as t t w o do se s in th e th re e pr ec ed in g ye ar s. W om en w ith e du ca tio n ar e be tte r pr ot ec te d ag ai ns t m at er na l t et an us : 95 .0 % o f w om en w ith s ec on da ry le ve l e du ca tio n ag ai ns t 8 6. 0% o f w om en w ith p ri m ar y le ve l e du ca tio n ad 8 1. 0% o f w om en w ith ou t e du ca tio n. D ur in g th e tw o w ee ks p re ce di ng t he s ur ve y, 1 3. 0% o f ch ild re n un de r fiv e co nt ra ct ed d ia rr ho ea . O f 7. 0% o f ch ild re n ag ed 6 m on th s, t hi s pr ev al en ce b ec om es 1 9. 0% a m on g th os e ag ed 6 -1 1 m on th s an d 24 .0 % a m on g th os e ag ed 1 2- 23 m on th s, b ef or e fa lli ng t o 14 .0 % a m on g th os e ag ed 2 4- 35 m on th s to o nl y 6. 0% a m on g ch ild re n ag ed 4 8- 59 m on th s. P re va le nc e pe ak s (6 -1 1 an d 12 -2 3 m on th s) c oi nc id e w ith w ea ni ng , p er io d du ri ng w hi ch th e ri sk in c on ta m in at io n of fo od a nd th e en vi ro nm en t a re th e hi gh es t. 17 Le ss t ha n ha lf of c hi ld re n (4 7. 0% ) ha vi ng h ad d ia rr ho ea h av e us ed w ha te ve r m et ho d of O RT . A m on g th es e, 3 1. 0% r ec ei ve d flu id s pr ep ar ed w ith O R T pa ck et s, 2 .0 % o f p re -c on di tio ne d O RT fl ui ds a nd 1 7. 0% o f re co m m en de d flu id s pr ep ar ed a t h om e. F or th os e w ho p ur ch as ed th ei r ow n O RT , t he a ve ra ge c os t i s 3, 00 0 do br as (0 .1 6 Eu ro s) in p ub lic o ut le ts a nd 5 ,0 00 d ob ra s (0 .2 7 Eu ro s) in p ri va te o ut le ts . A m on g ch ild re n w ho h av e ha d di ar rh oe a, m or e th an s ix o ut o f t en (6 1. 4% ) d ra nk m or e th an u su al , w hi le 3 8. 0% d ra nk a s m uc h or le ss . C lo se to 81 .0 % c on tin ue d to e at , a lth ou gh e at in g a lit tle le ss , a s m uc h or m or e th an u su al w hi le 1 9. 0% a te m uc h le ss th an u su al o r ne ar ly n ot hi ng . C lo se to h al f o f c hi ld re n (4 9. 0% ) r ec ei ve d an in cr ea se in fl ui ds w hi le c on tin ui ng to e at . O nl y 4. 0% o f ch ild re n pr es en te d sy m pt om s of a cu te p ne um on ia d ur in g th e tw o w ee ks p re ce di ng t he s ur ve y. A m on g th es e ch ild re n, 7 1. 0% co ns ul te d an a pp ro pr ia te h ea lth c ar e pr ov id er : 10 .0 % in a p ub lic h os pi ta l, 23 .0 % in a p ub lic h ea lth c en tr e, 1 7. 0% in a p ub lic h ea lth p os t w hi le 7. 0% c on su lte d a pr iv at e cl in ic a nd 4 .0 % c on su lte d a pr iv at e do ct or . A m on g th es e, 5 6. 0% r ec ei ve d an a nt ib io tic (5 0. 0% in a n ur ba n se tti ng a nd 63 .0 % in a r ur al s et tin g) . Fo r th os e w ho p ur ch as ed th ei r an tib io tic s, th e av er ag e co st is 5 ,0 00 d ob ra s (0 .2 7 Eu ro s) a t a p ub lic o ut le t a nd 3 ,0 00 do br as (0 .1 6 Eu ro s) a t a p ri va te o ut le t. A bo ut 37 .0 % o f m ot he rs / ca re ta ke rs ( 48 .0 % i n an u rb an s et tin g an d 30 .0 % i n a ru ra l se tti ng ) kn ow t w o pn eu m on ia d an ge r si gn s, th at i s : “d iff ic ul ty in b re at hi ng ” an d “r ap id b re at hi ng ”. T he m os t c ur re nt ly c ite d sy m pt om s ne ce ss ita te d th e ch ild b ei ng im m ed ia te ly ta ke n to a h ea lth se rv ic e, a re b y or de r of im po rt an ce , “ w he n th e ch ild d ev el op ed fe ve r” (8 2. 0% ), “w he n th e ch ild b ec am e m or e ill ” (5 2. 0% ) a nd “ w he n th e ch ild ex pe ri en ce d di ffi cu lty in b re at hi ng ” (4 9. 0% ). A lto ge th er , m or e th an th re e qu ar te rs (7 6. 0% ) o f h ou se ho ld s ut ili se s ol id fu el s fo r c oo ki ng a lth ou gh th e fr eq ue nc y of th e ut ili sa tio n of fu el v ar ie s ac co rd in g to th e co ns id er ed s oc io -e co no m ic c at eg or y. R ec ou rs e to s ol id fu el s is le ss s pr ea d in th e D is tr ic t o f Á gu a G ra nd e, w hi ch is th e m os t ur ba ni se d (5 2. 0% ), an d in h ou se ho ld s w he re t he h ea d of t he h ou se ho ld h as a t le as e a se co nd ar y le ve l ed uc at io n (4 9. 0% ) an d th e ri ch er ho us eh ol ds ( 31 .0 % ). T hi s pe rc en ta ge is h ig he r in t he D is tr ic ts o f Pr ín ci pe a nd L em bá ( re sp ec tiv el y, 9 7. 0% a nd 9 5. 0% o f ho us eh ol ds ) an d th e po or es t h ou se ho ld s w ho u til is e so lid fu el s ex cl us iv el y. M or e th an tw o th ir ds o f h ou se ho ld s ut ili se w oo d to c oo k th ei r m ea ls a nd 2 3. 0% h av e re co ur se to b en ze ne w hi le le ss th an 9 .0 % c ha rc oa l. In S ão T om é an d Pr ín ci pe , o nl y on e ho us eh ol d ou t o f t w o (3 o ut o f 4 a m on g th e w el l o ff) ut ili se c lo se d ov en s w ith e xh au st s to c oo k th ei r m ea ls . Le ss th an h al f o f ho us eh ol ds (4 9. 0% ) o w n a m os qu ito n et o f w hi ch o nl y 36 .0 % a t l ea st a n im pr eg na te d m os qu ito n et . Th e ho us eh ol ds in th e D is tr ic t of Á gu a G ra nd e, t ho se b et te r of f an d th os e w ho se h ea d of h ou se ho ld h as a t le as t a se co nd ar y le ve l of e du ca tio n ar e fa vo ur ed : re sp ec tiv el y 50 .0 % , 5 3. 0% a nd 4 8. 0% o f h ou se ho ld s ow n at le as t o ne im pr eg na te d m os qu ito n et . M or e th an h al f o f c hi ld re n (5 3. 0% ) s le pt u nd er 18 a m os qu ito n et t he n ig ht p re ce di ng t he s ur ve y an d 42 .0 % s le pt u nd er a n im pr eg na te d m os qu ito n et . F or t ho se w ho b ou gh t th ei r tr ea te d m os qu ito n et , t he a ve ra ge c os t i s 2 7, 00 0 do br as (1 .5 E ur os ) a t a p ub lic o ut le t a nd 2 7, 00 0 do br as (1 .5 E ur os ) a t a p ri va te o ut le t. Th e pr ev al en ce o f fe ve r du ri ng t he t w o w ee ks p re ce di ng t he s ur ve y is 1 8. 0% w ith a p ea k in c hi ld re n ag ed 1 2- 23 m on th s (2 3. 0% ) an d in t he D is tr ic t of L em bá ( on e qu ar te r of c hi ld re n) . O ne f ev er ed c hi ld o ut o f fo ur w as t re at ed w ith a n “a pp ro pr ia te ” an ti- m al ar ia l d ru g an d 17 .0 % re ce iv ed a nt i-m al ar ia l dr ug s w ith in 2 4 ho ur s af te r sy m pt om s ap pe ar ed : 1 2. 0% r ec ei ve d ar m od ia qu in e, 2 .0 % r ec ei ve d ch lo ro qu in e, 1 .0 % SP /F an si da r w hi le t hr ee q ua rt er s (7 5% ) re ce iv ed o th er m ed ic at io n su ch a s Pa ra ce ta m ol /P an ad ol /A ce ta m in op he n. F or th os e w ho b ou gh t th ei r a nt i-m al ar ia l d ru gs , t he a ve ra ge c os t i s 5 ,0 00 d ob ra s ( 0. 27 E ur o) a t a p ub lic o ut le t a nd 1 5, 00 0 do br as (0 .8 3% ) a t a p ri va te o ut le t. In te rm s of in te rm itt en t p re ve nt iv e an ti- m al ar ia l t re at m en t, 90 .0 % o f w om en a ge d 15 -4 9 ga ve b ir th d ur in g th e tw o ye ar s pr ec ed in g th e su rv ey re ce iv ed a nt i-m al ar ia l m ed ic at io n du ri ng th ei r pr eg na nc y. A m on g th em , n o on e re ce iv ed 2 o r m or e do se s of S P/ Fa ns id ar a nd 1 0. 0% r ec ei ve d ch lo ro qu in e. W at er a nd S an ita tio n A bo ut 8 6. 0% o f t he p op ul at io n ut ili se a n im pr ov ed p ot ab le w at er s ou rc e (8 8. 0% in u rb an s et tin gs a nd 8 3. 0% in r ur al s et tin gs ). T he in ha bi ta nt s of L ob at a (9 7. 0% ), th e m os t w el l o ff (9 5. 0% ) a nd h ou se ho ld s w he re it s he ad h as h ad a t l ea st a s ec on da ry le ve l e du ca tio n (9 2. 0% ) a re th os e be tte r eq ui pp ed . Th e pr in ci pa l s ou rc es o f po ta bl e w at er a re t he p ub lic f ou nt ai ns ( 53 .0 % o f th e po pu la tio n) , h ou se ho ld c on ne ct io n to t he n et w or k (2 2. 0% ) a nd p ro te ct ed w el ls (7 .0 % ). M or e th an o ne q ua rt er o f ho us eh ol ds ( 26 .9 % ) en jo y a so ur ce o f dr in ka bl e w at er i n sit u, t ha t is , in t he h om e. Th is t yp e of a cc es s is m or e w id es pr ea d in th e D is tr ic t o f Á gu a G ra nd e (4 1. 0% ), in u rb an a re as (3 2. 0% ), in th e m os t w el l o ff ho us eh ol ds (7 4. 0% ) a nd in th os e di re ct ed b y a pe rs on w ith a t l ea st a s ec on da ry le ve l o f e du ca tio n (4 6. 0% ). F or th os e ho us eh ol ds w ho h av e to o bt ai n th ei r w at er o ut si de th e ho m e, th e av er ag e tim e is 1 6 m in ut es , a lth ou gh 4 3. 0% o bt ai n th ei r w at er in le ss th an 1 5 m in ut es a nd 1 4. 0% d ed ic at e 30 m in ut es o r l on ge r t o th is ta sk . In m or e th an tw o th ir ds o f h ou se ho ld s (6 7. 0% ), an a du lt fe m al e is g en er al ly r es po ns ib le fo r th e co lle ct io n of d ri nk in g w at er , w he n th e so ur ce is lo ca te d aw ay fr om th e ho m e. A n ad ul t m al e do es n ot a cc om pl is h th is ta sk e xc ep t i n on e ca se o ut o f f iv e. O nl y 28 .0 % o f t he p op ul at io n liv e in h ou se ho ld s en jo yi ng to ile ts fo r th e re m ov al o f h um an e xc re m en t. T oi le ts h av e a hi gh er u til is at io n ra te in ri ch er h ou se ho ld s (8 0. 0% ), w he re th e he ad o f t he h ou se ho ld h as h ad a t l ea st a s ec on da ry le ve l e du ca tio n (4 9. 0% ) a nd a m on g re si de nt s of Á gu a G ra nd e (4 2. 0% ) t ha n am on g th e po or es t h ou se ho ld s (1 .0 % ) f or w ho m th e sa fe re m ov al o f h um an e xc re m en ts is a re al p ub lic h ea lth p ro bl em . 19 Le ss th an 7 .0 % o f h ou se ho ld s ut ili se to ile ts li nk ed to a s ew er s ys te m , 1 3. 0% li nk ed to a s ce pt ic ta nk o r a la tr in e, w hi le o nl y 1. 0% e nj oy im pr ov ed se lf- ae ra te d la tr in es a nd 7 .0 % c om po st to ile ts . Th e pr op or tio n of c hi ld re n ag ed b et w ee n 0 to 2 y ea rs w ho e nj oy th e sa fe re m ov al o f t he ir e xc re m en ts is e st im at ed a t 1 9. 0% , n at io na lly (2 4. 0% in ur ba n ar ea s an d 12 .0 % in ru ra l a re as ). T hi s pr op or tio n, 3 3. 0% in th e D is tr ic t o f Á gu a G ra nd e, v ar ie s fr om b et w ee n le ss th an 6 .0 % in P rí nc ip e to 15 .0 % i n Lo ba ta . Th e ri ch es t ho us eh ol ds a nd t ho se w he re t he h ea d of t he h ou se ho ld h as r ec ei ve d at l ea st a s ec on da ry le ve l e du ca tio n ar e re la tiv el y m or e nu m er ou s in te rm s of s af e re m ov al o f t he ir c hi ld re n’ s ex cr em en ts (r es pe ct iv el y 60 .0 % a nd 4 1. 0% ). Fe w h ou se ho ld s be ne fit fr om g oo d co ve ra ge o f i m pr ov ed w at er p ro vi si on a nd im pr ov ed m ea ns o f e xc re m en t r em ov al : re sp ec tiv el y 86 .0 % a nd 28 .0 % , w hi le 2 6. 0% o nl y ha ve a cc es s to b ot h at th e sa m e tim e. I n th e ur ba n se tti ng , 3 1. 0% h av e ac ce ss to tw o so ur ce s w hi le th e pe rc en ta ge is on ly 2 0. 0% in th e ru ra l s et tin g. T he re si de nt s of Á gu a G ra nd e, th os e w he re th e he ad o f t he h ou se ho ld h as h ad a t l ea st s ec on da ry e du ca tio n an d th e be tte r- of f h ou se ho ld s al l h av e gr ea te r a cc es s (r es pe ct iv el y, 4 0. 0% , 4 8. 0% a nd 7 6. 0% ). L es s th an 1 .0 % o f t he p oo r e nj oy th e sa m e pr iv ile ge . R ep ro du ct iv e H ea lth A m on g m ar ri ed w om en o r t ho se w ith p ar tn er s, 3 0. 0% c ur re nt ly u til is e es se nt ia lly m od er n co nt ra ce pt io n. P re va le nc e of c on tr ac ep tio n is h ig he r in th e D is tr ic t o f P rí nc ip e (4 4. 0% o f w om en ) a nd a m on g w om en a ge d 30 -3 4 ye ar s (3 9. 0% ). A bo ut 1 6. 0% o f f em al e us er s ha ve re co ur se to th e pi ll 10 .0 % to th e IU D a nd 2 .0 % th e co nd om . C ur re nt ly , 1 6. 0% o f t ot al c on tr ac ep tio n ne ed s ar e un sa tis fie d. T he d em an d fo r s at is fie d co nt ra ce pt io n is e st im at ed a t 6 6. 0% , w ith li ttl e va ri at io n am on g ca te go ri es . N ea rl y al l w om en b et w ee n 15 a nd 4 9 ye ar s (9 9. 0% ) h av e re ce iv ed p re -n at al c ar e pr ov id ed b y a qu al ifi ed p er so n (d oc to r, nu rs e or m id -w ife ), at le as t o ne d ur in g th ei r p re gn an cy . C lo se to 9 5. 0% o f w om en c on su lte d a nu rs e or m id -w ife , a nd 3 .9 .0 % c on su lte d a do ct or . C lo se t o 83 .0 % o f w om en h av e ha d a bl oo d te st , o f w hi ch 9 6. 0% h av e ha d th ei r bl oo d pr es su re t es te d, 8 3. 0% t he ir u ri ne , a nd 9 7. 0% w er e w ei gh ed a s w el l. D ur in g th e 10 -1 4 ye ar p er io d pr ec ed in g th e su rv ey , t he m at er na l m or ta lit y ra te w as e st im at ed a t 14 8 m at er na l de at hs f or e ac h 10 0, 00 0 liv e bi rt hs . 20 Ed uc at io n Sl ig ht ly m or e th an o ne in fi ve c hi ld re n ag ed 3 6 to 5 9 m on th s (2 7. 0% ) a tte nd s a pr e- sc ho ol e du ca tio n pr og ra m m e. A m on g ch ild re n in th ei r fir st pr im ar y sc ho ol y ea r, 82 .0 % a tte nd ed a p re -s ch oo l p ro gr am m e th e pr ec ed in g ye ar . Th e ch an ce s fo r a c hi ld to a tte nd p re -s ch oo l a re h ig he r if th e ch ild r ea ch es 4 8 to 5 9 m on th s (3 6. 0% ), liv e in t he b et te r- of f ho us eh ol ds ( 51 .0 % ) or w he n th e m ot he r ha s ha d at le as t a se co nd ar y ed uc at io n (3 9. 0% ). A m on g ch ild re n at th e of fic ia l p ri m ar y sc ho ol e nt ry a ge ( 7 ye ar s) , 7 4. 0% a re p re se nt ly e nr ol le d in th e fir st y ea r of p ri m ar y sc ho ol . W ha te ve r th ei r h ou si ng e nv ir on m en t o r t he se x of th e ch ild , 9 4. 0% o f c hi ld re n at th e pr im ar y sc ho ol a ge (7 -1 2 ye ar s) a tte nd s ch oo l. Th e ne t a tte nd an ce r at e of s ec on da ry s ch oo l o r be yo nd a ge d 13 -1 7 ye ar s is 3 5. 0% fo r bo ys a s w el l a s fo r gi rl s. N ev er th el es s, th e ch ild re n fr om w el l-o ff ho us eh ol ds a nd t ho se w ho se m ot he r ha s ha d a m in im um o f a se co nd ar y le ve l ed uc at io n ha ve a r ea l ad va nt ag e ov er t he ir l es s- ad va nt ag ed p ee rs (r es pe ct iv el y, 6 2. 0% a nd 6 8. 0% ). A m on g ch ild re n in th ei r fir st y ea r, 87 .0 % r ea ch fi fth g ra de . Th er e is p ra ct ic al ly n o di ffe re nc e in te rm s of a ge . O n th e ot he r ha nd , t he b et te r- of f ch ild re n an d th os e w ith m ot he rs h av in g ha d a se co nd ar y ed uc at io n or m or e pe rf or m b et te r (r es pe ct iv el y, 9 8. 0% a nd 9 2. 0% a ga in st 7 6. 0% re sp ec tiv el y fo r t he p oo re st c hi ld re n an d th os e w ith u ne du ca te d m ot he rs . O nl y 32 .0 % o f c hi ld re n at th e ag e of p ri m ar y sc ho ol c om pl et io n (1 2) a tte nd ed s ch oo l i n th e la st y ea r of p ri m ar y le ve l e du ca tio n. Th is r at e of ac hi ev em en t i s hi gh er a m on g th e be tte r- of f h ou se ho ld s an d am on g ch ild re n w ho se m ot he r h as a s ec on da ry le ve l e du ca tio n or m or e : 6 6. 0% a nd 58 .0 % r es pe ct iv el y ag ai ns t le ss t ha n 17 .0 % r es pe ct iv el y fo r th e po or es t ch ild re n an d th os e w ho se m ot he r is u ne du ca te d. M or e th an t hr ee qu ar te rs (7 8. 0% ) o f c hi ld re n in th e la st p ri m ar y sc ho ol y ea r d ur in g th e pr ec ed in g ye ar a re c ur re nt ly a tte nd in g se co nd ar y sc ho ol . C on tr ar y to th e ra te o f ac hi ev em en t fo r pr im ar y ed uc at io n, t hi s se co nd ar y tr an si tio n ra te is n ea rl y th e sa m e th ro ug ho ut t he s oc ia l g ro up s. G lo ba lly , g en de r pa ri ty is a s pe rf ec t i n pr im ar y as it is in s ec on da ry . Se ve n ou t o f t en w om en a ge d 15 -2 4 ye ar s kn ow h ow to re ad a nd w ri te . Th is p er ce nt ag e is m or e pr ev al en t a m on g th e ri ch (9 0. 0% a ga in st 5 0. 0% am on gs t t he p oo re st ), am on g ur ba n w om en (7 3. 0% a ga in st 6 5. 0% o f r ur al w om en ), an d am on g fe m al e re si de nt s of th e D is tr ic t o f Á gu a G ra nd e (7 9. 0% a ga in st 4 6. 0% fo r t ho se in C au é) . 21 C hi ld p ro te ct io n C lo se t o se ve n ou t of t en c hi ld re n (6 9. 0% ) un de r fiv e ye ar s of a ge h av e be en r eg is te re d. If th er e is n o di ffe re nc e be tw ee n bo y an d gi rl re gi st ra tio n or ty pe o f h ou si ng , t he d is pa ri tie s ar e no te w or th y w he n lin ke d to d is tr ic ta l r es id en ce (b et w ee n 79 .0 % a nd 6 5. 0% ), an d to th e qu al ity of h ou se ho ld li fe a nd t o ed uc at ed m ot he rs : 78 .0 % a nd 7 9. 0% , r es pe ct iv el y, o f ch ild re n fr om b et te r of f ho us eh ol ds a nd t ho se w ith t he m os t ed uc at ed m ot he rs a re r eg is te re d w hi le p er ce nt ag es fo r ch ild re n fr om th e po or es t f am ili es o r w ith u ne du ca te d m ot he rs a re a t 6 3. 0% a nd 7 0. 0% re sp ec tiv el y. R eg is tr at io n de pe nd s, e ss en tia lly , o n th e ag e of th e ch ild : th os e re gi st er ed a t l es s th an o ne y ea r ( 30 .0 % ) a ga in st 9 8. 0% fo r c hi ld re n re ac hi ng 4 8- 59 m on th s. D ur in g th e w ee k pr ec ed in g th e su rv ey , l es s th an 8 .0 % o f c hi ld re n ag ed 5 -1 4 ye ar s w er e w or ki ng , w ha te ve r th ei r se x. T he p er ce nt ag e in cr ea se s w ith th e ag e of th e ch ild (6 .0 % o f t ho se a ge d 5 to 1 1 an d 10 .0 % o f t ho se a ge d 12 to 1 4 ye ar s) a nd is s lig ht ly h ig he r in r ur al a re as th an in u rb an on es (1 0. 0% a ga in st 6 .0 % ) a s w el l a s in P rí nc ip e (1 7. 0% a ga in st 3 .0 % in Á gu a G ra nd e) . A m on g th es e ch ild re n, c lo se to th re e qu ar te rs (7 4. 0% ) w or k in fa m ily b us in es s an d le ss th an 3 .0 % a re in vo lv ed in d om es tic a ct iv iti es fo r m or e th an 2 8 ho ur s pe r w ee k. W or k ou ts id e th e ho m e af fe ct s le ss t ha n 3. 0% o f ch ild re n of w hi ch o nl y 1. 0% a re r em un er at ed . C lo se t o 82 .0 % o f ch ild l ab ou re rs a ls o at te nd s ch oo l an d cl os e to 8 .0 % o f st ud en ts a re a ls o in vo lv ed in c hi ld la bo ur . G en er al ly , 3 .0 % o f w om en c ur re nt ly m ar ri ed h ad d on e so b ef or e th e ag e of 1 5 an d 36 .0 % b ef or e th e ag e of 1 8. O nl y m ar ri ag e be fo re 1 8 ye ar s in cr ea se s w ith th e ag e of w om en (3 3. 0% o f t ho se a ge d 20 to 2 4 ag ai ns t 4 0. 0% o f t ho se a ge d 40 -4 4) . In so fa r a s th e su rv ey is c on ce rn ed , p ol yg am y is u nk no w n in S ão T om é e Pr ín ci pe . M or e th an h al f o f w om en a ge d 15 to 1 9 ha ve a n ol de r hu sb an d/ pa rt ne r by 5 to 9 y ea rs a nd o nl y 17 % a re te n ye ar s yo un ge r th an th ei r hu sb an d/ pa rt ne r is . O n th e ot he r ha nd , 3 6. 0% o f w om en b et w ee n 20 a nd 2 4 ha ve a n ol de r hu sb an d/ pa rt ne r by 5 to 9 y ea rs , a nd 1 6. 0% a re te n ye ar s yo un ge r th an th ei r hu sb an d/ pa rt ne r, at te st in g to th e fa ct th at a ge d oe s no t f av ou r ag e di ff er en ce s am on g co up le s. Le ss th an o ne th ir d (3 2. 0% ) f in d th at th ei r h us ba nd /p ar tn er b ea ts th em fo r a ny o ne o f t he ta rg et ed r ea so ns , e sp ec ia lly “ ne gl ec tin g th e ch ild re n” (2 0. 0% ), “c on tr ad ic tin g hi m in a d is cu ss io n” ( 17 .0 % ), “g oi ng o ut w ith ou t ad vi si ng h im ” (1 5. 0% ), “ bu rn in g th e m ea l” , a nd “ r ef us in g se xu al re la tio ns ”. Th e at tit ud e am on g w om en t ow ar ds d om es tic v io le nc e va ri es a cc or di ng t o th e co nt ex t, w ith w om en m or e fa vo ur ab le t o it in t he D is tr ic ts o f C au é (m or e th an h al f o f a ll w om en ), Le m bá a nd L ob at a (4 4. 0% a nd 4 2. 0% r es pe ct iv el y) th an th os e in M é- Zo ch i ( 29 .0 % ) a nd Á gu a G ra nd e (2 6. 0% ). R ur al w om en a re m or e re ce pt iv e th an th ei r u rb an c ou nt er pa rt s (3 5. 0% a ga in st 3 0. 0% ) a re . Pa ra do xi ca lly , t he y ou ng es t w om en se em m or e re ce pt iv e to th is ty pe o f v io le nc e (3 3. 0% o f t ho se a ge d 15 to 1 9 ag ai ns t 2 9. 0% fo r th os e ag ed 4 5 to 4 9 ye ar s) , w hi le th e m os t w el l-o ff w om en a nd t ho se m or e ed uc at ed a re n ot ew or th y fo r th ei r di sa gr ee m en t : o nl y 20 .0 t o 21 .0 % b el ie ve th at a h us ba nd m ay b ea t hi s w ife w hi le tw ic e th at ra te (4 0. 0 to 4 2. 0% ) i s pr ev al en t a m ou nt th e po or es t w om en a nd th os e w ith ou t e du ca tio n. 22 Le ss t ha n 16 .0 % o f ch ild re n ag ed 2 t o 9 ye ar s ha ve a n of fic ia lly d ec la re d ha nd ic ap pe d. A m on g th es e, 1 8. 0% “ ca nn ot e xp re ss t he m se lv es no rm al ly ” an d 13 .0 % a m on g th os e ag ed 3 to 9 y ea rs a re “ in ca pa bl e of n am in g at le as t o ne o bj ec t” . H IV /A ID S, s ex ua l b eh av io ur , o rp ha ns a nd v ul ne ra bl e ch ild re n N ea rl y al l w om en ( 97 .0 % ) ha ve h ea rd o f A ID S ye t 46 .0 % k no w o nl y th e th re e m ai n ty pe s of p re ve nt io n of H IV t ra ns m is si on , i n pa rt ic ul ar “h av in g a lo ya l a nd n on -in fe ct ed p ar tn er ”, “ ut ili si ng a c on do m fo r e ac h se xu al re la tio n” a nd “ ab st ai ni ng ”. M or e th an h al f (c lo se t o 53 .0 % ) re je ct t he t w o m os t w id es pr ea d m is co nc ep tio ns a nd t ha t a se em in gl y he al th y pe rs on c an b e in fe ct ed . 87 .0 % kn ow th at H IV /A ID S ca nn ot b e tr an sm itt ed b y su pe rn at ur al m ea ns a nd 7 5. 0% k no w th at H IV /A ID S ca nn ot b e tr an sm itt ed b y m os qu ito b ite s. C lo se to o ne w om an in fo ur h as c om pl et e kn ow le dg e of H IV /A ID S tr an sm is si on p re ve nt io n m et ho ds . G en er al ly , 9 1. 0% o f w om en k no w th at A ID S ca n be t ra ns m itt ed f ro m t he m ot he r to th e ch ild a nd m or e th an th re e qu ar te rs ( 76 .0 % ) kn ow a ll th re e m ot he r- to -c hi ld m et ho ds o f t ra ns m is si on , w hi le 5 .0 % a re ig no ra nt o f a ny s pe ci fic m ea ns o f t ra ns m is si on . C lo se to o ne q ua rt er o f w om en a ge d 15 -4 9 ye ar s do n ot a gr ee w ith d is cr im in at or y at tit ud es v is -à -v is p er so ns li vi ng w ith A ID S. T hr ee w om en ou t o f t en d id n ot c ar e fo r a ho us eh ol d m em be r in fe ct ed w ith A ID S, 4 4. 0% p re fe r ke ep in g se cr et th e fa ct th at a h ou se ho ld m em be r ha s A ID S, cl os e to 2 5. 0% b el ie ve th at a te ac he r sh ou ld n ot b e al lo w ed to te ac h an d 46 .0 % w ou ld n ot b uy v eg et ab le s fr om a n in fe ct ed s el le r. M or e th an th re e qu ar te rs (7 6. 0% ) a gr ee w ith a t l ea st o ne d is cr im in at or y at tit ud e. C lo se to s ev en w om en o ut o f t en (6 9. 0% ) k no w o f a v ol un ta ry te st in g ce nt re fo r H IV /A ID S, w hi le 3 7. 0% h av e ac tu al ly ta ke n th e te st . A m on g th e la tte r, 91 .0 % h av e re ce iv ed th ei r t es t r es ul ts . A t t he n at io na l l ev el , 9 .0 % o f w om en a ge d 15 to 1 9 ye ar s ha d se xu al r el at io ns b ef or e re ac hi ng 1 5, a nd 5 3. 0% a ge d 20 to 2 4 be fo re th e ag e of 1 8. A bo ut 1 2. 0% o f w om en a ge d 15 to 2 4 ha d se xu al r el at io ns d ur in g th e tw el ve m on th s pr ec ed in g th e su rv ey w ith m en te n ye ar s or m or e th ei r se ni or . O ne t hi rd o f w om en b et w ee n 15 a nd 2 4 (3 4. 0% ) ad m itt ed t o ha vi ng h ad s ex ua l re la tio ns w ith a n on -r eg ul ar p ar tn er d ur in g th e 12 m on th s pr ec ed in g th e su rv ey . O f t he la tte r, on ly 5 6. 0% u til is ed a c on do m d ur in g hi gh -r is k re la tio ns . A m on g ch ild re n ag ed 1 0 to 1 4 ye ar s, 0 .4 % h as lo st b ot h pa re nt s an d al l c ur re nt ly g o to s ch oo l. A m on g ch ild re n ag ed 0 to 1 7 ye ar s liv in g w ith on ly o ne p ar en t, 51 .0 % h av e bo th p ar en ts li vi ng a nd 0 .2 % h av e lo st b ot h pa re nt s, 1 .6 % h av e on ly a fa th er , w hi le 0 ,8 % h av e on ly a m ot he r. 23 O f 1 00 c hi ld re n ag ed 0 to 1 7, 5 .0 % a re v ul ne ra bl e, 6 .0 % h av e at le as t o ne d ec ea se d pa re nt a nd c lo se to 1 1. 0% a re o rp ha ns o r vu ln er ab le . Th e pe rc en ta ge o f o rp ha ne d or v ul ne ra bl e ch ild re n is s lig ht ly h ig he r i n ho us eh ol ds w ith c hi ld re n ag ed 1 0 to 1 4 (1 3. 0% ) a nd th os e w ith c hi ld re n ag ed 15 -1 7 ye ar s ag ai ns t 6 to 1 0. 0% a m on g yo un ge r c hi ld re n. O nl y 4. 0% o f o rp ha ne d ch ild re n re ce iv ed s up po rt . A m on g ho us eh ol ds w ith o rp ha ne d ch ild re n, 1 .0 % r ec ei ve d m ed ic al s up po rt in th e la st 1 2 m on th s, a nd 2 .0 % s ch oo l at te nd an ce s up po rt . D ur in g th e la st t hr ee m on th s, 1 .0 % r ec ei ve d ps yc ho lo gi ca l or e m ot io na l su pp or t an d 2. 0% m at er ia l/ so ci al su pp or t. W ith r eg ar d to m al nu tr iti on f or t he u nd er f iv es a nd f or g ir ls a ge d 15 -1 7 ex po se d to H IV /A ID S ri sk s, o rp ha n or v ul ne ra bl e ch ild re n do n ot su ffe r m or e th an o th er c hi ld re n do . 24 I. In tr od uc tio n Co nt ex t Th is r ep or t i s ba se d on th e M ul tip le In di ca to r C lu st er S ur ve y ca rr ie d ou t i n Sã o To m é e Pr ín ci pe in 2 00 6 by U N IC EF a nd b y th e G ov er nm en t o f Sã o To m é e Pr ín ci pe , t hr ou gh it s N at io na l S ta tis tic s In st itu te . Th is s ur ve y pr ov id es in va lu ab le in fo rm at io n on t he s itu at io n of c hi ld re n an d w om en in S ão T om é e Pr ín ci pe a nd is b as ed la rg el y on t he n ee d to m on ito r th e ob je ct iv es a nd t ar ge ts s et in r ec en t in te rn at io na l a gr ee m en ts su ch a s t he M ill en ni um D ec la ra tio n, a do pt ed b y al l 1 91 M em be r S ta te s o f t he U ni te d N at io ns in S ep te m be r o f 2 00 0, a nd th e Pl an o f A ct io n of th e W or ld F it fo r C hi ld re n, a do pt ed b y 18 9 M em be r St at es d ur in g a sp ec ia l s es si on o n ch ild re n of th e U ni te d N at io ns G en er al A ss em bl y, in M ay o f 20 02 . Th es e tw o co m m itm en ts a re b as ed o n pr om is es m ad e by th e in te rn at io na l c om m un ity d ur in g th e 19 90 G lo ba l C hi ld re n’ s Su m m it. By s ig ni ng t he se i nt er na tio na l ag re em en ts , t he g ov er nm en ts h av e co m m itt ed t he m se lv es t o im pr ov e th e co nd iti on o f th ei r ch ild re n an d to m on ito r p ro gr es s in th is d ir ec tio n. U N IC EF h as b ee n ch ar ge d w ith a s up po rt ro le w ith in th is fr am ew or k (s ee ta bl e be lo w ). A C om m itm en t t o A ct io n : N at io na l a nd In te rn at io na l R ep or tin g R es po ns ib ili tie s Th e go ve rn m en ts t ha t si gn ed t he M ill en ni um D ec la ra tio n as w el l a s th e D ec la ra tio n an d th e Pl an o f A ct io n fo r a W or ld F it fo r C hi ld re n al so c om m itt ed t he m se lv es to m on ito ri ng p ro gr es s to w ar ds th e go al s a nd o bj ec tiv es th ey c on ta in ed :. "W e sh al l m on ito r re gu la rl y at th e na tio na l a nd , w he re a pp ro pr ia te , a t th e re gi on al le ve l a nd as se ss p ro gr es s to w ar ds t he g oa ls a nd t ar ge ts o f th e pr es en t Pl an o f A ct io n at t he n at io na l, re gi on al a nd g lo ba l l ev el s. A cc or di ng ly , w e w ill s tr en gt he n ou r na tio na l s ta tis tic al c ap ac ity to co lle ct , a na ly se a nd d is ag gr eg at e da ta , i nc lu di ng b y se x, a ge , a nd o th er r el ev an t fa ct or s th at m ay le ad to d is pa ri tie s, an d su pp or t a w id e ra ng e of c hi ld -fo cu ss ed re se ar ch . W e w ill e nh an ce in te rn at io na l co -o pe ra tio n to su pp or t of st at is tic al ca pa ci ty -b ui ld in g ef fo rt s an d bu ild co m m un ity c ap ac ity f or m on ito ri ng , a ss es sm en t an d pl an ni ng ”. (A W or ld F it fo r C hi ld re n, pa ra gr ap h 60 .) “… W e w ill c on du ct p er io di c pr og re ss r ev ie w s at th e na tio na l a nd s ub -n at io na l l ev el s of p ro gr es s 25 in o rd er to a dd re ss o bs ta cl es m or e ef fe ct iv el y an d ac ce le ra te a ct io ns … “ (A W or ld F it fo r C hi ld re n, pa ra gr ap h 61 .) Th e Pl an o f A ct io n (p ar ag ra ph 6 1) a ls o ca lls f or t he s pe ci fic i nv ol ve m en t of U N IC EF i n th e pr ep ar at io n of p er io di c re po rt s : “ … A s th e w or ld ’s le ad a ge nc y fo r ch ild re n, th e U ni te d N at io ns C hi ld re n’ s Fu nd is r eq ue st ed to c on tin ue t o pr ep ar e an d di ss em in at e, i n cl os e co lla bo ra tio n w ith G ov er nm en ts , re le va nt fu nd s, pr og ra m m es , a nd th e sp ec ia lis ed a ge nc ie s of th e U ni te d N at io ns s ys te m , a nd a ll ot he r re le va nt a ct or s, as a pp ro pr ia te , i nf or m at io n on th e pr og re ss m ad e in th e im pl em en ta tio n of th e D ec la ra tio n an d th e Pl an o f A ct io n" . Si m ila rl y, th e M ill en ni um D ec la ra tio n (p ar ag ra ph 3 1) c al ls fo r p er io di c re po rt in g on p ro gr es s : “… W e re qu es t th e G en er al A ss em bl y to r ev ie w o n a re gu la r ba si s th e pr og re ss m ad e in im pl em en tin g th e pr ov is io ns o f th is D ec la ra tio n, a nd a sk t he S ec re ta ry -G en er al t o is su e pe ri od ic re po rt s fo r c on si de ra tio n by th e G en er al A ss em bl y an d as a b as is fo r f ur th er a ct io n ". ST P ha s ad op te d th e C on ve nt io n on t he R ig ht s of C hi ld re n (C RC ) an d ha s su bs cr ib ed t o di ffe re nt c om m itm en ts a ri si ng s in ce t he G lo ba l C hi ld re n’ s Su m m it (G C S) in N ew Y or k in S ep te m be r of 1 99 0, w ith th e pa rt ic ip at io n of 1 58 H ea ds o f S ta te o r of G ov er nm en ts . R es pe ct o f t he se co m m itm en ts a nd t o th os e w hi ch f ol lo w ed a fte rw ar d (M D G , W FF C , e tc .) ha s le ad t o th e im pl em en ta tio n of d iff er en t ty pe s of p ro gr am m es fa vo ur in g ch ild re n an d w om en . T hu s, f ro m 1 99 1 to 1 99 6, w ith t he c o- op er at io n fr am ew or k be tw ee n th e go ve rn m en t an d U N C IE F, t he se pr og ra m m es w er e de ve lo pe d an d im pl em en te d in m at er na l an d ch ild h ea lth , po ta bl e w at er p ro vi si on , sa ni ta tio n, p re -s ch oo l an d pr im ar y ed uc at io n, c om m un ity d ev el op m en t a nd s oc ia l i ns er tio n of s tr ee t c hi ld re n. T he o bj ec tiv es s ou gh t w er e to r ed uc e th e m at er na l a nd in fa nt r at es an d im pr ov e th e qu al ity o f l ife fo r ch ild re n, in p ar tic ul ar th ei r nu tr iti on a nd th ei r ed uc at io n1 . D ur in g th e fo llo w in g pr og ra m m in g pe ri od (1 99 7 – 20 01 ), th e sa m e do m ai ns w er e ta rg et ed , w ith re ne w ed v ig ou r t o im pr ov e co ns id er ab ly c ov er ag e, p ro vi si on a nd q ua lit y of b as ic s oc ia l s er vi ce s, in p ar tic ul ar in te rm s of h ea lth , b as ic e du ca tio n an d w at er a nd s an ita tio n. T he p ro gr am m e so ug ht a ls o to s tr en gt he n ca pa ci tie s at a ll le ve ls in th e do m ai ns o f he al th , ba si c ed uc at io n, w at er a nd s an ita tio n as w el l as m on ito ri ng a nd e va lu at io n to e ns ur e su st ai na bi lit y of t he s er vi ce s pr ov id ed . Im pr ov ed p ro te ct io n an d as si st an ce to v ul ne ra bl e ch ild re n as w el l a s th e st re ng th en in g of c om m un ity c ap ac iti es in th e m an ag em en t of b as ic s er vi ce w er e th e ob je ct iv es s ou gh t d ur in g th is p er io d2 . 1 Vi de th e N at io na l C o- op er at io n Pr og ra m m e 19 97 -2 00 1, p .8 2 Vi de th e N at io na l C o- op er at io n Pr og ra m m e 19 97 -2 00 1, p .1 1 26 Th e co m bi ne d ef fe ct o f th es e pr og ra m m es h as p ro du ce d no n- ne gl ig ib le q ua lit at iv e ch an ge s in t he l iv es o f Sa ot om ea ns ; th an ks t o th e tw o pr ev io us M IC S of th e m id -1 99 0s a nd in 2 00 0, th es e ch an ge s ha ve b ee n no te d. I n ef fe ct , s in ce 1 99 0, o ne n ot es , l ik e in o th er d ev el op in g co un tr ie s, a po si tiv e ev ol ut io n of h ea lth , n ut ri tio n, c hi ld d ev el op m en t, an d ed uc at io n an d ch ild p ro te ct io n in di ca to rs . Th e in fa nt -ju ve ni le m or ta lit y ra te ha s de cr ea se d fr om 1 38 p er t ho us an d in 1 99 4 to 9 7 pe r th ou sa nd i n 20 00 ( M IC S II R ep or t fo r 20 00 ). T hu s, b et w ee n 19 98 a nd 2 00 2, t he n et at te nd an ce r at e fo r pr im ar y le ve l e du ca tio n re ac he d 10 0% a m on g bo ys a nd 9 4% a m on g gi rl s. Eq ua lly , t he g ro ss a tte nd an ce r at e fo r pr im ar y le ve l e du ca tio n te nd s t o be h ig he r d ur in g th e pe ri od b et w ee n 19 91 a nd 2 00 5 : 1 31 % in 1 99 1, 4 7. 2% in 2 00 1 an d 14 9. 3% in 2 00 5. M al nu tr iti on h as d ec re as ed c ou nt ry w id e, to ge th er w ith a d ec re as e in th e pr op or tio n of c hi ld re n su ffe ri ng fr om m od er at e an d se ve re lo w b ir th w ei gh t ( 13 .0 % in 2 00 2 ag ai ns t 1 1. 0% in 2 00 3) . N ev er th el es s, d es pi te th is p ro gr es s, m uc h re m ai ns to b e do ne to im pr ov e ev en m or e th e qu al ity o f l ife fo r c hi ld re n an d w om en , i n pa rt ic ul ar in th e do m ai n of t he f ig ht a ga in st e ar ly m or ta lit y an d m al nu tr iti on t ha t st ill a ffe ct a c on si de ra bl e nu m be r of c hi ld re n, a nd H IV /A ID S an d th e pa in fu l c on se qu en ce s f or c hi ld re n. P ro m ot io n an d of u ni ve rs al b as ic e du ca tio n sh ou ld re m ai n a m aj or p re oc cu pa tio n fo r t he c ou nt ry . Th is fi na l r ep or t p re se nt s th e re su lts o f t he in di ca to rs a nd o f t he m es c ov er ed b y th e su rv ey . Su rv ey o bj ec tiv es Th e 20 06 M ul tip le In di ca to r C lu st er S ur ve y in S ão T om é e Pr ín ci pe h as th e fo llo w in g pr in ci pa l o bj ec tiv es : • Pr ov id e up da te d in fo rm at io n to e na bl e ev al ua tio n of th e si tu at io n of c hi ld re n an d w om en in S ão T om é e Pr ín ci pe ; • Pr ov id e ne ce ss ar y da ta f or p ro gr es s m on ito ri ng i n re la tio n to t he o bj ec tiv es o f th e M ill en ni um D ev el op m en t G oa ls , th e W or ld F it fo r C hi ld re n an d ot he rs fi xe d gl ob al ly a s th e ba si s fo r f ut ur e ac tio n ; • C on tr ib ut e to th e im pr ov em en t o f d at a co lle ct io n an d m on ito ri ng s ys te m s in S ão T om é e Pr ín ci pe , a nd to s tr en gt he n te ch ni ca l e xp er tis e in te rm s of c on ce pt io n, im pl em en ta tio n an d an al ys is o f t he se s ys te m s. 27 II . S am pl in g an d su rv ey m et ho do lo gy Sa m pl e co nc ep ti on Th e su rv ey p la n fo r t he S ão T om é e Pr ín ci pe M ul tip le In di ca to r C lu st er S ur ve y (M IC S) w as c on ce iv ed to p ro vi de e st im at io ns o n a la rg e nu m be r of in di ca to rs o n th e si tu at io n of c hi ld re n an d w om en , a t t he n at io na l l ev el , i n ur ba n an d ru ra l z on es a nd fo r th e se ve n co un tr y di st ri ct s of Á gu a G ra nd e, M é- Zo ch i, C au é, C an ta ga lo , L em bá , L ob at a an d Pr ín ci pe . Th e di st ri ct s w er e id en tif ie d as th e pr in ci pa l d om ai ns o f t he s am pl in g an d th e sa m pl in g w as s el ec te d in tw o ph as es . A m on g th e 14 9 se le ct ed z on es , 1 00 c lu st er s ur ve y zo ne s w er e se le ct ed w ith a ta ilo re d pr op or tio na l pr ob ab ili ty . A fte r th e es ta bl is hm en t of a l is t of h ou se ho ld s in t he s el ec te d su rv ey z on es , a sy st em at ic s am pl in g of 5 64 5 ho us eh ol ds w as ra nd om ly s el ec te d. O f th es e ho us eh ol ds , it w as n ot p os si bl e to v is it 20 d ue t o th e in ac ce ss ib ili ty o f so m e an d/ or t he a bs en ce o f ca pa bl e re sp on de nt s du ri ng t he c ol le ct io n pe ri od . T he s am pl in g w as s tr at ifi ed b y di st ri ct a nd w as n ot s el f- w ei gh te d. Th e ta bl e be lo w g iv es t he di st ri bu tio n of th e ho us eh ol d sa m pl in gs a cc or di ng b y di st ri ct . D is tr ic t U rb an Ru ra l To ta l Á gu a G ra nd e 80 0 0 80 0 M é- Zo ch i 12 0 68 0 80 0 C an ta ga lo 54 0 27 0 80 0 C au é 34 5 46 0 80 0 Le m bá 54 0 27 0 80 0 Lo ba ta 18 0 63 0 80 0 Pr ín ci pe 13 5 67 5 80 0 To ta l C ou nt ry 26 60 29 85 56 00 To e na bl e re su lts a t t he n at io na l l ev el , w ei gh te d sa m pl in gs w er e ut ili se d. A d et ai le d de sc ri pt io n of th e sa m pl in g pl an is p ro vi de d in A pp en di x A . 28 Q ue st io nn ai re s Th re e se ri es o f qu es tio nn ai re s w er e ut ili se d fo r th e su rv ey : 1) a h ou se ho ld q ue st io nn ai re t o co lle ct i nf or m at io n on a ll de f ac to h ou se ho ld m em be rs , o n th e ho us eh ol d its el f a nd o n th e pl ac e of th e dw el lin g; 2 ) a q ue st io nn ai re fo r w om en , a dm in is te re d in e ac h ho us eh ol d to a ll w om en ag ed 1 5 to 4 9; a nd , 3 ) a c hi ld q ue st io nn ai re , a dm in is te re d to m ot he rs o r th os e re sp on si bl e fo r al l c hi ld re n un de r fiv e ye ar s of a ge li vi ng in th e ho us eh ol d. T he se q ue st io nn ai re s co nt ai n th e fo llo w in g m od ul es : Th e qu es tio nn ai re fo r h ou se ho ld s co nt ai ns th e fo llo w in g m od ul es : o Li st o f h ou se ho ld m em be rs o Ed uc at io n o W at er a nd s an ita tio n o H ou se ho ld c ha ra ct er is tic s o Is su es li nk ed to m al ar ia o O rp ha ne d an d vu ln er ab le c hi ld re n o C hi ld la bo ur o H an di ca p o M at er na l m or ta lit y o Sa lt io di sa tio n Th e in di vi du al q ue st io nn ai re fo r w om en , a dm in is te re d to a ll w om en a ge d be tw ee n 15 a nd 4 y ea rs li vi ng in h ou se ho ld s, co nt ai ns th e fo llo w in g m od ul es : o In fa nt m or ta lit y o Te ta nu s to xo id o M at er na l a nd n eo -n at al h ea lth o M ar ri ag e an d un io n o C on tr ac ep tio n o A tti tu de s on d om es tic v io le nc e o Se xu al b eh av io ur o K no w le dg e ab ou t H IV 29 Th e qu es tio nn ai re fo r c hi ld re n le ss th an fi ve y ea rs w as a dm in is te re d to m ot he rs o r t o pe rs on s re sp on si bl e fo r c hi ld re n un de r f iv e ye ar s liv in g in th e ho us eh ol ds . N or m al ly , t hi s qu es tio nn ai re s ho ul d be a dm in is te re d to m ot he rs w ith c hi ld re n un de r f iv e ye ar s bu t i n ca se s w he re th e m ot he r is n ot p ar t o f t he li st o f h ou se ho ld m em be rs , t ha t i s, if s he d oe s no t l iv e in th e ho us eh ol d, th e pr in ci pa l p er so n in c ha rg e of th e ch ild is id en tif ie d an d in te rv ie w ed . Th e qu es tio nn ai re c on ta in s th e fo llo w in g m od ul es : o O ffi ci al b ir th re gi st ra tio n an d ea rl y ed uc at io n o V ita m in A o Br ea st fe ed in g o Tr ea tm en t o f i lln es se s o M al ar ia o V ac ci na tio n o A nt hr op om et ry Th es e qu es tio nn ai re s ar e ba se d on th e M IC S3 q ue st io nn ai re m od el 3 . T he S ão T om é e Pr ín ci pe M IC S su rv ey q ue st io nn ai re s ar e th er ef or e ba se d on th e Po rt ug ue se v er si on , t ra ns la te d fr om th e Fr en ch , o f t hi s m od el . Pr el im in ar y m oc k te st in g of th e qu es tio nn ai re s w as th en c on du ct ed in th e Sa ot om ea n ca pi ta l d ur in g 15 d ay s in M ay o f 2 00 6. B as ed o n th e re su lts o f t he p re lim in ar y te st , m od ifi ca tio ns w er e th en m ad e to th e fo rm ul at io n an d th e in iti al tr an sl at io n of th e qu es tio nn ai re s. A c op y of th e Sã o To m é e Pr ín ci pe M IC S qu es tio nn ai re s c an b e fo un d in A pp en di x F. A pa rt fr om th e ad m in is tr at io n of q ue st io nn ai re s, th e fie ld w or k te am s te st ed th e io di ne in k itc he n sa lt ut ili se d by h ou se ho ld s an d m ea su re d th e w ei gh t an d he ig ht o f ch ild re n un de r fiv e ye ar s of a ge . Th e de ta ils a nd c on cl us io ns o f th es e m ea su re m en ts a re p ro vi de d in t he r es pe ct iv e ch ap te rs o f t hi s re po rt . Tr ai ni ng a nd fi eld w or k Tr ai ni ng fo r da ta c ol le ct or s w as c ar ri ed o ut d ur in g 20 d ay s in A pr il of 2 00 6. T hi s tr ai ni ng c on si st ed in c ou rs es o n su rv ey te ch ni qu es a nd th e co nt en t of q ue st io nn ai re s, a s w el l as m oc k in te rv ie w s be tw ee n tr ai ne es t o fa m ili ar is e th em i n in te rv ie w in g te ch ni qu es , th at i s, t o co nd uc t in te rv ie w s co rr ec tly . To w ar ds th e en d of th e tr ai ni ng p er io d, tr ai ne es s pe nt fi ve d ay s do in g fie ld w or k in th e D is tr ic t o f Á gu a G ra nd e to e xe rc is e th ei r n ew s ki lls , t ha t is , t he y un de rt oo k ho us eh ol d pr ac tic e in te rv ie w s. 3 T he m od el fo r t he M IC S3 q ue st io nn ai re c an b e fo un d in w w w .c hi ld in fo .o rg , o r i n th e U N IC EF w eb si te , 2 00 6. 30 Se ve n te am s un de rt oo k th e co lle ct io n of d at a; e ac h te am w as c om po se d of 3 5 in te rv ie w er s, 1 d ri ve r, 1 m on ito r, 1 an th ro po m et ri ci an a nd 1 su pe rv is or . Fi el dw or k be ga n on 1 7 M ay 2 00 6 an d en de d on 2 0 Ju ne 2 00 6. D at a tr ea tm en t T he d at a w as e nt er ed u til is in g th e C SP ro s of tw ar e in st al le d on 8 m ic ro co m pu te rs b y 16 d at a en tr y op er at or s an d 3 da ta e nt ry s up er vi so rs . To en su re q ua lit y co nt ro l, al l t he q ue st io nn ai re s w er e en te re d tw ic e an d la te r s ub m itt ed to in te rn al c on si st en cy c on tr ol s. D ur in g th e en tir e pr oc es s, st an da rd p ro ce du re s an d pr og ra m m es d ev el op ed fo r th e gl ob al M IC S3 p ro je ct a nd a da pt ed fo r Sã o To m é e Pr ín ci pe s pe ci fic iti es w er e ut ili se d du ri ng th e en tir e pr oc es s. D at a pr oc es si ng b eg an o n 15 Ju ne 2 00 6 an d en de d 20 S ep te m be r 2 00 6. T he d at a w as a na ly se d ut ili si ng th e St at is tic al Pa ck ag e fo r S oc ia l S ci en ce s (S PS S) , V er si on 1 4, a nd th e m od el s yn ta x an d ta bu la tio n pl an s de ve lo pe d by U N IC EF fo r t hi s ta sk . 31 II I. Sa m pl e re pr es en ta tiv ity a nd c ha ra ct er is tic s of s ur ve ye d ho us eh ol ds a nd in di vi du al s Sa m pl e r ep re se nt at iv ity O f t he 5 64 6 ho us eh ol ds s el ec te d fo r th e sa m pl in g, 5 64 5 w er e oc cu pi ed , a nd 5 62 5 fa ci lit at ed th e in te rv ie w , a ch ie vi ng a ra te o f r es po ns e of 9 9. 6% . In th e su rv ey ed h ou se ho ld s, 4 74 4 w om en a ge d 15 to 4 9 w er e id en tif ie d. O f t he se w om en , 4 61 2 w er e in te rv ie w ed s uc ce ss fu lly , w ith a r es po ns e ra te o f 9 7. 2% . A s w el l, 31 70 c hi ld re n un de r fiv e w er e in cl ud ed in th e ho us eh ol d qu es tio nn ai re s, o f w hi ch 3 14 0 qu es tio nn ai re s w er e co m pl et ed fo r th es e ch ild re n, in di ca tin g a re sp on se r at e of 9 9. 1% . Th e gl ob al r at e of r es po ns e ha s be en c al cu la te d as 9 6. 9% a nd 9 8. 7% r es pe ct iv el y w ith re ga rd to th e in te rv ie w s of w om en a nd c hi ld re n un de r f iv e (T ab le H H .1 ). A cc or di ng to th e re su lts s ho w n in T ab le H H .1 , t he ra te o f r es po ns e is q ui te h ig h, w hi ch d em on st ra te s go od r ep re se nt iv ity o f t he s am pl in g. T he di ffe re nc es in th e re sp on se ra te b et w ee n re si de nt ia l z on es a nd d is tr ic ts a re n ea rl y ne gl ig ib le . W ith re ga rd to th e re sp on se ra te fo r h ou se ho ld s, it is id en tic al w he th er in u rb an o r ru ra l s et tin gs ( 99 .7 % a nd 9 9. 6% ) an d va ri es v er y lit tle b et w ee n th e di st ri ct s (9 8. 3% in P rí nc ip e an d 10 0% f or Á gu a G ra nd e, M é- Zo ch i, C an ta ga lo a nd L em bá . Th e gl ob al r es po ns e ra te fo r w om en a ge d 15 to 4 9 is s lig ht ly le ss in ru ra l a re as (9 5. 7% ) t ha n in ur ba n ar ea s (9 8. 0% ) m os t lik el y lin ke d to w om en ’s a ct iv iti es o ut si de t he h om e. It is w ea ke r in P rí nc ip e (8 7. 8) y et v ar ie s w ea kl y be tw ee n di st ri ct s (9 9. 2% fo r Á gu a G ra nd e an d 95 .7 % fo r C an ta ga lo ). T he g lo ba l r at e of r es po ns e fo r ch ild re n un de r fiv e is m or e ho m og en ou s be tw ee n re si de nt ia l z on es (b et w ee n 99 .7 % in Á gu a G ra nd e an d 96 .6 % in P rí nc ip e) . Th e re sp on se r at e is r el at iv el y w ea ke r in P rí nc ip e ca n be e xp la in ed by th e w or k ho ur s i m po se d on th e da ta c ol le ct io n te am s an d w or k co nd iti on s th at d id n ot fa ci lit at e in te rv ie w s. H ou se ho ld ch ar ac te ris tic s Th e di st ri bu tio n by a ge a nd s ex o f t he s ur ve ye d po pu la tio n is s up pl ie d in T ab le H H .2 . Th is d is tr ib ut io n is u til is ed a s w el l t o pr od uc e th e ag e py ra m id in F ig ur e H H .1 . In t he 5 62 5 ho us eh ol ds in te rv ie w ed s uc ce ss fu lly d ur in g th e su rv ey , 2 27 28 h ou se ho ld m em be rs w er e re co rd ed . O f th es e ho us eh ol d m em be rs , 1 14 77 a re m en a nd 1 12 51 w om en . Ba se d on th es e fig ur es , t he s ur ve y es tim at ed th e av er ag e si ze o f h ou se ho ld s as 4 .0 in di vi du al s. Ta bl e H H .2 s ho w s an a ge p yr am id re la tiv el y la rg er a t t he b as e, w hi ch in di ca te s th at th e po pu la tio n is s til l v er y yo un g : c lo se to 4 2. 0% a re u nd er 15 , c lo se to h al f ( 48 .4 % ) a re b et w ee n 0 an d 17 y ea rs o f a ge a nd a bo ut 5 2. 0% a re o ld er th an 1 8. T ho se a ge d 65 o r o ld er a re e st im at ed a t 5 .0 % . Th e 32 po pu la tio n ab le to w or k or th e es se nt ia lly a ct iv e po pu la tio n (1 5- 64 y ea rs ) i s es tim at ed a t 5 3. 1% . Fr om th is a ge s tr uc tu re , i t i s cl ea r th at th er e is re la tiv el y st ro ng d ep en de nc e. T he m is si ng a ge g ro up s re pr es en t a fe eb le p er ce nt ag e (2 .0 p er th ou sa nd ). Th e ag e st ru ct ur e pr es en ts s om e ir re gu la ri tie s af fe ct in g th e an al ys is o f p ar tic ul ar ly la rg e sp ec ifi c gr ou ps , i n pa rt ic ul ar th e ag e gr ou ps 0 -4 y ea rs , 15 -1 9 ye ar s, a nd 4 5- 49 y ea rs . Th e di re ct e ffe ct o f m or ta lit y be in g to r ed uc e pr og re ss iv el y th e nu m be rs in th e ol de st a ge g ro up s, in a bs en ce o f st ro ng m ig ra tio n, th e si ze o f t he 0 -4 p op ul at io n sh ou ld b e le ss th an th at o f t he 5 -9 . Su rv ey d at a sh ow s an in ve rs e te nd en cy , w hi ch m ay h av e tw o po ss ib le e xp la na tio ns : on t he o ne h an d, t he e ff ec t of t he a ttr ac tio n fo r ro un de d fig ur es li ke “ 0” o r “5 ” in s ur ve ys , a nd o n th e ot he r, th e be ha vi ou r of t he in te rv ie w er s m or e co nc er ne d w ith r ed uc in g th ei r w or kl oa d th an w ith c ol le ct in g ex ac t da ta . In t he la tte r ca se , i t sh ou ld b e no te d th at e ac h ch ild a ge d 0 – 4 lis te d am on g ho us eh ol d m em be rs a re in cl ud ed in a s pe ci fic m ot he r/ pe rs on in c ha rg e qu es tio nn ai re , i n ot he r w or ds , a n ad di tio na l t as k. S om e in te rv ie w er s ar e th us te m pt ed to e st im at e so m e ch ild re n’ s ag es a s ol de r th an 0 – 4 . Ei th er s itu at io n im pl ie s a po pu la tio n tr an sf er o f t he y ou ng es t t o th e ol de st . Th e yo un ge st (0 – 4 y ea rs ) r ep re se nt 1 3. 1% of th e to ta l p op ul at io n an d th e ol de r (5 – 9 y ea r ol ds ) 1 4. 8% . Th er e is n o di ffe re nc e be tw ee n se xe s am on g th es e ag e gr ou ps . A s im ila r pr ob le m c an b e se en w ith th os e of th e po pu la tio n ag ed 1 5 – 19 y ea rs , a lth ou gh w ith d iff er en ce s in r el at io n to th e se x of th e pe rs on in te rv ie w ed . M al es a ge d be tw ee n 15 -1 9 ac co un t f or 1 2. 5% o f t he m al e po pu la tio n w hi le fe m al es a cc ou nt fo r o nl y 9. 7% o f t he fe m al e po pu la tio n. Th e m os t p la us ib le e xp la na tio n w ou ld b e a « co ns ci en tio us » o m is si on o r a n « er ro r in c at eg or is in g » by th e in te rv ie w er s of y ou ng g ir ls a ge d 15 – 19 a m on gs t t he lo w er -a ge d gr ou ps , b y no t h av in g co m pl et ed a w om en ’s q ue st io nn ai re g iv en th at a ll w om en a ge d 15 to 4 9 w er e el ig ib le to th is qu es tio nn ai re . Th e fa ct th at b oy s of th e sa m e ag e w er e no t a ff ec te d by th is p he no m en on s up po rt s th is h yp ot he si s. Th e ph en om en on o f a ge tr an sf er to a n ol de r (5 0 – 54 ) a ge g ro up is a ls o ob se rv ed fo r th os e ag ed 4 5 – 49 . In th is c as e, a s w el l, on ly th e fe m al es w er e af fe ct ed . In fa ct , w om en 4 5 – 49 r ep re se nt m er el y 2. 6% o f t he fe m al e po pu la tio n w hi le m en o f t he s am e ag e re pr es en t 3 .2 % o f t he m al e po pu la tio n. O n th e ot he r ha nd , m en a ge d 50 – 5 4% r ep re se nt a m er e 2. 7% o f t he ir g ro up w hi le w om en o f t he s am e ag e re pr es en t 4 .5 % o f t he fe m al e po pu la tio n. A d el ib er at e ac tio n on th e pa rt o f t he in te rv ie w er s to m ak e w om en in el ig ib le w ho w ou ld o th er w is e be in te rv ie w ed (w om en ag ed 1 5- 49 ) f or th e w om en ’s q ue st io nn ai re is su sp ec te d. By c om pa ri ng th e nu m be rs o f th e M IC S to t ho se o f th e G en er al P op ul at io n an d H ab ita t C en su s (G PH C ) of 2 00 1, t he re a re s lig ht d iff er en ce s. A cc or di ng t o th e G PH C , t he p op ul at io n of t ho se u nd er 1 5 ye ar s re pr es en t 42 % o f th e to ta l po pu la tio n, w hi le M IC S 3 es tim at es t hi s sa m e po pu la tio n at 4 2. 4% in 2 00 6. T he p op ul at io n ag ed 1 5 – 49 r ep re se nt s 48 % fo r t he G PH C a nd 4 5. 7% fo r M IC S3 . C on ce rn in g th os e ag ed o ve r 5 0, th e G PH C g iv es 1 0% w hi le th e M IC S3 is 1 2. 7% . If th e G PH C r es ul ts a re c or re ct , M IC S3 m ay h av e un de r- es tim at ed th e un de r- 15 p op ul at io n as w el l a s th at a ge d 15 – 4 9. 33 Fi gu re 1 : H H 1 D is tr ib ut io n (p er ce nt ag e) o f h ou se ho ld p op ul at io n, b y se x an d ag e 34 Ta bl e H H .3 p ro vi de s ba si c in fo rm at io n on h ou se ho ld s. It co nt ai ns d et ai ls o n ea ch h ou se ho ld , s uc h as t he s ex o f th e ho us eh ol d he ad , t he re si de nt ia l d is tr ic ts , t ha t u rb an /r ur al s ta tu s an d th e nu m be r of h ou se ho ld m em be rs . Th es e ba si c ch ar ac te ri st ic s ar e eq ua lly u til is ed in a ll ta bl es in t hi s re po rt ; t he f ig ur es o f th is t ab le a re a ls o in te nd ed t o pr es en t th e nu m be r of o bs er va tio ns a cc or di ng t o th e re po rt ’s p ri nc ip le a na ly tic al ca te go ri es . Th e ho us eh ol d w ei gh ed a nd n on -w ei gh te d nu m be rs a re e qu al , g iv en t ha t sa m pl in g w ei gh ts w er e no rm al is ed . ( se e A pp en di x A ). T hi s ta bl e al so in di ca te s th at th e ho us eh ol d pr op or tio ns w he re a t l ea st o ne c hi ld u nd er 1 8 ye ar s, a t l ea st o ne u nd er fi ve a nd a t l ea st o ne e lig ib le fe m al e ag ed b et w ee n 15 a nd 4 9 ye ar s w er e fo un d. T ab le H H 3 sh ow s th at th e m aj or ity o f h ou se ho ld s (5 6. 7% ) a re in u rb an s et tin gs . It al so s ho w s th at m or e th an s ix h ou se ho ld s ou t o f t en (6 1. 9% ) a re h ea de d by a m al e. T he m aj or ity o f h ou se ho ld s (6 3. 3% ) a re lo ca lis ed in th e D is tr ic ts o f Á gu a G ra nd e, w ith m or e th an o ne th ir d (3 5. 5% ) a nd M é- Zo ch i w ith m or e th an o ne q ua rt er (2 7. 8% ). T he D is tr ic ts o f C au é (5 .0 % ) a nd P rí nc ip e (5 .4 % ) ar e th os e w ith th e w ea ke st r ep re se nt at io n. T he m aj or ity o f h ou se ho ld s ar e co m po se d of 2 to 5 p eo pl e : m or e th an o ne h ou se ho ld o ut o f f ou r (2 6. 4% ) a re m ad e up o f 2 o r 3 pe rs on s an d m or e th an o ne h ou se ho ld o ut o f t hr ee (3 0. 8% ) a re m ad e up o f 4 o r 5 pe rs on s. A li ttl e le ss th an o ne fif th o f t he to ta l ( 18 .6 % ) h ou se ho ld s co m po se d of o ne p er so n or p eo pl e liv in g al on e ar e fa ir ly w el l r ep re se nt ed in th e sa m pl e. In 7 1. 4% o f ho us eh ol ds a c hi ld u nd er 1 8 re si de s, an d in 4 1. 3% o f ho us eh ol ds a c hi ld u nd er 5 . In m or e th an 6 7. 0% o f ho us eh ol ds o ne fi nd s a fe m al e be tw ee n 15 a nd 4 9 ye ar s. Ch ar ac te ri st ic s of p eo pl e su rv ey ed Ta bl es H H .4 a nd H H .5 p ro vi de in fo rm at io n on b as ic c ha ra ct er is tic s of w om en s ur ve ye d w ho a ge is b et w ee n 15 a nd 4 9 ye ar s an d w ith c hi ld re n un de r 5 . In th es e tw o ta bl es , t he to ta l n um be r o f w ei gh te d an d no n- w ei gh te d ob se rv at io ns is e qu al , g iv en th at s am pl e w ei gh ts w er e no rm al is ed (s ta nd ar di se d) . A pa rt fr om u se fu l i nf or m at io n on th e ba si c ch ar ac te ri st ic s of w om en a nd c hi ld re n, th es e ta bl es p ro vi de a s w el l t he n um be r of ob se rv at io ns in e ac h of th e ba se c at eg or ie s. T he se c at eg or ie s ar e ut ili se d in th e di ff er en t t ab ul at io ns in th is re po rt . Ta bl e H H 4 pr ov id es b as e ch ar ac te ri st ic s on w om en in te rv ie w ed a ge d be tw ee n 15 a nd 4 9. I t c on ta in s in fo rm at io n on th e di st ri bu tio n of w om en by d is tr ic ts , t yp e of u rb an /r ur al r es id en ce , a ge , f am ily s itu at io n, th e m ot he r’ s st at us , e du ca tio n4 , t he q ui nt ile s5 a nd th e he al th in de x. G lo ba lly , 4 U nl es s ot he rw is e st at ed , t he te rm “ ed uc at io n” r ef er s to th e le ve l o f i ns tr uc tio n ac hi ev ed b y th e re sp on de nt o f t ho se q ue st io ne d th ro ug ho ut th is r ep or t w he n it is u se d as a b ac kg ro un d va ri ab le ,. 5 Pr in ci pa l c om po ne nt s a na ly si s w as p er fo rm ed b y us in g in fo rm at io n on th e ow ne rs hi p of h ou se ho ld g oo ds a nd a m en iti es (a ss et s) to a ss ig n w ei gh ts to ea ch h ou se ho ld a ss et a nd to o bt ai n w ea lth sc or es fo r e ac h sa m pl ed h ou se ho ld (t he a se ts u se d in th es e ca lc ul at io ns w er e th e fo llo w in g : e le ct ri ct y, ra di o, 35 th e nu m be r of w ei gh te d an d no n- w ei gh te d ob se rv at io ns w as id en tic al (4 61 1 an d 46 10 , r es pe ct iv el y) . H ow ev er , i t i s us ef ul to p oi nt o ut n ot ab le di ffe re nc es a cc or di ng to c er ta in p ar tic ul ar c at eg or ie s be ca us e of a n ov er - o r u nd er -s am pl in g. T he r an ge o f d iff er en ce s is p ar tic ul ar ly im po rt an t fo r th e di st ri ct s, i n pa rt ic ul ar t ha t of Á gu a G ra nd e (1 79 6 an d 77 7, r es pe ct iv el y, M é- Zo ch i (1 23 8 an d 66 5, r es pe ct iv el y) , C au é 20 9 an d 67 4 re sp ec tiv el y) a nd P rí nc ip e (1 96 a nd 5 14 , r es pe ct iv el y) . Th es e di ffe re nc es w er e eq ua lly n ot ew or th y ac co rd in g to th e en vi ro nm en t, in p ar tic ul ar th e ur ba n en vi ro nm en t (2 81 8 an d 34 10 , re sp ec tiv el y ag ai ns t 17 91 a nd 2 20 1 re sp ec tiv el y in r ur al e nv ir on m en ts ). W ith r eg ar d to t he o th er ca te go ri es , t he o bs er ve d di ffe re nc es a re re la tiv el y w ea k. O f a ll in te rv ie w ed w om en , 6 1. 2% li ve in a n ur ba n se tti ng a nd 3 8. 8% in a ru ra l s et tin g. N ea rl y 60 .0 % o f t he se w om en a re u nd er 3 0 ye ar s of a ge , of w hi ch 2 1. 7% a re b et w ee n 15 a nd 2 4 ye ar s, 20 .9 % a re a ge d fr om 3 0 to 2 4 an d 19 .1 % a re a ge d 25 to 2 9 ye ar s. W om en a ge d 45 to 4 9 m ak e up th e sm al le st a ge g ro up , r ep re se nt in g on ly 5 .8 % . C lo se to s ix o ut o f t en (5 9. 2% ) o f t he se w om en a re m ar ri ed o r l iv e in u ni on , w hi le s in gl e w om en in th is a ge g ro up re pr es en t 2 6. 0% . Th os e se pa ra te d di vo rc ed o r w id ow ed a cc ou nt fo r l es s th an 1 5. 0% o f a ll w om en in th ei r r ep ro du ct iv e ye ar s. Th e gr ea t m aj or ity o f th es e w om en h av e al re ad y gi ve n bi rt h to o ne c hi ld : cl os e to 7 2. 0% h av e gi ve n bi rt h to a t l ea st o ne c hi ld a nd o nl y 28 % ha ve n ev er h ad a c hi ld . M os t w om en a re e du ca te d : m or e th an 6 0% h av e a pr im ar y le ve l e du ca tio n an d 29 % s ec on da ry le ve l e du ca tio n or m or e. A s m al l n um be r o f w om en (l es s th an 6 .0 % ) h av e ne ve r b ee n to s ch oo l. C er ta in b as ic c ha ra ct er is tic s f or c hi ld re n un de r f iv e ye ar s ar e pr es en te d in T ab le H H .5 w hi ch g iv es th e di st ri bu tio n of th es e ch ild re n ac co rd in g to s ev er al a ttr ib ut es , s uc h as s ex , r es id en tia l d is tr ic t, ag e in m on th s an d th e m ot he r’ s or th e pe rs on in c ha rg e’ s ed uc at io n le ve l a nd h ea lth . In re la tio n to th e nu m be r o f w ei gh te d an d no n- w ei gh te d ob se rv at io ns , t he s am e ca n be s ai d fo r w om en b et w ee n 15 -4 9 ye ar s o f a ge w ith re ga rd to th e ra ng e of d iff er en ce s an d th e co nc er ne d ca te go ri es (d is tr ic t a nd re si de nt ia l e nv ir on m en t). . Cl os e to o ne th ir d of c hi ld re n (3 2. 7% ) l iv e in th e D is tr ic t o f Á gu a G ra nd e an d m or e th an o ne q ua rt er (2 6. 4% ) i n th at o f M é- zo ch i w hi le th os e of C au é an d Pr ín ci pe a cc ou nt fo r re la tiv el y a sm al l a m ou nt o f c hi ld re n (le ss th an 6 .0 % ). In te rm s of th e se x of th e ch ild , b oy s an d gi rl s ar e ne ar ly eq ua l ( 50 .2 % a nd 4 9. 8 re sp ec tiv el y) . In r el at io n to t he r es id en tia l e nv ir on m en t, th e ur ba n ha s m or e re pr es en ta tio n th an t he r ur al ( 56 .9 % a nd te le vi si on , p or ta bl e te le ph on e, fi xe d- lin e te le ph on e, re fr ig er at or , w at ch , b ic yc le , m ot or cy cl e, c ar /t ru ck , b oa t, pi pe d w at er ). E ac h ho us eh ol d w as th en w ei gh te d by th e nu m be r o f h ou se ho ld m em be rs , a nd th e ho us eh ol d po pu la tio n w as d iv id ed in to fi ve g ro up s o f e qu al si ze , f ro m th e po or es t q ui nt ile to th e ri ch es t qu in til e, b as ed o n th e w ea lth sc or es o f h ou se ho ld s t he y w er e liv in g in . T he w ea lth in de x is a ss um ed to c ap tu re th e un de rl yi ng lo ng -te rm w ea lth th ro ug h in fo rm at io n on th e ho us eh ol d as se ts , a nd is in te nd ed to p ro du ce a ra nk in g of h ou se ho ld s b y w ea lth , f ro m p oo re st to ri ch es t. Th e w ea lth in de x do es n ot pr ov id e in fo rm at io n on a bs ol ut e po ve rt y, c ur re nt in co m e or e xp en di tu re le ve ls , a nd th e w ea lth sc or es c al cu la te d ar e ap pl ic ab le fo r o nl y th e pa rt ic ul ar d at a se t th ey a re b as ed o n. F ur th er in fo rm at io n on th e co ns tr uc tio n of th e w ea lth in de x ca n be fo un d in R ut st ei n an d Jo hn so n, 2 00 4, a nd F ilm er a nd P ri tc he tt, 2 00 1 36 53 .1 % r es pe ct iv el y. A s ca n be e xp ec te d, t he w ei gh t of a ge g ro up s lo w er s w ith a ge b ec au se o f m or ta lit y. Th e un de r 13 m on th o ld c hi ld re n re pr es en t 22 .5 % o f ch ild re n un de r fiv e 11 .6 % a nd 1 0. 9% r es pe ct iv el y fo r th os e un de r si x m on th s an d th os e be tw ee n si x an d el ev en m on th s) . Th is p er ce nt ag e fa lls to 2 1. 5% fo r ch ild re n ag ed 1 2 to 2 3 m on th s, to 1 9. 7% fo r th os e ag ed 2 4- 35 m on th s an d to 1 9. 9% fo r th os e ag ed b et w ee n 48 to 5 9 m on th s. I n a pr ac tic al ly in ex is te nt m ig ra to ry c on te xt , t he q ua lit y of d at a on a ge r at he r th an to a no th er fa ct or s uc h as a h ig he r m or ta lit y ra te fo r t he c on ce rn ed c at eg or ie s re su lts in th e re la tiv el y w ea k w ei gh t o f t he la st g ro up a nd th e fa ct th at th e pe rc en ta ge o f c hi ld re n ag ed 2 4 an d 35 m on th s is lo w er th an fo r th os e ag ed 3 6 to 4 7 m on th s. T he ta bl e al so s ho w s th at fo r 72 % o f c hi ld re n, th e m ot he r or p er so n in c ha rg e ha s a pr im ar y sc ho ol le ve l e du ca tio n an d fo r 19 .8 % a s ec on da ry s ch oo l e du ca tio n or m or e. Th e un de r fiv es a re u ne qu al ly d is tr ib ut ed b et w ee n th e w ea lth i nd ex q ui nt ile s : t he y ar e so m ew ha t re pr es en te d in t he r ic he st q ui nt ile ( 16 .0 % ) an d ve ry m uc h re pr es en te d in t he p oo r an d po or es t qu in til es (c lo se to 2 2. 0% r es pe ct iv el y) , w hi ch c an b e ex pl ai ne d by v ar io us fa ct or s su ch a s th e sm al l s iz e an d lo w er r at e of r ep ro du ct io n of th e w ea lth ie st c at eg or ie s. 37 IV . C hi ld m or ta lit y O ne o f th e ov er ar ch in g go al s of t he M ill en ni um D ev el op m en t G oa ls ( M D G s) a nd t he W FF C i s to r ed uc e in fa nt a nd u nd er -5 m or ta lit y. S pe ci fic al ly , th e M D G s ca ll fo r a re du ct io n in u nd er -5 m or ta lit y by t w o- th ir ds b et w ee n 19 90 a nd 2 01 5. M on ito ri ng pr og re ss t ow ar ds t hi s go al i s an i m po rt an t bu t di ffi cu lt ob je ct iv e. M ea su ri ng c hi ld ho od m or ta lit y m ay s ee m e as y, b ut a tte m pt s us in g di re ct q ue st io ns , s uc h as “ H as a ny on e in th is h ou se ho ld d ie d in th e la st y ea r? ” gi ve in ac cu ra te re su lts . U si ng d ir ec t m ea su re s of c hi ld m or ta lit y fr om b ir th h is to ri es i s tim e co ns um in g, m or e ex pe ns iv e, a nd r eq ui re s gr ea te r at te nt io n to t ra in in g an d su pe rv is io n. A lte rn at iv el y, in di re ct m et ho ds d ev el op ed to m ea su re c hi ld m or ta lit y pr od uc e ro bu st e st im at es t ha t ar e co m pa ra bl e w ith t he o ne s ob ta in ed f ro m o th er s ou rc es . I nd ir ec t m et ho ds m in im iz e th e pi tfa lls o f m em or y la ps es , i ne xa ct o r m is in te rp re te d de fin iti on s an d po or in te rv ie w in g te ch ni qu e. In fa nt m or ta lit y ra te is th e pr ob ab ili ty o f d yi ng b ef or e th e fir st b ir th da y. U nd er -5 m or ta lit y ra te is th e pr ob ab ili ty o f d yi ng b ef or e th e fif th b ir th da y. In M IC s ur ve ys , i nf an t an d un de r- 5 m or ta lit y ra te s ar e ca lc ul at ed b as ed o n an i nd ir ec t es tim at io n te ch ni qu e kn ow n as th e Br as s m et ho d (U ni te d N at io ns , 1 98 3; 1 99 0a ; 1 99 0b ). T he d at a us ed in th e es tim at io n ar e th e m ea n nu m be r o f c hi ld re n ev er b or n fo r 5- ye ar a ge g ro up s of w om en a ge d 15 to 4 9, a nd th e pr op or tio n of th es e ch ild re n w ho a re d ea d, a ls o fo r 5- ye ar a ge gr ou ps o f w om en . Th e te ch ni qu e co nv er ts th es e da ta in to p ro ba bi lit ie s of d yi ng b y ta ki ng in to a cc ou nt b ot h th e m or ta lit y ri sk s to w hi ch c hi ld re n ar e ex po se d an d th ei r l en gt h of e xp os ur e to th e ri sk o f d yi ng , a ss um in g a pa rt ic ul ar m od el a ge p at te rn o f m or ta lit y. Ba se d on p re vi ou s in fo rm at io n on m or ta lit y in S ão T om é e Pr ín ci pe , t he n or th m od el li fe ta bl e w as s el ec te d as m os t a pp ro pr ia te . Ta bl e C M .1 p ro vi de s es tim at es o f c hi ld m or ta lit y by v ar io us b ac kg ro un d ch ar ac te ri st ic s, w hi le T ab le C M .2 p ro vi de s th e ba si c da ta us ed in th e ca lc ul at io n of th e m or ta lit y ra te s fo r th e na tio na l t ot al . Th e in fa nt m or ta lit y ra te is e st im at ed a t 4 5 pe r th ou sa nd , w hi le th e pr ob ab ili ty o f d yi ng a t t he u nd er -5 m or ta lit y ra te (U 5M R) is a ro un d 66 p er th ou sa nd . Th es e es tim at es h av e be en c al cu la te d by av er ag in g m or ta lit y es tim at es o bt ai ne d fr om w om en a ge d 25 -2 9 an d 30 -3 4, a nd r ef er t o m id -2 00 3. D iff er en ce s ex is t in m or ta lit y pr ob ab ili ty b et w ee n so m e so ci al c at eg or ie s. T he se d iff er en ce s ar e ho w ev er s m al l b et w ee n bo ys a nd g ir ls : m al e ch ild m or ta lit y is on ly tw o po in ts h ig he r t ha n fo r g ir ls (4 6 p er th ou sa nd a ga in st 4 8 pe r t ho us an d) w hi le th e m al e un de r f iv e m or ta lit y ra te is o ne po in t l ow er t ha n th at f or g ir ls (6 5 pe r th ou sa nd a ga in st 6 6 pe r th ou sa nd ). O n th e ot he r ha nd , d iff er en ce s be tw ee n di st ri ct s ar e cl ea re r. C hi ld m or ta lit y ra te s ar e lo w es t i n th e D is tr ic ts o f M é- zo ch i ( 35 p er th ou sa nd ) a nd L ob at a (3 9 pe r t ho us an d) a nd h e hi gh es t 38 in th os e of P rí nc ip e (6 2 pe r th ou sa nd ) an d Le m bá ( 56 p er th ou sa nd ). T he lo w es t r at e is 7 7. 0% h ig he r th an th e hi gh es t r at e. Th e te nd en cy is th e sa m e fo r th e un de r fiv e m or ta lit y ra te s : th e hi gh es t r at e is P rí nc ip e’ s (9 5 pe r th ou sa nd ), cl os e to tw ic e (1 .9 6) h ig he r th an th e lo w es t ( in M é- zo ch i, w ith 4 9 pe r th ou sa nd ). M or ta lit y ra te s ar e al so h ig he r in r ur al e nv ir on m en ts th an in u rb an o ne s : 4 7 pe r t ho us an d in u rb an a re as a ga in st 4 3 pe r t ho us an d in ru ra l a re as , w ith th e un de r f iv e m or ta lit y ra te s at 7 0 pe r t ho us an d ag ai ns t 6 1 pe r t ho us an d. Th e ch ild a nd u nd er fi ve m or ta lit y ra te s lo w er in r el at io n to th e m ot he r’ s le ve l o f e du ca tio n. T he r at es a re h ig he r am on g ch ild re n w ho se m ot he r do es n ot h av e an y ed uc at io n (r es pe ct iv el y 50 a nd 7 5 pe r th ou sa nd ) a nd lo w er a m on g ch ild re n w ith m ot he rs w ith a t le as t a s ec on da ry e du ca tio n (r es pe ct iv el y 39 a nd 5 6 pe r th ou sa nd ), or , a d ec re as e of 2 8% a nd 3 4% r es pe ct iv el y. O n th e ot he r ha nd , th e in flu en ce o f t he le ve l o f q ua lit y of li fe s ee m s ne gl ig ib le o n m or ta lit y : t he c hi ld m or ta lit y ra te is e st im at ed a t 4 6 pe r th ou sa nd in th e po or es t 6 0% o f h ou se ho ld s, an d 45 p er th ou sa nd in th e 40 % w ea lth ie r ho us eh ol ds . Th e pr ob ab ili ty o f d yi ng in th e un de r fiv es fo llo w s th is te nd en cy (r es pe ct iv el y 67 a nd 6 5 pe r t ho us an d) . 39 Fi gu re 2 : C M 1 M or ta lit y ra te fo r th e un de r fiv es , b y so ci o- ec on om ic g ro up in gs 40 Fi gu re C M .2 p re se nt s a se ri es o f e st im at io ns o f u nd er fi ve m or ta lit y ra te s, b as ed o n re sp on se s fr om w om en fr om d iff er en t a ge g ro up s, an d fo r d iff er en t p oi nt s in ti m e, in di ca tin g th us th e es tim at ed te nd en cy o f m or ta lit y ra te s fo r t he u nd er fi ve s fr om th e su rv ey d at a. M IC S es tim at io ns g lo ba lly in di ca te a d ec re as e in m or ta lit y du ri ng th e la st 1 5 ye ar s. A s tu dy o n th e M ot he r a nd C hi ld H ea lth in di ca to rs b y th e M in is tr y of H ea lth a nd u nd er ta ke n in 1 99 6 by D rs A nt ón io L im a an d Lá za ro S ou sa , i nd ic at ed th at th e un de r f iv es m or ta lit y ra te s pa ss ed fr om 7 6 pe r th ou sa nd b et w ee n 19 91 – - 1 99 4 to 6 6 pe r th ou sa nd fo r th e pe ri od 1 99 7 –- 2 00 0, in o th er w or ds a d ec re as e of 1 5% . Th e m os t re ce nt M IC S3 e st im at io n (6 6 de at hs p er 1 00 0 liv e bi rt hs ) f or 2 00 0 –- 2 00 6 se em s to in di ca te s om e st ag na tio n in th e m or ta lit y ra te s ag ai ns t an e xp ec te d de cr ea se f ol lo w in g th e te nd en cy i nd ic at ed b y th e ab ov e- m en tio ne d st ud y. N ev er th el es s, c om pa re d to t he 2 00 1 G en er al Po pu la tio n an d H ab ita t C en su s (G PH C ) re su lts , w ith 7 2 de at hs p er 1 00 0 liv e bi rt hs , t hi s es tim at io n in di ca te s a de cr ea se o f ab ou t 9% be tw ee n 20 01 a nd 2 00 3. W ith r eg ar d to c hi ld m or ta lit y, th e sa m e te nd en cy b et w ee n th e G PH C a nd th e M IC S3 is o bs er va bl e. T he m os t re ce nt M IC S3 e st im at io n in c hi ld m or ta lit y (4 5 de at hs p er 1 00 0 liv e bi rt hs ) i s ab ou t 1 7. 0% lo w er th an th at o f t he G PH C in 2 00 1 (5 4 de at hs pe r 1 20 00 li ve b ir th s) . G lo ba lly , t he se r es ul ts in di ca te a d ec re as in g te nd en cy in c hi ld m or ta lit y, w ha te ve r t he s ou rc e, e ve n if co m pa ri so n of d at a qu al ity c an no t b e de fin iti ve ly e st ab lis he d. A m or e pr of ou nd e va lu at io n of th es e ap pa re nt d ec re as es a nd d iff er en ce s, a s w el l a s th ei r d et er m in an ts , s ho ul d be u nd er ta ke n by a n in de pe nd en t a nd s ub st an tiv e an al ys is . Fi gu re 3 : C M 2 M or ta lit y ra te te nd en cy fo r th e un de r fiv es 41 V . N ut ri tio n N ut rit io na l s ta tu s C hi ld re n' s nu tr iti on al s ta tu s is a r ef le ct io n of th ei r ov er al l h ea lth . W he n ch ild re n ha ve a cc es s to a n ad eq ua te fo od s up pl y, lo w er e xp os ur e to re pe at ed il ln es s, a nd w el l c ar ed fo r, th ey a re c on si de re d as w el l n ou ri sh ed a nd a bl e to re ac h th ei r g ro w th p ot en tia l. U nd er -n ut ri tio n is a ss oc ia te d w ith m or e th an h al f o f a ll ch ild d ea th s w or ld w id e. U nd er no ur is he d ch ild re n ar e m or e lik el y to d ie fr om c om m on ch ild ho od a ilm en ts , a nd th os e w ho s ur vi ve h av e re cu rr in g si ck ne ss es a nd fa lte ri ng g ro w th . Th re e qu ar te rs o f t he c hi ld re n w ho d ie fr om c au se s re la te d to m al nu tr iti on w er e on ly m ild ly o r m od er at el y m al no ur is he d - s ho w in g no o ut w ar d si gn o f t he ir v ul ne ra bi lit y. T he M D G s ta rg et is to re du ce b y ha lf th e pr op or tio n of p eo pl e w ho s uf fe r fr om h un ge r be tw ee n 19 90 a nd 2 01 5. Th e W FF C g oa l is t o re du ce t he p re va le nc e of m al nu tr iti on a m on g un de r- 5 ch ild re n by a t l ea st o ne th ir d be tw ee n 20 00 a nd 2 01 0, w ith s pe ci al a tte nt io n to c hi ld re n un de r 2 ye ar s of a ge . A re du ct io n in th e pr ev al en ce o f m al nu tr iti on w ill a ss is t i n th e go al to re du ce c hi ld m or ta lit y. In a w el l-n ou ri sh ed p op ul at io n, th er e is a re fe re nc e di st ri bu tio n of h ei gh t a nd w ei gh t f or u nd er -5 c hi ld re n. U nd er -n ou ri sh m en t i n a po pu la tio n ca n be g au ge d by c om pa ri ng c hi ld re n to a r ef er en ce p op ul at io n. Th e re fe re nc e po pu la tio n us ed i n th is r ep or t is t he W H O /C D C /N C H S re fe re nc e, w hi ch w as re co m m en de d fo r u se b y U N IC EF a nd th e W or ld H ea lth O rg an iz at io n (W H O ) a t t he ti m e th e su rv ey w as im pl em en te d. Ea ch o f th e th re e nu tr iti on al s ta tu s in di ca to rs c an b e ex pr es se d in s ta nd ar d de vi at io n un its ( z- sc or es ) fr om t he m ed ia n of t he r ef er en ce po pu la tio n. W ei gh t-f or -a ge i s a m ea su re o f bo th a cu te a nd c hr on ic m al nu tr iti on . C hi ld re n w ho se w ei gh t-f or -a ge i s m or e th an t w o st an da rd d ev ia tio ns be lo w th e m ed ia n of t he r ef er en ce p op ul at io n ar e co ns id er ed m od er at el y or s ev er el y un de rw ei gh t w hi le t ho se w ho se w ei gh t-f or -a ge is m or e th an th re e st an da rd d ev ia tio ns b el ow th e m ed ia n ar e cl as si fie d as se ve re ly u nd er w ei gh t. H ei gh t-f or -a ge is a m ea su re o f lin ea r gr ow th . C hi ld re n w ho se h ei gh t-f or -a ge is m or e th an tw o st an da rd d ev ia tio ns b el ow t he m ed ia n of th e re fe re nc e po pu la tio n ar e co ns id er ed s ho rt f or t he ir a ge a nd a re c la ss ifi ed a s m od er at el y or s ev er el y st un te d. Th os e w ho se h ei gh t-f or -a ge is m or e th an th re e st an da rd d ev ia tio ns b el ow th e m ed ia n ar e cl as si fie d as s ev er el y st un te d. St un tin g is a r ef le ct io n of c hr on ic m al nu tr iti on a s a re su lt of fa ilu re to re ce iv e ad eq ua te n ut ri tio n ov er a lo ng p er io d an d re cu rr en t o r c hr on ic il ln es s. 42 Fi na lly , c hi ld re n w ho se w ei gh t-f or -h ei gh t i s m or e th an tw o st an da rd d ev ia tio ns b el ow th e m ed ia n of th e re fe re nc e po pu la tio n ar e cl as si fie d as m od er at el y or s ev er el y w as te d, w hi le th os e w ho fa ll m or e th an th re e st an da rd d ev ia tio ns b el ow th e m ed ia n ar e se ve re ly w as te d. W as tin g is us ua lly t he r es ul t of a r ec en t nu tr iti on al d ef ic ie nc y. Th e in di ca to r m ay e xh ib it si gn ifi ca nt s ea so na l sh ift s as so ci at ed w ith c ha ng es i n th e av ai la bi lit y of fo od o r d is ea se p re va le nc e. In t he M IC S II I, w ei gh ts a nd h ei gh ts o f al l un de r- 5 ch ild re n w er e m ea su re d us in g an th ro po m et ri c eq ui pm en t re co m m en de d by U N IC EF (U N IC EF , 2 00 6) . Th e fin di ng s in th is s ec tio n ar e ba se d on th e re su lts o f t he se m ea su re m en ts . T ab le N U .1 s ho w s th e pe rc en ta ge s of c hi ld re n cl as si fie d in to e ac h of th es e ca te go ri es , b as ed o n th e an th ro po m et ri c m ea su re m en ts t ha t w er e ta ke n du ri ng f ie ld w or k. A dd iti on al ly , th e ta bl e in cl ud es t he p er ce nt ag e of c hi ld re n w ho a re o ve rw ei gh t, w hi ch t ak es i nt o ac co un t th os e ch ild re n w ho se w ei gh t f or h ei gh t i s ab ov e tw o st an da rd d ev ia tio ns fr om th e m ed ia n of th e re fe re nc e po pu la tio n. In T ab le N U .1 , c hi ld re n w ho se d at es o f b ir th a re n ot k no w n ar e no t t ak en in to a cc ou nt . Fo r t he s pe ci fic c as e of S ão T om é e Pr ín ci pe , a ll ch ild re n se le ct ed a re w ei gh ed . C lo se to 9 .0 % w er e ex cl ud ed fr om th e an al ys is fo r on e of th e fo llo w in g re as on s : th ey w er e no t w ei gh ed o r m ea su re d, th ei r m ea su re m en ts a re a bo ve t w o st an da rd d ev ia tio ns f ro m t he m ed ia n of t he r ef er en ce p op ul at io n, o r th ei r da te o f bi rt h is n ot k no w n. Ex cl us io n ca se s ar e m or e fr eq ue nt in th e D is tr ic t o f P rí nc ip e (1 5. 2% ), am on g ch ild re n un de r 6 m on th s an d be tw ee n 6 – 11 m on th s (2 1. 5% a nd 14 .4 % re sp ec tiv el y) . Ta bl e N U .1 s ho w s ab ou t 9. 2% o f ch ild re n un de r fiv e in S ão T om é e Pr ín ic pe s uf fe r fr om m od er at e un de rw ei gh t an d 1. 2% a re c on si de re d as su ffe ri ng fr om s ev er e un de rw ei gh t. C lo se to o ne c hi ld o ut o f f ou r (2 3. 0% ) o f c hi ld re n su ffe r fr om m od er at e st un tin g or a re to o sh or t f or th ei r ag e an d on e ch ild e ou t o f t en s uf fe r fr om s ev er s tu nt in g. A bo ut 8 .0 % e ith er is w as tin g m od er at el y or is to o th in fo r th ei r he ig ht w hi le 1 .4 % is w as tin g se ve re ly . M or e th an o ne c hi ld o ut o f t en (1 0. 7% a re o ve rw ei gh t. 43 Fi gu re N U. 1: P ou rc en ta ge d e m al nu tri tio n ch ez le s m oi ns d e 5 an s, S ão T om é et P rín ci pe , 2 00 6 0, 0 5, 0 10 ,0 15 ,0 20 ,0 25 ,0 30 ,0 35 ,0 0 6 12 18 24 30 36 42 48 54 60 L' âg e (e n M oi s) Pourcent In su ffi sa nc e po nd ér al e R et ar d de c ro is sa nc e E m ac ia tio n Fi gu re 4 : N U .1 P er ce nt ag e of m al nu tr iti on in u nd er fi ve s A cc or di ng to th es e in di ca to rs , d iff er en ce s m ay b e es ta bl is he d be tw ee n th e nu tr iti on al s ta tu s of g ir ls a nd b oy s. T he g re at es t d iff er en ce fo r gi rl s re la te s to s ev er e un de rw ei gh t ( 0. 8% a ga in st 1 .6 % ), m od er at e or s ev er e st un tin g (2 1. 6% a ga in st 2 4. 3% w hi le o ve rw ei gh t i s in d et ri m en t t o th em 11 .8 % a ga in st 9 .7 % ). R ur al c hi ld re n ha ve a g re at er r is k of s uf fe ri ng f ro m m od er at e or s ev er e un de rw ei gh t (1 1. 4% a ga in st 7 .5 % ) an d se ve re 1. 1% ag ai ns t 0 .4 % ), m od er at e or s ev er e st un tin g (2 8. 2% a ga in st 1 9. 0% a nd s ev er e st un tin g (1 2. 2% a ga in st 8 .5 % ) a nd w as tin g 12 .2 % a ga in st 8 .5 % th an u rb an c hi ld re n. 44 Th e te nd en cy is t he s am e fo r ov er w ei gh t (1 1. 9% a ga in st 9 .9 % ). M od er at e or s ev er e un de rw ei gh t is m or e fr eq ue nt in t he D is tr ic ts o f Le m bá (1 1. 2% ) an d C au é (1 0. 8% ), am on g ch ild re n ag ed 1 2 – 23 m on th s (1 3. 1% ), ch ild re n w ho se m ot he r is n ot e du ca te d 12 .6 % ) an d th e po or es t ho us eh ol ds 1 2. 7% ); it is w ea ke r in th e D is tr ic t o f P rí nc ip e (0 .4 % ) a nd a m on g th os e ag ed le ss th an 6 m on th s an d th e w ea lth ie r w ho ig no re th is so rt o f m al nu tr iti on . M od er at e or s ev er s tu nt in g is m or e fr eq ue nt a m on g ch ild re n w ho se m ot he rs d id n ot g o to s ch oo l ( re sp ec tiv el y 25 .1 % a nd 11 .1 % a ga in st r es pe ct iv el y 18 .2 % a nd 8 .8 % f or t ho se c hi ld re n w ho se m ot he r ha s ha d a se co nd ar y le ve l or m or e of e du ca tio n) . I t is a ls o w id es pr ea d am on g ch ild re n in t he p oo re st h ou se ho ld s (r es pe ct iv el y 30 .6 % a nd 1 4. 5% a ga in st r es pe ct iv el y 12 .2 % a nd 5 .0 % f or c hi ld re n fr om w ea lth ie r ho us eh ol ds ). O ve rw ei gh t is p ar tic ul ar ly f re qu en t in P rí nc ip e (2 3. 7% a ga in st a n at io na l a ve ra ge o f 10 .7 % ), am on g ch ild re n un de r 6 m on th s (2 2. 4% ) a nd th os e fr om s ix to 1 1 m on th s (1 4. 9% ). It is in te re st in g to u nd er lin e th at fr om th e po in t o f v ie w o f t he s tr uc tu re b y ag e an d ac co rd in g to th e th re e m al nu tr iti on in di ce s, c hi ld re n fr om 1 2 to 2 3 m on th s ar e m or e af fe ct ed t ha n th os e yo un ge r or o ld er ( Fi gu re N U .1 ). Th is s itu at io n is n or m al b ec au se a t th at a ge m an y ch ild re n ar e be in g w ea ne d fr om b re as tfe ed in g an d ar e th us c on ta m in at ed th ro ug h w at er , f oo d an d th e en vi ro nm en t. Br ea st fee di ng Br ea st fe ed in g fo r th e fir st fe w y ea rs o f l ife p ro te ct s ch ild re n fr om in fe ct io n, p ro vi de s an id ea l s ou rc e of n ut ri en ts , a nd is e co no m ic al a nd s af e. H ow ev er , m an y m ot he rs s to p br ea st fe ed in g to o so on . T he re a re o fte n pr es su re s to s w itc h to a n in fa nt fo rm ul a, w hi ch c an c on tr ib ut e to g ro w th fa lte ri ng a nd m ic ro nu tr ie nt m al nu tr iti on a nd is u ns af e if cl ea n w at er is n ot r ea di ly a va ila bl e. T he W FF C g oa l s ta te s th at c hi ld re n sh ou ld b e ex cl us iv el y br ea st fe d fo r si x m on th s an d co nt in ue t o be b re as tfe d fo r tw o ye ar s of a ge a nd b ey on d, a nd in tr od uc ed t o sa fe , a pp ro pr ia te a nd ad eq ua te c om pl em en ta ry fe ed in g at s ix m on th s. Th e W H O /U N IC EF h av e th e fo llo w in g fe ed in g re co m m en da tio ns : • Ex cl us iv e br ea st fe ed in g fo r t he fi rs t s ix m on th s • C on tin ue d br ea st fe ed in g fo r t w o ye ar s or m or e • Sa fe , a pp ro pr ia te a nd a de qu at e co m pl em en ta ry fo od s be gi nn in g at si x m on th s • Fr eq ue nc y of c om pl em en ta ry fe ed in g: a t l ea st tw ic e pe r d ay fo r 6 -8 -m on th -o ld s; a t l ea st th re e tim es p er d ay fo r 9 -1 1 m on th o ld s It is a ls o re co m m en de d th at b re as tfe ed in g sh ou ld b e in iti at ed w ith in o ne h ou r o f b ir th . Th e in di ca to rs o f r ec om m en de d ch ild fe ed in g pr ac tic es a re a s fo llo w s: • Ex cl us iv e br ea st fe ed in g ra te (< 6 m on th s & < 4 m on th s) 45 • Ti m el y co m pl em en ta ry fe ed in g ra te (6 -9 m on th s) • C on tin ue d br ea st fe ed in g ra te (1 2- 15 & 2 0- 23 m on th s) • Ti m el y in iti at io n of b re as tfe ed in g (w ith in 1 h ou r o f b ir th ) • Fr eq ue nc y of c om pl em en ta ry fe ed in g (6 -1 1 m on th s) • A de qu at el y fe d in fa nt s (0 -1 1 m on th s) Ta bl e N U .2 p re se nt s th e pr op or tio n of w om en w ho b eg an b re as tfe ed in g th ei r n ew bo rn s w ith in th e ho ur fo llo w in g bi rt h an d w om en w ho b eg an br ea st fe ed in g w ith in th e da y fo llo w in g th e bi rt h (th is in cl ud es th os e w ho b eg an b re as tfe ed in g w ith in th e ho ur ). M or e th an o ne th ir d of w om en 35 .3 % ) be ga n br ea st fe ed in g le ss t ha n on e ho ur a fte r th e bi rt h an d 81 .0 % l es s th an o ne d ay a fte r th e bi rt h. Br ea st fe ed in g w ith in t he h ou r fo llo w in g bi rt h is m or e fr eq ue nt in th e D is tr ic t o f P rí nc ip e (7 5. 5% ) a nd Á gu a G ra nd e (4 0. 6% ), in u rb an a re as (3 6. 4% ), am on g ch ild re n be tw ee n 12 a nd 2 3 m on th s (3 9. 2% ), am on g ch ild re n w ho se m ot he rs h av e a se co nd ar y le ve l or m or e of e du ca tio n (3 6. 1% ). T hi s pr ac tic e is l es s w id es pr ea d in th e D is tr ic t o f M é- zo ch i ( 25 .3 % ), in r ur al a re as (3 4. 5% ), am on g ch ild re n 6- 11 1 m on th s (2 5. 6% ), an d ch ild re n w ho se m ot he r ha s no t b ee n to s ch oo l ( 32 .5 % ). 46 Fi gu re 5 : N U 2 Pe rc en ta ge o f m ot he rs h av in g in iti at ed b re as tfe ed in g le ss th an o ne h ou r or o ne d ay a fte r gi vi ng b ir th In T ab le N U .3 , t he b re as tfe ed in g st at us is b as ed o n re po rt s by m ot he rs /c ar e- gi ve rs a bo ut in fa nt c on su m pt io n of s ol id s an d liq ui ds th e 24 h ou rs pr ec ed in g th e in te rv ie w . In fa nt s re ce iv in g no th in g ot he r th an m at er na l m ilk d ef in e ex cl us iv e br ea st fe ed in g. Th is t ab le p re se nt s ex cl us iv e 47 br ea st fe ed in g of i nf an ts d ur in g th e fir st s ix m on th s of t he ir l iv es ( ap ar t fr om t ho se 0 – 3 m on th s an d th os e ag ed 0 – 5 m on th ), as w el l as co m pl em en ta ry b re as tfe ed in g of in fa nt s 6 to 9 m on th s an d co nt in ue d br ea st fe ed in g of c hi ld re n ag ed 1 2 to 1 5 m on th s a nd fr om 2 0 to 2 3 m on th s. C lo se t o se ve n ch ild re n ou t of t en a ge d un de r th re e m on th s ar e br ea st fe d ex cl us iv el y an d 60 .4 % o f th os e un de r si x m on th s ar e ex cl us iv el y br ea st fe d. 6 0. 0% o f c hi ld re n ag ed 6 to 9 m on th s ar e br ea st fe d an d re ce iv e so lid a nd s em i-s ol id fo od s at th e sa m e tim e. 8 8% o f c hi ld re n ag ed 1 2 an d 15 m on th s co nt in ue to b e br ea st fe d w hi le o nl y 18 .0 % c on tin ue to b e br ea st fe d fr om 2 0 to 2 3 m on th s. E xc lu si ve b re as tfe ed in g is g en er al ly m or e fr eq ue nt in b oy s un de r 6 m on th s th an in g ir ls o f t he s am e ag e (6 3. 9% a ga in st 5 7. 3% ). It is a ls o m or e w id es pr ea d in u rb an a re as (6 1. 7% ag ai ns t 58 .0 % ). C hi ld re n fr om w ea lth ie r ho us eh ol ds a re m or e fr eq ue nt ly e xc lu si ve ly b re as tfe d th an o th er s (6 4. 3% , a ga in st 5 6. 5% a m on g th e po or es t). O n th e ot he r ha nd , b et w ee n 6 to 9 m on th s, g ir ls a re m or e lik el y to b e br ea st fe d at th e sa m e tim e as s ol id a nd s em i-s ol id fo od s (6 1. 3% ag ai ns t 5 8. 6% ). U rb an c hi ld re n ha ve g re at er te nd en cy to fo llo w th is p ra ct ic e th an r ur al c hi ld re n (6 8. 8% a ga in st 4 8. 0% ) d o. B re as tfe d bo ys a re re la tiv el y m or e nu m er ou s th an b re as tfe d gi rl s ag ed 1 2 to 1 5 m on th s (9 0. 0% a ga in st 8 6. 8% ). T hi s pr ac tic e is m ir ro re d in r ur al s et tin gs ( 93 .6 % ag ai ns t 8 4. 9% ). Fi gu re N U .3 p re se nt s th e de ta ile d br ea st fe ed in g st at us , b y ag e of t he c hi ld in m on th s. Ev en a t th e ea rl ie st m on th s, th e m aj or ity o f ch ild re n re ce iv e flu id s or f oo ds o th er t ha n m at er na l m ilk . A t th e en d of t he s ix m on th s, th e pe rc en ta ge o f ex cl us iv el y br ea st fe ed c hi ld re n is ap pr ox im at el y 10 p er c en t. O nl y ab ou t 1 8 pe r c en t o f c hi ld re n co nt in ue to b e br ea st fe d af te r t he ir s ec on d ye ar . 48 Fi gu re 6 : N U .3 D is tr ib ut io n (o r pe rc en ta ge ) o f c hi ld re n un de r th re e, b y fe ed in g m et ho d an d by a ge 49 Th e ad eq ua cy o f i nf an t f ee di ng in c hi ld re n le ss th an 1 2 m on th s i s pr ov id ed in T ab le N U .4 . D iff er en t c ri te ri a of a de qu at e fe ed in g ar e us ed , de pe nd in g on th e ag e of th e ch ild . F or in fa nt s a ge d 0- 5 m on th s, ex cl us iv e br ea st fe ed in g is c on si de re d as a de qu at e fe ed in g. In fa nt s ag ed 6 -8 m on th s ar e co ns id er ed to b e ad eq ua te ly fe d if th ey re ce iv e br ea st m ilk a nd c om pl em en ta ry fo od a t l ea st tw ic e a da y, w hi le in fa nt s ag ed 9 -1 1 m on th s ar e co ns id er ed to b e ad eq ua te ly fe d if th ey re ce iv e br ea st m ilk a nd e at in g co m pl em en ta ry fo od a t l ea st th re e tim es a d ay . A bo ut 6 0. 4% o f c hi ld re n fr om 0 to 5 m on th s (6 3. 9% o f b oy s an d 57 .3 % o f g ir ls ) w er e ex cl us iv el y br ea st fe d. A m on g ch ild re n fr om 6 to 8 m on th s, 49 .4 % (5 9. 3% in u rb an a re as a nd 3 2. 0% in ru ra l a re as ) r ec ei ve d m at er na l m ilk a nd c om pl em en ta ry fo od s at le as t t w ic e pe r 2 4 ho ur s. A m on g ch ild re n 9 – 11 m on th s, 3 8. 9% w er e ad eq ua te ly n ou ri sh ed b y re ce iv in g m at er na l m ilk a nd c om pl em en ta ry fo od s at le as t t hr ee ti m es p er 2 4 ho ur s. F or c hi ld re n ag ed 6 to 1 1 m on th s, 4 4. 3% (4 4. 5% in b oy s an d 44 .2 % in g ir ls ) w er e ad eq ua te ly n ou ri sh ed b y m at er na l m ilk a nd co m pl em en ta ry fo od s a t l ea st th e re co m m en de d tim es p er 2 4 ho ur s. T he p ro po rt io n ad eq ua te ly n ou ri sh ed c hi ld re n is h ig he r i n th e D is tr ic t o f Á gu a G ra nd e (6 3. 4) , i n ur ba n se tti ng s (5 6. 4% ) a nd a m on g ch ild re n w ho se m ot he rs h av e a se co nd ar y or h ig he r l ev el o f e du ca tio n (6 7. 8% ). T he pr op or tio n is lo w er in th e D is tr ic t o f C au é (2 9. 0% ) a nd in ru ra l a re as (2 8. 3% ). G lo ba lly , o nl y ha lf (5 3. 6% ) o f c hi ld re n ag ed 0 to 1 1 m on th s ha ve re ce iv ed a de qu at e no ur is hm en t. C hi ld re n fr om th e D is tr ic t o f Á gu a G ra nd e (6 6. 2% ), ur ba n ch ild re n (5 9. 3% ) a nd th os e fr om th e w ea lth ie st ho us eh ol ds (5 9. 0% ) a re th e be st n ou ri sh ed . C hi ld re n liv in g in th e D is tr ic t o f C an ta ga lo (3 8. 7% ), ru ra l c hi ld re n (4 2. 3% ) a nd th os e fr om th e w ea lth ie st a nd p oo re st (r es pe ct iv el y 50 .5 % a nd 4 7. 4% ) a re th e le as t w el l n ou ri sh ed . Sa lt io di sa tio n Io di ne D ef ic ie nc y D is or de rs (I D D ) i s th e w or ld 's le ad in g ca us e of p re ve nt ab le m en ta l r et ar da tio n an d im pa ir ed p sy ch om ot or d ev el op m en t i n yo un g ch ild re n. I n its e xt re m es f or m s, io di ne d ef ic ie nc y ca us es c re tin is m . I t al so in cr ea se s th e ri sk s of s til lb ir th a nd m is ca rr ia ge in p re gn an t w om en . I od in e de fic ie nc y is m os t c om m on ly a nd v is ib ly a ss oc ia te d w ith g oi tr e. ID D ta ke s its g re at es t t ol l i n im pa ir ed m en ta l g ro w th a nd d ev el op m en t, co nt ri bu tin g in tu rn to p oo r sc ho ol p er fo rm an ce , r ed uc ed in te lle ct ua l ab ili ty a nd im pa ir ed w or k pe rf or m an ce . T he in te rn at io na l g oa l i s to a ch ie ve s us ta in ab le e lim in at io n of io di ne d ef ic ie nc y by 2 00 5. T he in di ca to r is th e pe rc en ta ge o f h ou se ho ld s co ns um in g ad eq ua te ly io di ze d sa lt (³1 5 pa rt s pe r m ill io n) . Fo llo w in g th e N at io na l T ec hn ic al C om m is si on ’s re co m m en da tio ns o n sa lt io di sa tio n, th e N at io na l A ss em bl y vo te d in fa vo ur o f a la w fi xi ng th e am ou nt o f i od in e in s al t t o be c on su m ed b y ho us eh ol ds to 6 0 pa rt s pe r m ill io n (p m ) o r m or e. T hi s la w c on fir m s th e re su lts o f a s tu dy in di ca tin g th at g oi tr e ri sk w as p ar tic ul ar ly h ig h am on gs t t he p op ul at io n, a nd th at o nl y su ch a m ea su re w ou ld h el p in lo w er in g th is ri sk fo r t he p op ul at io n, le ad in g to a n io di ne c on te nt a da pt ed to th e co un tr y’ s ne ed s. 50 In S ão T om é e Pr ín ci pe , t he g ov er nm en t, w ith U N IC EF ’s te ch ni ca l a ss is ta nc e, h as p ro m ul ga te d a la w s tip ul at in g th e sa lt pr od uc ed , i m po rt ed an d so ld i n th e co un tr y m us t be io di se d. C us to m s pr oc ed ur es h av e be en e st ab lis he d to a llo w t he v er ifi ca tio n of im po rt ed s al t is u p to t he st an da rd s as d ef in ed b y la w . If s al t is g en er al ly io di se d, t he a m ou nt o f io di ne is n ot s uf fic ie nt ly h ig h to c om pe ns at e th e le ve l o f de fic ie nc y am on gs t t he S ao to m ea n po pu la tio n. C oo ki ng s al t w as t es te d in 8 3. 6% o f ho us eh ol ds t o de te rm in e th ei r io di ne c on te nt b y ut ili si ng s al t te st in g ki ts e va lu at in g th e pr es en ce o f po ta ss iu m io da te . Ta bl e N U .5 in di ca te s th at in a s m al l p ro po rt io n of h ou se ho ld s (1 5. 1% ), th er e w as n o sa lt. I n 36 .6 % o f h ou se ho ld s, th e te st ed sa lt co nt ai ne d 15 p pm o r m or e of io di ne . Th e us e of io di se d sa lt is le ss w id es pr ea d am on g ho us eh ol ds in th e D is tr ic t o f C au é (1 6. 2% ) a nd m or e w id es pr ea d in th at o f P rí nc ip e (6 0. 4% ). I n ur ba n se tti ng s ne ar ly fo ur h ou se ho ld s ou t o f t en (3 9. 7% ) h ad a va ila bl e en ou gh io di se d sa lt an d in ru ra l ar ea s io di se d sa lt w as a va ila bl e in l es s th an o ne t hi rd o f ho us eh ol ds ( 32 .5 % ). A de qu at e co ns um pt io n of i od is ed s al t is a ls o un eq ua l ac co rd in g to th e le ve l o f h ou se ho ld li fe : a lit tle le ss th an h al f ( 46 .8 % ) o f w ea lth ie r ho us eh ol ds c on su m e su ffi ci en t i od is ed s al t w hi le o ne o ut o f th re e po or es t h ou se ho ld s (2 9. 5% ) h av e th is ty pe o f s al t a va ila bl e. O nl y 17 .7 % o f h ou se ho ld s co ns um e io di se d sa lt ad eq ua te ly u nd er th e te rm s of th e la w o f N ov em be r 19 96 , s til l i n ef fe ct , a nd w hi ch s tip ul at es th at th e re qu ir ed c on te nt o f i od in e fo r h ou se ho ld c on su m pt io n sh ou ld b e 60 p pm o r m or e an d co ns eq ue nt ly th e sa lt so ld in th e co un tr y m us t b e up to th is s ta nd ar d. T he u til is at io n of io di se d sa lt in h ou se ho ld s is le ss w id es pr ea d in th e D is tr ic t o f C au é (5 .4 % ) a nd m or e w id es pr ea d in th os e of P rí nc ip e (2 3. 4% ) an d Á gu a G ra nd e (2 2. 8% ). I n ur ba n ar ea s, c lo se t o on e ho us eh ol d ou t o f fiv e (1 9. 9% ) ha ve e no ug h io di se d sa lt av ai la bl e w hi le in th e ru ra l a re as , o nl y 14 .8 % o f h ou se ho ld s ow n th is ty pe o f s al t. C or re ct c on su m pt io n of io di se d sa lt is a ls o un eq ua l a cc or di ng to th e ho us eh ol d le ve l o f l ife : m or e th an o ne q ua rt er (2 6. 0% ) o f t he w ea lth ie st h ou se ho ld s co ns um e io di se d sa lt ad eq ua te ly w hi le a m on gs t t he p oo re st on ly 1 2. 3% , o r l es s th an h al f, ha ve a va ila bl e th is ty pe o f s al t. 51 Fi gu re N U. 4 P ou rc en ta ge d e m én ag es c on so m m an t d u se l c or re ct em en t i od é, S ão T om é et P rín ci pe , 2 00 6 45 ,6 33 ,7 25 ,1 16 ,2 23 ,6 32 ,0 60 ,4 39 ,7 32 ,5 36 ,6 0, 0 10 ,0 20 ,0 30 ,0 40 ,0 50 ,0 60 ,0 70 ,0 Pourcentage D is tri ct s Fi gu re 7 : N U .4 P er ce nt ag e of h ou se ho ld s c or re ct ly c on su m in g io di se d sa lt 52 V ita m in A S up pl em en ta tio n V ita m in A is e ss en tia l f or e ye h ea lth a nd p ro pe r f un ct io ni ng o f t he im m un e sy st em . I t i s fo un d in fo od s su ch a s m ilk , l iv er , e gg s, r ed o r o ra ng e fr ui ts , r ed p al m o il an d gr ee n le af y ve ge ta bl es , a lth ou gh t he a m ou nt o f V ita m in A r ea di ly a va ila bl e to t he b od y fr om t he se s ou rc es v ar ie s w id el y. In th e de ve lo pi ng a re as o f t he w or ld , w he re V ita m in A is la rg el y co ns um ed in th e fo rm o f f ru its a nd v eg et ab le s, d ai ly p er c ap ita in ta ke is o fte n in su ffi ci en t t o m ee t di et ar y re qu ir em en ts . I na de qu at e in ta ke s ar e fu rt he r co m pr om is ed b y in cr ea se d re qu ir em en ts f or t he V ita m in a s ch ild re n gr ow o r d ur in g pe ri od s of il ln es s, a s w el l a s in cr ea se d lo ss es d ur in g co m m on c hi ld ho od in fe ct io ns . A s a re su lt, V ita m in A d ef ic ie nc y is qu ite p re va le nt in th e de ve lo pi ng w or ld a nd p ar tic ul ar ly in c ou nt ri es w ith th e hi gh es t b ur de n of u nd er -5 d ea th s Th e 19 90 W or ld S um m it fo r C hi ld re n se t t he g oa l o f v ir tu al e lim in at io n of V ita m in A d ef ic ie nc y an d its c on se qu en ce s, in cl ud in g bl in dn es s, b y 20 00 . T hi s go al w as a ls o en do rs ed a t t he P ol ic y C on fe re nc e on E nd in g H id de n H un ge r in 1 99 1, th e 19 92 In te rn at io na l C on fe re nc e on N ut ri tio n, an d th e U N G en er al A ss em bl y Sp ec ia l S es si on o n C hi ld re n in 2 00 2. T he c ri tic al r ol e of V ita m in A fo r ch ild h ea lth a nd im m un e fu nc tio n al so m ak es c on tr ol o f t he d ef ic ie nc y a pr im ar y co m po ne nt o f c hi ld s ur vi va l e ffo rt s, a nd th er ef or e is c ri tic al to th e ac hi ev em en t o f t he fo ur th M D G : a tw o- th ir ds re du ct io n in u nd er -5 m or ta lit y by 2 01 5. Fo r c ou nt ri es w ith V ita m in A d ef ic ie nc y pr ob le m s, c ur re nt in te rn at io na l r ec om m en da tio ns c al l f or h ig h- do se V ita m in A s up pl em en ta tio n ev er y fo ur to s ix m on th s, ta rg et in g al l c hi ld re n be tw ee n th e ag es o f 6 -5 9 m on th s liv in g in th e af fe ct ed a re as . P ro vi di ng y ou ng c hi ld re n w ith tw o hi gh - do se V ita m in A c ap su le s a ye ar ( at s ix -m on th ly in te rv al s) is a s af e, c os t-e ffe ct iv e, e ffi ci en t st ra te gy f or e lim in at in g V ita m in A d ef ic ie nc y an d im pr ov in g ch ild s ur vi va l. G iv in g V ita m in A to n ew m ot he rs w ho a re b re as tfe ed in g he lp s pr ot ec t t he ir c hi ld re n du ri ng th e fir st m on th s of li fe an d he lp s to r ep le ni sh t he m ot he r's s to re s of V ita m in A , w hi ch a re d ep le te d du ri ng p re gn an cy a nd la ct at io n. F or c ou nt ri es w ith V ita m in A su pp le m en ta tio n pr og ra m m es , t he d ef in iti on o f t he in di ca to r i s th e pe rc en ta ge o f c hi ld re n 6- 59 m on th s of a ge re ce iv in g at le as t o ne h ig h do se o f V ita m in A s up pl em en t i n th e la st si x m on th s. In 1 99 2, s tu di es o n m ic ro nu tr ie nt d ef ic ie nc ie s, su ch a s V ita m in A , i nd ic at ed th at th e re tin ol ra te in th e un de r fiv es w as v er y w ea k (le ss th an 1 00 m cg /l ). T hu s, U N IC EF a nd th e M in is tr y of H ea lth im pl em en te d th e « V ita m in A C ap su le P ro gr am m e » de st in ed to p os t-p ar tu m m ot he rs a nd ch ild re n ag ed 6 to 5 9 m on th s. Ba se d on U N IC EF /W H O d ir ec tiv es , t he S ão T om é e Pr ín ci pe M in is tr y of H ea lth r ec om m en ds th at c hi ld re n ag ed 6 to 5 9 m on th s an d 29 d ay s re ce iv e a V ita m in A c ap su le e ve ry s ix m on th s, u nt il th ei r fif th b ir th da y. I n ce rt ai n pa rt s of th e co un tr y, th e V ita m in A c ap su le s ar e as so ci at ed w ith v ac ci na tio n se rv ic es a nd a re g iv en w he n th e ch ild c om es i nt o co nt ac t w ith t he se s er vi ce s af te r re ac hi ng 6 m on th s. It is e qu al ly 53 re co m m en de d th at th ei r m ot he rs ta ke V ita m in A s up pl em en ta tio n ei gh t w ee ks p ri or to la bo ur g iv en th e in cr ea se in V ita m in A n ee ds d ur in g pr eg na nc y an d br ea st fe ed in g. D ur in g th e si x m on th s pr ec ed in g M IC S3 , 3 3. 4% o f c hi ld re n ag ed 6 – 5 9 m on th s re ce iv ed a h ig h do se o f V ita m in A s up pl em en ts d ur in g th e la st si x m on th s w hi le 2 7. 0% a t s om e tim e or a no th er p ri or to th e la st s ix m on th s. V ita m in A s up pl em en ta tio n is s lig ht ly m or e w id es pr ea d in u rb an se tti ng s (3 6. 5% th an in ru ra l a re as (3 2. 0% ), an d m or e am on gs t g ir ls (3 4. 5% ) t ha n bo ys (3 2. 0% ) a re . Th e di ff er en ce s be tw ee n di st ri ct s ar e gr ea te r : 63 .4 % in P rí nc ip e an d on ly 2 5. 4% in Á gu a G ra nd e an d 27 .5 % in C an ta ga lo . V ita m in A s up pl em en ta tio n lo w er s co ns id er ab ly w ith th e ag e of ch ild re n, w ith th e yo un ge st r ep re se nt in g gr ea te r nu m be rs : 43 .8 % r es pe ct iv el y fo r th os e ag ed 6 – 1 1 m on th s an d 12 – 2 3 m on th s ag ai ns t 3 4. 2% fo r th os e ag ed 2 4 -- 35 m on th s an d 20 .2 % f or t ho se a ge d 48 – 5 9 m on th s. T he m ot he r’s o r th e ca re ta ke r’s l ev el o f in st ru ct io n in flu en ce s po si tiv el y su pp le m en ta tio n of V ita m in A (3 6. 8% w he n th e m ot he r h as a s ec on da ry o r h ig he r l ev el o f e du ca tio n ag ai ns t o nl y 20 .9 % if s he h as n ot be en to s ch oo l) w hi le th e le ve l o f h ou se ho ld li fe h as a c on tr ar y ef fe ct (3 6. 0% a m on gs t t he p oo re st a ga in st 3 0. 0% a m on gs t t he w ea lth ie r) . Po st -p ar tu m V ita m in A s up pl em en ta tio n of m ot he rs s ee m s m or e w id es pr ea d th an fo r ch ild re n. T ab le N U .7 in di ca te s th at m or e th an s ix o ut o f te n (6 3. 1% ) o f m ot he rs w ho h av e gi ve n bi rt h du ri ng th e tw o ye ar s pr ec ed in g M IC S re ce iv ed V ita m in A s up pl em en t e ig ht w ee ks b ef or e th e bi rt h of th ei r c hi ld . Th is p er ce nt ag e is s lig ht ly h ig he r i n ru ra l w om en (6 5. 0% ) t ha n in u rb an w om en (6 1. 8% ). T he m os t f av ou re d di st ri ct s ar e th os e of Pr ín ci pe ( 84 .2 % ) an d Le m bá ( 71 .1 % ) w hi le t he D is tr ic t of C an ta ga lo i s th e le as t (5 5. 8% o f m ot he rs ). V ita m in A s up pl em en ta tio n co ve ra ge in cr ea se s w ith th e le ve l o f e du ca tio n of th e m ot he r (5 7. 9% fo r th os e w ho h av e no t g on e to s ch oo l a nd 6 4. 7% fo r th os e w ith a s ec on da ry le ve l o r hi gh er o f e du ca tio n) a nd th e le ve l o f h ou se ho ld li fe (6 0. 7% o f m ot he rs li vi ng in th e po or es t h ou se ho ld s an d 72 .9 % o f t ho se in th e w ea lth ie st ). Lo w b irt h w eig ht W ei gh t a t b ir th is a g oo d in di ca to r no t o nl y of a m ot he r's h ea lth a nd n ut ri tio na l s ta tu s bu t a ls o of th e ne w bo rn 's ch an ce s of s ur vi va l, gr ow th , lo ng -te rm h ea lth a nd p sy ch os oc ia l d ev el op m en t. Lo w b ir th w ei gh t (le ss t ha n 2, 50 0 gr am s) c ar ri es a r an ge o f gr av e he al th r is ks f or c hi ld re n. Ba bi es w ho w er e un de rn ou ri sh ed in th e w om b fa ce a n in cr ea se d ri sk o f d yi ng d ur in g th ei r e ar ly m on th s an d ye ar s. T ho se w ho s ur vi ve h av e an im pa ir ed im m un e fu nc tio n an d in cr ea se d ri sk o f d is ea se ; t he y ar e lik el y to r em ai n un de rn ou ri sh ed , w ith r ed uc ed m us cl e st re ng th , t hr ou gh ou t th ei r liv es , an d su ffe r a hi gh er i nc id en ce o f di ab et es a nd h ea rt d is ea se i n la te r lif e. C hi ld re n bo rn u nd er w ei gh t al so t en d to h av e a lo w er in te lli ge nc e qu ot ie nt (I Q ) a nd c og ni tiv e di sa bi lit ie s, a ffe ct in g th ei r p er fo rm an ce in s ch oo l a nd th ei r j ob o pp or tu ni tie s as a du lts . In th e de ve lo pi ng w or ld , l ow b ir th w ei gh t s te m s pr im ar ily fr om th e m ot he r's p oo r he al th a nd n ut ri tio n. T hr ee fa ct or s ha ve th e m os t i m pa ct : th e m ot he r's p oo r nu tr iti on al s ta tu s be fo re c on ce pt io n, s ho rt s ta tu re (d ue m os tly to u nd er -n ut ri tio n an d in fe ct io ns d ur in g he r ch ild ho od ) a nd po or n ut ri tio n du ri ng p re gn an cy . In ad eq ua te w ei gh t g ai n du ri ng p re gn an cy is p ar tic ul ar ly im po rt an t, si nc e it ac co un ts fo r a la rg e pr op or tio n 54 of f oe ta l gr ow th r et ar da tio n. M or eo ve r, di se as es s uc h as d ia rr ho ea a nd m al ar ia , w hi ch a re c om m on i n m an y de ve lo pi ng c ou nt ri es , ca n si gn ifi ca nt ly im pa ir fo et al g ro w th if th e m ot he r b ec om es in fe ct ed w hi le p re gn an t. In t he i nd us tr ia liz ed w or ld , ci ga re tte s m ok in g du ri ng p re gn an cy i s th e le ad in g ca us e of l ow b ir th w ei gh t. In d ev el op ed a nd d ev el op in g co un tr ie s al ik e, te en ag er s w ho g iv e bi rt h w he n th ei r o w n bo di es h av e ye t t o fin is h gr ow in g ru n th e ri sk o f b ea ri ng u nd er w ei gh t b ab ie s. O ne o f t he m aj or c ha lle ng es is in m ea su ri ng th e in ci de nc e of lo w b ir th w ei gh t i s th e fa ct th at m or e th an h al f o f i nf an ts in th e de ve lo pi ng w or ld ar e no t w ei gh ed . I n th e pa st , m os t e st im at es o f l ow b ir th w ei gh t f or d ev el op in g co un tr ie s w er e ba se d on d at a co m pi le d fr om h ea lth fa ci lit ie s. H ow ev er , t he se e st im at es a re b ia se d fo r m os t d ev el op in g co un tr ie s be ca us e th e m aj or ity o f n ew bo rn s ar e no t d el iv er ed in fa ci lit ie s, a nd th os e w ho a re , r ep re se nt o nl y a sm al l s am pl e of a ll bi rt hs . Si nc e m an y in fa nt s ar e no t w ei gh ed a t b ir th , t he w ei gh ts o f t ho se w ho a re w ei gh ed m ay b ia s th e sa m pl e of a ll bi rt hs . T he re po rt ed b ir th w ei gh ts us ua lly c an no t b e us ed to e st im at e th e pr ev al en ce o f l ow b ir th w ei gh t a m on g al l c hi ld re n. T he re fo re , t he p er ce nt ag e of b ir th s w ei gh in g be lo w 2, 50 0 gr am s is e st im at ed fr om tw o ite m s in th e qu es tio nn ai re : t he m ot he r's a ss es sm en t o f t he c hi ld 's si ze a t b ir th (i .e . v er y sm al l, sm al le r th an av er ag e, a ve ra ge , l ar ge r th an a ve ra ge , v er y la rg e) a nd th e m ot he r's r ec al l o f t he c hi ld 's w ei gh t o r th e w ei gh t a s re co rd ed o n a he al th c ar d if th e ch ild w as w ei gh ed a t b ir th .6 Ta bl e N U .8 in di ca te s th at , a lto ge th er , 8 2. 4% o f ne w bo rn s w er e w ei gh ed a t bi rt h an d 7. 8% w ei gh ed le ss t ha n 25 00 g r. at b ir th . Th er e is n ot im po rt an t va ri at io n w ith r eg ar d to lo w b ir th w ei gh t ac co rd in g to s oc ia l c at eg or ie s, es pe ci al ly b et w ee n ur ba n an d ru ra l s et tin gs ( re sp ec tiv el y 8. 5% a nd 6 .9 % ). T he m os t i m po rt an t v ar ia tio n is o bs er ve d be tw ee n th e di st ri ct s an d th e w ea lth q ui nt ile s : f ro m 6 .2 % in th e D is tr ic t o f P rí nc ip e, th e pe rc en ta ge o f lo w b ir th w ei gh t ri se s to 9 .0 / in t ha t of Á gu a G ra nd e. Th e di sp ar ity i s th e sa m e be tw ee n ch ild re n fr om t he w ea lth ie r ho us eh ol ds to th e po or es t o ne s. L ow b ir th w ei gh t i s in va ri ab le w he th er th e m ot he r h as b ee n to s ch oo l o r n ot . 6 Fo r a d et ai le d de sc rip tio n of th is m et ho do lo gy , s ee B oe rm a, W ei ns te in , R ut st ei n an d So m m er fe lt, 1 99 6. 55 Fi gu re N U .5 P ou rc en ta ge d e no ur ris so ns p es an t m oi ns de 2 50 0 G ra m m es á la n ai ss an ce ,S ão T om é et Pr ín ci pe , 2 00 6 9 7 8 8 8 8 6 8 0, 0 1, 0 2, 0 3, 0 4, 0 5, 0 6, 0 7, 0 8, 0 9, 0 10 ,0 Ag ua -G ran de Mé -zó ch i C an tag alo Ca ué Le mb á Lo ba ta Pr inc ipe To tal Pourcentage D is tri ct s Fi gu re : N U .5 P er ce nt ag e of n ew bo rn s w ei gh in g le ss th an 2 50 0 gr . a t b ir th 56 V I. H ea lth o f t he c hi ld Im m un iz at io n M D G 4 a im s to r ed uc e ch ild m or ta lit y by t w o th ir ds b et w ee n 19 90 a nd 2 01 5. I m m un iz at io n pl ay s a ke y pa rt in t hi s go al . I m m un iz at io n ha s sa ve d th e liv es o f m ill io ns o f ch ild re n in t he t hr ee d ec ad es s in ce t he l au nc h of t he E xp an de d Pr og ra m m e on I m m un iz at io n (E PI ) in 1 97 9. W or ld w id e, th er e ar e st ill 2 7 m ill io n ch ild re n ov er lo ok ed b y ro ut in e im m un iz at io n an d, a s a re su lt, v ac ci ne -p re ve nt ab le d is ea se s ca us e m or e th an tw o m ill io n de at hs e ve ry y ea r. A W FF C g oa l i s to e ns ur e fu ll im m un iz at io n of c hi ld re n un de r on e ye ar o f a ge a t 9 0 pe r ce nt n at io na lly , w ith a t l ea st 8 0 pe rc en t c ov er ag e in ev er y di st ri ct o r e qu iv al en t a dm in is tr at iv e un it. Sã o To m é e Pr ín ci pe , l ik e al l o th er W H O m em be r c ou nt ri es , s ub sc ri be s to g lo ba l i ni tia tiv es s uc h as e ra di ca tio n of p ol io , e lim in at io n of n eo -n at al te ta nu s an d m ea sl es . Th us , s in ce 1 97 9, th e co un tr y ha s in iti at ed a n en la rg ed v ac ci na tio n pr og ra m m e (E V P) ta rg et in g ch ild re n un de r on e an d w om en in r ep ro du ct iv e ag e. T he s tr at eg ie s an d ac tiv iti es d ev el op ed g lo ba lly b y th is p ro gr am m e ha ve b ee n ap pl ie d, w ith r em ar ka bl e re su lts a t th e re gi on al le ve l. A cc or di ng to th e U N IC EF W H O g ui de lin es , c hi ld re n sh ou ld re ce iv e a BC G v ac ci na tio n to p ro te ct th em a ga in st tu be rc ul os is , t hr ee d os es o f D PT to p ro te ct t he m a ga in st d ip ht he ri a, p er tu ss is a nd t et an us , t hr ee d os es o f po lio v ac ci ne , a nd a m ea sl es v ac ci na tio n by t he a ge o f 12 m on th s. M ot he rs w er e as ke d to p ro vi de v ac ci na tio n ca rd s fo r th e un de r- fiv es . In te rv ie w er s co pi ed v ac ci na tio n in fo rm at io n fr om t he c ar ds o n to t he M IC S qu es tio nn ai re . W ith in t he E V P fr am ew or k in S ão T om é e Pr ín ci pe , a v ac ci na tio n ca le nd ar f or c hi ld re n le ss t ha n on e ye ar h as b ee n es ta bl is he d. Th us , f ro m th ei r bi rt h, t he c hi ld m us t re ce iv e BC G a nd p ol io v ac ci ne s. Th e fir st D PT a nd p ol io d os es a re a dm in is te re d du ri ng t he f ir st s ix w ee ks in t he in fa nt ’s li fe . Th e se co nd d os e D PT 2 an d Po lio 2) is ta ke n af te r t he 1 0t h w ee k an d th e th ir d do se (D PT 3 an d Po lio 3) a t t he 1 4t h w ee k. T he m ea sl es va cc in e is g iv en t o th e ch ild n in e m on th s af te r bi rt h. To s tr en gt he n th e ch ild ’s p ro te ct io n ag ai ns t po lio a nd D PT , t he E V P re co m m en ds t he ad m in is tr at io n of a n ew d os e on e ye ar a fte r t he th ir d do se . Ta bl e C H .1 in di ca te s th at , a lto ge th er , 7 9. 0% o f c hi ld re n ha ve a h ea lth c ar d. I n lie u of th e he al th c ar d, th e in te rv ie w er r eq ue st ed th e m ot he r to re ca ll w he th er e ac h va cc in at io n w as g iv en t o he r ch ild o r no t. W ith r eg ar d to D PT a nd p ol io , t he m ot he rs w er e re qu es te d to p ro vi de t he nu m be r o f t im es th e ch ild re ce iv ed th em . Th is ta bl e, w hi ch a ls o in di ca te s th e pe rc en ta ge o f c hi ld re n ha vi ng r ec ei ve d ea ch v ac ci na tio n, c hi ld re n 57 ag ed 1 2 to 2 3 m on th s co ns tit ut e th e de no m in at or s o th at o nl y th os e ch ild re n w ith s uf fic ie nt a ge t o be c om pl et el y va cc in at ed a re t ak en i nt o ac co un t. In th e up pe r pa rt o f t he ta bl e, a ll ch ild re n w ho w er e va cc in at ed a t o ne ti m e or a no th er p ri or to th e su rv ey a re r eg is te re d ac co rd in g to th ei r va cc in at io n ca rd o r in fo rm at io n pr ov id ed b y th ei r m ot he r. In th e lo w er p ar t o nl y th os e ch ild re n va cc in at ed b ef or e th ei r fir st b ir th da y ar e in cl ud ed , a s re co m m en de d. F or c hi ld re n w ith ou t v ac ci na tio n ca rd s, th e pr op or tio n of v ac ci na tio ns g iv en b ef or e th e fir st b ir th da y is s up po se d to b e th e sa m e as fo r t ho se c hi ld re n w ith a v ac ci na tio n ca rd . A bo ut 8 .1 % o f c hi ld re n ag ed 1 2 to 2 3 m on th s w er e gi ve n th e BC G v ac ci ne a t t he a ge o f 1 2 m on th s an d th ei r f ir st D PT d os e w as a dm in is te re d at th e ra te o f 9 7. 9% . Fo r th e fo llo w in g D PT d os es , t he p er ce nt ag e is lo w er : 9 7. 0% fo r th e se co nd d os e an d 91 .4 % fo r th e (F ig ur e N U .4 ). E qu al ly , 97 .4 % o f c hi ld re n w er e gi ve n po lio 0 a t t he a ge o f 1 2 m on th s al th ou gh th is p er ce nt ag e fa lls g ra du al ly to 8 7. 4% fo r P ol io 3 . Th e ra te o f c ov er ag e ag ai ns t m ea sl es a t t he a ge o f 1 2 m on th s is e st ab lis he d at 8 3. 4% , w hi ch is lo w er th an fo r o th er v ac ci ne s. G lo ba lly , m or e th an th re e ch ild re n ag ed 12 – 23 m on th s ou t o f t en (7 6. 0% ) w er e gi ve n al l t he re co m m en de d va cc in es b y th ei r f ir st b ir th da y. 58 Fi gu re 8 : C H .1 P er ce nt ag e of c hi ld re n ag ed 1 2- 23 m on th s h av in g re ce iv ed r ec om m en de d va cc in at io ns b ef or e th ei r 12 th m on th In S ão T om é e Pr ín ci pe th e va cc in at io n fr am ew or k ca le nd ar r ec om m en ds th re e do se s of H ep at iti s B an d on e ye llo w fe ve r va cc in at io n, b ot h of w hi ch w er e in tr od uc ed in 2 00 3. H ep at iti s B1 is g iv en a t th e si xt h w ee k of a ge , H ep at iti s B2 o ne m on th a fte rw ar ds ( at t he t en th w ee k) a nd H ep at iti s B 3 by th e 14 th w ee k. T he y el lo w fe ve r v ac ci ne is g iv en to th e ch ild n in e m on th s af te r b ir th . 59 Ta bl e C H .1 c in di ca te s th at H ep at iti s B va cc in e co ve ra ge i s at 8 7. 6% f or t he f ir st d os e, 8 2. 9% f or t he t hi rd d os e, w hi le y el lo w f ev er v ac ci ne co ve ra ge is e st im at ed a t 7 6. 9% . Ta bl es C H .2 a nd C H .2 c pr es en t t he r at es o f v ac ci ne c ov er ag e fo r ch ild re n be tw ee n 12 a nd 2 3 m on th s, a cc or di ng to c on te xt c ha ra ct er is tic s. T he nu m be rs in di ca te th e pe rc en ta ge o f c hi ld re n w ho w er e va cc in at ed a t o ne m om en t o r an ot he r be fo re th e su rv ey a nd a re b as ed o n in fo rm at io n dr aw n fr om th e he al th c ar ds a nd fr om in fo rm at io n pr ov id ed b y th e m ot he rs /c ar eg iv er s. V ac ci ne c ov er ag e fo r B C G is v er y st ro ng w ha te ve r t he ca te go ry u nd er c on si de ra tio n : t he lo w es t r at e of c ov er ag e is fo un d am on g ch ild re n fr om th e w ea lth ie r ho us eh ol ds (9 3. 5% ) a nd th os e fr om th e D is tr ic t o f L ob at a (9 5. 3% ) w hi le it is a s hi gh a s 10 0% in th e D is tr ic ts o f P rí nc ip e, C an ta ga lo a nd M é- Zo ch i, am on g th e po or a nd in r ur al a re as . W ith a f ew r ar e ex ce pt io ns , t hi s te nd en cy is n ea rl y th e sa m e fo r th e ot he r va cc in es . C on si de ri ng a ll va cc in at io ns , b oy s ar e be tte r pr ot ec te d : 84 .3 % o f a ll bo ys w er e gi ve n th e re co m m en de d va cc in es , a ga in st 7 5. 0% fo r gi rl s. G lo ba lly , t he D is tr ic ts o f M é- zo ch i ( 91 .1 % ), C au é (8 6. 4% ) a nd Pr ín ci pe (8 6. 3% ) h av e th e be st c ov er ag e, w hi le th os e of L ob at a (6 6. 2% ) a nd L em bá (7 3. 7% ) h av e re la tiv el y po or c ov er ag e. I n th e sa m e m an ne r, ru ra l c hi ld re n ha ve a b et te r im m un iz at io n ra te th an u rb an c hi ld re n (8 3. 0% a ga in st 7 7. 0% ). T he re is a ls o a st ro ng p os iti ve c or re la tio n be tw ee n th e m ot he r’ s le ve l o f e du ca tio n an d va cc in at io n co ve ra ge fo r ch ild re n : t he r at e of g lo ba l c ov er ag e ri se s fr om 6 1. 7% in c as es w he re th e m ot he r ha s no t be en to s ch oo l, to 7 9. 9% w he n sh e ha s be en to p ri m ar y sc ho ol , t o 84 .7 % w he n th e m ot he r ha s a le ve l o f se co nd ar y or h ig he r le ve l o f ed uc at io n. T he le ve l o f h ou se ho ld li fe s ee m s to h av e a po si tiv e ef fe ct o n va cc in at io n co ve ra ge , r is in g fr om 7 9. 6% fo r ch ild re n fr om th e po or es t ho us eh ol ds to 8 5. 1% a m on g th e w ea lth ie st h ou se ho ld s. ~ Te ta nu s t ox oi d O ne o f t he M D G s co ns is ts in r ed uc in g by th re e qu ar te rs th e ra te o f m at er na l m or ta lit y, w ith a s tr at eg y de si gn ed to e lim in at e m at er na l t et an us . A no th er o bj ec tiv e is th e re du ct io n of n eo -n at al m or ta lit y to n ot m or e th an o ne c as e pe r 10 00 li ve b ir th s in e ac h di st ri ct . A W FF C o bj ec tiv e is to el im in at e m at er na l l an d ne o- na ta l t et an us b y 20 15 . Pr ev en tio n of m at er na l an d ne o- na ta l te ta nu s co ns is ts i n en su ri ng t ha t al l pr eg na nt w om en r ec ei ve a t le as t tw o do se s of t et an us t ox oi d. N ev er th el es s, if w om en h av e no t b e gi ve n tw o do se s o f t hi s va cc in e du ri ng th ei r p re gn an cy , t he y an d th ei r n ew bo rn a re c on si de re d as p ro te ct ed if th e fo llo w in g co nd iti on s ar e pr es en t : • Th ey h av e re ce iv ed a t l ea st tw o do se s of te ta nu s to xo id , t ha t l as t d ur in g th e pr ec ed in g th re e ye ar s • Th ey h av e re ce iv ed a t l ea st th re e do se s of te ta nu s to xo id , t he la st d ur in g th e pr ec ed in g fiv e ye ar s • Th ey h av e re ce iv ed a t l ea st fo ur d os es , t he la st d ur in g th e pr ec ed in g te n ye ar s • Th ey h av e re ce iv ed a t l ea st fi ve d os es , g iv in g th em li fe lo ng p ro te ct io n 60 Ta bl e C H .3 p re se nt s th e st at us o f p ro te ct io n ag ai ns t t et an us in w om en w ith a li ve b ir th d ur in g th e la st tw el ve m on th s. F ig ur e C H .2 in di ca te s th e pr ot ec tio n st at us o f w om en in te rm s of n eo -n at al te ta nu s ac co rd in g to c on te xt ua l c ha ra ct er is tic s. C lo se to tw o w om en o ut o f t hr ee (6 5. 7% ) h av e re ce iv ed a t l ea st 2 d os es o f t et an us to xo id d ur in g th ei r p re gn an cy , a nd c lo se to o ne w om an o ut o f fiv e (1 9. 7% ) w er e gi ve n at le as t tw o do se s du ri ng t he la st t hr ee y ea rs . Pr ot ec tio n ag ai ns t ne o- na ta l t et an us is b et te r in u rb an a re as : cl os e to se ve n ur ba n w om en o ut o f t en w er e gi ve n tw o do se s of te ta nu s to xo id a ga in st s ix r ur al w om en . A t t he d is tr ic t l ev el , t he p ro po rt io n of w om en ha vi ng r ec ei ve d at le as t t w o do se s du ri ng th ei r pr eg na nc y is h ig he r in L em bá (7 3. 6% ) a nd lo w er in P rí nc ip e (o nl y 47 .3 % ). A lto ge th er , 8 7. 3% o f w om en a re p ro te ct ed a ga in st n eo -n at al te ta nu s, w ith li gh t v ar ia tio ns a cc or di ng to c on te xt ua l c at eg or ie s. T he p ro po rt io n of w om en p ro te ct ed is st ro ng er in t he D is tr ic t of M é- zo ch i ( 89 .4 % ) an d lo w er in t ha t of C au é (8 0. 2% ). T he d is pa ri ty b et w ee n ur ba n an d ru ra l a re as is n eg lig ib le ( 1 pe rc en ta ge p oi nt ). O n th e ot he r ha nd , t he a ge o f th e w om en s ee m s to n eg at iv el y in flu en ce a ga in st n eo -n at al c ov er ag e : t he p ro po rt io n of va cc in at ed w om en d ec re as es fr om 9 2. 3% fo r w om en a ge d 15 to 1 9, to 8 3. 8% fo r t ho se a ge d be tw ee n 30 a nd 3 4, d ow n to 7 6. 4% fo r t ho se a ge d 45 to 4 9. T he le ve l o f e du ca tio n is a ls o in di ca tiv e : t he c ov er ag e ra te in cr ea se s fr om 8 0. 9% fo r w om en w ho h av e ne ve r be en to s ch oo l, to 8 5. 7% fo r th os e w ith a p ri m ar y le ve l e du ca tio n, a nd a ga in , t o 95 .0 % fo r th os e w om en w ith a s ec on da ry o r hi gh er le ve l o f e du ca tio n. T he im pa ct o f t he le ve l o f h ou se ho ld li fe re m ai ns a m bi gu ou s. 61 Fi gu re C H .2 P ou rc en ta ge d e fe m m es a ya nt a cc ou ch é d' un e nf an t v iv an t a u co ur s de s 12 d er ni èr s m oi s qu i so nt p ro té gé es c on tr e le té ta no s né on at al ,S ão T om é et P rí nc ip e, 2 00 6 87 ,8 89 ,4 81 ,9 80 ,2 88 ,4 88 ,3 87 ,8 86 ,9 87 ,9 80 ,9 85 ,7 95 ,0 87 ,3 0, 0 20 ,0 40 ,0 60 ,0 80 ,0 10 0, 0 D is tr ic ts A gu a- G ra nd e M é- zó ch i C an ta ga lo C au é Le m bá Lo ba ta Pr in ci pe M ilie u de R és id en ce U rb ai n R ur al N iv ea u d' ét ud e de s m ér es S an s é du ca tio n Pr im ai re S ec on da ire + To ta l Po ur ce nt ag e Fi gu re 9 : C H .2 P er ce nt ag e of w om en h av in g gi ve n bi rt h to a li ve c hi ld d ur in g th e pr ec ee di ng 1 2 m on th s p ro te ct ed fr om n eo -n at al te ta nu s 62 O ra l R eh yd ra tio n Tr ea tm en t D ia rr ho ea i s th e se co nd l ea di ng c au se o f de at h am on g un de r- 5 ch ild re n w or ld w id e. M os t di ar rh oe a- re la te d de at hs i n ch ild re n ar e du e to de hy dr at io n fr om lo ss o f l ar ge q ua nt iti es o f w at er a nd e le ct ro ly te s fr om th e bo dy in li qu id s to ol s. M an ag em en t o f di ar rh oe a - ei th er th ro ug h or al re hy dr at io n sa lts (O RS ) o r a re co m m en de d ho m e flu id (R H F) - ca n pr ev en t m an y of th es e de at hs . P re ve nt in g de hy dr at io n an d m al nu tr iti on by in cr ea si ng fl ui d in ta ke a nd c on tin ui ng to fe ed th e ch ild a re a ls o im po rt an t s tr at eg ie s fo r m an ag in g di ar rh oe a. Th e go al s ar e to r ed uc e by o ne -h al f d ea th s du e to d ia rr ho ea a m on g un de r- 5 ch ild re n by 2 01 0 co m pa re d to 2 00 0 (W FF C ) ( 2) a nd to r ed uc e by tw o th ir ds t he m or ta lit y ra te a m on g un de r- 5 ch ild re n by 2 01 5 co m pa re d to 1 99 0 (M D G s) . I n ad di tio n, t he W FF C c al ls f or a r ed uc tio n in t he in ci de nc e of d ia rr ho ea b y 25 p er c en t. Th e in di ca to rs a re : • Pr ev al en ce o f d ia rr ho ea • O ra l r eh yd ra tio n th er ap y • H om e m an ag em en t o f d ia rr ho ea • O R T or in cr ea se d flu id s an d co nt in ue d fe ed in g In th e M IC S qu es tio nn ai re , m ot he rs (o r ca re ta ke rs ) w er e as ke d to r ep or t w he th er th ei r ch ild h ad h ad d ia rr ho ea in th e tw o w ee ks p ri or to th e su rv ey . I f s o, th e m ot he r w as a sk ed a s er ie s of q ue st io ns a bo ut w ha t t he c hi ld h ad to d ri nk a nd e at d ur in g th e ep is od e an d w he th er th is w as m or e, o r l es s, th an th e ch ild u su al ly a te a nd d ra nk . Ta bl e C H .4 i nd ic at es t ha t 13 .1 % o f ch ild re n un de r fiv e ha d di ar rh oe a du ri ng t he t w o w ee ks p re ce di ng t he s ur ve y. Th is p re va le nc e fo r di ar rh oe a is p ar tic ul ar ly h ig h in th e D is tr ic t o f L em bá (2 3. 0% ) i n re la tio n to o th er d is tr ic ts , w hi ch v ar y be tw ee n 10 .3 % in L ob at a an d 13 .5 % in Á gu a G ra nd e. T he a ge o f t he c hi ld a ls o in flu en ce s th e le ve l o f d ia rr ho ea p re va le nc e, w hi ch in cr ea se s by o ne p oi nt d ur in g w ea ni ng : 18 .9 % fo r th os e ag ed 6 to 1 1 m on th s, a nd 2 4. 3% fo r th os e ag ed b et w ee n 12 a nd 2 3 m on th s w hi le a m on gs t c hi ld re n yo un ge r or o ld er , l es s th an 7 .0 % h ad di ar rh oe a du ri ng th e la st tw o w ee ks . Ta bl e C H .4 p re se nt s, a s w el l, th e pe rc en ta ge o f c hi ld re n re ce iv in g di ffe re nt ty pe s of r ec om m en de d flu id s du ri ng th e di ar rh oe a ep is od e. G iv en th at th ei r m ot he rs w er e ab le to c ite a ty pe o f f lu id , t he to ta l o f t he se p er ce nt ag es is n ot n ec es sa ri ly e qu al to 1 00 . A bo ut 3 1. 4% o f c hi ld re n w er e gi ve n flu id s pr ep ar ed f ro m O RT p ac ke ts ; o nl y 1. 7% w as g iv en p re -c on di tio ne d O R T flu id s, a nd 1 7. 1% w as g iv en r ec om m en de d ho m em ad e flu id s. A bo ut 4 7. 1% o f c hi ld re n w ith d ia rr ho ea w er e gi ve n on e or m or e re co m m en de d ho m e tr ea tm en ts (T ha t i s, th ey w er e tr ea te d w ith O RT o r re co m m en de d ho m em ad e flu id s) , w hi ch s ig ni fie s th at th e m aj or ity (5 2. 9% ) d id n ot r ec ei ve tr ea tm en t. G ir ls h ad m or e ch an ce o f b ei ng tr ea te d 63 th an b oy s (5 1. 3% a ga in st 4 2. 9% ). E qu al ly , r ur al c hi ld re n re ce iv e m or e tr ea tm en t t ha n ur ba n ch ild re n (5 3. 1% a ga in st 4 3. 3% ) d o. I n ad di tio n, th e yo un ge st r ec ei ve m or e tr ea tm en t th an o ld er c hi ld re n do : re sp ec tiv el y 58 .0 % o f ch ild re n ag ed 0 – 6 m on th s an d th os e ag ed 6 t o 11 m on th s re ce iv ed O RT tr ea tm en t w hi le th e pr op or tio n va ri es b et w ee n 41 .0 % a nd 4 8. 0% a m on gs t o ld er c hi ld re n. T he r el at io n be tw ee n O R T on th e on e ha nd , a nd th e le ve l o f t he m ot he r’s e du ca tio n an d th e le ve l o f h ou se ho ld li fe o n th e ot he r re m ai ns a m bi gu ou s, e ve n if ch ild re n fr om th e m or e ed uc at ed a nd w ea lth ie r ho us eh ol ds s ee m to b e m or e fa vo ur ab le (r es pe ct iv el y, 5 8. 0% a nd 6 7. 0% ) t ha n th os e fr om th e le ss e du ca te d an d po or er ho us eh ol ds (r es pe ct iv el y 51 .3 % a nd 4 7. 0% ). Fi gu re C H .3 P ou rc en ta ge d 'e nf an ts d e 0- 59 m oi s at te in ts d e di ar rh ée d ur an t l es 2 s em ai ne s et a ya nt re çu u n tra ite m en t R VO , S ão T om é et P rín ci pe , 2 00 6 54 56 34 40 50 36 43 40 53 35 49 0, 0 10 ,0 20 ,0 30 ,0 40 ,0 50 ,0 60 ,0 Ag ua - G ra nd e C an ta ga lo Le m bá Pr in ci pe S em ed uc aç ão S ec un da rio + Pourcentage Fi gu re 1 0: C H .3 P er ce nt ag e of c hi ld re n be tw ee n 0 – 59 m on th s w ith d ia rr ho ea d ur in g th e la st tw o w ee ks w ho r ec ei ve d O R T tr ea tm en t 64 Ta bl e C H .5 in di ca te s th at c lo se to tw o th ir ds (6 1. 4% ) o f c hi ld re n un de r f iv e w ith d ia rr ho ea d ur in g th e la st tw o w ee ks h av e in cr ea se d th ei r i nt ak e of fl ui ds , w hi le 3 7. 9% h av e th e sa m e or le ss in ta ke o f f lu id s. N ea rl y 81 .0 % h av e co nt in ue d th ei r in ta ke o f f oo d, e at in g le ss , t he s am e or m or e th an u su al , w hi le fo r 18 .9 % a te c on si de ra bl y le ss th an u su al o r ha ve h ar dl y ea te n. C lo se to 6 3. 0% o f c hi ld re n re ce iv ed m or e flu id s th an u su al w hi le c on tin ui ng to e at . C lo se to o ne -h al f o f c hi ld re n w ith d ia rr ho ea d ur in g th e la st tw o w ee ks w er e at te nd ed to in th ei r h om e. Th er e ar e im po rt an t d iff er en ce s in h om e m an ag em en t o f d ia rr ho ea a cc or di ng to c on te xt ua l c ha ra ct er is tic s. In th e D is tr ic t o f M é- zo ch i, 72 .0 % o f ch ild re n re ce iv ed a n O R T or m or e flu id s th an u su al w hi le c on tin ui ng to e at , w hi le th os e in C an ta ga lo le ss th an 4 2. 0% o f c hi ld re n be ne fit ed fr om th e sa m e ty pe o f t re at m en t. T he d iff er en ce s ar e ve ry m in or b et w ee n gi rl s an d bo ys , o n th e on e ha nd , a nd b et w ee n ur ba n an d ru ra l a re as o n th e ot he r (r es pe ct iv el y 64 .1 % a ga in st 6 1. 6% , a nd 6 3. 7% a ga in st 6 1. 6% ). C hi ld re n ag ed 2 4 – 35 m on th s se em to r ec ei ve b et te r tr ea tm en t t ha n ot he rs (7 4. 5% a ga in st 5 3 to 6 8. 0% f or t he o th er s) . D iff er en ce s in h om e m an ag em en t of d ia rr ho ea a re v er y sm al l be tw ee n ru ra l an d ur ba n ar ea s (r es pe ct iv el y 50 .7 % a nd 4 8. 2% ), an d is lo w er in th e D is tr ic t o f C an ta ga lo (3 4. 4% ) a nd h ig he r in M é- zo ch i ( 56 .3 % ). H om e m an ag em en t i s lo w er fo r c hi ld re n 0 to 1 1 m on th s (2 9. 2% a ga in st m or e th an h al f a m on g ol de r c hi ld re n) . 65 Fi gu re 1 1: C H .4 P er ce nt ag e of c hi ld re n be tw ee n 0 – 59 m on th s w ith d ia rr ho ea d ur in g th e la st tw o w ee ks w ho r ec ei ve d O R T tr ea tm en t o r in cr ea se d am ou nt s o f flu id s f ol lo w ed b y fo od . 66 C ar e se ek in g an d an tib io tic tr ea tm en t o f p ne um on ia Pn eu m on ia is th e le ad in g ca us e of d ea th in c hi ld re n an d th e us e of a nt ib io tic s in u nd er -5 s w ith s us pe ct ed p ne um on ia is a k ey in te rv en tio n. A W FF C g oa l i s to re du ce b y on e- th ir d th e de at hs d ue to a cu te re sp ir at or y in fe ct io ns . C hi ld re n w ith s us pe ct ed p ne um on ia a re t ho se w ho h ad a n ill ne ss w ith a c ou gh a cc om pa ni ed b y ra pi d or d iff ic ul t br ea th in g an d w ho se sy m pt om s w er e no t d ue to a p ro bl em in th e ch es t a nd a b lo ck ed n os e. Th e in di ca to rs a re : • Pr ev al en ce o f s us pe ct ed p ne um on ia • C ar e se ek in g fo r s us pe ct ed p ne um on ia • A nt ib io tic tr ea tm en t f or s us pe ct ed p ne um on ia • K no w le dg e of th e da ng er s ig ns o f p ne um on ia Ta bl e C H .6 p re se nt s th e pr ev al en ce fo r pr es um ed p ne um on ia a nd , i f c ar e ha s be en s ou gh t o ut si de th e ho m e, th e lo ca tio n of th e ca re c en tr e. . A bo ut 4 .3 % o f c hi ld re n ag ed 0 to 5 9 m on th s w er e fo un d to h av e sy m pt om s of p ne um on ia d ur in g th e tw o w ee ks p re ce di ng th e su rv ey . Th es e ca se s of s us pe ct ed p ne um on ia a re s lig ht ly m or e fr eq ue nt a m on g ch ild re n ag ed 2 4 – 35 m on th s (6 .4 % ) an d in th e D is tr ic ts o f M é- zo ch i ( 5. 5% ) an d Le m bá ( 5. 3% ), w hi le t he y ar e re la tiv el y ra re in t he D is tr ic ts o f C an ta ga lo ( 2. 9% ) an d Pr ín ci pe (1 .5 % ) an d am on g ch ild re n 0 to 1 1 m on th s (2 .8 % ). O f t he se c hi ld re n, 7 1. 3% w er e se en a t a n ap pr op ri at e he al th fa ci lit y. R ec ou rs e to a n ap pr op ri at e he al th fa ci lit y is m or e w id es pr ea d in th e D is tr ic t o f C an ta ga lo (9 0. 1% o f c hi ld re n) , a m on g ch ild re n ag ed 0 to 2 3 m on th s (8 0. 0% ) a nd a m on g ch ild re n w ho se m ot he r ha s no t b ee n to sc ho ol ( 86 .0 % ). A m on g th e ap pr op ri at e fa ci lit ie s, pu bl ic f ac ili tie s ar e th e m os t so ug ht a fte r, w ith m or e th an h al f of c hi ld re n (2 3. 3% ) se ek in g at te nt io n in h ea lth c en tr es , 1 6. 6% in h ea lth p os ts a nd 1 0. 0% in h os pi ta ls . Re co ur se to a n ap pr op ri at e fa ci lit y va ri es a cc or di ng to th e di st ri ct : in th e D is tr ic t o f L em bá , 5 7. 1% o f c hi ld re n ha ve m or e re co ur se to h ea lth c en tr es , w hi le in th at o f C an ta ga lo , 7 0. 7% o f c hi ld re n se ek c ar e in h ea lth po st s. T he w ea lth ie r c hi ld re n al so s ee k pu bl ic h ea lth c en tr es (4 1. 9% a ga in st a n av er ag e of 2 3. 3% ). Ta bl e C H .7 p re se nt s th e ut ili sa tio n of a nt ib io tic s in th e tr ea tm en t o f p re su m ed p ne um on ia in c hi ld re n un de r f iv e, b y se x, a ge , p la ce o f r es id en ce , an d so ci o- ec on om ic fa ct or s. I n Sã o To m é e Pr ín ci pe , 5 6. 0% o f c hi ld re n un de r fiv e su ffe ri ng fr om s us pe ct ed p ne um on ia r ec ei ve d an a nt ib io tic du ri ng t he t w o w ee ks p re ce di ng t he s ur ve y. Th is p er ce nt ag e is g re at er in r ur al ( 62 .7 % ) th an in u rb an ( 50 .1 % ) ar ea s, a nd lo w er a m on g gi rl s (5 4. 7% a ga in st 5 7. 3% ). A lth ou gh im po rt an t d is pa ri tie s ar e no te d in o th er c at eg or ie s, th ei r v al ue s ar e to o lo w to re fle ct si gn ifi ca nt d iff er en ce s. C on ce rn an t l es a ut re s ca té go ri es , b ie n de s éc ar ts im po rt an ts s on t n ot és , l es e ffe ct ifs so nt tr ès fa ib le s po ur re flé te r d es d iff ér en ce s si gn ifi ca tiv es . 67 In di ca tio ns o f d an ge r s ig ns fo r p ne um on ia a re p re se nt ed in T ab le C H .7 A . It is c le ar th at th e le ve l o f t he m ot he r’s k no w le dg e on d an ge r s ig ns is an im po rt an t i nd ic at or w ith re ga rd to s ee ki ng tr ea tm en t. O ve ra ll, 3 7. 3% o f w om en a re fa m ili ar w ith tw o da ng er s ig ns fo r p ne um on ia : di ffi cu lt an d ra pi d br ea th in g. Th e m os t w id el y kn ow n id en tif ie d sy m pt om t o ta ke a c hi ld t o a he al th f ac ili ty is f ev er ( 81 .6 % o f m ot he rs ). M or e th an 44 .0 % o f m ot he rs id en tif ie d ra pi d br ea th in g an d 48 .9 % d iff ic ul t br ea th in g as d an ge r si gn s le ad in g to a n im m ed ia te t ra ns fe r of t he c hi ld t o a he al th fa ci lit y. T he p er ce nt ag e of w om en fa m ili ar w ith tw o da ng er s ig ns fo r pn eu m on ia is h ig he r in r ur al (4 7. 6% ) t ha n in u rb an (2 9. 5% ) a re as . Th e le ve l o f f am ili ar ity o f t he tw o da ng er s ig ns a ls o de pe nd s on th e re si de nt ia l d is tr ic t : t he p er ce nt ag e is th us g re at er in th e D is tr ic t o f P rí nc ip e (4 8. 4% ) a nd lo w er in th os e of L em bá (2 7. 0% ) a nd Á gu a G ra nd e (2 3. 0% ). U til isa tio n of so lid fu els M or e th an 3 b ill io n pe op le a ro un d th e w or ld r el y on s ol id fu el (b io m as s an d co al ) f or th ei r ba si c en er gy n ee ds , i nc lu di ng c oo ki ng a nd h ea tin g. C oo ki ng a nd h ea tin g w ith s ol id fu el le ad to h ig h le ve ls o f i nd oo r s m ok e, a c om pl ex m ix o f h ea lth -d am ag in g po llu ta nt s. T he m ai n pr ob le m w ith th e us e of s ol id f ue l i s pr od uc ts o f in co m pl et e co m bu st io n, in cl ud in g C O , p ol ya ro m at ic h yd ro ca rb on s, S O 2, a nd o th er t ox ic e le m en ts . U se o f so lid f ue l i nc re as es t he r is ks o f ac ut e re sp ir at or y ill ne ss , p ne um on ia , c hr on ic o bs tr uc tiv e lu ng d is ea se , c an ce r, an d po ss ib ly tu be rc ul os is , l ow bi rt h w ei gh t, ca ta ra ct s an d as th m a. T he p ri m ar y in di ca to r i s th e pr op or tio n of th e po pu la tio n us in g so lid fu el a s th e pr im ar y so ur ce o f d om es tic en er gy fo r c oo ki ng . Ta bl e C H .8 in di ca te s th at o ve ra ll, 7 5. 5% o f Sã o To m é e Pr ín ci pe h ou se ho ld s ut ili se s ol d fu el f or c oo ki ng . U til is at io n of s ol d fu el s is le as t in ur ba n ar ea s (6 5. 8% ) an d st ro ng er in r ur al a re as w he re c lo se to 9 h ou se ho ld s ou t o f 10 ( 88 .2 % ) ut ili se t hi s ty pe o f f ue l. H ou se ho ld b eh av io ur w ith re ga rd to th e ut ili sa tio n of s ol id fu el s va ri es a ls o ac co rd in g to d is tr ic t o f r es id en ce : 96 .9 % o f P rí nc ip e ho us eh ol ds , w hi le in M é- zo ch i 8 1. 1% us e so lid fu el s an d 52 .2 % in Á gu a G ra nd e. T he e ff ec ts o n th e le ve l o f h ou se ho ld li fe a nd th e le ve l o f e du ca tio n of th e he ad o f h ou se ho ld w ith re ga rd t o th e co nt in ue d ut ili sa tio n of s ol id f ue ls a re p ar tic ul ar ly im po rt an t. T he p er ce nt ag e of h ou se ho ld s ut ili si ng t he se f ue ls r an ge s fr om 93 .0 % w he n th e he ad o f t he h ou se ho ld is u ne du ca te d to 8 0. 9% w he n a pr im ar y le ve l e du ca tio n ha s be en a tta in te d, to o nl y 49 .1 % w he n th e he ad of h ou se ho ld h as h ad a m in im um o f a s ec on da ry le ve l o f e du ca tio n. E qu al ly , t hi s pe rc en ta ge r an ge s fr om n ea rl y 10 0% a m on gs t t he p oo re st , t o 94 .5 % a m on g th e po or , t o 79 .3 % a m on g th e le ss p oo r, to 6 2. 9% a m on g th e w ea lth y de cr ea si ng to 3 1. 25 A M O N G T H E W EA LT H IE ST . Th is ta bl e al so c le ar ly in di ca te s th at th e hi gh u se o f s ol id fu el s by a g re at er u se o f w oo d fo r co ok in g (c lo se to 6 7. 0% ) a nd a le ss er u se o f c ha rc oa l ( 23 .1 % ). Le ss th an 9 .0 % u til is e ch ar co al a nd le ss th an 1 .0 % h av e ac ce ss to g as a nd e le ct ri ci ty . U til is at io n of s ol id fu el c au se s po llu tio n, in v ar yi ng d eg re es , o f t he in te ri or s, g iv en th at th e co nc en tr at io n of p ol lu ta nt s va ri es a cc or di ng to th e ty pe o f f ue l u se d in th e di ffe re nt ty pe s of s to ve s. U til is at io n of c lo se d st ov es w ith c hi m ne ys re du ce s in te rn al p ol lu tio n, w hi le a n op en s to ve /f ir e 68 w ith ou t c hi m ne y or h oo d in di ca te s th at th er e is n ot p ro te ct io n ag ai ns t t he d an ge rs o f s ol id fu el s. T he ty pe s of s to ve s ut ili se d w ith s ol id fu el is pr es en te d in T ab le C H .9 . N at io na lly , a bo ut h al f o f a ll ho us eh ol ds u til is e a cl os ed s to ve w ith c hi m ne y an d th e ot he r h al f a n op en s to ve /f ir e w ith ou t c hi m ne y. T he fo rm er ar e m or e w id es pr ea d in r ur al h ou se ho ld s (5 4. 5% ), in t he d is tr ic t of C au é (7 0. 6% ) an d Le m bá ( 57 .5 % ) an d le ss f re qu en t in u rb an h ou se ho ld s (4 5. 5% ) an d in t he D is tr ic t of Á gu a G ra nd e (4 0. 5% ). D iff er en ce s ac co rd in g to t he h ou se ho ld ’s le ve l o f lif e ar e si gn ifi ca nt : t he p er ce nt ag es ra ng e fr om 3 6. 5% a m on gs t th e po or es t to 5 5. 4% a m on gs t th e le ss p oo r, to 6 4. 5% a m on g th e w ea lth y, a nd t o m or e th an 7 5. 0% a m on g th e w ea lth ie st . M al ar ia In S ão T om é e Pr ín ci pe , m al ar ia is o ne o f th e pr in ci pa l c au se s of c hi ld m or ta lit y fo r th e un de r fiv es . It co nt ri bu te s, e qu al ly , t o an ae m ia i n ch ild re n an d ca us es s ig ni fic an t ab se nc es a t sc ho ol . Pr ev en tio n m ea su re s, i n pa rt ic ul ar w ith i m pr eg na te d m os qu ito n et s, m ay s ig ni fic an tly re du ce c hi ld m or ta lit y ra te s. I n re gi on s w he re m al ar ia is e nd em ic , i nt er na tio na l r ec om m en da tio ns s ug ge st t he t re at m en t of a ny f ev er in t he ch ild a s m al ar ia a nd to im m ed ia te ly a dm in is te r a c om pl et e tr ea tm en t o f r ec om m en de d an ti- m al ar ia ls . C hi ld re n pr es en tin g sy m pt om s of s ev er e m al ar ia , su ch a s fe ve r or c on vu ls io ns , sh ou ld b e ta ke n to a h ea lth f ac ili ty . E qu al ly , ch ild re n co nv al es ci ng f ro m m al ar ia s ho ul d re ce iv e su pp le m en ta ry fl ui ds a nd fo od a nd th e yo un ge st s ho ul d co nt in ue to b e br ea st fe d. Th e qu es tio nn ai re is c om po se d of q ue st io ns o n th e av ai la bi lit y an d ut ili sa tio n of m os qu ito n et s bo th in h ou se ho ld s an d by c hi ld re n un de r fiv e as w el l a s m al ar ia tr ea tm en t a nd in te rm itt en t p ro ph yl ax is . T ab le C H .1 0 in di ca te s t ha t i n Sã o To m é e Pr ín ci pe , 4 9. 2% o f h ou se ho ld s ow n at le as t on e m os qu ito n et (5 8. 4% in u rb an s et tin gs a nd o nl y 37 .3 % in r ur al a re as ). T he r at e of m os qu ito o w ne rs hi p va ri es a cc or di ng to th e di st ri ct : tw o ho us eh ol ds o ut o f t hr ee in Á gu a G ra nd e an d le ss th an h al f i n M é- zo ch i. It in cr ea se s as w el l w ith th e ho us eh ol d’ s he ad ’s l ev el o f e du ca tio n an d th e le ve l o f h ou se ho ld li fe , r an gi ng fr om 3 1. 5% a m on g th e po or es t, to 6 9. 9% a m on g th e w ea lth ie st a nd 3 7. 3% w he n th e he ad o f t he h ou se ho ld ha s ne ve r b ee n to s ch oo l, to 6 2. 8% w he n sh e/ he h as h ad a h ig he r l ev el o r m or e. O ve ra ll, 3 6. 0% o f h ou se ho ld s ow n at le as t o ne m os qu ito n et tr ea te d w ith in se ct ic id e. D iff er en ce s be tw ee n so ci al c at eg or ie s ar e m ai nt ai ne d. T he ra te o f o w ne rs hi p of a t l ea st o ne im pr eg na te d m os qu ito n et is h ig he r in u rb an a re as (4 4. 1% ), in th e D is tr ic t o f Á gu a G ra nd e (m or e th an h al f o f ho us eh ol ds ), am on g th e m or e ed uc at ed h ea ds o f h ou se ho ld s (4 8. 4% ) a nd th e ri ch es t h ou se ho ld s (5 3. 4% ); it is lo w er in ru ra l a re as (2 5. 4% , i n th e D is tr ic t o f M é- zo ch i ( 21 .3 % , a m on g un ed uc at ed h ea ds o f h ou se ho ld s (2 0. 8% ) a nd a m on g th e po or es t h ou se ho ld s (2 1. 9% ). 69 Su rv ey r es ul ts in di ca te th at 5 2. 8% o f c hi ld re n un de r fiv e ha ve s le pt u nd er a m os qu ito n et th e ni gh t p re ce di ng th e su rv ey a nd th at 4 1. 7% h av e sl ep t u nd er a n im pr eg na te d m os qu ito n et (T ab le C H .1 1) . Th er e ar e no s ig ni fic an t d is pa ri tie s be tw ee n th e un de r f iv es , w he th er g ir ls o r bo ys , i n re la tio n to t he u se o f im pr eg na te d m os qu ito n et s. O n th e ot he r ha nd , di ffe re nc es i n ce rt ai n ot he r ca te go ri es a re s ig ni fic an t, w he th er t he m os qu ito n et s ar e tr ea te d or n ot . In th e D is tr ic t o f Á gu a G ra nd e, 6 2. 2% o f c hi ld re n ha ve s le pt u nd er a tr ea te d m os qu ito n et w hi le in th os e of M é- zo ch i a nd C an ta ga lo , r es pe ct iv el y, o nl y 25 .4 % a nd 3 0. 1% s le pt u nd er tr ea te d m os qu ito n et s. D iff er en ce s ar e al so s ig ni fic an t b et w ee n ur ba n an d ru ra l a re as ( 51 .1 % a ga in st 2 9. 2% ) an d be tw ee n ch ild re n fr om t he w ea lth ie st a nd p oo re st h ou se ho ld s (6 3. 0% a ga in st 2 9. 4% ). E qu al ly , t he yo un ge st c hi ld re n ha ve a b et te r c ha nc e of s le ep in g un de r a n im pr eg na te d m os qu ito n et (5 7. 5% a ga in st 4 1. 0% fo r t he o ld es t). Q ue st io ns o n th e pr ev al en ce a nd tr ea tm en t o f f ev er w er e as ke d fo r al l c hi ld re n un de r fiv e. A bo ut 1 8. 0% o f t he m w er e ill w ith fe ve r du ri ng th e tw o w ee ks p re ce di ng th e su rv ey (T ab le C H .1 2) . Fe ve r pr ev al en ce d ec re as es w ith a ge , t o 23 .4 % , i n ch ild re n ag ed 1 1 to 2 3 m on th s. F ev er r at es ar e sl ig ht ly h ig he r i n ch ild re n w ho se m ot he r h as h ad a t l ea st a p ri m ar y sc ho ol e du ca tio n, o r a s ec on da ry o r h ig he r l ev el o f e du ca tio n (m or e th an 18 .0 % ) th an f or t ho se w ho se m ot he r ha s ne ve r be en t o sc ho ol ( 13 .7 % ). I f di ffe re nc es i n fe ve r pr ev al en ce b et w ee n ur ba n an d ru ra l ar ea s is pr ac tic al ly z er o (1 8. 0% a nd 1 7. 0% ), th os e be tw ee n di st ri ct s ar e si gn ifi ca nt (n ea rl y on e qu ar te r of L em bá c hi ld re n an d 20 .3 % i n C au é ag ai ns t 16 .9 % in L ob at a an d on ly 1 4. 8% in C an ta ga lo ). A s w el l, ch ild re n fr om th e po or es t h ou se ho ld s ar e m or e af fe ct ed th an th os e fr om th e w ea lth ie st (1 9. 7% a ga in st 1 4. 1% ). P ar ad ox ic al ly , c hi ld re n w ho se m ot he r ha s ne ve r be en to s ch oo l a re m or e af fe ct ed th at th os e w ho se m ot he r ha s ha d a se co nd ar y ed uc at io n of m or e (1 3. 7% a ga in st 1 8. 4% ). M ot he rs w er e as ke d to m en tio n al l m ed ic at io ns a dm in is te re d to t he ir c hi ld f or t he t re at m en t of f ev er , w he th er m ed ic at io n gi ve n at h om e or pr es cr ib ed b y or g iv en in a h ea lth fa ci lit y. O n th e w ho le , d ur in g th e la st tw o w ee ks c lo se to o ne fe ve ri sh c hi ld o ut o f f ou r (2 4. 7% ) w er e tr ea te d by a n « ap pr op ri at e » an ti- m al ar ia l a nd 1 7. 0% w er e gi ve n an ti- m al ar ia ls w ith in 2 4 ho ur s af te r s ym pt om s ap pe ar ed . « A pp ro pr ia te » a nt i-m al ar ia ls a re c hl or oq ui ne , P S, a c om pl ex b as ed o n A rt em is ia , e tc . In S ão T om é e Pr ín ci pe , l es s th an 2 .0 % o f fe ve ri sh ch ild re n re ce iv ed c hl or oq ui ne a nd 1 .2 % P S/ Fa ns id ar . A bo ut 6 .4 % w er e gi ve n A rt em is ia -b as ed th er ap y. M or e th an th re e ou t o f f ou r ch ild re n w er e gi ve n ot he r m ed ic at io n, in cl ud in g an ti- py re tic s s uc h as p ar ac et am ol , a sp ir in a nd ib up ro fe n. G ir ls h av e m or e ch an ce s of re ce iv in g an a pp ro pr ia te tr ea tm en t ( 31 .0 % a ga in st 1 8. 9% ). C hi ld re n fr om th e D is tr ic ts o f C au é an d M é- zo ch i r ec ei ve be tte r t re at m en t t ha n th os e in Á gu a G ra nd e (1 8. 3% ) a nd C an ta ga lo (2 4. 8% ). T he c ha nc es o f h av in g an a pp ro pr ia te tr ea tm en t a re h ig he r i n ru ra l ar ea s (2 8. 0% ) th an in u rb an o ne s (2 2. 3% ). T he c ha nc es o f ha vi ng a n ap pr op ri at e an ti- m al ar ia l t re at m en t d ec re as es w ith th e m ot he r’s le ve l o f ed uc at io n, w ith 3 7. 7% o f c hi ld re n w ith m ot he rs w ith n o sc ho ol in g an d 17 .7 % fo r t ho se w ho se m ot he r h as h ad a m in im um o f s ec on da ry le ve l o f ed uc at io n. 70 Fe ve ri sh c hi ld re n ta ki ng a n an ti- m al ar ia l w ith in 2 4 ho ur s af te r th e fir st s ym pt om s ap pe ar ed is a ls o va ri ed , d ep en di ng o n so ci al c at eg or ie s, in th e sa m e di re ct io n ye t w ith s lig ht ly lo w er th an ta ki ng a n ap pr op ri at e an ti- m al ar ia l d ur in g th e la st tw o w ee ks . C ha nc es a re s tr on ge r fo r gi rl s (2 3. 8% ), ch ild re n re si di ng i n th e D is tr ic t of C au é, f or c hi ld re n ag ed 2 3 – 35 m on th s an d th os e ag ed 4 8 – 59 m on th s (m or e th an 2 6. 0% re sp ec tiv el y) , c hi ld re n w ho se m ot he r ha s no t be en t o sc ho ol ( 27 .6 % ) an d am on g ch ild re n w ho se h ou se ho ld ’s le ve l o f lif e is m id dl e- in co m e. C ha nc es d ec re as e in th e D is tr ic ts o f L ob at a (1 0. 5% ) a nd P rí nc ip e (1 2. 8% ), an d ch ild re n w ith th e m os t e du ca te d m ot he rs (1 2. 7% ). Pr eg na nt w om en li vi ng in z on es w er e m al ar ia p re va le nc e is s tr on g ha ve fo ur ti m es m or e ch an ce s th an o th er a du lts o f c on tr ac tin g th is il ln es s an d tw ic e of d yi ng . If in fe ct ed , p re gn an t w om en ri sk a na em ia , p re m at ur e la bo ur , a nd g iv in g bi rt h to a s til lb or n. T he ir in fa nt s ri sk u nd er w ei gh t at b ir th , w hi ch c om pr om is es th ei r su rv iv al d ur in g th ei r fir st y ea r. F or th is r ea so n, m ea su re s ha ve b ee n ta ke n to p ro te ct p re gn an t w om en b y di st ri bu tin g im pr eg na te d m os qu ito n et s an d by m ed ic at in g th em d ur in g th ei r pr e- na ta l co ns ul ta tio ns ( in te rm itt en t pr ev en tiv e tr ea tm en t or IP T) . W ith in th e Sã o To m é e Pr ín ci pe M IC S fr am ew or k, w om en e re a sk ed to re pl y to q ue st io ns re la te d to th e m ed ic at io ns th ey re ce iv ed d ur in g th ei r la st p re gn an cy d ur in g th e la st t w o ye ar s. T he w om en a re c on si de re d as h av in g re ce iv ed a n in te rm itt en t pr ev en tiv e tr ea tm en t if th ey re ce iv ed a t l ea se 2 d os es o f P S/ Fa ns id ar d ur in g th ei r p re gn an cy . In te rm itt en t pr ev en tiv e tr ea tm en t fo r m al ar ia a m on g pr eg na nt w om en h av in g gi ve n bi rt h du ri ng t he t w o ye ar s pr ec ed in g th e su rv ey i s pr es en te d in T ab le C H .1 3. I t i nd ic at es th at 9 0. 2% o f p re gn an t w om en re ce iv ed in te rm itt en t p re ve nt iv e tr ea tm en t a ga in st m al ar ia . W ha te ve r t he di st ri ct , e ig ht w om en o ut o f te n w er e gi ve n th is t re at m en t, al th ou gh c ov er ag e is s tr on ge r in Á gu a G ra nd e (9 4. 2% a nd P rí nc ip e (9 3. 4% ) an d re la tiv el y lo w er in C an ta ga lo (7 9. 8% ). T he le ve l o f e du ca tio n al so is a p os iti ve fa ct or w ith re ga rd to in te rm itt en t p re ve nt iv e tr ea tm en t : 8 3. 6% o f w om en w ith n o ed uc at io n, m or e th an 9 0. 0% o f w om en w ith a t l ea st a p ri m ar y le ve l e du ca tio n. Th e ef fe ct o f l ev el o f ho us eh ol d lif e re m ai ns am bi gu ou s. C lo se to o ne w om an o ut o f t en w er e gi ve n ch lo ro qu in e an d no w om an to ok tw o or m or e do se s of F an si da r. Su pp ly s ou rc es a nd c os ts Th e Sã o To m é e Pr ín ci pe M IC S qu es tio nn ai re i nc lu de d qu es tio ns o n th e so ur ce s an d co st s of t he f ou r ty pe s of p ro vi si on i n re sp ec t of im pr eg na te d m os qu ito n et s, a nt i-m al ar ia ls , an tib io tic s an d or al r eh yd ra tio n sa lts . T hi s in fo rm at io n is v er y im po rt an t as h ey p er m it an ev al ua tio n of th es e pr og ra m m es , b as ed o n po pu la tio n an d th e sp ec ifi c ta rg et g ro up s’ le ve l o f c ov er ag e by th e pr og ra m m es . T hi s in fo rm at io n is al so u se fu l t o co nt ro l p ro vi si on o f f re e or s ub si di se d m at er ia l, an d to e va lu at e th ei r co st g iv en th at th ei r pr ic e m ay c on st itu te a n ob st ac le to it s us e. I t m ay a ls o be e ss en tia l t o pr og ra m m e m an ag er s w ho w is h to d et er m in e th e w ei gh t o f e ith er th e pu bl ic o r p ri va te s ec to r i n th e pr ov is io n of th es e m at er ia ls , a s w el l a s th e re la tiv e si gn ifi ca nc e of e ac h of th e so ur ce s. 71 Th e so ur ce s an d co st s f p ro vi di ng im pr eg na te d m os qu ito n et (I M ) a re in di ca te d in T ab le C H .1 4. T hi s ta bl e gi ve s in fo rm at io n on IM a cq ui si tio n fr om e ith er p ub lic o r pr iv at e so ur ce s, th e pe rc en ta ge o f ho us eh ol ds w ho r ec ei ve d th e IM s at n o co st , a nd t he a ve ra ge c ot o f t he I M fo r th os e ho us eh ol ds w ho p ai d fo r th em . . A ll to ge th er , 5 7. 6% o f ho us eh ol ds r ec ei ve d m os qu ito n et s fr om a p ub lic s ou rc e, w hi le o nl y 2. 2% a re f ro m pr iv at e so ur ce s an d 40 .2 % f ro m o th er s ou rc es . Th e pe rc en ta ge o f ho us eh ol ds h av in g re co ur se t o th e pu bl ic s ec to r fo r IM s is h ig he r in t he D is tr ic ts o f C an ta ga lo , C au é an d Le m bá ( 88 .0 % t o 91 .2 % , a ga in st a n av er ag e of 5 8. 0% ), in r ur al a re as ( 66 .9 % a ga in st 5 3. 5% i n ur ba n ar ea s) , am on g th e po or es t ( 78 .3 % a ga in st 3 8. 2% a m on g th e w ea lth ie st ), an d th os e ho us eh ol ds w he re th e he ad o f h ou se ho ld h as n ev er b ee n to s ch oo l (6 2. 2% a ga in st 5 0. 0% w he n th e le ve l o f e du ca tio n is a t l ea st th e se co nd ar y) . O n th e ot he r ha nd , t ho se h av in g gr ea te r re co ur se to s ou rc es o th er th an p ub lic a nd p ri va te a re m or e fr eq ue nt i n Á gu a G ra nd e (5 7. 1% a ga in st a n av er ag e of 4 0. 2% ) an d am on g th e w ea lth ie st ( 60 .8 % ). I f th e pe rc en ta ge o f ho us eh ol ds o bt ai ni ng t he ir I M s fr om t he p ri va te s ec to r is r el at iv el y lo w , i t is h ow ev er h ig he r in t he D is tr ic t of P rí nc ip e (8 .0 % ag ai ns t a n av er ag e of 2 .2 % ). F or h ou se ho ld s w ho b ou gh t t he ir tr ea te d m os qu ito n et s, th e av er ag e pr ic e is 2 7, 00 0 do br as (1 .5 E ur os ) f ro m p ub lic so ur ce s an d 27 ,0 00 d ob ra s (1 .5 E ur os ) f ro m p ri va te s ou rc es . Th e St at e, w ith r eg ar d to it s Fi gh t a ga in st M al ar ia p ol ic y, a pp ea rs a s th e pr im ar y do no r of IM s. T o th is e ff ec t, it is w or th n ot in g th e nu m er ou s se ns iti sa tio n ca m pa ig ns a ga in st m al ar ia , o fte n in vo lv in g th e fr ee d is tr ib ut io n of I M s. A m on g ho us eh ol ds h av in g ac qu ir ed a f re e IM , 4 2. 0% ob ta in ed it fr om a p ub lic fa ci lit y an d 32 .5 % fr om a p ri va te o ne . U rb an h ou se ho ld s (5 8. 4% ) a nd th e po or es t ( 51 .1 % ) r ec ei ve d th e m os t f re e IM s fr om S ta te s ou rc es . H ou se ho ld s in th e D is tr ic ts o f C au é (9 0. 1% ) a nd L em bá (1 00 .0 % ) r ec ei ve th ei r IM s fr ee fr om p ri va te s ou rc es . M or e ru ra l ho us eh ol ds re ce iv e th ei r I M s fr ee fr om p ri va te s ou rc es th an u rb an h ou se ho ld s (3 9. 2% a ga in st 2 5. 1% ). Th e so ur ce s an d co st s of p ro vi di ng a nt i-m al ar ia ls fo r t he u nd er fi ve s ar e in di ca te d in T ab le C H .1 5. A m on g ch ild re n w ith fe ve r d ur in g th e la st 2 w ee ks w ho h av e be en t re at ed w ith a nt i-m al ar ia ls , 3 8. 8% b en ef ite d fr om p ub lic s ou rc es a nd o nl y 5. 3% f ro m p ri va te s ou rc es . M or e th an h al f (5 9. 9% ) c om e fr om o th er s ou rc es . R ec ou rs e to p ub lic s ou rc es fo r an ti- m al ar ia l s up pl ie s is m or e fr eq ue nt in r ur al a re as (4 4. 6% a ga in st 3 4. 5% in ur ba n ar ea ) a nd in th e D is tr ic t o f M é- zo ch i ( 51 .0 % ). M or e th an o ne c hi ld o ut o f f ou r (2 5. 8% ) w er e gi ve n fr ee a nt i-m al ar ia l i n a pu bl ic fa ci lit y w hi le n o pr iv at e fa ci lit y pr ov id ed it fr ee . Fo r t ho se h av in g ha d to p ay fo r t he ir a nt i-m al ar ia ls , t he a ve ra ge c os t i s 5, 00 0 do br as (0 .2 7 Eu ro s) fr om pu bl ic s ou rc es a nd 1 5, 00 0 do br as (0 .8 3e ur os ) f ro m p ri va te s ou rc es . Th e so ur ce s an d co st s o f p ro vi di ng a nt ib io tic s fo r t he tr ea tm en t o f p ne um on ia in th e un de r f iv es a re in di ca te d in T ab le C H .1 6. C lo se to 6 5. 0% o f ch ild re n ar e pr ov id ed w ith a nt ib io tic s fo r pn eu m on ia in p ub lic fa ci lit ie s an d 31 .3 % h as r ec ou rs e to a p ri va te s ou rc e. M or e ur ba n ch ild re n ha ve be ne fit ed f ro m S ta te s ou rc es t ha n th os e fr om r ur al a re as . A m on g ch ild re n ha vi ng r ec ei ve d an tib io tic p ne um on ia t re at m en t, le ss t ha n 4. 0% re ce iv ed i t fr ee i n a pu bl ic f ac ili ty . N o ch ild r ec ei ve d its a nt ib io tic s fr ee f ro m p ri va te s ou rc es . Fo r th os e w ho b ou gh t th ei r an tib io tic s, t he av er ag e co st is 5 ,0 00 d ob ra s (0 .2 7 Eu ro s) fr om p ub lic s ou rc es a nd 3 ,0 00 d ob ra s (0 .1 6 Eu ro s) fr om p ri va te s ou rc es . 72 Th e so ur ce s an d co st s of p ro vi di ng o ra l r eh yd ra tio n sa lts ( O RS ) f or t he u nd er f iv es a re in di ca te d in T ab le C H .1 7. C lo se to 9 6. 0% o f O RS a re fr om p ub lic s ou rc es a nd le ss th an 2 .0 % fr om p ri va te s ou rc es . H ar dl y on e ch ild r ec ei ve d O RS fr ee (1 .2 % ). F or th os e w ho p ur ch as ed th ei r O RS , th e av er ag e co st is 3 ,0 00 d ob ra s ( 0. 16 E ur os ) f ro m p ub lic s ou rc es a nd 5 ,0 00 d ob ra s ( 0. 27 E ur os ) f ro m p ri va te s ou rc es . 73 V II . E nv ir on m en t W at er a nd sa ni ta tio n Sa fe d ri nk in g w at er is a b as ic n ec es si ty fo r g oo d he al th . U ns af e dr in ki ng w at er c an b e a si gn ifi ca nt c ar ri er o f d is ea se s su ch a s tr ac ho m a, c ho le ra , ty ph oi d an d sc hi st os om ia si s. D ri nk in g w at er c an a ls o be ta in te d w ith c he m ic al , p hy si ca l a nd r ad io lo gi ca l c on ta m in an ts w ith h ar m fu l e ffe ct s on hu m an h ea lth . In a dd iti on t o its a ss oc ia tio n w ith d is ea se , a cc es s to d ri nk in g w at er m ay b e pa rt ic ul ar ly im po rt an t fo r ch ild re n an d w om en , e sp ec ia lly in th e ru ra l a re as , w he re th ey b ea r t he p ri m ar y re sp on si bi lit y of c ar ry in g w at er , o fte n fo r l on g di st an ce s. Th e M D G g oa l i s to re du ce b y ha lf, b et w ee n 19 90 a nd 2 01 5, th e pr op or tio n of p eo pl e w ith ou t s us ta in ab le a cc es s to s af e dr in ki ng w at er a nd b as ic sa ni ta tio n. T he W FF C g oa l c al ls fo r a re du ct io n in th e pr op or tio n of h ou se ho ld s w ith ou t a cc es s to h yg ie ni c sa ni ta tio n fa ci lit ie s an d af fo rd ab le sa fe d ri nk in g w at er b y at le as t o ne th ir d. Th e lis t o f i nd ic at or s u se d in M IC S is a s f ol lo w s: W at er • U se o f i m pr ov ed d ri nk in g w at er s ou rc es • U se o f a de qu at e w at er tr ea tm en t m et ho ds • Ti m e to s ou rc e of d ri nk in g w at er • Pe rs on c ol le ct in g dr in ki ng w at er Sa ni ta tio n • U se o f i m pr ov ed s an ita tio n fa ci lit ie s • Sa ni ta ry d is po sa l o f c hi ld 's fa ec es Th e di st rib ut io n of th e po pu la tio n by so ur ce o f d rin ki ng w at er is sh ow n in T ab le E N .1 a nd F ig ur e 7. 1. 74 Th e po pu la tio n us in g im pr ov ed so ur ce s o f d rin ki ng w at er a re th os e us in g an y of th e fo llo w in g so ur ce s of s up pl y: p ip ed w at er (i nt o dw el lin g, ya rd o r p lo t), p ub lic ta p/ st an dp ip e, tu be w el l/ bo re ho le , p ro te ct ed w el l a nd ra in w at er c ol le ct io n. B ot tle d w at er is c on si de re d as a n im pr ov ed w at er s ou rc e on ly if th e ho us eh ol d is u si ng a n im pr ov ed w at er s ou rc e fo r o th er p ur po se s, s uc h as h an d w as hi ng a nd c oo ki ng . Fi gu re 1 2: E N .1 D is tr ib ut io n (b y pe rc en ta ge ) o f t he h ou se ho ld p op ul at io n, b y so ur ce o f d ri nk in g w at er A ll to ge th er , 8 6. 2% o f t he p op ul at io n ut ili se s an im pr ov ed d ri nk in g w at er s ou rc e -- 88 .4 % in u rb an a re as a nd 8 3. 2% in ru ra l a re as . C ov er ag e is re la tiv el y go od in a l t he d is tr ic ts , i n pa rt ic ul ar th os e of L ob at a an d Á gu a G ra nd e w he re , r es pe ct iv el y 96 .5 a nd 9 0. 4% o f t he p op ul at io n us es a n im pr ov ed s ou rc e. T he D is tr ic t o f C au é ha s th e lo w es t c ov er ag e ra te , w ith s ev en p eo pl e ou t o f t en h av in g ac ce ss to im pr ov ed so ur ce s. M em be rs fr om th e w ea lth ie st h ou se ho ld s ha ve m or e ac ce ss th an th e re st : 94 .5 % a ga in st 7 8. 2% a nd 7 9. 0% re sp ec tiv el y fo r t he p oo r a nd fo r t he p oo re st 87 .4 % fo r t ho se w ith m id dl e in co m es a nd 9 1. 7% fo r t he w ea lth y. H ou se ho ld h ea ds w ith a m in im um se co nd ar y ed uc at io n al so h av e m or e ac ce ss : 9 2. 1% a ga in st 8 5. 4% w he re th e he ad o f h ou se ho ld h as n ot b ee n to s ch oo l. 75 Ta bl e EN .1 i nd ic at es t ha t 22 .0 % o f th e po pu la tio n ut ili se s pi pe d po ta bl e w at er l oc at ed i n th ei r ho us eh ol d co m po un d; f or 5 2. 5% w at er i s ac ce ss ib le fr om p ub lic fo un ta in s. N ev er th el es s, th e ty pe s of s ou rc es o f d ri nk in g w at er v ar y co ns id er ab ly a cc or di ng to s om e so ci al c at eg or ie s. Pr ov is io n of p ip ed d ri nk in g w at er lo ca te d in th e ho us eh ol d co m po un d is m or e w id es pr ea d in th e D is tr ic t o f Á gu a G ra nd e (3 7. 0% a ga in st 8 .0 % in C an ta ga lo a nd P rí nc ip e) , a m on g ho us eh ol ds w ho se h ea d of h ou se ho ld h as a m in im um o f a se co nd ar y le ve l of e du ca tio n (3 6. 4% a ga in st 12 .9 % f or h ea ds o f ho us eh ol ds w ith n o ed uc at io n) , a nd a m on g th e w ea lth ie st ( 58 .1 % a ga in st 8 .4 % a m on g th e po or es t an d po or a nd 1 3. 0% am on g th os e w ith m id dl e in co m e) . Th e pu bl ic fo un ta in is m or e fr eq ue nt ly u til is ed in th e D is tr ic ts o f L em bá a nd L ob at a (r es pe ct iv el y 76 .9 % a nd 73 .6 % , a ga in st 3 8. 1% to 4 6. 0% in P rí nc ip e, Á gu a G ra nd e an d M é- zo ch i) an d am on g th e ur ba n po or es t ( 68 .9 % a ga in st 4 8. 0% fo r t he w ea lth y an d 20 .2 % f or t he w ea lth ie st ). A s m al l pa rt o f th e po pu la tio n is s up pl ie d pi pe d w at er t o th ei r ho us es ( le ss t ha n 4. 0% ), ev en a m on g th e m or e pr iv ile ge d ca te go ri es li vi ng in th e w ea lth ie st h ou se ho ld s (1 3. 5% ) a nd th os e w ho se h ea d of h ou se ho ld h as a m in im um o f a s ec on da ry le ve l o f ed uc at io n (8 .1 % ). I f le ss t ha n 10 .0 % o f th e en tir e po pu la tio n ut ili se a n un pr ot ec te d w at er s ou rc e (fo un ta in s, r iv er s an d st re am s) , i t is w or th no tin g th e ex ce pt io na l c as e of th e D is tr ic t o f P rí nc ip e : c lo se to h al f ( 43 .3 % ) o f i ts p op ul at io n liv es w ith th is v er y un he al th y si tu at io n. H ou se ho ld s w er e as ke d ab ou t w ay s th ey m ay b e tr ea tin g w at er a t h om e to m ak e it sa fe r to d ri nk - bo ili ng , a dd in g bl ea ch o r ch lo ri ne , u si ng a w at er f ilt er a nd u si ng s ol ar d is in fe ct io n w er e co ns id er ed a s pr op er t re at m en t of d ri nk in g w at er . H om e w at er t re at m en t is in di ca te d in T ab le EN .2 , w hi ch g iv es p er ce nt ag es f or t he h ou se ho ld m em be rs u til is in g ap pr op ri at e w at er t re at m en t m et ho ds , s ep ar at el y fo r al l h ou se ho ld s, f or ho us eh ol ds u til is in g im pr ov ed d ri nk in g w at er s ou rc es a nd u ni m pr ov ed . L es s th an 1 4. 0% o f t he p op ul at io n ut ili se s a w at er tr ea tm en t m et ho d co ns id er ed a de qu at e, f or a ll dr in ki ng w at er s ou rc es , w ha te ve r th ei r ty pe : 1 1. 3% a dd b le ac h or c hl or in e an d 2. 3% b oi l th ei r w at er . T hi s pe rc en ta ge i s hi gh er i n th e D is tr ic t of C au é (2 0. 2% a ga in st 2 .7 % i n th at o f Pr ín ci pe ), am on g th e w ea lth ie st h ou se ho ld s (2 1. 5% a ga in st 8 .0 % am on g th e po or es t), a nd a m on g ho us eh ol ds w ho se h ea d of h ou se ho ld h as a m in im um o f a s ec on da ry le ve l e du ca tio n (1 9. 3% a ga in st 1 0. 7% fo r th os e w ith n o ed uc at io n) . Th is p er ce nt ag e is p ra ct ic al ly th e sa m e fo r im pr ov ed w at er s ou rc es (1 5. 1% ) an d, p ar ad ox ic al ly , i t f al ls to le ss t ha n 10 .0 % fo r u ni m pr ov ed w at er s ou rc es . Th e am ou nt o f t im e ne ce ss ar y to o bt ai n w at er is in di ca te d in T ab le E N .3 w hi le th e pe rs on w ho n or m al ly c ol le ct s th e w at er is in di ca te d in T ab le EN .4 . It sh ou ld b e no te d th at t he se r es ul ts in cl ud e a ro un d tr ip f ro m t he h ou se t o th e so ur ce o f dr in ki ng w at er . In fo rm at io n re ga rd in g th e nu m be r o f t ri ps m ad e du ri ng o ne d ay w as n ot c ol le ct ed . Ta bl e EN .3 in di ca te s th at fo r 25 .8 % o f h ou se ho ld s, th e so ur ce o f d ri nk in g w at er is a t h om e. C on tr ar ily , 1 6. 0% o f h ou se ho ld s tr av el le ss th an 3 0 m in ut es to r ea ch th e w at er s ou rc e, c ol le ct th e w at er a nd r et ur n, a nd 1 0. 0% n ee d be tw ee n 30 a nd 6 0 m in ut es to d o th e sa m e. T he m ea n tim e fo r a ro un d tr ip t o th e w at er s ou rc e is 1 6 m in ut es f or h ou se ho ld s w ith ou t ac ce ss t o w at er . Th is t im e is n ec es sa ri ly h ig he r in r ur al a re as ( 17 .1 76 m in ut es ) t ha n in u rb an a re as (1 5. 3 m in ut es ). T he in ha bi ta nt s of th e D is tr ic t o f M é- zo ch i n ee d m or e tim e fo r t hi s ta sk (c lo se to 2 0 m in ut es ) w hi le th os e in L em bá n ee d on a ve ra ge o nl y ha lf th at ti m e (1 0 m in ut es ). Ta bl e EN .4 in di ca te s th at in th e m aj or ity o f h ou se ho ld s, it is g en er al ly a n ad ul t f em al e w ho is re sp on si bl e fo r c ol le ct in g dr in ki ng w at er w he n th e so ur ce o f w at er i s aw ay f ro m t he h ou se ho ld : cl os e to 6 7. 0% o f w om en ). O nl y 20 .0 % o f ad ul t m al es d o co lle ct w at er , w hi le t he r es t of t he ho us eh ol ds it is g ir ls a nd b oy s un de r 15 w ho c ol le ct th e ho us eh ol d’ s w at er (r es pe ct iv el y 9. 3% a nd 4 .2 % ). M or e fe m al es th at a re a du lt co lle ct w at er i n th e D is tr ic t of C an ta ga lo ( 71 .4 % ), in t he h ou se ho ld s w he re t he h ea d of h ou se ho ld h as h ad n o ed uc at io n (7 2. 5% ) an d am on g th e w ea lth ie st ( 71 .9 % ). O n he o th er h an d, it is in r ur al a re as w he re a du lt m al es c ol le ct d ri nk in g w at er m or e fr eq ue nt ly ( 22 .7 % a ga in st 1 6. 6% in ur ba n ar ea s) a nd in th e D is tr ic t o f P rí nc ip e (2 2. 8% a ga in st 1 5. 2% in th at o f L em bá ). In ad eq ua te d is po sa l of h um an e xc re ta a nd p er so na l hy gi en e is a ss oc ia te d w ith a r an ge o f di se as es i nc lu di ng d ia rr ho ea l di se as es a nd p ol io . Im pr ov ed s an ita tio n fa ci lit ie s fo r ex cr et a di sp os al i nc lu de f lu sh o r po ur f lu sh t o a pi pe d se w er ag e sy st em , s ep tic t an k or l at ri ne ; v en til at ed im pr ov ed p it la tr in e, p it la tr in e w ith a sl ab a nd c om po st in g to ile t. Ta bl e EN .5 in di ca te s th at 2 8. 0% o f t he S ão T om é e Pr ín ci pe p op ul at io n liv e in h ou se ho ld s w ith im pr ov ed s an ita ry in st al la tio ns . Th e ut ili sa tio n of im pr ov ed s an ita ry in st al la tio ns v ar ie s co ns id er ab ly b et w ee n so ci al c at eg or ie s. F or e xa m pl e, 3 2. 7% o f th e ur ba n po pu la tio n ha ve a cc es s to im pr ov ed s an ita ry i ns ta lla tio ns a ga in st 2 1. 5% o f th e ru ra l po pu la tio n. Eq ua lly , t he u til is at io n of i m pr ov ed i ns ta lla tio ns v ar ie s co ns id er ab ly be tw ee n th e D is tr ic t of Á gu a G ra nd e, t he b es t-e qu ip pe d (4 1. 9% ) an d th at o f C an ta ga lo , t he le as t eq ui pp ed ( 13 .6 % ). T he w ea lth y ar e cl ea rl y be tte r eq ui pp ed th an th e po or : re sp ec tiv el y on e th ir d of w ea lth y ho us eh ol d in ha bi ta nt s an d cl os e to 8 0. 0% o f t he w ea lth ie st u til is e im pr ov ed in st al la tio ns w hi le r es pe ct iv el y le ss th an 1 .0 % a nd 8 .1 % a m on g th e po or es t a nd p oo r ha ve a cc es s to th es e to ile ts . Si m ila r di ffe re nc es a re a ls o ob se rv ed a cc or di ng t o th e he ad o f ho us eh ol d’ s ed uc at io n le ve l : w he re t hi s le ve l is s ec on da ry o r hi gh er e du ca tio n, c lo se t o 50 .0 % u til is e im pr ov ed to ile ts w hi le o nl y 18 .0 % o f h ou se ho ld s w ho se h ea d of h ou se ho ld h as n o ed uc at io n ha ve a cc es s to s uc h a to ile t. N ea rl y si x ho us eh ol ds o ut o f t en s im pl y do n ot h av e ac ce ss to to ile ts , w ith a ra ng e of s er io us la cu na a cc or di ng to d is tr ic ts : 68 .0 % in ru ra l a re as , 74 .2 % in C an ta ga lo , 7 2. 2% in th at o f M é- zo ch i a nd 6 6. 3% in P rí nc ip e. H ow ev er , f lu sh in g sa ni ta ry in st al la tio ns li nk ed to a s ew ag e sy st em o r t o a se pt ic t an k ar e ra re in S ão T om é e Pr ín ci pe ( re sp ec tiv el y 6. 7% a nd 1 1. 9% ) an d un eq ua lly d is tr ib ut ed a m on g its p op ul at io n. Th es e ty pe s of to ile ts a re m or e w id es pr ea d am on g th e w ea lth ie st ( re sp ec tiv el y 21 .6 % a nd 4 3. 5% a ga in st l es s th an 1 .0 % r es pe ct iv el y am on g th e po or a nd po or es t) an d am on g th e m os t e du ca te d ho us eh ol ds (r es pe ct iv el y 15 .0 % a nd 2 2. 9% ). Sa fe d is po sa l o f c hi ld fa ec es is th e di sp os al o r w as hi ng o ff in to ile ts o r l at ri ne s of th e ch ild ’s la st fa ec es . D is po sa l o f f ae ce s fo r c hi ld re n ag ed 0 to 2 ye ar s is in di ca te d in T ab le E N .6 . Sa fe d is po sa l o f ch ild f ae ce s in a s an ita ry in st al la tio n is o nl y po ss ib le f or le ss t ha n on e ch ild o ut o f fiv e 77 (1 9. 0% ). F or 1 5. 0% f ae ce s ar e th ro w n in to la tr in es /t oi le ts a nd fo r le ss th an 2 .0 % th ey a re b ur ie d. Se ve n ou t o f t en c hi ld re n ha ve th ei r fa ec es th ro w n in to th e bu sh o r i nt o th e se a/ ri ve r ( re sp ec tiv el y 46 .3 % a nd 2 2. 7% ). Ta bl e EN .7 in di ca te s th e ov er al l p ic tu re o f p er ce nt ag es in r es pe ct o f h ou se ho ld s w ith im pr ov ed d ri nk in g w at er s ou rc es a nd m ea ns fo r th e sa fe di sp os al o f f ae ce s . 8 6. 2% o f a ll ho us eh ol ds u til is e im pr ov ed w at er s ou rc es (8 8. 4% in ru ra l a re as a nd 8 3. 2% in ru ra l a re as ). It is in th e D is tr ic t o f Á gu a G ra nd e th at h ou se ho ld s ar e be tte r e qu ip pe d in im pr ov ed w at er s ou rc es (9 0. 4% ) c om pa re d to th e D is tr ic ts o f C au é (7 1. 8% a nd a bo ve a ll, in Pr ín ci pe (5 5. 8% ). It is a ls o am on g th e w ea lth ie st a nd m os t e du ca te d ho us eh ol ds w he re im pr ov ed w at er s ou rc es e xi st . Th e pe rc en ta ge o f p eo pl e is 8 6. 2% a m on g th e w ea lth ie st a nd o nl y 78 .2 % a m on g th e po or es t. T hi s pe rc en ta ge is 9 2. 1% w he re th e he ad o f h ou se ho ld h as a m in im um o f a se co nd ar y le ve l o f ed uc at io n an d 85 .4 % w he re th e he ad o f ho us eh ol d ha s no t h ad a ny e du ca tio n. W ith r eg ar d to im pr ov ed m et ho ds fo r th e di sp os al o f fa ec es , o nl y 28 .0 % , a s in di ca te d in t he T ab le , a re e qu ip pe d. Th e di ff er en ce s be tw ee n so ci al c at eg or ie s ar e m or e fa vo ur ab le in t he D is tr ic t of Á gu a G ra nd e (4 1. 9% a ga in st 1 3. 6% i n C an ta ga lo , in u rb an a re as ( 32 .7 % a ga in st 2 1. 5% i n ru ra l ar ea s) , fo r th e m or e ed uc at ed ho us eh ol ds ( 48 .9 % a ga in st 1 7. 5% f or h ou se ho ld s w ho se h ea d of h ou se ho ld h as n ot b ee n to s ch oo l), a nd f or t he w ea lth ie st ( 79 .6 % a ga in st le s th an 1 .0 % fo r th e po or es t a nd 8 .1 % fo r th e po or ). N at io na lly , 2 6. 4% o f h ou se ho ld s ut ili se b ot h im pr ov ed w at er s ou rc es a nd im pr ov ed s ys te m s of fa ec es d is po sa l. D iff er en ce s be tw ee n ca te go ri es a re th e sa m e if th e w at er s ou rc es a nd d is po sa l s ys te m s a re c on si de re d se pa ra te ly . 78 V II I. R ep ro du ct iv e he al th Co nt ra ce pt io n A pp ro pr ia te fa m ily p la nn in g is im po rt an t f or th e he al th o f w om en a nd c hi ld re n in : 1) th e pr ev en tio n of e ar ly o r la te p re gn an ci es , 2 ) s pa ci ng be tw ee n bi rt hs , a nd 3 ) l im it th e nu m be r o f c hi ld re n. A W or ld F it fo r C hi ld re n ob je ct iv e is th e ac ce ss to in fo rm at io n an d se rv ic es p er m itt in g th e pr ev en tio n of e ar ly p re gn an ci es , u n- sp ac ed p re gn an ci es , l at e pr eg na nc ie s or to o m an y pr eg na nc ie s. C ur re nt u til is at io n of c on tr ac ep tio n w as m en tio ne d by 3 0. 3% o f m ar ri ed w om en o r liv in g w ith a p ar tn er (T ab le R H .1 ). T he m os t w id es pr ea d m et ho d, u til is ed b y 16 .4 % o f m ar ri ed o r un io n w om en is t he p ill , f ol lo w ed b y th at o f in je ct io n (1 0. 3% ) of m ar ri ed w om en . A m uc h- re du ce d pr op or tio n of w om en m en tio ne d th e us e of th e ca le nd ar , t he IU D , f em al e st er ili sa tio n or th e co nd om . Le ss th an 1 .0 % o f w om en u til is e pe ri od ic ab st in en ce , w ith dr aw al , m al e st er ili sa tio n, v ag in al m et ho ds o r L ac ta tio na l a m en or rh ea m et ho ds (L A M ). Pr ev al en ce o f co nt ra ce pt io n is s lig ht ly h ig he r in r ur al a re as ( 31 .6 % ) th an i n ur ba n on es ( 29 .4 % . A t th e di st ri ct l ev el , P rí nc ip e in di ca te s th e hi gh es t l ev el o f c on tr ac ep tio n (4 4. 4% ) f ol lo w ed b y th e D is tr ic ts o f C au é (3 4. 5% ) a nd L em bá (3 2. 6% ). C on tr ac ep tiv e pr ev al en ce in cr ea se s w ith ag e th ro ug h to 3 0 to 3 4 ye ar s, d ec re as in g ag ai n fo r t ho se o ld er . Th us a m on g ad ol es ce nt s 15 to 1 9 m ar ri ed o r w ith p ar tn er s, o nl y 24 .3 % c ur re nt ly ut ili se a c on tr ac ep tio n m et ho d, w hi le 3 2. 9% o f w om en a ge d 20 t o 24 y ea rs a nd 3 9. 1% o f w om en a ge d 30 t o 34 y ea rs u til is e a co nt ra ce pt io n m et ho d. C on tr ac ep tiv e pr ev al en ce fa lls to 2 9. 5% , t o 21 .4 % fo r t ho se a ge d 40 to 4 4 ye ar s an d to le ss th an 1 5. 0% fo r t ho se a ge d 45 to 4 9 ye ar s. A c or re la tio n ex is ts b et w ee n th e le ve l of e du ca tio n in w om en a nd c on tr ac ep tio n pr ev al en ce . T he p er ce nt ag e of w om en u til is in g on e co nt ra ce pt io n m et ho d in cr ea se s, f ro m 2 3. 8% a m on g th os e w ith ou t ed uc at io n to m or e th an 3 0. 0% f or t ho se w ith a t le as t a pr im ar y le ve l ed uc at io n. A p ar t f ro m d iff er en ce s i n pr ev al en ce , t he m et ho ds v ar y ac co rd in g to th e le ve l o f e du ca tio n. O nl y ab ou t 8 .0 % o f w om en w ith ou t e du ca tio n ut ili se th e pi ll an d 13 .5 % a re in je ct ed . A m on g th os e w ith a t l ea st a p ri m ar y le ve l o f e du ca tio n, 17 .5 % u til is e th e pi ll an d 10 .9 % a re i nj ec te d. O n th e ot he r ha nd , 1 5. 3% o f w om en u til is in g co nt ra ce pt iv es w ith a m in im um o f a se co nd ar y ed uc at io n us e th e pi ll an d 7. 6% a re in je ct ed . 79 Co nt ra ce pt io n ne ed s N ee ds to b e m et 7 i n te rm s of c on tr ac ep tio n m ak e re fe re nc e to fe cu nd w om en w ho d o no t u til is e an y m et ho d of c on tr ac ep tio n bu t w ho w ou ld lik e to s pa ce th ei r n ex t b ab y or s im pl y w is h to s to p ha vi ng c hi ld re n. T he n ee ds to b e co ve re d ar e id en tif ie d in th e M IC S fr am ew or k by u til is in g a se ri es o f q ue st io ns o n pr ef er en ce s an d cu rr en t b eh av io ur s i n th e us e of c on tr ac ep tiv es , f ec un di ty a nd fe rt ili ty . W om en w ho se n ee ds a re n ot m et in te rm s of b ir th s pa ci ng a re w om en c ur re nt ly m ar ri ed o r in u ni on s, f ec un d (w ho a re a ct ua lly p re gn an t o r w ho a re p la nn in g to b e re ad y to b ec om e pr eg na nt ), w ho d o no t c ur re nt ly u til is e co nt ra ce pt iv es a nd w ho w is h to s pa ce th ei r ba bi es . Pr eg na nt w om en a re c on si de re d to w is h to s pa ce th ei r b ab ie s w he n th ey d o no t w an t b ab ie s at th at m om en t o r t he y ha ve b ec om e pr eg na nt . W om en w ho ar e no t p re gn an t a re c la ss ed in th is c at eg or y if th ey w is h to h av e an ot he r c hi ld b ut w is h th is c hi ld o nl y af te r t w o ye ar s or a fte r g et tin g m ar ri ed . W om en w ho se n ee ds a re m et in te rm s of b ir th s pa ce s ar e th os e w ho a re a ct ua lly m ar ri ed o r in u ni on , f ec un d (a re p re gn an t o r cu rr en tly th in k th ey a re p hy si ca lly r ea dy t o be co m e pr eg na nt ), w ho d o no t ut ili se a ny m ea ns o f co nt ra ce pt io n an d w ho w is h to li m it th ei r ba bi e

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