Zimbabwe - Multiple Indicator Cluster Survey - 2009

Publication date: 2009

C M Y CM MY CY CMY K i ZIMBABWE MULTIPLE INDICATOR MONITORING SURVEY (MIMS) 2009 REPORT AUGUST 2010 ii This report was prepared by the Zimbabwe National Statistics Agency (ZIMSTAT), formerly the Central Statistical Office (CSO), Zimbabwe, with technical and financial assistance from the United Nations Children’s Fund (UNICEF). For further information contact: The Director General, Zimbabwe National Statistics Agency (ZIMSTAT), P.O. Box CY 342, Causeway, Harare, Zimbabwe, Telephone: 263 4 706681/8 or 263 4 703971, Fax: 263 4 728529 or 263 4 708854, Email: dg@zimstats.co.zw, website: http//www.zimstat.co.zw The Country Representative, United Nations Children’s Fund (UNICEF), 6 Fairbridge Road, Belgravia, Harare, Zimbabwe, Telephone: 263 4 703941/2, Fax: 263 4 730093, Email: harare@unicef.org. iii Summary Table of Findings: Multiple Indicator Monitoring Survey (MIMS) Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, MIMS, Zimbabwe, 2009. Note: MICS Indicators are defined in Appendix Table E. Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1 4.1 Under-five mortality rate, (10 year preceding the survey) 86 per thousand 2 4.2 Infant mortality rate, (10 year preceding the survey) 60 per thousand NUTRITION Nutritional status 6 1.8 (proxy) Underweight prevalence, (6-59 months) 11.8 Percent 7 Stunting prevalence, (6-59 months) 35.2 Percent 8 Wasting prevalence, (6-59 months) 2.4 Percent Breastfeeding 45 Timely initiation of breastfeeding 51.2 Percent 15 Exclusive breastfeeding rate 25.9 Percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 83.2 20.5 percent percent 17 Timely complementary feeding rate 89.3 Percent 18 Frequency of complementary feeding 55.6 Percent 19 Adequately fed infants 41.1 Percent Vitamin A 42 Vitamin A supplementation (under-fives) 22.6 Percent 43 Vitamin A supplementation (post-partum mothers) 33.8 Percent Low birth weight 9 Low birth weight infants 10.5 Percent 10 Infants weighed at birth 65.8 Percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 90.8 Percent 26 Polio immunization coverage 61.1 Percent 27 DPT immunization coverage 62.9 Percent 28 4.3 Measles immunization coverage 68.9 Percent 31 Fully immunized children 36.8 Percent 29 Hepatitis B immunization coverage 61.4 Percent Tetanus toxoid 32 Neonatal tetanus protection 64.5 Percent Care during illness 33 Use of oral rehydration therapy (ORT) 77.8 Percent 35 Received ORT or increased fluids, and continued feeding 34.9 Percent 23 Care seeking for suspected pneumonia 42.6 Percent 22 Antibiotic treatment of suspected pneumonia 16.0 Percent Solid fuel use 24 Solid fuels 68.5 Percent Malaria 36 Household availability of insecticide-treated nets (ITNs) 27.4 Percent 37 6.7 Under-fives sleeping under insecticide- treated nets 17.3 Percent 38 Under-fives sleeping under mosquito nets 22.6 Percent 39 6.8 Antimalarial treatment (under-fives) 13.9 Percent 40 Intermittent preventive malaria treatment (pregnant women) 13.9 Percent ENVIRONMENT Water and Sanitation 11 7.8 Use of improved drinking water sources 72.8 Percent 13 Water treatment 34.8 Percent 12 7.7 Use of improved sanitation facilities 60.3 Percent 14 Disposal of child's faeces 53.8 Percent Durability of housing Finished walls 86.0 Percent Finished flooring 65.2 Percent iv Finished roof 63.8 Percent Mean number of persons per sleeping room 2.5 Percent Status of the environment around the household Safe refuse disposal 57.9 Percent No air pollution in the neighbourhood 82.9 Percent REPRODUCTIVE HEALTH Fertility Total Fertility Rate 3.7 Children per woman Contraception 21 5.3 Contraceptive prevalence 64.9 Percent Maternal and newborn health 20 5.5 Antenatal care (at least once) 93.4 Percent 5.5 Antenatal care (four or more times) 56.8 Percent Timeliness of antenatal care (0-4 months of pregnancy) 31.4 Percent 44 Content of antenatal care Blood test taken 61.6 Percent Blood pressure measured 73.9 Percent Urine specimen taken 35.8 Percent Weight measured 80.2 Percent 4 5.2 Skilled attendant at delivery 60.2 Percent 5 Institutional deliveries 58.5 Percent Home deliveries 38.8 Percent EDUCATION Education 52 Pre-school attendance 17.7 Percent 53 School readiness 74.5 Percent 54 Net intake rate in primary education 74.0 Percent 55 Net primary school attendance rate 91.2 Percent 56 Net secondary school attendance rate 44.8 Percent 57 Children reaching grade five 89.1 Percent 2.2 Children reaching grade seven 82.4 Percent 58 Transition rate to secondary school 80.7 Percent 59 Net primary completion rate 42.6 Percent 61 3.1 Gender parity index primary school secondary school 0.98 1.01 Ratio Ratio Literacy 60 Adult literacy rate (women 15-24 years) 91.0 Percent CHILD PROTECTION Birth registration 62 Birth registration 37.8 Percent Possession of a birth certificate 36.9 Percent Early marriage and polygamy 67 Marriage before age 15 Marriage before age 18 4.7 31.8 Percent Percent 68 Young women aged 15-19 currently married/in union 21.3 Percent 70 Polygamy 10.1 Percent 69 Spousal age difference Women aged 15-19 Women aged 20-24 23.0 18.2 percent percent Domestic violence 100 Attitudes towards domestic violence 49.4 Percent HIV AND AIDS AND ORPHANED AND VULNERABLE CHILDREN HIV and AIDS knowledge and attitudes Comprehensive knowledge about HIV prevention among young women (15-24 years) 53.3 Percent Comprehensive knowledge about HIV prevention among women aged 15-49 years 55.2 Percent 89 Knowledge of mother- to-child transmission of HIV 65.4 Percent 86 Attitude towards people with HIV and AIDS 43.0 Percent 87 Women who know where to be tested for HIV 85.0 Percent 88 Women who have been tested for HIV 44.9 Percent v 90 Counselling coverage for the prevention of mother-to-child transmission of HIV 66.2 Percent 91 Testing coverage for the prevention of mother-to-child transmission of HIV 53.4 Percent Support to orphaned and vulnerable children 75 Prevalence of orphans 24.5 Percent 78 Children’s living arrangements 26.1 Percent 76 Prevalence of vulnerable children 36.6 Percent 77 6.4 School attendance of orphans versus non- orphans (10-14 years) 0.9 Ratio 81 External support to children orphaned and made vulnerable (by HIV and AIDS) 20.8 Percent 79 Malnutrition (underweight) among children orphaned and made vulnerable (by HIV and AIDS) – WHO Standard 1.08 Ratio Malnutrition (underweight) among children orphaned and made vulnerable (by HIV and AIDS) – NCHS Standard 1.14 Ratio vi TABLE OF CONTENTS PAGE Summary Table of Findings iii List of Tables ix List of Appendix Tables xii List of Figures xxii List of Abbreviations xxv Preface xxvii Executive Summary xxviii CHAPTER 1: INTRODUCTION 1 1.1 Background 1 1.2 Survey Objectives 2 1.3 Socio-Economic Background 2 CHAPTER 2: SAMPLE AND SURVEY METHODOLOGY 4 2.1 Sample Design 4 2.2 Questionnaires 5 2.3 Pre-Test 6 2.4 Training 6 2.5 Fieldwork 6 2.6 Data Processing 6 2.7 Quality Control 7 2.8 Survey Limitations and Constraints 7 CHAPTER 3: SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 9 3.1 Sample Coverage 9 3.2 Characteristics of Households and their Population 10 3.2.1 Population composition 10 3.2.2 Household composition and distribution 11 3.2.3 Household wealth quintiles 12 3.2.4 Source of external household support 13 3.2.5 Type of external household support 14 3.2.6 Expenditures on health and education 14 3.3 Characteristics of Respondents 16 3.3.1 Population background characteristics 16 3.3.2 Women background characteristics 23 3.3.3 Children background characteristics 24 CHAPTER 4: CHILD MORTALITY 26 4.1 Neonatal Mortality 27 4.2 Post-neonatal Mortality 28 4.3 Infant Mortality 28 4.4 Child Mortality 28 4.5 Under-5 Mortality 29 CHAPTER 5: CHILD NUTRITION 31 5.1 Nutritional Status of Children 31 5.1.1 Stunting, wasting, underweight and overweight (WHO standard) 32 5.1.2 Stunting, wasting, underweight and overweight (NCHS standard) 34 5.1.3 Malnutrition according to the Mid-Upper-Arm Circumference (MUAC) 36 5.1.4 Oedema prevalence 38 5.2 Breastfeeding 38 5.2.1 Breastfeeding initiation 39 5.2.2 Exclusive breastfeeding 40 5.2.3 Timely complementary feeding 41 5.2.4 Continued breastfeeding 41 5.3 Infant and Young Child Feeding Patterns 42 5.3.1 Infant and young child feeding patterns by age 42 vii 5.3.2 Adequacy in infant feeding 43 5.4 Vitamin A Supplementation 45 5.4.1 Vitamin A supplementation among children 46 5.4.2 Vitamin A supplementation among mothers 48 5.5 Low Birth Weight 48 CHAPTER 6: CHILD HEALTH 50 6.1 Child Immunization 50 6.2 Tetanus Toxoid 53 6.3 Diarrhoea and Oral Rehydration Treatment 54 6.3.1 Prevalence of diarrhoea 54 6.4 Care Seeking and Antibiotic Treatment of Pneumonia 56 6.4.1 Prevalence of suspected pneumonia 56 6.4.2 Care seeking for suspected pneumonia 57 6.4.3 Antibiotic treatment for suspected pneumonia 57 6.5 Solid Fuel Use 58 6.5.1 Types of fuel used for cooking 59 6.5.2 Current availability of electricity 60 6.5.3 Type of stove used for cooking 61 6.6 Malaria 61 6.6.1 Fever prevalence in under-5 year olds 62 6.6.2 Ownership of Insecticide Treated Nets (ITNs) 62 6.6.3 Ownership of at least one mosquito net 63 6.6.4 Use of Insecticide Treated Nets by under-5 year olds 63 6.6.5 Treatment of malaria in children under five years 63 6.6.6 Intermittent preventive treatment or malaria 64 CHAPTER 7: ENVIRONMENT 65 7.1 Water and Sanitation 65 7.1.1 Safe drinking water 65 7.1.2 Safe sanitation 71 7.2 Quality of Housing 75 7.2.1 Type of dwelling unit 75 7.2.2 Type of dwelling walls 76 7.2.3 Type of dwelling floor 77 7.2.4 Type of dwelling roof 78 7.2.5 Crowding 79 7.3 Status of the Environment Around the Household 81 7.3.1 Status of garbage disposal around the household 81 7.3.2 Refuse disposal 82 7.3.3 Excreta condition around the household 83 7.3.4 Use of area around the house 84 7.3.5 Air quality condition in the household neighbourhood 85 CHAPTER 8: REPRODUCTIVE HEALTH 87 8.1 Fertility 87 8.2 Contraception 88 8.2.1 Contraceptive prevalence 88 8.2.2 Perceived timing of last birth 90 8.2.3 Method of contraception 91 8.3 Antenatal Care (ANC) Coverage 92 8.3.1 Access to antenatal care 93 8.3.2 Pregnancy duration at first antenatal care visit 94 8.3.3 Personnel providing antenatal care 95 8.3.4 Type of services received by pregnant women 96 8.4 Place and Assistance at Delivery 97 8.4.1 Place of delivery 97 8.4.2 Assistance at delivery 99 viii CHAPTER 9: EDUCATION 101 9.1 Pre-School Attendance and School Readiness 101 9.2 Primary and Secondary School Participation 102 9.2.1 Net intake rate in primary education 102 9.2.2 School attendance 103 9.2.3 Children of secondary school age attending primary school 105 9.2.4 Survival rate to Grade 5 and Grade 7 106 9.2.5 Net primary completion rate (Grade 7) 106 9.2.6 Transition rate to secondary school 106 9.2.7 Female to male education ratio (or gender parity index - GPI) 107 9.2.8 Women literacy assessment 108 CHAPTER 10: CHILD PROTECTION 110 10.1 Birth Registration Status 110 10.1.1 Birth registration 111 10.1.2 Possession of birth certificate 112 10.1.3 Reasons for non-registration of birth 112 10.1.4 Knowledge of where to register child’s birth 113 10.2 Child Care Arrangements 114 10.3 Early Marriages 115 10.3.1 Age at first marriage 116 10.3.2 Marriage before ages 15 and 18 years 117 10.3.3 Young women aged 15-19 years currently married/in union 118 10.3.4 Women in polygamous marriage/union 119 10.3.5 Spousal Age Difference 120 10.4 Domestic Violence 122 10.4.1 Domestic violence, women aged 15-49 years 122 10.4.2 Domestic violence, young women aged 15-24 years 125 10.4.3 Knowledge of the existence of the Domestic Violence Act 126 CHAPTER 11: HIV AND AIDS AND ORPHANED AND VULNERABLE CHILDREN 127 11.1 Knowledge of HIV Transmission 127 11.1.1 Comprehensive knowledge of HIV transmission among women aged 15-49 years 128 11.1.2 Comprehensive knowledge of HIV transmission among young women aged 15-24 years 131 11.1.3 Knowledge of mother-to-child transmission of HIV 131 11.1.4 Attitudes towards people living with HIV (stigma and discrimination) 132 11.1.5 Knowledge of where to be tested for HIV and use of such services 133 11.2 Counseling and HIV Testing During Antenatal Care 134 11.3 Orphans and Vulnerable Children 135 11.3.1 Children’s living arrangements and orphanhood 136 11.3.2 Orphans and vulnerable children prevalence (0-17 years) 138 11.3.3 Orphans and vulnerable children school attendance 139 11.3.4 Orphans and vulnerable children nutrition 141 11.3.5 External support to orphans and vulnerable children 142 SELECTED BIBLIOGRAPHY 144 Appendix A A Commitment to Action: National and International Reporting Responsibilities 145 Appendix B Sample Design 146 Appendix C Estimates of Sampling Errors 156 Appendix D Data Quality Tables 172 Appendix E MICS Indicators: Numerators and Denominators 183 Appendix F Data Tables 189 Appendix G List of Personnel Involved in the Survey 293 Appendix H Questionnaires 299 ix LIST OF TABLES PAGE Table 3.1 Results of household and individual interviews Number of households, women, and children under 5 by results of the interviews, and household, women's and under-5's response rates, MIMS, Zimbabwe, 2009 9 Table 3.2 Results of household and individual interviews number of households sampled, occupied and interviewed and response rate (percentage), MIMS, Zimbabwe, 2009 10 Table 3.3 Household composition percent distribution of households by selected characteristics, MIMS, Zimbabwe, 2009 11 Table 3.4 Wealth quintiles Percentage distribution of the population by wealth quintiles, according to rural and urban and province, MIMS, Zimbabwe, 2009 13 Table 3.5 Expenditures on health and education mean household expenditure and external support for health and education, US$, MIMS, Zimbabwe, 2009 15 Table 3.6 Summary - Main usual activity females aged 15-54 years by activity in the 12 months preceding the survey, MIMS, Zimbabwe, 2009 22 Table 3.7 Women's background characteristics Percent distribution of women aged 15-49 years by background characteristics, MIMS, Zimbabwe, 2009 23 Table 3.8 Children's background characteristics Percent distribution of children under five years of age by background characteristics, MIMS, Zimbabwe, 2009 25 Table 4.1 Child mortality Infant, neonatal, post-neonatal, child and under-5 mortality rates based on births during the 10-year preceding the survey, MIMS, Zimbabwe, 2009 27 Table 4.2 Child mortality Neonatal, post neonatal, infant, child, and under-5 mortality rates for the 5-year period preceding the survey, by background characteristics, MIMS, Zimbabwe 2009 30 Table 5.1 Child malnourishment-WHO child growth standards Percentage of Children Aged 6-59 Months who are severely or moderately undernourished, MIMS, Zimbabwe, 2009 33 Table 5.2 Child malnourishment – NCHS child growth standards Percentage of Children Aged 6-59 Months who are severely or moderately undernourished, MIMS, Zimbabwe, 2009 35 Table 5.3 Mid-Upper Arm Circumference (MUAC) Percentage distribution of children age 6-59 months by classification of mid-upper arm circumference, MIMS, Zimbabwe, 2009 37 Table 5.4 Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6-11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, MIMS, Zimbabwe, 2009 44 Table 5.5 Children's Vitamin A supplementation Percent distribution of children aged 6-59 months by whether they received a high dose vitamin a supplement in the last 6 months, MIMS, Zimbabwe, 2009 47 Table 6.1 Vaccinations among children Percentage of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, MIMS, Zimbabwe, 2009 51 x Table 6.2 Antibiotic treatment of pneumonia Percentage of children aged 0-59 months with suspected pneumonia who received antibiotic treatment, MIMS, Zimbabwe, 2009 58 Table 7.1 Household water treatment Percent distribution of household population according to drinking water treatment method used in the household, and percentage of household population that applied an appropriate water treatment method, MIMS, Zimbabwe, 2009 67 Table 7.2 Person collecting water Percent distribution of households according to the person collecting drinking water used in the household, MIMS, Zimbabwe, 2009 69 Table 7.3 Availability of water Percent Distribution of Household Population by Availability of Drinking Water Source, According to Selected Characteristics, MIMS, Zimbabwe, 2009 70 Table 7.4 Use of improved and functioning toilet facilities Percentage of household population using improved sanitation, functioning facilities, and improved functioning facilities, MIMS, Zimbabwe, 2009 73 Table 7.5 Use of improved water sources and improved sanitation Percentage of household population using both improved drinking water sources and sanitary means of excreta disposal, MIMS, Zimbabwe, 2009 74 Table 7.6 Crowding Mean number of household members per sleeping room by selected characteristics, MIMS, Zimbabwe, 2009 81 Table7.7 Status of garbage disposal around the household Percent distribution of households according to status of garbage disposal around the household, MIMS, Zimbabwe, 2009 82 Table 8.1 Use of contraception Percentage of women aged 15-49 years currently married or in union who are using (or whose partner is using) a contraceptive method, MIMS, Zimbabwe, 2009 89 Table 8.2 Perceived timing of last birth percentage of women aged 15-49 years with a live birth during last two years by perceived timing of their last birth, MIMS, Zimbabwe, 2009 91 Table 8.3 Use of contraception Percentage of women aged 15-49 years, married or in union, who are using (or whose partner is using) a contraceptive method by method of contraception, MIMS, Zimbabwe 2009 92 Table 9.1 Education gender parity Ratio of girls to boys attending primary education and ratio of girls to boys attending secondary education, MIMS, Zimbabwe, 2009 107 Table 9.2 Female literacy (15-49 years) Percentage of women aged 15-49 years that are literate, MIMS, Zimbabwe, 2009 109 Table 10.1 Age at first marriage Percentage of women who were first married by specific exact ages and mean age at first marriage, according to current age, MIMS, Zimbabwe, 2009 117 Table 11.1 Knowledge of preventing HIV transmission Percentage of women aged 15-49 years who know the main ways of preventing HIV transmission, MIMS, Zimbabwe, 2009 129 Table 11.2 HIV testing and counselling coverage during antenatal care percentage of women aged 15-49 years who gave birth in the 2 years preceding the survey who were offered HIV testing and counseling with their antenatal care, MIMS, Zimbabwe, 2009 135 xi Table 11.3 Children's living arrangements and orphanhood percentage of children aged 0-17 years who are paternal, maternal and double orphans, MIMS, Zimbabwe, 2009 137 Table 11.4 Prevalence of orphanhood and vulnerability among children percentage of children aged 0-17 years who are orphaned or vulnerable, MIMS, Zimbabwe, 2009 138 Table 11.5 School attendance of orphaned and vulnerable children School attendance of children aged 10-14 years by orphanhood, MIMS, Zimbabwe, 2009 141 xii LIST OF APPENDIX TABLES PAGE CHAPTER 3: SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Table A3.1 Results of household and individual interviews Number of households, women, and children under 5 by results of the interviews, and household, women's and under-five's response rates, MIMS, Zimbabwe, 2009 189 Table A3.2 Household age distribution by sex Percentage distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, MIMS, Zimbabwe, 2009 190 Table A3.3 Household composition Percentage distribution of households by selected characteristics, MIMS, Zimbabwe, 2009 191 Table A3.4 Source of external support Percentage of Households Who Received External Support by Source, MIMS, Zimbabwe, 2009 192 Table A3.5 Type of external support received Percentage of households who received external support by type of support, MIMS, Zimbabwe, 2009 193 Table A3.6 Language spoken in household Percentage distribution of household population by language, MIMS, Zimbabwe, 2009 194 Table A3.7 Religion of head of household Percentage distribution of household population by religion, MIMS, Zimbabwe, 2009 195 Table A3.8 Marital status (total) Percentage distribution of population aged 15 years and above by marital Status, MIMS, Zimbabwe, 2009 196 Table A3.9 Marital status (female) Percentage distribution of population aged 15 years and above by marital status, MIMS, Zimbabwe, 2009 197 Table A3.10 Marital status (male) Percentage distribution of population aged 15 years and above by marital status, MIMS, Zimbabwe, 2009 198 Table A3.11 Educational attainment (total) Percentage distribution of household members aged 6 years and above by educational level attended, MIMS, Zimbabwe, 2009 199 Table A3.12 Educational attainment (female) Percentage distribution of household members aged 6 years and above by educational level attended, MIMS, Zimbabwe, 2009 200 Table A3.13 Educational attainment (male) Percentage distribution of household members aged 6 years and above by educational level attended, MIMS, Zimbabwe, 2009 201 Table A3.14a Main usual activity (total) Percentage distribution of household members aged 15-54 years by main activity during past 12 months, MIMS, Zimbabwe, 2009 202 Table A3.14b Summary - Main usual activity (total) Percentage distribution of household members aged 15-54 years by main usual activity in the 12 Months Preceding the Survey, MIMS, Zimbabwe, 2009 203 Table A3.15 Main usual activity (female) Percentage distribution of household members aged 15-54 years by main usual activity during the past 12 months, MIMS, Zimbabwe, 2009 204 xiii Table A3.16a Main usual activity (male) Percentage distribution of household members aged 15-54 years by main usual activity during the past 12 months, MIMS, Zimbabwe, 2009 205 Table A3.16b Summary-Main usual activity (male) Males aged 15-54 years by main usual activity in the 12 months preceding the survey, MIMS, Zimbabwe, 2009 206 Table A3.17 Women's background characteristics Percentage distribution of women aged 15-49 years by background characteristics, MIMS, Zimbabwe, 2009 207 Table A3.18 Children's background characteristics Percentage distribution of children under five years of age by background characteristics, MIMS, Zimbabwe, 2009 208 CHAPTER 4: CHILD MORTALITY Table A4.1 Child mortality Infant, neonatal, post-neonatal, child and under-5 mortality rates based on births during the 10-year preceding the survey, MIMS, Zimbabwe, 2009 209 CHAPTER 5: CHILD NUTRITION Table A5.1 Child malnourishment - WHO child growth standards Percentage of Children Aged 6-59 Months who are severely or moderately undernourished, MIMS, Zimbabwe, 2009 210 Table A5.2 Oedema prevalence Percentage of children 0-59 months with oedema, MIMS, Zimbabwe, 2009 211 Table A5.3 Initial breastfeeding Percentage of women aged 15-49 years with a birth in the two years preceding the survey who breastfed their baby within one hour of birth and within one day of birth, MIMS, Zimbabwe, 2009 212 Table A5.4 Breastfeeding Percentage of living children according to breastfeeding status at each age group, MIMS, Zimbabwe, 2009 213 Table A5.5 Infant feeding patterns by age Percentage distribution of children aged under 3 years by feeding pattern by age group, MIMS, Zimbabwe, 2009 214 Table A5.6 Adequately fed infants Percentage of infants under 6 months of age exclusively breastfed, percentage of infants 6-11 months who are breastfed and who ate solid/semi-solid food at least the minimum recommended number of times yesterday and percentage of infants adequately fed, MIMS, Zimbabwe, 2009 215 Table A5.7 Children's vitamin A supplementation Percentage distribution of children aged 6-59 months by whether they received a high dose Vitamin A supplement in the last 6 months, MIMS, Zimbabwe, 2009 216 Table A5.8 Post-partum mothers' vitamin A supplementation Percentage of women aged 15-49 years with a live birth in the 2 years preceding the survey by whether they received a high dose vitamin A supplement before the infant was 8 weeks old, MIMS, Zimbabwe, 2009 217 Table A5.9 Low birth weight infants Percentage of live births in the 2 years preceding the survey that weighed below 2500 grams at birth, MIMS, Zimbabwe, 2009 218 xiv CHAPTER 6: CHILD HEALTH Table A6.1 Vaccinations among children-summary Percentage of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, MIMS, Zimbabwe, 2009 219 Table A6.1c Vaccinations among children (continued) Percentage of children aged 18-29 months immunized against childhood diseases at any time before the survey and before the first birthday, MIMS, Zimbabwe, 2009 220 Table A6.1d Vaccinations among children (continued) Percentage of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, MIMS, Zimbabwe, 2009 220 Table A6.2a Vaccinations by background characteristics Percentage of children aged 18-29 months currently vaccinated against childhood diseases, MIMS, Zimbabwe, 2009 221 Table A6.2b Vaccinations by background characteristics Percentage of children aged 12-23 months currently vaccinated against childhood diseases, MIMS, Zimbabwe, 2009 222 Table A6.2c Vaccinations by background characteristics (continued) Percentage of children aged 18-29 months currently vaccinated against childhood diseases, MIMS, Zimbabwe, 2009 223 Table A6.2d Vaccinations by background characteristics (continued) Percentage of children aged 12-23 months currently vaccinated against childhood diseases, MIMS, Zimbabwe, 2009 224 Table A6.3 Neonatal tetanus protection Percentage of mothers with a birth in the last 12 months protected against neonatal tetanus, MIMS, Zimbabwe, 2009 225 Table A6.4 Oral rehydration treatment Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solution (ORS) or other oral rehydration treatment (ORT), MIMS, Zimbabwe, 2009 226 Table A6.5 Home management of diarrhoea Percentage of Children Aged 0-59 Months with Diarrhoea in the Last 2 Weeks who Took Increased Fluids and Continued to Feed During the Episode, MIMS, Zimbabwe, 2009 227 Table A6.6 Care seeking for suspected pneumonia Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks taken to a health provider, MIMS, Zimbabwe, 2009 228 Table A6.7 Antibiotic treatment of pneumonia Percentage of children aged 0-59 months with suspected pneumonia who received antibiotic treatment, MIMS, Zimbabwe, 2009 229 Table A6.8 Solid fuel use Percentage distribution of households according to type of cooking fuel, and percentage of households used solid fuels for cooking, MIMS, Zimbabwe, 2009 230 Table A6.9 Solid fuel use by type of stove or fire Percentage of households using solid fuels for cooking by type of stove or fire, MIMS, Zimbabwe, 2009 231 Table A6.10 Availability of insecticide treated nets Percentage of households with at least one insecticide treated net (ITN), MIMS, Zimbabwe, 2009 232 Table A6.11 Children sleeping under bednets Percentage of children aged 0-59 months who slept under an insecticide treated net during the previous night, MIMS, Zimbabwe, 2009 233 xv Table A6.12 Treatment of children with anti-malarial drugs Percentage of children aged 0-59 months who were ill with fever in the last two weeks who received anti-malarial drugs, MIMS, Zimbabwe, 2009 234 Table A6.13 Intermittent preventive treatment for malaria Percentage of women aged 15-49 years who gave birth during the two years preceding the survey who received intermittent preventive therapy (IPT) for malaria during pregnancy, MIMS, Zimbabwe, 2009 235 CHAPTER 7: ENVIRONMENT Table A7.1 Use of improved water sources Percentage distribution of household population according to main source of drinking water and percentage of household population using improved drinking water sources, MIMS, Zimbabwe, 2009 236 Table A7.2 Household water treatment Percentage distribution of household population according to drinking water treatment method used in the household, and percentage of household population that applied an appropriate water treatment method, MIMS, Zimbabwe, 2009 237 Table A7.3 Time to source of water Percentage distribution of households according to time to go to source of drinking water, get water and return, and mean time to source of drinking water, MIMS, Zimbabwe, 2009 238 Table A7.4 Person collecting water Percentage distribution of households according to the person collecting drinking water used in the household, MIMS, Zimbabwe, 2009 239 Table A7.5 Use of sanitary means of excreta disposal Percentage distribution of household population according to type of toilet facility used by the household, and the percentage of household population using sanitary means of excreta disposal, MIMS, Zimbabwe, 2009 240 Table A7.6 Disposal of child's faeces Percentage distribution of children aged 0-2 years according to place of disposal of child's faeces, and the percentage of children aged 0-2 years whose stools are disposed of safely, MIMS, Zimbabwe, 2009 241 Table A7.7 Use of improved water sources and improved sanitation Percentage of household population using both improved drinking water sources and sanitary means of excreta disposal, MIMS, Zimbabwe, 2009 242 Table A7.8 Type of dwelling Percentage distribution of households by type of dwelling, MIMS, Zimbabwe, 2009 243 Table A7.9 Type of dwelling walls Percentage distribution of households by type of dwelling walls, MIMS, Zimbabwe, 2009 244 Table A7.10 Type of dwelling floor Percentage distribution of households by type of dwelling floor, MIMS, Zimbabwe, 2009 245 Table A7.11 Type of dwelling roof Percentage distribution of households by type of dwelling roof, MIMS, Zimbabwe, 2009 246 Table A7.12 Number of sleeping rooms Percentage distribution of households by number of sleeping rooms, MIMS, Zimbabwe, 2009 247 xvi Table A7.13 Refuse disposal Percentage distribution of households according to refuse disposal method, MIMS, Zimbabwe, 2009 248 Table A7.14 Status on excreta condition around the household Percentage distribution of households according to status on excreta condition around the household, MIMS, Zimbabwe, 2009 249 Table A7.15 Characteristics of the residential area Percentage distribution of households according to characteristics of the residential area, MIMS, Zimbabwe, 2009 250 Table A7.16 Air quality condition around the household Percentage distribution of households according to air quality condition around the household, MIMS, Zimbabwe, 2009 251 CHAPTER 8: REPRODUCTIVE HEALTH AND FERTILITY Table A8.1 Total Fertility Rates for the 3 Years Preceding the Survey Percentage of women aged 15-49 years currently pregnant, and mean number of children ever born to women age 40-49 years, MIMS, Zimbabwe, 2009 252 Table A8.2 Use of contraception Percentage of women aged 15-49 years currently married or in union who are using (or whose partner is using) a contraceptive method, MIMS, Zimbabwe, 2009 253 Table A8.3 Number of antenatal care visits Percentage of women aged 15-49 years with a live birth during last two years by number of antenatal care visits, MIMS, Zimbabwe, 2009 254 Table A8.4 Timing of first antenatal care Percentage distribution of women who had a live birth during 2 years preceding the survey by timing of first antenatal care visit, MIMS, Zimbabwe, 2009 255 Table A8.5 Antenatal care provider Percentage distribution of women aged 15-49 who gave birth in the two years preceding the survey by type of personnel providing antenatal care, MIMS, Zimbabwe, 2009 256 Table A8.6 Antenatal care Percentage of pregnant women receiving antenatal care among women aged 15-49 years who gave birth in two years preceding the survey and percentage of pregnant women receiving specific care as part of the antenatal care received, MIMS, Zimbabwe, 2009 257 Table A8.7 Place of Delivery Percentage distribution of women 15-49 with a birth in 2 years preceding the survey by place of delivery, MIMS, Zimbabwe, 2009 258 Table A8.8 Assistance during delivery Percentage distribution of women aged 15-49 with a birth in two years preceding the survey by type of personnel assisting at delivery, MIMS, Zimbabwe, 2009 259 CHAPTER 9: EDUCATION Table A9.1 Early childhood education Percentage of children aged 36-59 months who are attending some form of organized early childhood education programme and percentage of first graders who attended pre-school, MIMS, Zimbabwe, 2009 260 Table A9.2 Primary school entry Percentage of children of primary school entry age (6 years) attending grade 1, MIMS, Zimbabwe, 2009 261 xvii Table A9.3 Primary school net attendance ratio, 2009 Percentage of children of primary school age (6-12 years) attending primary school (NAR), MIMS, Zimbabwe, 2009 262 Table A9.4 Primary school net attendance ratio, 2008 Percentage of children of primary school age (6-12 years) attending primary school (NAR), (2008), MIMS, Zimbabwe, 2009 263 Table A9.5 Reasons for not attending primary school Percentage of children of primary school age who do not attend school and reasons for not attending, MIMS, Zimbabwe, 2009 264 Table A9.6 Secondary school net attendance ratio Percentage of children of secondary school age (13-18 years) attending secondary school (NAR), MIMS, Zimbabwe, 2009 265 Table A9.7 Reasons for not secondary attending school Percentage of children of secondary school age who do not attend school and reasons for not attending, MIMS, Zimbabwe, 2009 266 Table A9.8 Secondary school age children attending primary school Percentage of children of secondary school age (13-18 years) attending primary school, MIMS, Zimbabwe, 2009 267 Table A9.9 Children reaching last year of primary school Percentage of children entering first grade of primary school who eventually reach grade 5 and grade 7, MIMS, MIMS, Zimbabwe, 2009 268 Table A9.10 Primary school completion and transition to secondary education Primary school completion rate and transition rate to secondary education, MIMS, Zimbabwe, 2009 269 Table A9.11 Education gender parity Ratio of girls to boys attending primary education and ratio of girls to boys attending secondary education, MIMS, Zimbabwe, 2009 270 Table A9.12 Adult literacy Percentage of women aged 15-24 years that are literate, MIMS, Zimbabwe, 2009 271 CHAPTER 10: CHILD PROTECTION Table A10.1 Birth registration Percentage distribution of children aged 0-59 months by whether birth is registered and reasons for non-registration, MIMS, Zimbabwe, 2009 272 Table A10.2 Knowledge of where to register a birth Percentage of children by whether the mother/caretaker knew where to register a birth, MIMS, Zimbabwe, 2009 273 Table A10.3 Number of travel outside the community during past one year Percentage of women aged 15-49 years by number of travel outside their home community and percent stayed out for more than one month at a time, according to selected characteristics, MIMS, Zimbabwe, 2009 274 Table A10.4 Percentage of women aged 15-49 years in marriage or union before their 15th birthday Percentage of women aged 20-49 years in marriage or union before their 18th birthday, and percentage of women aged 15-19 years currently married or in union, MIMS, Zimbabwe, 2009 275 Table A10.5 Spousal age difference Percentage distribution of currently married/in union women aged 15-19 and 20-24 years according to the age difference with their husband or partner, MIMS, Zimbabwe, 2009 276 Table A10.6 Attitudes toward domestic violence Percentage of women aged 15-49 years who believe a husband is justified in beating his wife/partner in various circumstances, MIMS, Zimbabwe, 2009 277 xviii Table A10.7 Attitudes toward domestic violence Percentage of women aged 15-24 years who believe a husband is justified in beating his wife/partner in various circumstances, MIMS, Zimbabwe, 2009 278 Table A10.8 Knowledge about domestic violence act Percentage distribution of women age 15-49 years by knowledge about domestic violence act, MIMS Zimbabwe, 2009 279 CHAPTER 11: HIV AND AIDS AND ORPHANS AND VULNERABLE CHILDREN Table A11.1 Knowledge of preventing HIV transmission Percentage of women aged 15-49 years who know the main ways of preventing HIV transmission, MIMS, Zimbabwe, 2009 280 Table A11.2 Identifying misconceptions about HIV and AIDS Percentage of women aged 15-49 years who correctly identify misconceptions about HIV and AIDS, MIMS, Zimbabwe, 2009 281 Table A11.3 Comprehensive knowledge of HIV transmission Percentage of women aged 15-49 years who have comprehensive knowledge of HIV and AIDS Transmission, MIMS, Zimbabwe, 2009 282 Table A11.4 Knowledge of mother-to-child HIV transmission Percentage of women aged 15-49 years who correctly identify means of HIV transmission from mother to child, MIMS, Zimbabwe, 2009 283 Table A11.5 Attitudes toward people living with HIV/AIDS Percentage of women aged 15-49 years who have heard of AIDS who express a discriminatory attitude towards people living with HIV and AIDS, MIMS, Zimbabwe, 2009 284 Table A11.6 Knowledge of a facility for HIV testing Percentage of women aged 15-49 years who know where to get an HIV test, percentage of women who have been tested and, of those tested the percentage who have been told the result, MIMS, Zimbabwe, 2009 285 Table A11.7 HIV testing and counselling coverage during antenatal care Percentage of women aged 15-49 years who gave birth in the 2 years preceding the survey who were offered HIV testing and counselling with their antenatal care, MIMS, Zimbabwe, 2009 286 Table A11.8 Children's living arrangements and orphanhood Percentage distribution of children aged 0-17 years according to living arrangements, percentage of children aged 0-17 years in households not living with a biological parent and percentage of children who are orphans, MIMS, Zimbabwe, 2009 287 Table A11.9 Prevalence of orphanhood and vulnerability among children Percentage of children aged 0-17 years who are orphaned or vulnerable, MIMS, Zimbabwe, 2009 288 Table A11.10 School attendance of orphaned and vulnerable children School attendance of children aged 10-14 years by orphanhood and vulnerability, MIMS, Zimbabwe, 2009 289 Table A11.11 School attendance of orphaned children School attendance of children aged 10-14 years by orphanhood, MIMS, Zimbabwe, 2009 290 Table A11.12 Malnutrition among orphans and vulnerable children (WHO standard) Percentage of children aged 0-4 years who are moderately or severely underweight, stunted or wasted by orphanhood and vulnerability due to AIDS, MIMS, Zimbabwe, 2009 291 Table A11.13 Malnutrition among orphans and vulnerable children (NCHS standard) Percentage of children aged 0-4 years who are moderately or severely underweight, stunted or wasted by orphan hood and vulnerability due to AIDS, MIMS, Zimbabwe, 2009 291 xix Table A11.14 Support for children orphaned and vulnerable Percentage of Children Aged 0-17 Years Orphaned or Vulnerable whose Households Received Free Basic External Support in Caring for the Child, MIMS, Zimbabwe, 2009 292 APPENDIX B: SAMPLE DESIGN Table B1 Distribution of sample EAs in total Zimbabwe master sample by province, urban and rural stratum 146 Table B2 Distribution of rural sample EAs in Zimbabwe master sample by province and sector stratum 147 Table B3 Distribution of urban sample EAs in Zimbabwe master sample by province and sector stratum 147 Table B4 Distribution of sample EAs in replicate zero of Zimbabwe master sample by province, urban and rural stratum 147 Table B5 Distribution of sample EAs in replicate one of Zimbabwe master sample by province, urban and rural stratum 148 Table B6 Distribution of sample households and women of reproductive age (15-49 years) in Zimbabwe DHS 2005-06 by state and urban/rural stratum, and corresponding response rates 148 Table B7 Distribution of sample households, currently married women, infants and children in Zimbabwe DHS 2005-06 by state and urban/rural stratum 149 Table B8 Proposed allocation of sample EAs and households for 2009 Zimbabwe MIMS sample by province, urban and rural stratum 150 Table B9 Weight adjust factor for Zimbabwe MIMS 2009 sample households based on sampling frame, by province, urban and rural strata 153 APPENDIX C: ESTIMATES OF SAMPLING ERRORS Table SE.1 Indicators Selected for Sampling Error Calculations List of indicators selected for sampling error calculations, and base populations (denominators) for each indicator, country, year 158 Table SE.2 Sampling Errors: Total sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 159 Table SE.2.1 Sampling Errors: Urban Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 160 Table SE.2.2 Sampling Errors: Rural Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 161 Table SE.2.3 Sampling Errors: Manicaland Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 162 Table SE.2.4 Sampling Errors: Mashonaland Central Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 163 Table SE.2.5 Sampling Errors: Mashonaland East Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 164 xx Table SE.2.6 Sampling Errors: Mashonaland West Province Sample Standard errors, coefficients of variation, design effects (deff), Square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 165 Table SE.2.7 Sampling Errors: Matabeleland North Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 166 Table SE.2.8 Sampling Errors: Matabeleland South Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 167 Table SE.2.9 Sampling Errors: Midlands Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 168 Table SE.2.10 Sampling Errors: Masvingo Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 169 Table SE.2.11 Sampling Errors: Harare Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 170 Table SE.2.12 Sampling Errors: Bulawayo Province Sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, MIMS, Zimbabwe, 2009 171 APPENDIX D: DATA QUALITY TABLES Table DQ.1 Age Distribution of Household Population single-year distribution of household population by sex (weighted), MIMS, Zimbabwe, 2009 172 Table DQ.3 Age Distribution of Eligible and Interviewed Under-5s Household population of children age 0-7, children whose mothers/caretakers were interviewed and percentage of under-5 children whose mothers/caretakers were interviewed (weighted), by five-year age group, MIMS, Zimbabwe, 2009 173 Table DQ.4 Age Distribution of Under-5 children Age distribution of under-5 children by 3-month groups (weighted), MIMS, Zimbabwe, 2009 174 Table DQ.5 Heaping on Ages and Periods Age and period ratios at boundaries of eligibility by type of information collected (household questionnaire), MIMS, Zimbabwe, 2009 175 Table DQ.5 Heaping on Ages and Periods Age and period ratios at boundaries of eligibility by type of information collected (women's questionnaire), MIMS, Zimbabwe, 2009 176 Table DQ.5 Heaping on Ages and Periods Age and period ratios at boundaries of eligibility by type of information collected (women's questionnaire), MIMS, Zimbabwe, 2009 176 Table DQ.6 Percentage of observations missing information for selected questions and indicators (women's questionnaire), MIMS, Zimbabwe, 2009 176 Table DQ.6 Percentage of observations missing information for selected questions and indicators (under-5 questionnaire), MIMS, Zimbabwe, 2009 176 xxi Table DQ.7 Presence of Mother in the Household and the Person Interviewed for the Under-5 Questionnaire Distribution of children under five by whether the mother lives in the same household, and the person interviewed for the under-5 questionnaire, MIMS, Zimbabwe, 2009 177 Table DQ.8 School Attendance by Single Age Distribution of household population age 5-24 by educational level and grade attended in the current year, MIMS, Zimbabwe, 2009 178 Table DQ.9 Sex Ratio at Birth Among Children Ever Born and Living Sex ratio at birth among children ever born, children living, and deceased children by age of women, MIMS, Zimbabwe, 2009 179 Table DQ.10 Distribution of Women by Time Since Last Birth Distribution of women aged 15-49 years with at least one live birth, by months since last birth, MIMS, Zimbabwe, 2009 180 Table DQ.11 Births by Year of Birth Number of births, percentage with complete birth date, sex ratio at birth and calendar year ratio by calendar year, according to living status, MIMS, Zimbabwe, 2009 181 Table DQ.12 Reporting of Age at Death in Days Distribution of reported deaths under one month of age by age at death in days by 5-year periods preceding the survey, MIMS, Zimbabwe, 2009 181 Table DQ.13 Reporting of Age at Death in Months Distribution of reported deaths under two years by age at death in months by 5-year periods preceding the survey, MIMS, Zimbabwe, 2009 182 xxii LIST OF FIGURES PAGE Figure 3.1 Population pyramid, percentage population, MIMS, Zimbabwe, 2009 10 Figure 3.2 Source of household support, percent of households receiving, MIMS, Zimbabwe, 2009 14 Figure 3.3 Type of external household support received, percentage of households, MIMS, Zimbabwe, 2009 14 Figure 3.4 Household population by language mainly used, percentage distribution, MIMS, Zimbabwe, 2009 17 Figure 3.5 household populations by religion, percent distribution, MIMS, Zimbabwe, 2009 17 Figure 3.6 Marital status of population aged 15 and above by sex, percentage distribution, MIMS, Zimbabwe, 2009 18 Figure 3.7 Marital status of female population aged 15 years and above, by rural and urban areas, percentage distribution, MIMS, Zimbabwe. 2009 19 Figure 3.8 Educational level attended by population aged 6 years and above, MIMS, Zimbabwe, 2009 20 Figure 3.9 Total population aged 15-54 years by main usual activity during the past 12 months, MIMS, Zimbabwe, 2009 21 Figure 4.1 Neonatal, post-neonatal, infant, child and under-five mortality rates based on births during the 10-year period preceding the survey, MIMS, Zimbabwe, 2009 28 Figure 4.2 Under-5 mortality rates by background characteristics, MIMS, Zimbabwe, 2009 29 Figure 5.1 Percentage of children under-5 who are undernourished and overweight, World Health Organization (WHO) standard, MIMS, Zimbabwe, 2009 34 Figure 5.2 Percentage of children under-5 who are undernourished and overweight, World Health Organization (NCHS) standard, MIMS, Zimbabwe, 2009 36 Figure 5.3 Percentage of mothers who started breastfeeding within one hour and within one day of birth, MIMS, Zimbabwe 2009 39 Figure 5.4 Percent of living children according to breastfeeding status at each age group by rural/urban area, MIMS, Zimbabwe, 2009 40 Figure 5.5 Percent of living children according to breastfeeding status at each age group by gender, MIMS, Zimbabwe, 2009 41 Figure 5.6 Infant feeding patterns by age: percent distribution of children aged under 3 years by feeding pattern by age group, MIMS, Zimbabwe, 2009 43 Figure 5.7 Proportion of infants aged 0-11 months who were Adequately/appropriately fed, MIMS, Zimbabwe, 2009 45 Figure 5.8 Percentage of infants weighed at birth and weighing less than 2 500 grams at birth, MIMS, Zimbabwe 2009 49 Figure 6.1 Percentage of children aged 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, MIMS, Zimbabwe, 2009 52 Figure 6.2 Percentage of children aged 12-23 months immunized against Hepatitis B at any time before the survey and before the first birthday, MIMS, Zimbabwe, 2009 52 Figure 6.3 Percentage of women aged 15-49 years with a live birth in the last 12 months who are protected against neonatal tetanus, MIMS, Zimbabwe, 2009 53 Figure 6.4 Percentage of children aged 0-59 months with diarhoea in the last two weeks who received Oral Rehydration Treatment (ORT), MIMS, Zimbabwe, 2009 55 xxiii Figure 6.5 Percentage of children aged 0-59 months with diarhoea in the last two weeks who Received Oral Rehydration Treatment (ORT) or increased fluids and continued feeding, MIMS, Zimbabwe, 2009 56 Figure 6.6 Percentage distribution of households according to use of solid fuels for cooking, MIMS, Zimbabwe, 2009 59 Figure 6.7 Availability of electricity on the day of the survey, percentage households, MIMS, Zimbabwe, 2009 61 Figure 6.8 Percentage of children aged 0-59 months who were ill with fever in the two weeks preceding the survey , MIMS, Zimbabwe, 2009 62 Figure 7.1 Percentage distribution of household members by source of drinking water, MIMS, Zimbabwe 2009 66 Figure 7.2 Type of toilet facility used, percentage of the population, MIMS, Zimbabwe 2009 72 Figure 7.3 Households by type of dwelling unit used, by rural and urban areas, percent households, MIMS, Zimbabwe 2009 75 Figure 7.4 Households using dwelling units with finished walls, percent households, MIMS, Zimbabwe 2009 77 Figure 7.5 Households using dwelling units with finished floors, percent households, MIMS, Zimbabwe 2009 78 Figure 7.6 Households using dwelling units with finished roofs, percent households MIMS, Zimbabwe 2009 79 Figure 7.7 Households using three or more sleeping rooms, percent households, MIMS, Zimbabwe 2009 80 Figure 7.8 Households using the appropriate refuse disposal method, percent households MIMS, Zimbabwe 2009 83 Figure 7.9 Households with no excreta visible and very clean recently swept area immediately around the house, percent households, MIMS, Zimbabwe 2009 84 Figure 7.10 Households with appropriate characteristics of the residential area, percent households, MIMS, Zimbabwe 2009 85 Figure 7.11 Households with the no air pollution in the neighbourhood, percent households MIMS, Zimbabwe 2009 86 Figure 8.1 Total fertility rates for the 3 years preceding the survey, MIMS, Zimbabwe, 2009 88 Figure 8.2 The proportion of women aged 15-49 years who gave birth in the two years preceding the survey and who received antenatal care during pregnancy for the recommended four or more times, MIMS, Zimbabwe, 2009 94 Figure 8.3 Women aged 15-49 years who gave birth in the two years preceding the survey, who attended first antenatal care during 0-4 months of pregnancy, percentage women, MIMS, Zimbabwe, 2009 95 Figure 8.4 Percent distribution of women aged 15-49 years who gave birth in the two years preceding the survey by type of personnel providing antenatal care, MIMS, Zimbabwe, 2009 95 Figure 8.5 The percentage of pregnant women aged 15-49 years receiving specific care as part of antenatal care, MIMS, Zimbabwe, 2009 97 Figure 8.6 Percentage distribution of women aged 15-49 years, with a birth in 2 years preceding the survey by place of delivery and province, MIMS, Zimbabwe, 2009 98 Figure 8.7 Percentage distribution of women aged 15-49 years, with a birth in 2 years preceding the survey by place of delivery, MIMS, Zimbabwe, 2009 98 Figure 8.8 Percentage distribution of women aged 15-49 years, with a birth in the 2 years preceding the survey by type of personnel assisting at delivery, MIMS, Zimbabwe, 2009 99 xxiv Figure 9.1 Percentage of children of primary school age (6-12 years) attending primary school, (Net Attendance Ratio), 2008 and 2009, MIMS, Zimbabwe 2009 103 Figure 9.2 Reasons for not attending primary school in the year 2009, percent, MIMS, Zimbabwe, 2009 104 Figure 9.3 Reasons for not attending secondary school in the year 2009, percent, MIMS, Zimbabwe, 2009 105 Figure 9.4 Young women (15-24 years) literacy rate, MIMS, Zimbabwe, 2009 108 Figure 10.1 Percentage distribution of children aged 0-59 months by possession of a birth certificate, MIMS, Zimbabwe 2009 112 Figure 10.2 Reasons for non-registration of births for children aged 6-59 months, MIMS, Zimbabwe, 2009 113 Figure 10.3 Children whose mother/caretaker did not know where to register a birth, percentage children, MIMS, Zimbabwe, 2009 114 Figure 10.4 Mothers/caretakers who had gone away from home for more than one month at a time in the 12 months preceding the survey, percentage woman, MIMS, Zimbabwe, 2009 115 Figure 10.5 Women aged 15-49 years in marriage/union before age 15 years and women aged 20-49 years in marriage/union before age 18 years, percentage, MIMS, Zimbabwe 2009 118 Figure 10.6 Young Women Aged 15-19 Years Currently Married or in Union, MIMS , Zimbabwe, 2009 119 Figure 10.7 Young Women Aged 15-19 Years in Polygamous Marriage or Union, MIMS , Zimbabwe, 2009 120 Figure 10.8 Spousal age difference for currently married /in union women aged 15-19 and 20-24 years, according to the age difference with their husband or partner, MIMS, Zimbabwe, 2009 121 Figure 10.9 Wife beating by husband/partner justification, percent women aged 15-49 years, MIMS, Zimbabwe, 2009 123 Figure 10.10 Knowledge of the domestic violence act by women aged 15-49 years, MIMS, Zimbabwe 2009 126 Figure 11.1 Percent of women aged 15-49 years who have comprehensive knowledge of HIV and AIDS transmission, MIMS Zimbabwe, 2009 130 Figure 11.2 Percentage of women aged 15-49 years who correctly identified means of HIV transmission from mother-to-child, MIMS, Zimbabwe 2009 132 Figure 11.3 Percentage of women aged 15-49 years who have heard of HIV and AIDS who expressed a discriminatory attitude towards people living with HIV and AIDS, MIMS, Zimbabwe 2009 133 Figure 11.4 School attendance of children aged 10-14 years by orphanhood and vulnerability, MIMS, Zimbabwe 2009 140 Figure 11.5 Percentage of children aged 0-4 years who are moderately or severely underweight, stunted or wasted by orphanhood and vulnerability (WHO standard), MIMS, Zimbabwe, 2009 142 Figure 11.6 Orphans and vulnerable children aged 0-17 years whose households received free basic formal external support in caring for child, percentage, Zimbabwe, MIMS, 2009 143 xxv LIST OF ABBREVIATIONS ACRWC African Charter on the Rights and Welfare of the Child AFASS Affordable, feasible, accessible, sustainable and safe AIDS Acquired Immuno-deficiency Syndrome ANC Antenatal Care ARI Acute Respiratory Infection ARV Anti- Retroviral drug BCG Bacillus-Calmette-Guerin BEAM Basic Education Assistance Module BoP Balance of Payment CDC Centres for Disease Control and Prevention CEDAW The Convention on the Elimination of all Forms of Discrimination against Women CHDs Child Health Days CIET Commission of Inquiry into Education and Training CO Carbon Monoxide CPR Contraceptive Prevalence Rate CRC Convention on the Rights of the Child CSFP Child Supplementary Feeding Programme CSO Central Statistical Office CSPro Census and Survey Processing System DK Don’t know DPT Diphtheria, Pertussis and Tetanus EAs Enumeration Areas ECD Early Childhood Development EFA Education for All EPI Expanded Programme of Immunization ESPP Enhanced Social Protection Project FDI Foreign Direct Investment GDP Gross Domestic Product GPA Global Political Agreement GPI Gender Parity Index Hep Hepatitis HH Household HIV Human Immuno-deficiency Virus IMR Infant Mortality Rate IPT Intermittent Presumptive Treatment IQ Intelligence Quotient ITN Insecticide Treated Net IU International Units IUD Intrauterine Devices LAM Lactational Amenorrhoea LPG Liquefied Petroleum Gas LSCFA Large Scale Commercial Farming Areas MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MIMS Multiple Indicator Monitoring Survey MTP Medium-Term Plan MUAC Mid-Upper-Arm Circumference xxvi NAC National AIDS Council NAP National Action Plan for Orphans and Vulnerable Children NAR Net Attendance Ratio NCHS National Centre for Health Statistics NER Net Enrollment Ratio NGOs Non-Governmental Organizations ORS Oral Rehydration Salts ORT Oral Rehydration Treatment OVC Orphans and Vulnerable Children PMTCT Prevention of Mother-to-Child Transmission PoS Programme of Support PPS Probability Proportional to Size PSUs Primary Sampling Units RHF Recommended Home Fluid SD Standard Deviation SE Sampling Error SIRDC Scientific Industrial Research and Development Center SMT Survey Management Team SO2 Sulphur Dioxide SPSS Statistical Package for the Social Sciences SSCFA Small Scale Commercial Farming Areas STERP Short-Term Emergency Recovery Programme STIs Sexually Transmitted Infections TBA Traditional Birth Attendant (trained) TFR Total Fertility Rate TT Tetanus Toxoid UDHR Universal Declaration of Human Rights UNAIDS The Joint United Nations Programme on HIV and AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund US$ United States Dollar VHW Village Health Workers VIP Ventilated Improved Pit Latrine WFFC World Fit for Children WHO World Health Organization ZDHS Zimbabwe Demographic and Health Survey ZEPI Zimbabwe Expanded Programme on Immunization ZMS02 Zimbabwe Master Sample 2002 Population Census N/A Not applicable * In tables represents an unweighted sample of less than 25 () In tables represents an unweighted sample of less than 50 xxvii PREFACE This is the first Multiple Indicator Monitoring Survey (MIMS), a customized version of the Multiple Indicator Cluster Survey (MICS) Round 3 which was conducted in Zimbabwe between April and May of 2009. The MIMS was designed to collect information on a large number of socio-economic and health indicators required to inform the planning, implementation and monitoring of national policies and programmes for enhancing the welfare of children and women. The MIMS also plays an important role in informing national policies such as the Short-Term Emergency Recovery Programme (STERP), 2009 and the Medium-Term Plan (MTP) 2010 – 2014. In addition, the MIMS also provides indicators for monitoring almost half of the 2015 Millennium Development Goals (MDGs), the 2010 World Fit for Children (WFFC) Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session (UNGASS), 2001 on the human immuno-deficiency virus (HIV) and the acquired immuno-deficiency syndrome (AIDS), and the African Summit on Malaria, 2000. This Main Report, produced following the publication of a MIMS Preliminary Report in November 2009, consists of 11 chapters as follows: Chapter 1 which is the introduction; Chapter 2 on sample and survey methodology; Chapter 3 on sample coverage and the characteristics of households and respondents; Chapter 4 on child mortality; Chapter 5 on child nutrition; Chapter 6 on child health; Chapter 7 on the environment; Chapter 8 on reproductive health; Chapter 9 on education; Chapter 10 on child protection; and Chapter 11 on HIV and AIDS and orphaned and vulnerable children. The Zimbabwe National Statistics Agency (ZIMSTAT), formerly the Central Statistical Office (CSO) wishes to acknowledge the efforts of various institutions and individuals who worked tirelessly to make this survey a success. The technical and financial assistance that was provided by the United Nations Children’s Fund (UNICEF) throughout the survey period is greatly appreciated. In addition, the contribution by various consultants in the areas of sampling, data processing and report writing, the media and the various stakeholders who participated in MIMS workshops cannot be overemphasized. This survey would not have been possible without the unwavering commitment of the Survey Management Team (SMT), field and data entry personnel and the patience and cooperation of respondents. The ZIMSTAT would also like to acknowledge the following institutions who are members of the MIMS Steering and Technical Committees for their valuable contribution towards the success of the survey: Ministry of Finance; Ministry of Health and Child Welfare; Ministry of Education, Sport, Arts and Culture (formerly Ministry of Education, Sport and Culture); Ministry of Labour and Social Services, (formerly Ministry of Public Service, Labour and Social Welfare); Ministry of Water Resources Development and Management, (formerly Ministry of Water Resources and Infrastructural Development); Ministry of Transport and Infrastructural Development; Ministry of Environment and Natural Resource Management, (formerly Ministry of Environment and Tourism); Ministry of Economic Planning and Investment Promotion, (formerly Ministry of Economic Development); Ministry of Women’s Affairs, Gender and Community Development; Ministry of Local Government, Urban and Rural Development; Ministry of Public Works, (formerly part of the Ministry of Local Government, Public Works and Urban Development); Ministry of Justice and Legal Affairs, (formerly Ministry of Justice, Legal and Parliamentary Affairs); Ministry of Media, Information and Publicity, (formerly Ministry of Information and Publicity); Food and Nutrition Council of the Scientific Industrial Research and Development Center (SIRDC); National AIDS Council (NAC); United Nations Population Fund (UNFPA); United Nations Development Programme (UNDP); the Joint United Nations Programme on HIV and AIDS (UNAIDS); World Health Organization (WHO); Centres for Disease Control and Prevention (CDC); and the World Bank. The input of the Harare City Health Department is greatly appreciated. M. Nyoni ACTING DIRECTOR GENERAL ZIMBABWE NATIONAL STATISTICS AGENCY (ZIMSTAT) xxviii EXECUTIVE SUMMARY This Report presents the detailed findings of the Zimbabwe Multiple Indicator Monitoring Survey (MIMS), conducted by the Zimbabwe National Statistics Agency (ZIMSTAT), formerly the Central Statistical Office (CSO) in April and May 2009, with financial and technical assistance from the United Nations Children’s Fund (UNICEF). The MIMS is a nationally representative survey of 12 500 households, 12 488 women aged 15-49 years and 7 499 children aged under -5 years. It allows for the estimation of some key indicators at the national and provincial levels. This is the first MIMS, a customized version of the Multiple Indicator Cluster Survey (MICS) Round 3. The MIMS is part of a worldwide survey program, originally developed to measure progress towards an internationally agreed set of goals that emerged from the 1990 World Summit for Children. This Main Report covers the following areas; sample and survey methodology, sample coverage and the characteristics of households and respondents, child mortality, child nutrition, child health, environment, reproductive health, education, child protection, and HIV and AIDS and orphaned and vulnerable children. This survey was conducted timeously when Zimbabwe was experiencing unprecedented socio- economic challenges which had direct implications on the welfare of children and women. The overall outcome of these continuous challenges in the past decade has been that the country’s real annual Gross Domestic Product (GDP) growth rate cumulatively declining by around 46 percent during the period 2000 to 2008 and annual hyper-inflation reaching a peak of 231 million percent in July 2008. The challenging socio-economic environment was exacerbated by recurrent droughts, the impact of the underlying HIV and AIDS pandemic and the cholera outbreak of 2008/2009 within the context of international isolation. With the signing of Zimbabwe’s Global Political Agreement (GPA) in September 2008, leading to the formation of an Inclusive Government in 2009, the country saw the introduction of multiple stable currencies in the economy in February 2009, resulting in macro-economic stability. CHILD MORTALITY For the ten years preceding the survey, Zimbabwe had neonatal, infant and under-5 mortality rates of 28, 60 and 86 per 1 000 live births respectively, with males having higher rates than females. For infant and under-5 mortality rural areas had higher rates than urban ones whilst for the neonatal mortality the opposite was true. For the five year period preceding the survey, all childhood mortality rates have increased from the Zimbabwe Demographic and Health Survey (ZDHS) (2005/06) levels as follows: neonatal mortality rate from 24 to 30 per 1 000 live births; post neonatal mortality rate from 36 to 37 per 1 000 live births; infant mortality rate from 60 to 67 per 1 000 live births; child mortality rate from 24 to 29 per 1 000 children surviving to the first birthday; and under-5 mortality rate from 82 to 94 per 1 000 live births. CHILD NUTRITION Using the latest World Health Organization (WHO) standard in estimating child nutrition, nationally, 35 percent of the children aged 6-59 months were stunted, 2 percent were wasted, and 12 percent were underweight while 3 percent were overweight. This means that Zimbabwe had severe stunting, mild wasting and moderate underweight malnutrition. Rural areas had higher levels of malnutrition than urban areas according to the three indices whilst the reverse was true for the overweight indicator. The stunting level in rural areas was 37 percent compared to 30 percent in urban areas, while wasting was 3 percent and 2 percent for rural and urban areas, respectively. Underweight in rural areas was 13 percent compared to 9 percent in urban areas. Males had higher malnutrition levels than females. For the National Centre for Health Statistics (NCHS) standard, nationally, 29 percent of the children aged 6-59 months were stunted, 2 percent were wasted, and 16 percent were underweight while 2 percent were overweight. This means that Zimbabwe had severe stunting, mild wasting and moderate underweight malnutrition. Rural areas had higher levels of malnutrition than urban areas according to the three indices whilst the reverse was true for the overweight indicator. The stunting level in rural areas was 31 percent compared to 24 percent in urban areas, while wasting was 2 percent and 1 percent for rural and urban areas, respectively. Underweight in rural areas was 18 percent compared to 12 percent in urban areas. xxix Exclusive breastfeeding for children under 6 months, although improving, was still very low in Zimbabwe. Twenty six (26) percent of children aged less than 6 months were exclusively breastfed, a level considerably lower than the ideal 100 percent. A higher proportion of children under 6 months (29 percent) in urban areas were exclusively breastfed compared to their rural counterparts (25 percent). A higher proportion of male children (29 percent) were exclusively breastfed in the first 6 months of birth compared to their female counterparts (23 percent). Overall, 66 percent of infants born in the two years preceding the survey were weighed at birth and 11 percent of infants were estimated to weigh less than 2 500 grams at birth. There was no rural- urban difference in low birth weight and generally there was little variation by province. CHILD HEALTH Full child immunization coverage was low and had worsened in Zimbabwe in the last three years. The percentage of children aged 12-23 months who had been fully immunized before their first birthday was 37 percent in 2009, compared to 41 percent in 2005/06. The percentage of children aged 12-23 months who had been immunized at any time before the survey and had full vaccination was 49 percent. Urban areas had higher full immunization coverage at any time before the survey (62 percent) than rural areas (43 percent). However, for individual vaccinations, immunization coverage was relatively high and had improved from the ZHDS 2005/06 levels. Approximately 91 percent and 84 percent of children aged 12-23 months received a Bacillus-Calmette-Guerin (BCG) and the first dose of Diphtheria, Pertussis and Tetanus (DPT) vaccinations, respectively, by the age of 12 months. The percentage declines for subsequent doses of DPT to 78 percent for the second dose, and 63 percent for the third dose. Similarly, 89 percent of children received Polio 1 by age 12 months and this declined to 79 percent by the second dose to 61 percent by the third dose. The coverage for measles vaccine by 12 months was lower than for the other vaccines at 69 percent. Approximately 84 percent of children aged 12-23 months received a Hepatitis B1 vaccination by the age of 12 months. The percentage declined for subsequent doses of Hepatitis B vaccinations to 76 percent for the second dose, and 61 percent for the third dose. For all individual vaccines, urban areas had higher vaccination rates than rural areas. At national level, 11 percent of the children under-5 years of age had diarrhoea in the last two weeks preceding the survey with no gender and rural-urban differentials. Children aged 12-23 months, which coincides with the weaning period, had the highest diarrhoea prevalence of 19 percent. Overall, 35 percent of the children either received Oral Rehydration Treatment (ORT) or increased fluids intake and continued feeding as is recommended. Children in urban areas who had diarrhoea in the two weeks preceding the survey had a higher likelihood of receiving the recommended treatment (46 percent) compared to those in the rural areas (31 percent). Six (6) percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey, with no significant gender differentials. Rural areas had a slightly higher proportion (7 percent) of children who had symptoms of pneumonia than urban areas (5 percent). Of all the children who had suspected pneumonia in the last two weeks preceding the survey, 16 percent received antibiotics. Urban areas had a higher percentage of children (25 percent) with suspected pneumonia, who received antibiotics than their rural counterparts (14 percent). The majority of households, 68 percent used wood as fuel for cooking, 31 percent used electricity with insignificant proportions using other fuel types. Overall, about (69 percent) of all households in Zimbabwe were using solid fuels for cooking, which was mainly wood. Use of solid fuels was lower in urban areas (16 percent), but very high in rural areas, where almost all of the households (97 percent) are using solid fuels. It is of concern that in Zimbabwe there is universal usage of open fire and open stove/coal pot for cooking by those households using solid fuels, with negative implications for the health, especially of women and children. The proportion of under fives who had experienced episodes of fever in the last two weeks preceding the survey was 8 percent, with no significant gender or rural-urban differentials. Results indicated that 17 percent of the children aged 0-59 months slept under an Insecticide Treated Net (ITN). A very high proportion, about three quarters of the children (76 percent) did not sleep under a bed net. xxx Overall, one in four (24 percent) of children aged 0-59 years with fever in the last two weeks were treated with an “appropriate” anti-malarial drug and 14 percent received any appropriate anti-malarial drugs within 24 hours of onset of symptoms. For women, nationally, 14 percent of those aged 15-49 years who gave birth during the two years preceding the survey received intermittent preventative treatment (IPT) for malaria during pregnancy. Rural areas had a higher proportion (16 percent) of women who had received IPT than urban areas (8 percent). ENVIRONMENT Nearly three quarters (73 percent) of the population used an improved water source compared to 78 percent in the ZDHS 2005/06. This implies a worsening situation. Most people (98 percent) in urban areas used an improved water source compared to rural areas with 61 percent. The ZDHS 2005/06 urban and rural proportions were 99 percent and 67 percent, respectively, indicating a worsening situation in the use of improved drinking water sources, mainly in the rural areas. Nationally, 35 percent of the population used drinking water appropriately treated at household level irrespective of its source (urban areas-50 percent, rural areas-28 percent). Water treatment by households of those people who used unimproved drinking water sources was very low in Zimbabwe. A third (33 percent) of those people, who used unimproved drinking water sources, had the water treated appropriately at household level (urban areas - 46 percent, rural areas - 33 percent). Use of improved sanitation facilities seemed to be on the increase in Zimbabwe. Sixty (60) percent of the population in Zimbabwe used improved toilet facilities compared to 42 percent in the ZDHS 2005/06. Urban areas had a very high proportion of the population (97 percent) using improved sanitation facilities compared to rural areas (43 percent). It is of concern that a third (33 percent) of Zimbabwe’s population had no toilet facility and used the bush or field. This percentage was high in rural areas (48 percent) and one percent in urban areas. In Zimbabwe, 54 percent of the children aged 0-2 years had their stools disposed of safely. Urban areas had a higher proportion (94 percent) of the children aged 0-2 years with stools disposed of safely compared to rural areas (38 percent). About half (52 percent) of the population lived in households that were using improved sources of drinking water and sanitary means of excreta disposal. A very high proportion (95 percent) of urban households did so compared to 31 percent of rural households. At national level, 86 percent of the households were using dwelling units with finished walls. Urban areas had near universal (98 percent) use of dwelling units with finished walls compared to rural areas (79 percent). Nearly two thirds (65 percent) of the households were using dwelling units with finished floors. Urban areas had a very high proportion (96 percent) use of dwelling units with finished floors compared to rural areas (48 percent). Almost another two thirds (64 percent) of the households were using dwelling units with finished roofs. Urban areas had near universal (99 percent) use of dwelling units with finished roofs compared to rural areas (45 percent). Internationally, the recommended average number of persons per sleeping room for healthy housing is two person per sleeping room, (WHO, 1988, 2004). Nationally, the mean number of persons per sleeping room was 2.5 indicating a general state of over-crowdedness in the population. Rural areas were more overcrowded with a higher mean number of persons per sleeping room (2.6) compared to urban areas (2.3). Forty nine (49 percent) of the households in Zimbabwe dumped garbage in a rubbish pit, followed by those who dumped garbage elsewhere (30 percent), burnt garbage (7 percent), buried garbage , dumped garbage in public dump and had garbage collected (4 percent each) and dumped garbage in public container (2 percent). Considering safe refuse disposal, 58 percent of the households used this method. Rural areas had a higher proportion (65 percent) of households who used a safe refuse disposal method compared to urban areas (46 percent). For a high proportion of households (83 percent) it was observed that there was no air pollution in the neighbourhood. The proportion of households with no air pollution in the neighbourhood was higher in rural areas (91 percent) than urban areas (69 percent). xxxi REPRODUCTIVE HEALTH Zimbabwe’s Total Fertility Rate (TFR) for the 3-year period preceding the MIMS survey was 3.7 children per woman. Rural areas had a higher TFR (4.4 children per woman) than the urban areas (2.6 children per woman). The contraceptive prevalence rate (CPR) for Zimbabwe for women aged 15-49 years currently married or in union who were using (or whose partner was using) a family planning method, was relatively high at 65 percent. However, Zimbabwe still has some way to go in order to reach universal family planning. Urban areas had a higher CPR of 69 percent than rural areas (63 percent). The most common method of contraception was the pill (50 percent), followed by injectables (8 percent), implants and male condoms (2 percent each) and female sterilization, male sterilization, intrauterine devices (IUD), female condom, diaphragm/foam jelly, periodic abstinence, withdrawal and the lactational amenorrhea method (LAM) (less than one percent each). Thirty five (35) percent of the women did not use any contraception. The proportion of women using any modern method of contraception was 63 percent whilst 2 percent used any traditional method. For Zimbabwe, the proportion of women aged 15-49 years who gave birth in the two years preceding the survey and who received antenatal care (ANC) during pregnancy for the recommended four or more times remained low at 57 percent. Urban areas had a higher proportion (60 percent) of women who received ANC during pregnancy four or more times compared to rural areas (56 percent). However, nationally, 93 percent of women aged 15-49 years who gave birth in two years preceding the survey received ANC during pregnancy at least once. Generally, there were no major differences of ANC coverage by rural and urban areas. Seven (7) percent of the women did not receive ANC at all. Considering the WHO recommended gestation at first ANC of 0-4 months, nationally, timely first ANC visit was low, with 31 percent of the women aged 15-49 years having attended the first ANC visit within this period (rural areas-32 percent, urban areas-30 percent). Timely first ANC visit increased with education of woman and generally with wealth and had no relationship with age of woman. Nationally, 59 percent of women aged 15-49 years who gave birth in two years preceding the survey delivered in health institutions (urban areas-86 percent, rural areas-48 percent), while 39 percent delivered at home (rural areas-50 percent, urban areas-10 percent). However, it is of concern that a relatively high proportion of the women delivered at home. Cases of home delivery have generally been on the increase since 1999, in the context of economic hardships and a weakened health delivery system. Sixty (60) percent of births which occurred in the two years preceding the survey were delivered by skilled health personnel (urban areas - 90 percent, rural areas - 49 percent). EDUCATION Overall, only 18 percent of children aged 36-59 months were attending pre-school, with a greater proportion of girls (20 percent) than boys (15 percent). Urban-rural differentials were not significant (urban-19 percent, rural-17 percent). In contrast, in 2009, three quarters (75 percent) of the children who were attending the first grade of primary school had attended pre-school the previous year. The proportion in the first grade of primary school with pre-school background among girls is slightly higher (76 percent) than boys (74 percent). Urban areas had a higher proportion of children (80 percent) who had attended pre-school the previous year compared to 72 percent of the children living in rural areas. Zimbabwe had a primary school net attendance ratio (NAR) of 91 percent implying that 9 percent of the children of primary school going age were not attending school in 2009. Girls had a slightly higher NAR of 92 percent than boys with 90 percent. Urban areas had a higher NAR (94 percent) than rural areas (90 percent). It is of concern that of the children of primary school going age who had not attended school in 2009, 71 percent of them had not done so because of financial constraints. A higher proportion of girls (74 percent) did not attend primary school because of financial constraints compared to boys (68 percent). For the majority who did not attend primary school due to financial reasons, rural areas had a higher proportion (73 percent) compared to urban areas (60 percent). Zimbabwe had a secondary school ((Form 1 to 6) NAR of 45 percent with no gender difference (urban areas-59 percent, rural areas-39 percent). Of the children of secondary school going age who had not attended school in 2009, 59 percent of them had not done so because of financial constraints. The other main reasons for non-attendance included marriage/pregnancy (9 percent) graduated/finished school/satisfied (8 percent) and not interested in school (7 percent). A higher proportion of boys (63 percent) did not attend secondary school because of financial constraints compared to girls (55 xxxii percent). For the majority who did not attend secondary school for financial reasons, rural areas had a higher proportion (64 percent) compared to urban areas (44 percent). The majority of the children starting grade one, (82 percent) will eventually reach Grade 7. Girls had a higher survival rate (85 percent) than boys (80 percent). Urban areas had a higher Grade 7 survival rate (88 percent) than rural areas (80 percent). The transition rate to secondary school was 81 percent, with a slightly higher proportion for girls (82 percent) than boys (80 percent). Urban areas had a higher transition rate to secondary education (91 percent) than rural areas (76 percent). There was gender parity for primary school with a Gender Parity Index (GPI) of 0.98 which is close to 1.00, with no rural-urban differences. For secondary education, there was gender parity at national level with a GPI of 1.01. However, in urban areas secondary school attendance was in favour of boys with a GPI of 0.86, whilst in the rural areas it was the reverse with a GPI in favour of girls of 1.08. A very high proportion (91 percent) of the women aged 15-24 years were literate with urban areas having a higher proportion (97 percent) than rural ones (87 percent). Nationally, 87 percent of the women aged 15-49 years were literate with urban areas having a higher proportion (96 percent) than rural ones (82 percent). CHILD PROTECTION Nationally, 38 percent of the births of under-5 year olds were registered. Urban areas had a higher percentage (57 percent) of under-5s with birth certificates than rural areas (30 percent). Thirty seven (37) percent of children under-5 years in Zimbabwe had birth certificates at hand with no gender differentials. Urban areas had a higher percentage (55 percent) of under-5s with birth certificates than rural areas (30 percent). Child births were not being registered mainly because fathers were not around or had no time (cited for 28 percent of the births not registered). The other reasons included the following: parents not having National Identity Card or Birth Certificate (24 percent), cost too high (13 percent) and place of registration far (8 percent). Nationally, 92 percent of the mothers and caretakers knew where to register child births, with no urban and rural differences. For the young women, nationally, 21 percent of women aged 15-19 years in Zimbabwe were married or in union at the time of the survey (rural areas - 28 percent, urban areas - 10 percent). About 10 percent of the women aged 15-49 years were in a polygamous union at the time of the survey, with rural areas having a higher proportion (12 percent) and urban areas having half of that proportion (6 percent). A tenth of the young women aged 15-19 years were in a polygamous union at the time of the survey, with rural areas having a higher proportion (10 percent) than urban areas (7 percent). In the MIMS (49 percent) of all women aged 15-49 years believed that a husband was justified in beating his wife/ partner for any of the following: when a wife goes out without telling him; when a wife neglects the children; when she argues with him; when she refuses sex with him and when she burns the food. The highest proportion of women (35 percent) believed that a husband was justified in beating his wife/partner when she neglected children. This was followed by those who believed that wife beating was justified if a wife went out without telling her husband (24 percent); when she argued with her husband (22 percent); when she refused to have sex with her husband (19 percent); and when she burnt food (10 percent). HIV AND AIDS AND ORPHANED AND VULNERABLE CHILDREN Nearly all the women (99 percent) aged 15-49 years had heard about human immuno-deficiency virus and the acquired immuno-deficiency syndrome (HIV and AIDS). Ninety seven (97) percent of the women knew at least one way of preventing HIV transmission, whilst (63 percent) knew all the three ways of preventing HIV transmission namely: having only one faithful uninfected sex partner; using a condom every time; and abstaining from sex. Urban areas had a higher proportion (68 percent) who knew all the three ways of preventing HIV transmission compared to rural areas (60 percent). Nationally, comprehensive knowledge about HIV transmission remains low. Slightly over half, (55 percent) of the women aged 15-49 years had comprehensive knowledge of HIV transmission, (urban areas - 66 percent, rural areas - 48 percent). A very high proportion (96 percent) of women knew that HIV can be transmitted from mother-to-child in Zimbabwe, (urban areas - 98 percent; rural areas xxxiii - 95 percent). The percentage of women who knew all three ways of mother-to-child transmission namely; during pregnancy, at delivery and through breastmilk, was 65 percent, (urban areas - 68 percent; rural areas - 64 percent). Overall, 43 percent of the women disagreed with all the four HIV and AIDS discriminatory statements, leaving a relatively high proportion (57 percent) still showing stigma and discrimination towards people living with HIV and AIDS. The four discriminatory statements were as follows: would not care for a family member who was sick with AIDS; if a family member had HIV I would want to keep it a secret; believe that a teacher with HIV should not be allowed to work; and would not buy food from a person with HIV and AIDS. This level of stigma and discrimination, however, is a marked decline from the ZDHS 2005/06 level of 83 percent. Rural areas (66 percent) had higher levels of stigma and discrimination than urban areas (42 percent). A high proportion 85 percent of women knew where to be tested for HIV, while 45 percent had actually been tested. Women from urban areas had a higher likelihood of knowing where to get tested for HIV, to have been tested and to have been told the test result than their rural counterparts. Nearly two-thirds (66 percent) of the women aged 15-49 years, who gave birth in the two years preceding the survey were provided with information about HIV prevention during ANC visits for the last pregnancy, (urban areas - 79 percent, rural areas - 61 percent). Nationally, 53 percent of women aged 15-49 years, who gave birth in the two years preceding the survey who had been tested received their HIV test result at the ANC visit for the last pregnancy, (urban areas - 68 percent, rural areas - 48 percent). Overall, 26 percent of the children were not living with a biological parent. The girl child was more likely not to live with a biological parent than the boy child. Rural areas had a higher proportion (28 percent) of children not living with a biological parent than urban areas (22 percent). Zimbabwe had an orphanhood prevalence of 24 percent, with no major gender differentials. Rural areas had higher orphanhood prevalence (25 percent) than urban areas (20 percent). Nationally the paternal orphanhood prevalence was 13 percent, while maternal orphanhood prevalences was much lower at 4 percent. The double orphanhood prevalence was 7 percent at national level. Thirty seven (37) percent of all the children aged 0-17 years were orphans and vulnerable. Orphans constituted 67 percent of orphans and vulnerable children (OVC) compared to 79 percent in the ZDHS 2005/06. Rural areas had a higher OVC prevalence (39 percent) than urban areas (31 percent). In Zimbabwe, 11 percent of children aged 10-14 years had lost both parents. The double orphan to non-orphan school attendance ratio was 0.90, showing that double orphans were disadvantaged compared to the non-orphaned children in terms of school attendance. Nationally, 47 percent of children aged 10-14 years were OVC, with an OVC-to-non-OVC school attendance ratio of 0.93 with no gender differences. Using the WHO standard, the overall underweight ratio of OVC to non-OVC was 1.08, stunting ratio (1.07) and wasting ratio (0.76). This means that OVC were more vulnerable to underweight and stunting than non-OVC, whilst for wasting the reverse was true. For the NCHS standard the overall underweight ratio of OVC to non-OVC was 1.14, stunting ratio (1.12) and wasting ratio (0.82). Twenty one (21) percent of the OVC had received some form of formal external support in the past 3 or 12 months preceding the survey (rural areas - 23 percent; urban areas 13 percent), while the majority (79 percent) did not. Urban areas had a higher proportion (87 percent) of OVC who did not receive any formal external support than rural areas (77 percent). The highest proportion of OVC (13 percent) received formal external support in the form of social and material support, followed by educational support (6 percent), emotional and psychosocial support (4 percent) and medical support (2 percent). Rural areas had higher proportions of OVC receiving formal external support than urban areas for all forms of support. xxxiv 1 CHAPTER 1 INTRODUCTION This introductory chapter covers the background to and objectives of the Zimbabwe Multiple Indicator Monitoring Survey (MIMS). It also highlights the content of this report. A brief socio- economic background of Zimbabwe concludes the chapter providing a broader context to the MIMS. 1.1 BACKGROUND This Report presents the detailed findings of the Zimbabwe Multiple Indicator Monitoring Survey (MIMS), conducted by the Zimbabwe National Statistics Agency (ZIMSTAT), formerly the Central Statistical Office (CSO), in April and May 2009, with financial and technical assistance from the United Nations Children’s Fund (UNICEF). The MIMS 2009 is a customised version of the third Multiple Indicator Cluster Survey1 (MICS3), which collects a broad array of valuable information on the situation of children and women in Zimbabwe. The MICS has been harmonized with other data collection efforts so that it produces internationally comparable information, which is the cornerstone of evidence-based decision making and formulation of policies, strategies and interventions, aimed at the improvement of the lives of children, women and other vulnerable groups. The MICS uses three modular questionnaires that can be customized to fit national data needs. It measures key indicators on the following topics: nutrition, child mortality, child health, reproductive health, child development, education, child protection, HIV and AIDS, sexual behaviour and Orphans and Vulnerable Children (OVC). In the process of customizing MICS3 to MIMS, additional non-MICS questions on household expenditure, migration, and environmental assessment were added and some modules such as child development and sexual behaviour were excluded. However, the MIMS data collection instruments remained mostly the same as the global MICS instruments to ensure comparability with national data sets such as the Zimbabwe Demographic and Health Survey (ZDHS) as well as data from other countries. The MIMS was based on the need to monitor progress towards goals and targets emanating from recent international agreements such as the Millennium Declaration which enshrines the Millennium Development Goals (MDGs), adopted by all 191 United Nations Member States in September 2000; the Plan of Action of A World Fit For Children (WFFC), adopted by 189 Member States at the United Nations Special Session on Children in May 2002; the Convention on the Rights of the Child, 1989; and the Convention on the Elimination of All Forms of Discrimination against Women, 1979 and the United Nations General Assembly Special Session (UNGASS), 2001 on the human immuno-deficiency virus (HIV) and the acquired immuno- deficiency syndrome (AIDS). All these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for women and children and to monitor progress towards that end. UNICEF was assigned a supporting role in this task as highlighted in Appendix Box A. Zimbabwe is a signatory and reports to the United Nations on all these international commitments. This final report presents in a total of 11 chapters, the results of the indicators and topics covered in the survey as follows: Chapter 1 is the introduction; followed by chapter 2 covering sample and survey methodology; and chapter 3 presents the sample coverage and the characteristics of households and respondents. The results are presented in the following chapters: chapter 4 on child mortality; chapter 5 on child nutrition; chapter 6 covers child health; chapter 7 looks at the environment including water and sanitation; chapter 8 covers 1 For more information on MICS3 see www.childinfo.org. 2 reproductive health; chapter 9 on education; chapter 10 on child protection; while chapter 11 concludes the report covering HIV and AIDS and orphaned and vulnerable children. The report appendices include details on the sample design (Appendix B), estimates of sampling errors (Appendix C), data quality tables (Appendix D), MICS indicators (Appendix E), MIMS data tables (Appendix F), list of personnel involved in the survey (Appendix G), and questionnaires (Appendix H). 1.2 SURVEY OBJECTIVES The MIMS, a customized version of the MICS3, is part of a worldwide survey program, originally developed to measure progress towards an internationally agreed set of goals that emerged from the 1990 World Summit for Children. Specifically, the MIMS 2009 objectives were to: • collect socio-economic data that will bring out an array of information on health, human capital and well-being of the population that can be used as a baseline for development interventions; • provide decision makers with evidence on children’s and women’s rights and other vulnerable groups in Zimbabwe; • serve as a monitoring tool on almost half of all the 2015 Millennium Development Goal (MDG) indicators, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action; and • build capacity of national partners in data collection, compilation, processing, analysis and reporting. 1.3 SOCIO-ECONOMIC BACKGROUND This survey was conducted timeously when Zimbabwe was experiencing unprecedented socio- economic challenges which had direct implications on the welfare of children and women. The last comparable household survey, the Zimbabwe Demographic and Health Survey (ZDHS), had been conducted in 2005/2006 and since then major socio-economic changes had occurred in the country. Zimbabwe has been experiencing a multiplicity of development challenges since 2000 to 2009, starting with the 1999/2000 Cyclone Eline floods that devastated some infrastructure and crops. Furthermore, droughts of 2001/2002, 2002/2003, 2004/2005 and 2006/2007 compounded the challenge of severe macroeconomic instability that was being experienced in the country during this period. The macroeconomic instability was characterized by hyperinflation, which reached an annual inflation rate of 231 million percent in July 2008. All this took place within a context of general international isolation of the country. The hyperinflationary environment adversely affected basic social services delivery in health, education, water and sanitation and social protection, particularly in the last quarter of 2008. The health and education sectors, for example, experienced severe budgetary constraints as well as an exodus of skills to other countries in the region and abroad, thus, weakening the country’s social delivery system. The overall outcome of these continuous challenges in the past decade has been that the country’s real annual Gross Domestic Product (GDP) growth rate cumulatively declined by around 46 percent during the period 2000 to 2008. The declining economy was openly characterized by various shortages including foreign currency, basic food, fuel, medical supplies, and water among others. On the social front, the economic challenges resulted in high levels of structural unemployment and underemployment, poverty and food insecurity, (Government of 3 Zimbabwe, Poverty Assessment Study Survey, 2003). The challenging socio-economic environment was exacerbated by the impact of the underlying HIV and AIDS pandemic and the cholera outbreak of 2008/2009. According to the Ministry of Health and Child Welfare, the cholera epidemic affected around 100 000 people resulting in an estimated 4 300 deaths. With the signing of Zimbabwe’s Global Political Agreement (GPA) in September 2008, leading to the formation of an Inclusive Government in 2009, the country saw the introduction of multiple stable currencies in the economy in February 2009. This move stabilized the macroeconomic environment, as reflected by a single digit hard currency inflation experienced since then. However, economic recovery remains highly constrained by weak aggregate demand and lack of domestic and foreign direct investment (FDI) in an environment of limited Balance of Payment (BoP) support. In such a transitionary environment of socio-economic recovery towards sustained growth and development, it is critical that policy, planning and programming be informed by recent and comprehensive data sets such as the MIMS. In this regard, this main report presents the results of the MIMS. 4 CHAPTER 2 SAMPLE AND SURVEY METHODOLOGY Chapter 2 presents the sample design, questionnaire content, the pre-test, training, fieldwork, data processing and is concluded by issues of survey quality control and survey limitations and constraints. 2.1 SAMPLE DESIGN The MIMS 2009 was designed to provide estimates on a large number of indicators on the health status of women, children and other vulnerable populations at the national level, for urban and rural areas, as well as for the 10 administrative provinces in Zimbabwe namely; Manicaland, Mashonaland Central, Mashonaland East, Mashonaland West, Matabeleland North, Matabeleland South, Midlands, Masvingo, Harare, and Bulawayo. Harare and Bulawayo provinces are predominantly urban provinces whilst the rest are predominantly rural. The sampling frame for the MIMS was based on the 2002 Zimbabwe Master Sample (ZMS02), developed by the ZIMSTAT, then the CSO after the 2002 Population Census. With the exception of Harare and Bulawayo, each of the other eight provinces was stratified into four groups according to land use: (i) communal lands, (ii) large scale commercial farming areas (LSCFA), (iii) urban and semi-urban areas, and (iv) small scale commercial farming areas (SSCFA) and resettlement areas. Only one urban stratum each was formed for Harare and Bulawayo. There were a total of 34 strata for the whole country. A representative probability sample of 12 500 households was selected for the MIMS 2009. The sample was selected in two stages with enumeration areas (EAs) as the first stage and households as the second stage sampling units. Each EA was delineated for the 2002 Population Census operations with well-defined boundaries identified on sketch maps, and the EA size was based on the expected workload for one interviewer. The EAs had an average of 100 households each, which was ideal for the survey listing operation. In total the ZMS02 consists of 1 200 EAs selected with probability proportional to size (PPS), the size being the number of households enumerated in the 2002 Population Census. The MIMS EA selection was a systematic, one-stage operation, carried out independently for each of the 34 strata. In the second stage, a complete listing of households was conducted in the 500 sample EAs for the MIMS 2009 from 23 to 28 February 2009 concurrently for the 10 provinces. The list of households obtained was used as the frame for the second stage random systematic selection of 25 households from each sample EA. Within these selected households, all women aged 15-49 years identified were eligible for individual interviews. In addition, children under five years in the selected households were also identified and either their mothers or caretakers were interviewed on their behalf and children’s measurements of weight, height and Mid-Upper- Arm Circumference (MUAC) taken and oedema checked. The sample was stratified by province and land use and is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix B. 5 2.2 QUESTIONNAIRES Three questionnaires were used in the survey as follows: • A household questionnaire was used to collect information on all de-jure and de- facto household members, dwelling units, household characteristics and to identify eligible individuals for the women and children questionnaire interviews; • A woman’s questionnaire was administered in each selected household to all women aged 15-49 years; and • A questionnaire for children under five years was administered to mothers or caretakers of all children under five years living in the household. The questionnaires included the following modules: Household Questionnaire - Household listing; - Education; - Employment; - Water and sanitation; - Household characteristics; - Environmental assessment; - Orphaned and vulnerable children (OVC) and HIV and AIDS; and - Education and household expenditures2. Woman’s Questionnaire (15-49 years old) - Child mortality/Birth history; - Tetanus Toxoid (TT); - Maternal and newborn health; - Marriage/union; - Contraception; - Attitude towards domestic violence; and - HIV and AIDS (women age 15-49 years). Questionnaire for Children Under Five Years - Birth registration and early learning; - Vitamin A – children 6 months and older; - Breastfeeding; - Care during illness; - Malaria for under-5 year olds; - Immunization; and - Anthropometry. The questionnaires were based on the MICS model questionnaire with modifications and additions. Even though the questionnaires were in English, they were translated into the various vernacular languages during interviews. Copies of the Zimbabwe MIMS questionnaires are provided in Appendix H. In addition to the administration of questionnaires, fieldwork teams measured the weights, heights and Mid-Upper-Arm Circumference (MUAC) and checked oedema of children age under 5 years. 2 In the questionnaire it is the module on poverty and household resources. 6 2.3 PRE-TEST The MIMS questionnaires were pre-tested from 9 to 17 March, 2009. Ten (10) teams were formed, made up of a supervisor and five interviewers each for the pretest, after they were trained on the questionnaires. The pre-test training was conducted during the same period, for 92 participants, with 7 participants coming from each of Zimbabwe’s 10 provinces (including the provincial supervisor). The remainder were from the ZIMSTAT, then the CSO, Survey Management Team (SMT), UNICEF and the Steering and Technical Committee members who facilitated the training sessions. A pre-test was conducted in three selected localities (2 urban and 1 rural) in Harare and Mashonaland East provinces to test the entirety of survey procedures. Based on the results of the pre-test, further modifications were made to the wording and flow of the questionnaires. 2.4 TRAINING In addition to the pre-test training above, two other training workshops were conducted namely; training of trainers, and the main training. The training of trainers was conducted on 5 March 2009 for 38 participants from the MIMS Steering and the Technical Committees and the Survey Management Team in preparation for the pre-test and main training. A total of 220 provincial staff (including provincial supervisors) and four data entry supervisors participated in the main fieldwork training, conducted from 30 March to 17 April, 2009. Data entry supervisors were invited to the main training in order for them to get a better understanding of the questionnaires and the survey techniques. The training included lectures on interviewing techniques, discussion of the questionnaires, and mock interviews among trainees in order to acquire skills in asking questions. Towards the end of the training period, trainees spent four days conducting field interviews in different urban and rural settings. Urban and rural areas were selected to provide the field staff with a better appreciation of working in the different environments. Supervisors and interviewers were selected based on their performance in the field practices, participation in class, assessment tests, fluency in the Zimbabwean languages and leadership qualities. At all levels of training, participants were trained to measure the height, weight and Mid Upper Arm Circumference (MUAC) and to check for oedema in children under 5 years (0-59 months). 2.5 FIELDWORK Fieldwork began on 20 April, 2009 and ended on the 30 May, 2009. The data were collected by 30 teams. Each team comprised of a supervisor, four interviewers, and one driver, one editor (who edited the questionnaires and took body and weight measurement with the assistance of the supervisor as well as check the oedema in children under 5 years). In the field, provincial supervisors, in close collaboration with the SMT, were responsible for monitoring the MIMS activities in a province. Field supervisors and editors for the MIMS were the primary links between the provincial supervisors and the interviewers, ensuring both the progress and high quality of fieldwork. 2.6 DATA PROCESSING Data was entered on 56 microcomputers by 56 data entry operators, four questionnaire administrators and four data entry supervisors using the Census and Survey Processing (CSPro) system. In order to ensure quality control, all questionnaires were double entered and Survey Management Team as secondary editors complemented the efforts of the data entry supervisors to perform internal consistency checks. Procedures and standard programs 7 developed under the global MICS3 Project were adapted to the MIMS questionnaire and used throughout the processing. One week data entry training was organized for all data entry operators from 27 April to 1 May, 2009. Data entry began on 5 May two weeks after fieldwork had started and the two activities ran concurrently thereafter. Data entry was completed on 24 June, 2009 and the last ten days included secondary editing. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software and the model program syntax and tabulation plans were customized for the MIMS. 2.7 QUALITY CONTROL Various quality control measures were put in place to ensure collection and dissemination of high quality data. Some of the controls used included: Training: All interviewers were trained at one central location and this ensured that the same information and understanding of the survey objectives, instruments and filed operations were shared amongst them resulting in consistency of definitions thus ensuring collection of reliable information. Field teams supervision: Effective office backup at the ZIMSTAT, then the CSO, head office during the data collection period enabled swift decision making in terms of handling any field work errors. A massive field presence for monitoring was mounted during the first three weeks of the data collection. Overall, field supervision visits were carried out throughout the six weeks of data collection. In addition, a standard field monitoring template which clearly identified survey problem areas was used. Field editing: Field supervisors thoroughly edited the questionnaires in the field for completeness, accuracy and consistency and requested the interviewers to do any necessary call backs Data entry feedback to the field teams: Data collection and data entry ran concurrently for most part of the survey, with the latter commencing two weeks after the survey started. Errors were compiled and sent back to the interviewers during field monitoring visits. This enhanced the quality of the data as mistakes in data collection were quickly rectified before the interviewers had moved to new enumeration areas. Data verification: All questionnaires were double entered to ensure accurate data capturing. Data entry checks and online editing: Online editors were used to rectify queries during data entry. The online editors were members of the SMT who were knowledgeable on the questionnaires. This saved time in the solving of queries. Queries that required call backs were immediately returned to the field. Secondary editing: The SMT, as secondary editors, complemented the efforts of the data entry supervisors to perform internal consistency checks. In addition, the data was cleaned thoroughly throughout the process, including checking of the tables for consistency and accuracy before the final tables were produced. 2.8 SURVEY LIMITATIONS AND CONSTRAINTS The MIMS was conducted under resource constraints in terms of both time and finance. For the data to be more holistic, it would have been ideal to administer the male questionnaire as well as the child labour and salt iodization core modules as well as the optional modules on disability, child development, maternal mortality and sexual behavior among others. The male questionnaire was critical for the reporting on HIV and AIDS and contraception issues. However, 8 the extra time needed to administer this male questionnaire, including the disability module would have resulted in lengthening the data collection period. This also applies to the maternal mortality questions whose methodology of data collection is lengthy. In addition, the MIMS sample size only allows for reliable estimates at the provincial level and not at district level. Despite these limitations, the MIMS remains a major survey of high quality and immense value to the nation particularly at this point when Zimbabwe is strategizing on the critical way forward in recovery and development. 9 CHAPTER 3 SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS This chapter presents the MIMS sample coverage and the characteristics of the households and their population including women aged 15-49 years, children under five years, as well as household wealth quintiles and expenditures on health and education. The sample coverage includes response rates by households, women and children by rural/urban areas and by provinces. The section on characteristics of households and their population starts by looking at the composition of the population, followed by the composition and distribution of households. The next section is on household wealth quintiles, followed by expenditures on health and education including household external support. The chapter comes to a conclusion with a section on the background characteristics of respondents including those of the total population (language, religion, marital status, education and main usual activity), as well as background characteristics of women aged 15-49 years and children under five years. 3.1 SAMPLE COVERAGE The MIMS is based on a representative sample of 12 500 households. The sample within provinces was selected in such a way as to allow separate estimates of some key indicators for the provinces. Of the sampled 12 500 households, 12 370 were found to be occupied and 11 469 were successfully interviewed, giving a household response rate of 93 percent, see Table 3.1. In the interviewed households, 12 488 eligible women aged 15-49 years were identified. Of these, 11 339 were successfully interviewed, yielding a response rate of 91 percent. In addition, 7 499 children under the age of five years were listed in the household questionnaire of which 7 242 questionnaires were completed giving a response rate of 97 percent, see Table 3.1. These high response rates assure reliability of the survey results. Table 3.1: Results of Household and Individual Interviews Number of Households, Women, and Children under 5 by Results of the Interviews, and Household, Women's and Under-5's Response Rates, MIMS, Zimbabwe, 2009 Area Urban Rural Total Number of households Sampled (Hs) 3 850 8 650 12 500 Occupied (Ho) 3 790 8 580 12 370 Interviewed (Hi) 3 446 8 023 11 469 Response rate (Hr) 90.9 93.5 92.7 Number of women Eligible (We) 4 183 8 305 12 488 Interviewed (Wi) 3 830 7 509 11 339 Response rate (Wr) 91.6 90.4 90.8 Overall response rate (Wor) 83.3 84.5 84.2 Number of children under 5 Eligible (Ce) 1 777 5 722 7 499 Information collected (Ci) 1 715 5 527 7 242 Response rate (Cr) 96.5 96.6 96.6 Overall response rate (Cor) 87.8 90.3 89.5 Hr = Hi / Ho (where Ho is HH8 = 1, 2, 3 or 6) Wr = Wi / We ; Wor = Wr X Hr ; where Wr is the chance of a woman responding and Wor is the chance of a woman in a household responding. Cr = Ci / Ce ; Cor = Cr X Hr ; where Cr is the chance of getting a response on a child and Cor is the chance of getting a response on a child in a household. Note: This table is un-weighted, however all other tables presented in this report are weighted unless mentioned otherwise. About 31 percent of the households (3 798 households) were urban and 69 percent (8 616 households) were rural with response rates of 91 and 94 percent, respectively. Out of all the 10 provinces, Mashonaland West province had the largest household response rate of 96 percent of the households while Bulawayo Province had the lowest (90 percent), see Table 3.2. 3.2 CHARACTERISTICS OF HOUSEHOLDS AND THEIR POPULATION 3.2.1 Population Composition The age and sex distribution of the survey population is provided in Appendix Table A3.2. The distribution is also used to produce the population pyramid in Figure 3.1. In the 11 469 households successfully interviewed in the survey, 52 194 household members were listed, of these 52 percent were females (27 013) and 48 percent were males (25 181) as in the 2002 Zimbabwe Population Census. The estimated average household size from the MIMS was 5 persons. Figure 3.1 provides the age-sex structure of the population. The pyramid is broad based and narrow at the top emphasizing the fact that the population was young since a sizeable proportion of the population were under 15 years (42 percent). Slightly above half (54 percent) of the population was aged 15-64 years and 4 percent was aged 65 years and above. These three broad age-group proportions are the same as those from the 2002 Zimbabwe Population Census. In Zimbabwe, the legal age of majority is 18 years. In the MIMS, about half of the population (49 percent) were under 18 years of age. Forty-eight (48) percent of the females and 51 percent of the males were under 18 years of age. Appendix D provides details on population by single years (Table DQ.1) and the Data Quality Tables. Table 3.2: Results of Household and Individual Interviews Number of Households Sampled , Occupied and Interviewed and Response Rate (Percentage), MIMS, Zimbabwe, 2009 Province Sampled households Occupied Households Interviewed households Response rate (percentage) Manicaland 1 450 1 446 1 345 93.0 Mashonaland Central 1 200 1 193 1 107 92.8 Mashonaland East 1 300 1 299 1 218 93.8 Mashonaland West 1 300 1 289 1 232 95.6 Matabeleland North 1 000 989 906 91.6 Matabeleland South 1 000 996 933 93.7 Midlands 1 400 1 314 1 221 92.9 Masvingo 1 350 1 346 1 233 91.6 Harare 1 500 1 498 1 372 91.6 Bulawayo 1 000 1 000 902 90.2 Total 12 500 12 370 11 469 92.7 Figure 3.1:Population Pyramid, Percent Population, MIMS, Zimbabwe, 2009 8 6 4 2 0 2 4 6 8 0 -4 5-9 10-14 15-19 2 0-24 25-29 3 0-34 35-39 4 0-44 45-49 50 -54 55-59 6 0-64 65-69 70 -74 75+ A ge G ro up Male Female Percent 11 3.2.2 Household Composition and Distribution Table 3.3 provides basic background information on the households. Within households, the sex of the household head, province, urban/rural status and number of household members are shown in the table. These background characteristics are also used in subsequent analysis in this report. The figures in the table are also intended to show the number of observations by major categories of analysis in the report. The weighted and unweighted total numbers of households are equal, since sample weights were normalized, see Table 3.3. The table also shows the proportions of households where at least one child under 18, at least one child under 5, and at least one eligible woman age 15-49 were found. About 65 percent of the households were male headed, 35 percent were female headed, see Table 3.3, whilst 0.2 percent were child headed, see Table 11.4. The small proportion of child headed households is probably because normally in Zimbabwe children are absorbed into adult headed households. Harare province had the highest proportion of households (17 percent), followed by Manicaland province (14 percent), whilst Matabeleland North and Matabeleland South provinces (5 percent each) had the lowest, followed by Bulawayo province 6 percent. The majority of households (65 percent) resided in rural areas. Table 3.3: Household Composition Percent Distribution of Households by Selected Characteristics, MIMS, Zimbabwe, 2009 Background characteristic Weighted percent Number of households Weighted Un-weighted Sex of household head Male 65.1 7 465 7 331 Female 34.9 4 004 4 138 Province Manicaland 13.8 1 582 1 345 Mashonaland Central 9.9 1 141 1 107 Mashonaland East 10.2 1 172 1 218 Mashonaland West 10.5 1 200 1 232 Matabeleland North 5.3 611 906 Matabeleland South 5.3 610 933 Midlands 12.0 1 380 1 221 Masvingo 10.5 1 207 1 233 Harare 16.6 1 907 1 372 Bulawayo 5.7 659 902 Area Urban 35.3 4 049 3 446 Rural 64.7 7 420 8 023 Number of household members 1 8.0 917 874 2-3 27.8 3 184 3 106 4-5 34.4 3 946 3 931 6-7 19.4 2 227 2 293 8-9 7.0 807 850 10+ 3.4 388 415 Total 100.0 11 469 11 469 At least one child aged < 18 years 82.6 11 469 11 469 At least one child aged < 5 years 49.2 11 469 11 469 At least one woman aged 15-49 years 79.0 11 469 11 469 12 About a third of the households (34 percent) had household sizes of 4-5 persons, 28 percent had 2-3 persons, 19 percent had 6-7 persons, 8 percent had 1 person, 7 percent had 8-9 persons and 3 percent had 10 or more persons. As earlier noted, the average household size was 5 persons. A high proportion of households (83 percent) had at least one child aged less than 18 years3, whilst about half (49 percent) of the households had at least one child under-5 years4 and 79 percent of the households had at least one woman aged 15-49 years. 3.2.3 Household Wealth Quintiles The wealth index is one of the background characteristics used for analysis throughout this report to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample. Information on household assets5, housing quality, water and sanitation facilities and fuel type used for cooking, were used to create an index representing the wealth of the household interviewed in the MIMS. The wealth index was developed and tested in a large number of countries in relation to inequalities in household income, use of health services, and health outcomes6. Each household was weighted by the number of household members, and the household population was divided into five groups of equal size, from the lowest (poorest) quintile to the highest (richest) quintile, based on the wealth scores of households they were living in. Wealth quintiles are expressed in terms of quintiles of individuals in the population rather than quintiles of individuals at risk for any population indicator. For example, the quintile rates for Antenatal Care (ANC) coverage refer to the ANC coverage among all women in the population quintile concerned and not quintiles of women who sought ANC who constitute the only members of the population at risk. Table 3.4 presents the wealth quintiles by rural and urban and province. Almost all of the urban population (97 percent) is represented in the fourth and highest quintiles, while 58 percent in rural areas are in the lowest and second wealth quintiles. Sixty (60) percent of the population in urban areas is in the highest wealth quintile in contrast to one percent in the rural areas. The wealth quintile distribution among provinces shows large variations. As expected, the two predominantly urban provinces Bulawayo and Harare had the largest proportions in the highest wealth quintile 72 and 60 percent, respectively. In contrast, the predominantly rural province of Matabeleland North had the largest proportion (70 percent) in the lowest quintile while Mashonaland East had the lowest proportion 12 percent. 3 In this report children aged 0-17 years and under 18 years are used interchangeably. 4 In this report children aged 0-5 years, under-5 years and 0-59 months are used interchangeably. 5 The assets included in the computation of the household wealth quintile were; persons per room, type of floor, type of dwelling, type of roof, type of wall, type of cooking fuel, electricity, radio, television, mobile phone, non-mobile phone, refrigerator, dish television, computer, laptop, deep freezer, DVD/VCD, bicycle, motorcycle or scooter, animal drawn cart, car, boat without motor, boat with motor, ownership of animals, source of drinking water and type of toilet facility. 6 Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. 13 Table 3.4: Wealth Quintiles Percentage Distribution of the Population by Wealth Quintiles, According to Rural and Urban and Province, MIMS, Zimbabwe, 2009 Background characteristic Wealth quintile Total Percent Number of population Lowest Second Middle Fourth Highest Province Manicaland 16.0 22.6 34.3 18.9 8.2 100.0 7 093 Mashonaland Central 23.8 35.3 23.3 12.6 5.0 100.0 5 498 Mashonaland East 11.5 26.9 34.6 20.8 6.2 100.0 5 239 Mashonaland West 23.7 20.1 20.4 23.7 12.0 100.0 5 408 Matabeleland North 69.5 9.8 8.3 7.0 5.4 100.0 3 112 Matabeleland South 33.1 22.7 28.3 10.3 5.5 100.0 3 073 Midlands 25.5 26.8 16.9 13.3 17.5 100.0 6 504 Masvingo 23.2 30.1 25.6 14.7 6.4 100.0 5 501 Harare 0.0 0.0 2.1 38.0 59.9 100.0 8 013 Bulawayo 0.0 0.0 0.0 28.1 71.9 100.0 2 753 Residence Urban 0.5 0.4 1.8 37.4 59.9 100.0 16 592 Rural 29.1 29.1 28.5 11.9 1.4 100.0 35 602 Total 20.0 20.0 20.0 20.0 20.0 100.0 52 194 3.2.4 Source of External Household Support Nationally, 46 percent of the households had received external support (rural areas-57 percent and urban areas-26 percent). Household external support decreased with education of household head and wealth, see Appendix Table A3.4. For the predominantly rural provinces, Matabeleland North had the highest proportion (70 percent) of households who had received external support, whilst Mashonaland West had the lowest (41 percent). The predominantly urban provinces of Harare and Bulawayo had 28 percent and 25 percent, respectively, of their households having received external support. The source of external household support was mainly from non-governmental organizations (NGOs) at 36 percent, followed by support from: family members living in Zimbabwe (7 percent); family members outside Zimbabwe (3 percent); missions or religious organizations (2 percent); friends living in Zimbabwe, neighbours in the community and Central Government (1 percent each); and local governments/chiefs and friends living outside Zimbabwe with very small proportions of less than one percent each, see Figure 3.2. 14 1.2 0.2 0.4 0.7 1 1.1 2.2 2.8 6.6 35.5 0 5 10 15 20 25 30 35 40 Other Friends living outside Zimbabwe Local governments/chiefs Central Government Neighbours in the community Friends living in Zimbabwe Missions or religious organisations Family members outside Zimbabwe Family members living in Zimbabwe NGO Percent So ur ce o f su pp or t Figure 3.2:Source of Household Support, Percent of Households Receiving, MIMS, Zimbabwe, 2009 3.2.5 Type of External Household Support The largest proportion of households (37 percent) received external support in the form of food, followed by cash (6 percent), reduced medical fees, reduced school fees and inputs for farm or non farm business (3 percent each) and helping by providing time, with a very small proportion of less than one percent, see Figure 3.3 and Appendix Table A3.5. Other types of support constituted 6 percent. Figure 3.3:Type of External Household Support Received, Percentage of Households, MIMS, Zimbabwe, 2009 5.8 0.1 2.8 2.9 3.2 5.9 36.7 0 5 10 15 20 25 30 35 40 Other type of support Helping by providing time Inputs for farm or non farm business Reduced school fees Reduced medical fees Cash Food Ty pe o f s up po rt Percent 3.2.6 Expenditures on Health and Education The MIMS solicited information on health and education expenditures and external support for both. Health Expenditure and External Support Households were asked about the total amount of money they had spent on health care and medicines, including costs of medicines, visits to doctors, clinics, hospitals, traditional healers and transportation to and from those places, in the month preceding the survey. Information on the total value of any help for health care and medicine received by the household from friends, relatives, employers or organizations was also collected. 15 Nationally, the mean household expenditure on health for those households that reported health expenditure was US$34, and it was higher for urban (US$52) than rural areas (US$22), see Table 3.5. The mean household expenditure on health increased with the education of the household head and household wealth quintile. For the predominantly rural provinces, Manicaland had the highest mean household expenditure on health (US$35), whilst Mashonaland Central had the lowest (US$19). Of all the provinces, Bulawayo and Harare had the highest mean household expenditure on health of US$64 and US$59, respectively. National level mean external support for household health expenditure was US$34. Urban areas had a higher mean external support for household health expenditure (US$63) than rural areas (US$17), see Table 3.5. Mean external support for household health expenditure generally increased with household wealth but had no relationship with the education of the household head. For the predominantly rural provinces, Matabeleland North had the highest mean external support for household health expenditure (US$38), whilst Matabeleland South had the lowest (US$10). Harare and Bulawayo had the highest mean external support for household health expenditure among all the provinces of US$101 and US$46, respectively. Table 3.5: Health and Education Expenditure Mean Expenditure in USD among reported spending, MIMS, Zimbabwe, 2009 Background characteristic Mean health expenditur e, US$ Number of households reporting health expenditure Mean External Support for Health Expenditure Number of households reporting health expenditure support Mean education expenditur e, US$ Number of households reporting education expenditure Mean External Support for education expenditure Number of households reporting health expenditure support Province Manicaland 35 426 18 124 62 816 54 94 Mashonaland Central 19 356 15 117 41 588 51 74 Mashonaland East 21 387 21 88 46 605 19 89 Mashonaland West 22 374 20 71 49 576 26 73 Matabeleland North 29 158 (38) (39) 58 290 (58) (35) Matabeleland South 21 141 (10) (35) 50 368 35 61 Midlands 20 367 19 124 66 847 35 112 Masvingo 23 261 16 51 62 678 26 87 Harare 59 730 101 138 250 1 198 170 117 Bulawayo 64 232 (46) (38) 260 414 (132) (39) Area Urban 52 1 394 63 304 207.05 2 501 125.83 264 Rural 22 2 037 17 522 39.65 3 878 28.19 518 Education of household head None 22 224 70 55 26 443 22 84 Primary 28 1 248 25 337 46 2 219 26 305 Secondary 31 1 574 34 353 97 2 931 65 308 Higher 73 376 44 80 352 770 222 80 Missing/DK 16 8 * 2* * 17* * 4* Wealth quintile Lowest 14 503 16 133 18 923 19 114 Second 16 587 10 155 28 1 115 17 161 Middle 23 657 19 174 30 1 243 23 183 Fourth 31 829 52 212 89 1 482 78 167 Highest 69 854 65 152 281 1 617 163 157 Total 34 3 430 34 827 105 6 380 61 782 16 Education Expenditure and External Support On education, households were asked about the total amount of money they had spent on expenses related to the education of children of the particular household. It included expenses such as school fees, uniforms, books and transportation. Information on the total value of any education-related help received by the household including any scholarships, help with fees, uniforms, books etc was also collected. The mean household expenditure on education was higher than that of health. Nationally, the mean household expenditure on education for those households that reported education expenditure was US$105, and it was higher for urban (US$207) than rural ones (US$40), see Table 3.5. The mean household expenditure on education increased with the education of the household head and household wealth quintile. For the predominantly rural provinces, Midlands had the highest mean household expenditure on education (US$66), whilst Mashonaland Central had the lowest (US$41). Of all the provinces, Bulawayo and Harare had the highest mean household expenditure on education of US$260 and US$250, respectively. Nationally, household education expenditure at US$61, was higher than the national mean health expenditure. Urban areas had a higher mean external support for household education expenditure (US$126) than rural areas (US$28), see Table 3.5. Mean external support for household education expenditure increased with the education of the household head and generally with household wealth. For the predominantly rural provinces, Matabeleland North had the highest mean external support for household education expenditure (US$58), whilst Mashonaland East had the lowest (US$19). Harare and Bulawayo had the highest mean external support for household education expenditure among all the provinces, of US$170 and US$132, respectively. 3.3 CHARACTERISTICS OF RESPONDENTS Characteristics of respondents include those of the total population (language, religion, marital status, education, and main usual activity), women and children under 5 years. Appendix Tables A3.17 and A3.18 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5 years. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in subsequent analysis in this report. 3.3.1 Population Background Characteristics i. Language The MIMS collected information on the main language used by the head of household. Nationally, 80 percent of the population mainly used Shona, 14 percent Ndebele, 1 percent English whilst 5 percent used other languages, see Figure 3.4 and Appendix Table A3.6. Both rural and urban areas and the provinces of Manicaland, Mashonaland Central, Mashonaland East, Mashonaland West, Midlands, Masvingo and Harare followed the national pattern. For Matabeleland South, Matabeleland North and Bulawayo provinces it was the reverse, with high proportions of 72 percent, 66 percent and 61 percent, respectively, using Ndebele. 17 Figure 3.4: Household Population by Language Mainly Used, Percentage Distribution, MIMS, Zimbabwe, 2009 5 1 14 80 0 10 20 30 40 50 60 70 80 90 Other language English Ndebele Shona La ng ua ge Percent ii. Religion The MIMS solicited information of the following possible religions; Christianity (Roman Catholic, Protestant, Pentecostal, Other Christians), Apostolic Sect, Moslem and Traditional. Information on those with no religion was also obtained. Christians (Roman Catholics, Protestant, Pentecostal and Other Christians) constituted 45 percent of the population, followed by the Apostolic sect (27 percent), Traditional (9 percent), Moslem (1 percent) and those with no religion (17 percent), see Figure 3.5 and Appendix Table A3.7. The specific Christian denominations had the following proportions: Protestants (15 percent), Pentecostal (13 percent), Roman Catholic (11 percent), Other Christians (8 percent), while other religions had a proportion of 0.4 percent. Figure 3.5: Household Population by Religion, Percent Distribution , MIMS, Zimbabwe, 2009 17.0 0.4 0.8 8.6 26.7 46.5 0 5 10 15 20 25 30 35 40 45 50 No Religion Other religion Moslem Traditional Apostolic Sect Christianity R el ig io n Percent Generally, there were no significant gender differences in religion and denominations. Urban areas had higher proportions of people belonging to the main Christian denominations than rural areas as follows; Roman Catholics (urban-14 percent, rural-10 percent), Protestants (urban-20 percent, rural-13 percent) and Pentecostals (urban-21 percent, rural-9 percent). On the other hand rural areas had higher proportions of people belonging to the Apostolic sect (rural-30 percent, urban-19 percent), other Christians (rural-8 percent, urban-7 percent), Traditional (rural-12 percent, urban-2 percent) and those with no religion (rural-18 percent, urban-15 percent), compared to urban areas. The proportions of people who belonged to Christianity increased with household wealth whilst those who belonged to the traditional religion decreased with household wealth. For those with no religion the proportion generally decreased with household wealth. 18 There were provincial disparities in terms of religion. Considering Christianity, for the predominantly rural provinces, Masvingo (57 percent) had the highest proportion of people belonging to that region whilst Mashonaland Central had the lowest proportion (22 percent). Of all the provinces, the predominantly urban provinces of Harare and Bulawayo had the highest proportions of 63 percent and 60 percent, respectively, belonging to the Christian religion. Considering the Apostolic sect, for the predominantly rural provinces, Mashonaland Central had the highest proportion (34 percent), whilst Midlands had the lowest (25 percent). Bulawayo and Harare provinces had relatively low proportions of people in the Apostolic sect of 20 percent and 17 percent, respectively. Matabeleland North had the highest proportion of people (22 percent) following the traditional religion and Manicaland province had the lowest (5 percent), followed by Midlands (6 percent). Harare and Bulawayo had very low proportions of their population following the traditional religion of one and 2 percent, respectively. Mashonaland Central had the highest proportion with no religion (25 percent), followed by Mashonaland West (24 percent) and lowest in Masvingo (7 percent). Harare and Bulawayo had 18 percent and 14 percent, respectively, with no religion. iii. Marital Status The MIMS collected information on the marital status of the population with the following answer options; married, living with partner, divorced, separated, widowed and never married/never lived with partner. Answers were accepted as provided by the respondent regardless of the legality of the marital status. Nationally, 53 percent of the population aged 15 years and above were married, 31 percent were never married/never lived with partner, 10 percent were widowed, 4 percent divorced, 2 percent separated and one percent were living with partners, see Figure 3.6. There were no gender differences for those who were married and those living with partners. For the never married/never lived with partner, males had a higher proportion (40 percent) than females (22 percent). Females had higher proportions than males in the following categories; widowed (females-16 percent, males-3 percent), divorced (females-5 percent, males-2 percent) and separated (females-2 percent, male-one percent). This is because men either have more than one wife or quickly remarry after divorce, separation or death of spouse. Figure 3.6:Marital Status of Population Aged 15 and Above by Sex, Percentage Distribution, MIMS, Zimbabwe, 2009 53 1 5 2 16 22 53 1 2 1 3 40 53 1 4 2 10 31 0 10 20 30 40 50 60 Married Living with Partner Divorced Separated Widowed Never married/never lived with partner Marital status Pe rc en t Female Male Total For the total population, rural areas had higher proportions than urban areas of the married (rural-55 percent, urban-50 percent) and widowed (rural-11 percent, urban-7 percent), see Appendix Table A3.8. On the other hand urban areas had higher proportions than rural areas of 19 the never married/never lived with partner (urban-35 percent, rural-28 percent), living with partner and separated (urban-2 percent each, rural-one percent each). The proportions for the divorced were the same for rural and urban areas (4 percent each). For the female population, rural areas had a higher proportion than urban areas of the married (rural-56 percent, urban-48 percent) and widowed (rural-18 percent, urban-12 percent), see Figure 3.7 and Appendix Table A3.9. On the other hand urban areas had higher proportions than rural areas of the never married/never lived with partner (urban-30 percent, rural-18 percent), separated (urban-3 percent, rural-2 percent), living with partner (urban-2 percent, rural-one percent). The proportions for the divorced were the same for rural and urban areas (5 percent each). Figure 3.7: Marital Status of Female Population Aged 15 Years and Above, by Rural and Urban Areas, Percentage Distribution, MIMS, Zimbabwe. 2009 48 2 5 3 12 30 56 1 5 2 18 18 53 1 5.0 2.0 16.0 22.0 10 20 30 40 50 60 Married Living with Partner Divorced Separated Widowed Never married/never lived with partner Marital status Pe rc en t Urban Rural Total For the male population, rural areas had the same proportions for the following categories; married (53 percent each), never married/never lived with partner (40 percent each), widowed (3 percent each), separated (1 percent each), see Appendix Table A3.10. For the divorced, rural areas had a slightly higher proportion than urban areas, while the reverse was true for those living with partners. Considering marital status by age group for the total population, the proportions married increased with age from 10 percent in the age group 15-19 years and peaked at 76 percent each in the age groups 30-34 years and 35-39 years, and falls steadily to 55 percent for the age group 60 years and above, see Appendix Table A3.8. As expected, the proportions never married/never lived with partner decreased with age, whilst the proportions widowed increased with age from less than one percent in the age groups under 25 years to 40 percent in the age group 60 years and above. The proportions of the divorced increased with age and peaked at 7 percent in the age group 35-39 years and declined thereafter. Marital status for the female and male populations followed the same general pattern as the total population, except for the levels which differed. Widowhood, for example, for females increased with age from less than one percent in the age groups under 25 years to 62 percent in the age group 60 years and above whilst for the males it increased with age from less than one percent in the age groups under 29 years to only 12 percent in the age group 60 years and above. However, there was no relationship between marital status and household wealth. For all the provinces, Mashonaland Central had the highest proportion of its population married (59 percent), whilst Bulawayo had the lowest proportion (38 percent), see Appendix Table A3.8. 20 Matabeleland South province had the highest proportion of widowed population (12 percent) whilst Harare province had the lowest proportion (7 percent), followed by Bulawayo and Mashonaland Central provinces (8 percent each). iv. Education Attendance of secondary and higher education is ideal for the attainment of positive welfare outcomes for women and children. At the time of the survey, 47 percent of the total population had attended the primary level of schooling as their highest level of education, followed by secondary level (40 percent), higher level (5 percent), and pre-school level (2 percent) whilst 5 percent had no education, see Figure 3.8. The patterns were the same for both females and males. Females had a slightly higher proportion whose highest level of schooling attended was primary (48 percent), compared to males (46 percent). For the secondary and higher levels of education, the reverse was true (secondary: males-41 percent, females-38 percent; higher: males-6 percent, females-4 percent). For those with no education, females had a higher proportion (7 percent), compared to males (4 percent). Figure 3.8:Educational Level Attended by Population Aged 6 Years and Above, MIMS, Zimbabwe, 2009 7 2 48 38 44 3 46 41 65 2 47 40 5 10 20 30 40 50 60 None Pre-school Primary Secondary Higher Level of education Pe rc en t Female Male Total Nationally, less than half of the total population (45 percent) had secondary and higher as their highest level of schooling attended. Males had a higher proportion (47 percent) whose highest level of schooling attended was secondary and higher, compared to females (42 percent). Urban areas had a higher proportion (66 percent) whose highest level of schooling attended was secondary and higher, compared to rural areas (34 percent) and this pattern is true for the female and male populations see Appendix Tables A3.11, A3.12, and A3.13. For the total population, secondary and higher level school attendance increased with household wealth and this was also true for both sexes. Attendance of secondary and higher level of schooling increased with age to a peak of 83 percent for the age group 35-39 years and declined thereafter. Of the predominantly rural provinces, Manicaland, Mashonaland West and Midlands had the highest proportions of total population whose highest level of schooling attended was secondary and higher (42 percent each), followed by Mashonaland East (41 percent), whilst Matabeleland North had the lowest proportion (28 percent). The predominantly urban provinces of Harare and Bulawayo had proportions of 69 percent and 63 percent, respectively, whose highest level of schooling attended was secondary and higher. For the female population, attendance of secondary and higher level of schooling increased with age to a peak of 75 percent each for the age groups 15-19 years and 20-24 years and declined 21 thereafter, see Appendix Table A3.12. For the male population, attendance of secondary and higher level of schooling increased with age to a peak of 83 percent for the age group 35-39 years and declined thereafter, see Appendix Table A3.13. These findings imply that females were more deprived of attendance of secondary and higher level of schooling earlier on than their male counterparts. v. Main Usual Activity/Employment Of the total population aged 15-54 years, 77 percent were economically active (employed7-76 percent and unemployed-1 percent), whilst 22 percent were economically inactive (student, homemaker, retired and those that did nothing else), see Table A3.14b. Figure 3.9 and Appendix Tables A3.14a show that of the total population, the highest proportion of the employed were; agricultural related own account workers (29 percent), followed by other own account workers (14 percent), paid permanent employees (13 percent), unpaid family worker (12 percent), paid casual/temporary/contract/ seasonal employees (8 percent), and employers (0.2 percent). Of the total population, the highest proportion of the economically inactive were students (14 percent), followed by homemakers (7 percent), retired with pension, retired without pension and those who did nothing else were insignificant proportions of less than 0.5 percent. The proportions of the employed total population generally increases with age, and decreases with education of household head and household wealth. The same pattern applies for the economically active total population. For the economically inactive total population, the reverse is true. These patterns are true for both females and males. For the predominantly rural provinces, Matabeleland North had the highest proportion of the economically active population (87 percent), whilst Mashonaland West had the lowest proportion (77 percent). Harare and Bulawayo provinces had proportions of economically active total populations of 70 percent and 62 percent, respectively. The reverse is true for the pattern of economically inactive in the predominantly rural provinces. Bulawayo and Harare had 38 percent and 29 percent of their total populations being economically inactive. Of the total female population aged 15-54 years, 74 percent were economically active (employed-73 percent and unemployed-one percent), whilst 25 percent were economically 7 The employed included the following; paid employee-permanent, paid employee-casual/temporary/contract/ seasonal, employer, own account worker (agricultural related), own account worker (other) and unpaid family worker. 0.8 0.4 0.0 7.4 14.0 1.4 12.4 14.4 28.6 0.2 7.7 12.7 0 5 10 15 20 25 30 35 Other specify Does nothing else Retired with pension Homemaker Student Economically Inactive Unemployed Unpaid family worker Own account worker(other) Own account worker(agricultural related) Employer Paid employee-… Paid employee-permanent Economically Active Percent M ai n A ct iv ity Figure 3.9: Total Population Aged 15-54 Years by Main Usual Activity During the Past 12 Months, MIMS, Zimbabwe, 2009 22 inactive (student, homemaker, retired and those that did nothing else). Table 3.6 and Appendix Table A 3.15 show that of the female total population, the highest proportion of the employed were; agricultural related own account workers (35 percent), followed by other own account workers (15 percent), unpaid family worker (11 percent), paid permanent employees (8 percent), paid casual/temporary/contract/ seasonal employees (5 percent), and employers (0.1 percent). Of the total female population, the highest proportion of the economically inactive were homemakers (13 percent), followed by students (12 percent), retired with pension, retired without pension and those who did nothing else were insignificant proportions of less than 0.4 percent. Table 3.6: Summary-Main Usual Activity Females Aged 15-54 Years by Activity in the 12 Months Preceding the Survey, MIMS, Zimbabwe, 2009 Background characteristic Economically active Economically inactive Other Missing/DK Total percent Number of women aged 15-54 years Employed Unemployed Province Manicaland 79.2 0.2 19.9 0.5 0.1 100.0 1 760 Mashonaland Central 83.1 0.2 16.6 0.2 0.0 100.0 1 311 Mashonaland East 77.5 0.1 21.8 0.6 0.0 100.0 1 254 Mashonaland West 72.6 0.0 26.0 1.4 0.0 100.0 1 339 Matabeleland North 86.1 0.0 13.1 0.9 0.0 100.0 715 Matabeleland South 80.3 0.0 19.2 0.5 0.0 100.0 734 Midlands 77.3 0.6 21.5 0.6 0.0 100.0 1 660 Masvingo 83.7 0.1 15.1 1.1 0.0 100.0 1 370 Harare 58.3 2.4 38.9 0.4 0.1 100.0 2 498 Bulawayo 46.6 5.4 47.3 0.8 0.0 100.0 867 Area Urban 57.2 2.3 39.9 0.5 0.0 100.0 5 157 Rural 83.5 0.1 15.7 0.8 0.0 100.0 8 350 Age 15-24 56.3 1.4 41.9 0.4 0.0 100.0 5 697 25-34 82.5 0.9 16.0 0.7 0.1 100.0 3 928 35-44 89.1 0.4 9.5 1.0 0.0 100.0 2 216 45-54 89.9 0.2 8.6 1.3 0.0 100.0 1 666 Education of household head None 82.8 0.4 16.0 0.8 0.0 100.0 1 086 Primary 78.6 0.5 20.0 0.9 0.0 100.0 5 103 Secondary 69.4 1.0 29.0 0.5 0.0 100.0 5 799 Higher 64.8 2.4 32.6 0.2 0.0 100.0 1 492 Missing/DK 74.5 25.5 0.0 0.0 100.0 28 Wealth quintile Lowest 89.9 0.0 9.1 0.9 100.0 2 356 Second 85.2 14.3 0.4 0.0 100.0 2 390 Middle 80.1 0.1 18.9 0.9 0.0 100.0 2 458 Fourth 63.3 0.9 34.9 0.9 100.0 2 908 Highest 57.6 2.8 39.2 0.3 0.0 100.0 3 395 Total 73.4 0.9 24.9 0.7 0.0 100.0 13 508 Of the total male population aged 15-54 years, 81 percent were economically active (employed- 79 percent and unemployed-2 percent), whilst 18 percent were economically inactive (student, homemaker, retired and those that did nothing else). Appendix Table A3.16a and A3.16b shows that of the total male population, the highest proportion of the employed were; agricultural related own account workers (22 percent), followed by other own account workers and unpaid family worker (14 percent each), paid permanent employees (18 percent), paid casual/temporary/contract/seasonal employees (10 percent), and employers (0.3 percent). 23 Of the total male population, the highest proportion of the economically inactive were students (17 percent), followed by homemakers (1 percent), retired with pension, retired without pension and those who did nothing else were insignificant proportions of less than 0.2 percent. 3.3.2 Women Background Characteristics Table 3.7 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to province, urban-rural areas, age, marital status, motherhood status, education8 and wealth index quintiles. Harare province had the highest proportion of women aged 15-49 years (19 percent), followed by Manicaland province (13 percent), whilst Matabeleland North and Matabeleland South provinces (5 percent each) had the lowest , followed by Bulawayo province (7 percent). The majority of women (61 percent) resided in rural areas. Table 3.7: Women's Background Characteristics Percent Distribution of Women Aged 15-49 Years by Background Characteristics, MIMS, Zimbabwe, 2009 Background characteristic Number of women Weighted percent Weighted Un-weighted Province Manicaland 13.0 1 476 1 255 Mashonaland Central 9.6 1 089 1 054 Mashonaland East 9.2 1 040 1 072 Mashonaland West 9.9 1 117 1 214 Matabeleland North 5.2 584 853 Matabeleland South 5.4 611 945 Midlands 12.3 1 400 1 203 Masvingo 10.0 1 130 1 163 Harare 19.0 2 153 1 530 Bulawayo 6.5 738 1 050 Area Urban 39.1 4 436 3 830 Rural 60.9 6 903 7 509 Age 15-19 23.1 2 616 2 690 20-24 21.3 2 412 2 376 25-29 18.8 2 129 2 067 30-34 12.9 1 459 1 449 35-39 10.7 1 208 1 181 40-44 7.3 828 826 45-49 6.1 687 750 Marital/Union status Currently married/in union 58.9 6 677 6 635 Formerly married/in union 14.9 1 688 1 675 Never married/in union 26.2 2 963 3 018 Motherhood status Ever gave birth 71.2 8 069 8 094 Never gave birth 28.8 3 270 3 245 Education None 2.8 316 346 Primary 29.2 3 310 3 550 Secondary 61.3 6 948 6 802 Higher 6.7 764 640 Missing /DK 0.0 1 1 Wealth quintiles Lowest 17.2 1 954 2 155 Second 17.4 1 972 2 144 Middle 17.5 1 989 2 174 Fourth 22.3 2 529 2 336 Highest 25.5 2 895 2 530 Total 100.0 11 339 11 339 8 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 24 The highest proportion (23 percent) of women aged 15-49 years, were in the age group 15-19 years and the distribution decreases with age group to 6 percent in the age group 45-49 years, see Table 3.7. The majority of women (59 percent) were currently married or in union, 26 percent were never married/in union, whilst 15 percent were formerly married or in union. The motherhood status shows that 71 percent of the women had ever given birth. The majority of women (61 percent) had completed secondary education, 29 percent had completed primary, and 7 percent had completed higher education, whilst 3 percent had no education at all. About half (48 percent) of the women came from households in the better-off fourth and highest wealth quintiles, 35 percent came from households in the poorer lowest and second wealth quintiles, whilst 18 percent came from households in the middle quintile. 3.3.3 Children Background Characteristics Some background characteristics of children under 5 are presented in Table 3.8. These include distribution of children by several attributes: sex, province and rural/urban, age in months, mother’s or caretaker’s education and household wealth. Male children constituted 51 percent of the children under-5 years, whilst females constituted 49 percent. Manicaland province had the highest proportion of children aged under five years (14 percent), followed by Harare province (13 percent), whilst Bulawayo province (5 percent) had the lowest, followed by Matabeleland North and Matabeleland South provinces (6 percent each). The majority of children (72 percent) resided in rural areas. The highest proportions of children (around 20 percent each) were in the age groups 12-23 months, 24-35 months, 36-47 months and 48-59 months. The proportions of children for the younger age groups were small at 9 percent and 10 percent for the under 6 months and 6-11 months, respectively, see Table 3.8. The majority of children (53 percent) were born to mothers who had completed secondary level of education, 37 percent were born to mothers who had completed primary education, and 5 percent each to those with no education and those with higher education. Generally, the proportions of children decreased with household wealth. 25 Table 3.8: Children's Background Characteristics Percent Distribution of Children Under Five Years of Age by Background Characteristics, MIMS, Zimbabwe, 2009 Background characteristic Number of under-5 children Weighted percent Weighted Un-weighted Sex Male 50.6 3 663 3 663 Female 49.4 3 579 3 579 Province Manicaland 14.0 1 012 863 Mashonaland Central 11.1 804 748 Mashonaland East 9.7 703 697 Mashonaland West 10.9 790 806 Matabeleland North 6.4 466 637 Matabeleland South 6.3 453 674 Midlands 12.0 873 815 Masvingo 11.7 848 864 Harare 13.4 968 692 Bulawayo 4.5 325 446 Area Urban 28.2 2 041 1 715 Rural 71.8 5 201 5 527 Age < 6 months 9.4 677 681 6-11 months 9.7 704 694 12-23 months 19.9 1 444 1 453 24-35 months 19.3 1 399 1 393 36-47 months 20.9 1 512 1 504 48-59 months 20.8 1 505 1 517 Mother’s education None 4.7 342 388 Primary 37.1 2 688 2 816 Secondary 53.1 3 848 3 740 Higher 5.0 363 296 Missing /DK 0.0 2 2 Wealth quintiles Lowest 24.3 1 762 1 870 Second 21.4 1 551 1 655 Middle 18.8 1 361 1 467 Fourth 19.2 1 393 1 246 Highest 16.2 1 174 1 004 Total 100.0 7 242 7 242 26 CHAPTER 4 CHILD MORTALITY Mortality indicators are useful for the assessment of the health status of a population as well as the evaluation of health policies and programmes. One of the overarching objectives of the Millennium Development Goals (MDGs) and A World Fit for Children (WFFC) is to reduce infant and under-five mortality. Specifically, MDG 4-‘Reduce Child Mortality’ calls for the reduction in under-5 mortality by two-thirds between 1990 and 2015. The WFFC first priority area on Promoting Healthy Lives, calls for the reduction in the infant and under-five mortality rate at least by one third by 2010, in pursuit of the target of reducing it by two thirds by 2015. In the first decade of independence (1980s), Zimbabwe made remarkable progress in improving the health status of its population as reflected in improving mortality indicators including the infant mortality rate (IMR) and under-5 mortality rate, (ZDHSs 1988 and 1994). However, in the second decade of independence (1990s), the mortality indicators started to rise and this was mainly attributed to the impact of the HIV and AIDS pandemic and more recently during the third decade, the economic decline which resulted in an over-stretched and under-funded health delivery system (ZDHSs 1999 and 2005/2006). According to the Ministry of Health and Child Welfare, (2006), the top ten causes of mortality in under-one year olds were as follows; Acute Respiratory Infection (ARI )- lower tract, certain conditions which originate in the perinatal period, intestinal infections, skin and subcutaneous diseases, malaria, ARI-upper tract, nutritional deficiencies, signs, symptoms and ill defined conditions, other endocrine and metabolic diseases, and other respiratory diseases. For the 1-4 year olds, the top ten causes of mortality were; nutritional deficiencies, ARI-lower tract, intestinal infections, malaria, signs, symptoms and ill defined conditions, ARI-upper tract, other viral diseases, skin and subcutaneous diseases, pulmonary tuberculosis, and other endocrine and metabolic diseases. The main determinants of whether a child suffers or dies from these causes are the child’s HIV and nutritional status; access to and functioning of the health system; family/household and community care practices; and availability of preventative services such as immunizations, safe sanitation and hygiene education. This chapter presents five types of childhood mortality namely neonatal, postneonatal, and infant, child and under-5 and these are defined as follows: - Neonatal mortality: the probability of dying within the first month of life; - Postneonatal mortality: the arithmetic difference between infant and neonatal mortality; - Infant mortality: the probability of dying between birth and the first birthday; - Child mortality: the probability of dying between the exact age one and the fifth birthday; and - Under-5 mortality: the probability of dying between birth and the fifth birthday. All rates are measured as deaths per 1 000 live births except child mortality which is measured as, deaths per 1 000 children surviving to the first birthday. For the MIMS, childhood mortality rates were calculated from mother’s birth history information using the direct method of estimation. Respondents were asked about the number of sons and daughters who lived with them, the number who lived elsewhere, and the number who had died. For each live birth, information was collected on sex, month, and year of birth; survivorship status and current age; and age at death if the child died. The direct estimation is based on the assumption that mortality among mothers is very low and the reported birth history is complete. However, for Zimbabwe, with its high rates of female 27 adult mortality due to the HIV and AIDS pandemic, this assumption might not necessarily hold and the resulting childhood mortality rates might be underestimated, (ZDHS 2005/06). The quality of mortality estimates from retrospective birth histories relies on the mother’s ability to recall all the children she had given birth to, including their birth dates and ages at death. Omissions lead to underreporting of childhood mortality. Child mortality rates can be estimated for varying periods preceding the survey. The longer the time period preceding the survey, for example, 10 years as opposed to 5 years, enables the basing of child mortality rates on a sufficient number of cases in each category, in order to ensure statistically reliable estimates. Table 4.1. provides estimates of the neonatal, the post neonatal, infant mortality, child and under-5 mortality rates for the ten-year period preceding the survey by various background characteristics. Table 4.1: Child Mortality Infant, Neonatal, Post-Neonatal, Child and Under-5 Mortality Rates Based on Births During the 10-Year Preceding the Survey, MIMS, Zimbabwe, 2009 Background characteristic Neonatal mortality rate Post- neonatal mortality rate Infant mortality rate Child mortality rate Under-5 mortality rate Sex of the child Male 30 34 65 29 92 Female 26 30 56 26 80 Province Manicaland 31 33 63 38 98 Mashonaland Central 33 38 71 27 96 Mashonaland East 29 37 66 39 103 Mashonaland West 29 37 66 25 89 Matabeleland North 18 28 46 16 61 Matabeleland South 15 22 37 19 56 Midlands 30 36 66 24 88 Masvingo 23 29 52 38 88 Harare 29 29 58 18 75 Bulawayo 30 24 54 21 73 Area Urban 29 28 57 19 76 Rural 27 34 61 31 90 Women’s education None 27 47 73 40 110 Primary 32 34 67 33 97 Secondary + 25 30 55 23 77 Wealth quintile Lowest 31 36 67 34 99 Second 25 33 58 30 86 Middle 25 33 57 33 88 Fourth 26 34 61 22 82 Highest 31 23 54 17 70 Total 28 32 60 27 86 4.1 Neonatal Mortality For the ten years preceding the survey, Zimbabwe had a neonatal mortality rate of 28 deaths per 1 000 live births, meaning that 3 percent of the children born alive died within the first month of life. A greater proportion of boys (30 per 1 000) died than girls (26 per 1 000), see Table 4.1 and Figure 4.1. For the neonatal mortality rate, urban areas had a slightly higher rate (29 per 1 000) than rural areas (27 per 1 000). The neonatal mortality rate was highest in 28 Mashonaland Central province (33 per 1 000 live births) and lowest in Matabeleland South province (15 per 1 000 live births). There was no clear relationship between neonatal mortality and mother’s education and household wealth. 4.2 Post-neonatal Mortality Zimbabwe had a post-neonatal mortality rate of 32 deaths per 1 000 live births, meaning that 3 percent of the children born alive died after the first month but before one year of life. A greater proportion of boys (34 per 1 000) died than girls (30 per 1 000), see Table 4.1 and Figure 4.1. Unlike, neonatal mortality, rural areas had a higher rate (34 per 1 000) than urban areas (28 per 1 000). The same provincial pattern as for the neonatal mortality rate prevailed for the post neonatal mortality rate, ranging from 22 per 1 000 live births in Matabeleland South to 38 per 1 000 live births in Mashonaland Central. Mashonaland East and Mashonaland West provinces had 37 per 1 000 live births each. The post-neonatal mortality rate decreased with the education of mother and generally with household wealth. Figure 4.1: Neonatal, Post-neonatal, Infant, Child and Under-five Mortality Rates Based on Births During the 10-Year Period Preceding the Survey, MIMS, Zimbabwe, 2009 26 30 56 26 80 30 34 65 29 92 28 32 60 28 86 0 10 20 30 40 50 60 70 80 90 100 Neonatal mortality rate Post neonatal mortality rate Infant mortality rate Child mortality rate Under-five mortality rate Childhood mortality rates Deaths per 1 000 Female Male Total 4.3 Infant Mortality For the ten-year period preceding the survey, Zimbabwe had an estimate infant mortality rate of 60 deaths per 1 000 live births, meaning that 6 percent of the children died before their first birthday. Boys had a higher likelihood of dying before their first birthday (65 per 1 000) than girls (56 per 1 000), see Table 4.1 and Figure 4.1. Rural areas had a higher infant mortality rate (61 per 1 000) than urban areas (57 per 1 000). For the predominantly rural provinces, infant mortality was highest in Mashonaland Central province (71 per 1 000) and lowest in Masvingo province (52 per 1 000). Harare and Bulawayo provinces had infant mortality rates of 58 per 1 000 live births and 54 per 1 000 live births, respectively. Infant mortality decreased with the education of mother and generally with household wealth. 4.4 Child Mortality The MIMS estimated a child mortality rate of 27 deaths per 1 000 children surviving to the first birthday, for the 10-year period preceding the survey. This means that about 3 percent of the children died between their first and fifth birthdays. A greater proportion of boys (29 per 1 000) died than girls (26 per 1 000) did so, see Table 4.1 and Figure 4.1. Rural areas had a higher child mortality rate (31 per 1 000) than urban areas (19 per 1 000). Child mortality was highest in Mashonaland East province (39 per 1 000) and lowest in Harare province (18 per 1 000). 29 Manicaland and Masvingo provinces had also high child mortality rates of 38 per 1 000 each and Matabeleland North province a low rate of 16 per 1 000. Child mortality decreased with the education of mother and generally with household wealth. 4.5 Under-5 Mortality For the ten-year period preceding the survey, the under-5 mortality rate was estimated at 86 per 1 000. Male children experienced higher (92 per 1 000) under-5 mortality than their female counterparts (80 per 1 000), see Table 4.1 and Figure 4.2. Under-5 mortality rate was higher for rural areas (90 per 1 000) than urban areas (76 per 1 000). The under-5 mortality was highest in Mashonaland East province (103 per 1 000) and lowest in Matabeleland South province (56 per 1 000). Under-5 mortality decreased with the education of mother and generally with household wealth. Generally, for the five childhood mortalities, Mashonaland Central and Mashonaland East provinces had the highest childhood mortality estimates whilst Matabeleland South province had the lowest. Figure 4.2: Under-5 Mortality Rates by Background Characteristics, MIMS, Zimbabwe, 2009 86 70 82 88 86 99 77 97 110 73 75 88 88 56 61 89 103 96 98 90 76 92 80 0 20 40 60 80 100 120 Zimbabwe Highes t Fourth Middle Second Lowes t Wealth Quintile Secondary+ P rimary None Education of Woman Bulawayo Harare Masvingo Midlands Matabeleland South Matabeleland North Mashonaland Wes t Mashonaland Eas t Mashonaland Central Manicaland P rovinces Rural Urban Area Male Female Sex Deaths per 1 000 live births For the five year period preceding the survey, all childhood mortality rates have increased from the ZDHS (2005/2006) levels as follows: neonatal mortality rate from 24 to 30 per 1 000 live births; post neonatal mortality rate from 36 to 37 per 1 000 live births; infant mortality rate from 60 to 67 per 1 000 live births, child mortality rate from 24 to 29 per 1 000 children surviving to the first birthday, under-5 mortality rate from 82 to 94 per 1 000 live births. Table 4.2 provides estimates of infant and under-5 mortality for the five-year period preceding the survey by various background characteristics. 30 Table 4.2: Child Mortality Neonatal, Post Neonatal, Infant, Child, and Under-5 Mortality Rates for the 5-Year Period Preceding the Survey, by Background Characteristics, MIMS, Zimbabwe 2009 Background characteristic Neonatal mortality (NN) Post neonatal mortality (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Sex Male 33 37 70 30 98 Female 27 37 65 28 90 Residence Urban 31 33 64 17 80 Rural 29 39 68 34 100 Mother's education No education 13 56 69 37 104 Primary 33 42 75 37 109 Secondary + 29 34 63 23 85 Wealth quintile Lowest 37 44 82 40 118 Second 23 34 57 30 85 Middle 21 38 60 37 94 Fourth 31 38 69 18 86 Highest 35 29 63 18 80 Total 30 37 67 29 94 31 CHAPTER 5 CHILD NUTRITION This chapter first covers the nutritional status of children including stunting, wasting, underweight, and overweight, the mid-upper-arm circumference (MUAC) and oedema. It then goes on to analyze breastfeeding practices including timely initiation of breastfeeding, exclusive breastfeeding, timely complementary feeding, continued breastfeeding, infant and young child feeding patterns by age, frequency of complementary feeding, and adequacy in infant feeding. The next section covers Vitamin A supplementation among children and mothers and the chapter comes to a conclusion with the analysis of low birth weight. 5.1 NUTRITIONAL STATUS OF CHILDREN The continuous rise in poverty levels in Zimbabwe has negative implications for good nutrition. Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they achieve their growth potential and are considered well nourished. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. The Millennium Development Goal (MDG 1) – ‘Eradicate extreme poverty and hunger’ target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will also assist in the goal of reducing child mortality as in MDG 4. In a well-nourished population, there is a standard distribution of height and weight for children under the age of five years. Undernourishment in a population can be determined by comparing children to this standard distribution. In 2006, the World Health Organization (WHO) released new growth standards for children under the age of five. However, Zimbabwe is still using the USA National Centre for Health Statistics (NCHS) 1978 standard. While this report presents nutrition indicators using the new WHO standards, the child nutrition results using the NCHS standard are also presented. The NCHS standard also allows for comparison with the ZDHS 2005/06 findings. The three standard indices of physical growth used to describe the nutritional status of children in this report are: height-for-age (stunting); weight-for-height (wasting) and weight-for-age (underweight). These indices are expressed in standard deviation units (z- scores) from the median of the WHO reference population. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations (-2SD) below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations (-3SD) below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height describes the current nutritional status of a child. Children whose weight-for- height is more than two standard deviations (-2SD) below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations (-3SD) below the median are classified as severely wasted. Wasting is a reflection of acute malnutrition, typically the result of a recent nutritional deficiency or disease. Severe acute malnutrition can be characterized by either wasting or bilateral pitting oedema. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. 32 Weight-for-age is a composite index of the height-for-age and weight-for-height which reflects both acute malnutrition (wasting) and chronic malnutrition (stunting). Children whose weight- for-age is more than two standard deviations (-2SD) below the median of the reference population are considered moderately or severely underweight while those whose weight-for- age is more than three standard deviations (-3SD) below the median are classified as severely underweight. Overall, in order to assess the extent of underweight, stunting and wasting, the following cut- off points were used: Mild malnutrition: below 10 percent; Moderate malnutrition: 10-20 percent; and Severe malnutrition: above 20 percent. Additionally, children who are overweight are those whose weight-for-height is two standard deviations (+2SD) above the median of the reference population. 5.1.1 Stunting, Wasting, Underweight and Overweight (WHO Standard) Using the latest WHO standard in estimating child nutrition, nationally 35 percent of the children aged 6-59 months were stunted, 2 percent were wasted, 12 percent were underweight while 3 percent were overweight, see Table 5.1. This means that Zimbabwe had severe stunting, mild wasting and moderate underweight malnutrition. Rural areas had higher levels of malnutrition than urban areas according to the three indices whilst the reverse was true for the overweight indicator. The stunting level in rural areas was 37 percent compared to 30 percent in urban areas, while wasting was 3 percent and 2 percent for rural and urban areas, respectively. Underweight in rural areas was 13 percent compared to 9 percent in urban areas whilst overweight was 5 percent for urban areas compared to 3 percent for rural areas. Consistent with various nutrition surveys in Zimbabwe, males had higher malnutrition levels than females as follows; stunting (males-38 percent, females-33 percent), wasting (males-3 percent, females-2 percent), and underweight (males-13 percent, females-11 percent), see Table 5.1. In addition, a slightly higher proportion of males (4 percent) also were overweight compared to females (3 percent). It should be noted that the wasting data was collected during April and May 2009 which coincides with the agricultural harvesting season, a time when food accessibility is generally higher than average and rates of diarrhoea and other illnesses are generally lower than average. The wasting data, therefore, likely represents the best-case scenario. Stunting decreased with mother’s education while wasting and underweight generally did so. Overweight increased with mother’s education. Stunting and wasting also decreased with household wealth. Underweight was highest in children from the lowest wealth quintile (16 percent) and lowest for those from the highest wealth quintile (7 percent). Overweight was highest for the children from the highest wealth quintile (6 percent) compared to the other wealth quintiles which had relatively the same level (3 percent each). 33 Table 5.1: Child Malnourishment-WHO Child Growth Standards Percentage of Children Aged 6-59 Months Who are Severely or Moderately Undernourished, MIMS, Zimbabwe, 2009 Background characteristic Weight for age: % below - 2 SD Weight for age: % below - 3 SD Number of children Height for age: % below - 2 SD Height for age: % below - 3 SD Number of children Weight for height: % below -2 SD Weight for height: % below - 3 SD Weight for height: % above +2 SD Number of children Sex Male 13.1 2.5 3 117 37.9 12.7 3 106 2.9 0.4 4.2 3 102 Female 10.5 2.0 3 089 32.5 10.2 3 081 1.9 0.6 2.6 3 082 Provinces Manicaland 9.9 2.1 866 36.8 11.1 864 1.6 0.7 3.9 863 Mashonaland Central 13.8 2.5 659 39.0 13.0 656 2.1 0.2 2.1 659 Mashonaland East 12.2 2.2 606 33.5 12.9 605 2.9 1.1 2.7 605 Mashonaland West 16.5 2.7 701 35.2 14.7 697 4.3 0.7 2.9 696 Matabeleland North 14.7 1.9 403 33.3 8.8 399 4.5 0.9 1.8 399 Matabeleland South 10.0 1.5 395 28.3 8.0 394 1.6 0.0 1.7 393 Midlands 13.4 3.4 750 41.3 13.6 748 2.4 0.1 3.0 748 Masvingo 10.0 1.9 728 37.9 11.0 724 2.1 0.2 3.9 721 Harare 8.9 2.3 822 31.8 9.8 822 1.7 0.7 5.6 822 Bulawayo 8.2 .9 277 24.6 6.3 279 1.1 0.0 5.0 277 Area Urban 9.0 1.8 1 746 30.0 9.6 1 747 1.6 0.4 4.8 1 744 Rural 12.9 2.5 4 461 37.3 12.2 4 441 2.8 0.5 2.8 4 440 Age of child 6-11 months 7.1 1.7 634 16.0 3.1 633 5.40 0.8 6.7 633 12-23 months 13.3 3.2 1 410 38.0 12.1 1 405 3.8 0.7 3.4 1 405 24-35 months 14.0 2.5 1 326 47.1 17.3 1 322 1.5 0.2 3.6 1 318 36-47 months 11.9 2.1 1 425 38.5 13.2 1 419 1.5 0.3 3.3 1 421 48-59 months 10.4 1.6 1 411 26.7 7.3 1 409 1.5 0.5 1.7 1 407 Mother’s education None 17.8 2.6 303 43.7 14.7 301 2.5 0.1 1.5 301 Primary 15.0 3.1 2 343 39.6 14.6 2 329 2.8 0.6 3.0 2 333 Secondary 9.4 1.7 3 249 32.4 9.5 3 246 2.2 0.4 3.6 3 239 Higher 7.2 2.0 310 23.9 4.3 310 2.3 1.4 5.2 309 Missing/DK * * 2* * * 2* * * * 2* Wealth quintile Lowest 15.7 3.2 1 489 39.6 13.3 1 474 3.6 0.7 3.0 1 475 Second 11.7 2.1 1 328 37.7 10.8 1 327 2.5 0.5 2.6 1 325 Middle 11.5 2.0 1 185 35.5 11.8 1 181 2.6 0.5 2.6 1 181 Fourth 11.6 1.7 1 200 35.2 13.2 1 203 1.6 0.2 3.0 1 199 Highest 6.9 2.2 1 005 25.2 7.2 1 003 1.5 0.6 6.3 1 003 Total 11.8 2.3 6 206 35.2 11.4 6 187 2.4 0.5 3.4 6 184 Stunting and underweight increased with age of child up to 24-35 months and decreased thereafter while wasting decreased with age of child. Overweight generally decreased with age of child, see Figure 5.1. 34 Figure 5.1: Percentage of Children Under-5 who are Undernourished and Overweight, World Health Organization (WHO) Standard, MIMS, Zimbabwe, 2009 0 5 10 15 20 25 30 35 40 45 50 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) Pe rc en t Underweight Stunted Wasted Overweight For the predominantly rural provinces, stunting prevalence was highest in Midlands (41 percent), and lowest in Matabeleland South (28 percent), see Table 5.1. The predominantly urban provinces of Bulawayo and Harare had stunting prevalences of 25 percent and 32 percent, respectively. For the predominantly rural provinces, wasting prevalence was highest in Matabeleland North (5 percent), followed by Mashonaland West (4 percent) and Mashonaland East (3 percent), whilst the rest of the provinces had (2 percent each). Bulawayo and Harare provinces also had relatively low wasting prevalences of one percent and 2 percent, respectively. Underweight prevalence was highest in Mashonaland West province (17 percent) and lowest in Manicaland, Matabeleland South, and Masvingo provinces (10 percent each). Bulawayo and Harare provinces had wasting prevalences of 8 percent and 9 percent, respectively. In addition, for the predominantly urban provinces, overweight prevalence was highest in Harare and Bulawayo and Manicaland provinces (5 percent each) and lowest in Matabeleland North and Matabeleland South at 2 percent each. 5.1.2 Stunting, Wasting, Underweight and Overweight (NCHS Standard) Using the NCHS standard in estimating child nutrition, nationally 29 percent of the children aged 6-59 months were stunted, 2 percent were wasted, 16 percent were underweight while 2 percent were overweight, see Table 5.2. This means that Zimbabwe had severe stunting, mild wasting and moderate underweight malnutrition. Rural areas had higher levels of malnutrition than urban areas according to the three indices whilst the reverse was true for the overweight indicator. The stunting level in rural areas was 31 percent compared to 24 percent in urban areas, while wasting was 2 percent and 1 percent for rural and urban areas, respectively. Underweight in rural areas was 18 percent compared to 12 percent in urban areas whilst overweight was 2 percent for urban areas compared to one percent for rural areas. 35 Table 5.2: Child Malnourishment – NCHS Child Growth Standards Percentage of Children Aged 6-59 Months Who are Severely or Moderately Undernourished, MIMS, Zimbabwe, 2009 Background characteristic Weight for age: % below - 2 SD Weight for age: % below - 3 SD Height for age: % below - 2 SD Height for age: % below - 3 SD Weight for height: % below - 2 SD Weight for height: % below - 3 SD Weight for height: % above +2 SD Number of children Sex Male 16.9 2.7 30.0 8.3 2.7 0.2 1.8 3 017 Female 15.7 2.2 27.6 8.1 1.5 0.3 1.5 3 011 Province Manicaland 15.3 2.7 30.1 9.0 1.7 0.3 2.0 849 Mashonaland Central 18.2 2.9 32.2 9.1 1.9 0.2 1.0 639 Mashonaland East 15.9 2.5 27.4 9.7 2.5 0.6 0.6 588 Mashonaland West 20.7 3.2 29.0 10.4 3.4 0.4 1.4 680 Matabeleland North 20.9 2.3 27.0 5.0 3.6 0.5 0.8 393 Matabeleland South 14.5 1.7 23.4 5.0 2.2 0.0 1.1 385 Midlands 18.2 3.6 32.7 9.8 2.1 0.0 2.2 731 Masvingo 14.8 1.5 32.5 6.4 2.2 0.2 2.0 697 Harare 11.6 1.9 25.2 7.9 1.0 0.2 2.7 797 Bulawayo 12.6 1.3 19.6 4.7 1.2 0.0 2.2 269 Area Urban 12.2 1.9 24.2 7.2 1.4 0.1 2.3 1 699 Rural 17.9 2.7 30.6 8.5 2.4 0.3 1.4 4 329 Age of child 6-11 months 8.5 1.6 12.8 1.7 3.0 0.2 5.6 629 12-23 months 21.6 4.3 34.7 9.4 4.7 0.6 2.3 1 387 24-35 months 19.9 3.3 32.8 10.0 1.3 0.2 0.9 1 286 36-47 months 15.2 1.6 31.8 9.6 1.2 0.2 0.9 1 369 48-59 months 12.2 1.0 23.4 6.9 1.0 0.1 0.7 1 356 Mother’s education None 20.4 1.6 34.6 7.5 1.9 0.0 0.6 272 Primary 20.2 3.5 33.9 11.5 2.4 0.4 1.5 2 264 Secondary 13.9 2.0 26.0 6.3 2.0 0.2 1.8 3 196 Higher 8.9 0.9 14.1 4.4 1.6 0.2 2.7 293 Missing/DK * * * * * * * 2* Wealth quintile Lowest 20.8 3.0 32.9 9.6 3.1 0.4 1.4 1 442 Second 16.9 2.5 31.1 7.8 2.5 0.3 1.5 1 288 Middle 16.8 2.5 28.7 8.4 2.1 0.3 1.3 1 146 Fourth 15.0 2.1 29.4 9.0 1.3 0.0 1.2 1 181 Highest 9.6 1.9 19.1 5.1 1.3 0.3 3.2 970 Total 16.3 2.5 28.8 8.2 2.1 0.3 1.7 6 028 36 Consistent with various nutrition surveys in Zimbabwe, regionally and globally, males had higher malnutrition levels than females as follows; stunting (males-30 percent, females-28 percent), wasting (males-3 percent, females-2 percent), and underweight (males-17 percent, females-16 percent), see Table 5.2. In addition, a slightly higher proportion of males (1.8 percent) also were overweight compared to females (1.5 percent). As mentioned earlier, the wasting data was collected during April and May 2009 which coincides with the agricultural harvesting season, a time when food accessibility is generally higher than average and rates of diarrhoea and other illnesses are generally lower than average. The wasting data, therefore, likely represents the best-case scenario. Stunting and underweight decreased with mother’s education while wasting generally did so. Overweight increased with mother’s education. Underweight and stunting decreased with household wealth while wasting generally did so. Underweight was highest in the children from the lowest wealth quintile (21 percent) and lowest for those from the highest wealth quintile (10 percent). Overweight was highest for children from the highest wealth quintile compared to the other wealth quintiles. Underweight, stunting and wasting increased with age of child up to 12-23 months and decreased thereafter. Overweight was highest in children in the 6-11 months age group (6 percent) and decreased to 2.3 percent in the age group 12-23 months and further down to around one percent in the other age groups, see Figure 5.2. Figure 5.2: Percentage of Children Under-5 who are Undernourished and Overweight, World Health Organization (NCHS) Standard, MIMS, Zimbabwe, 2009 0 5 10 15 20 25 30 35 40 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) Pe rc en t Underweight Stunted Wasted Overweight For the predominantly rural provinces, stunting prevalence was highest in Midlands and Masvingo (33 percent each), followed by Mashonaland Central (32 percent) and lowest in Matabeleland South (23 percent), see Table 5.2. The predominantly urban provinces of Bulawayo and Harare had stunting prevalences of 20 percent and 25 percent, respectively. Wasting prevalence was highest in Matabeleland North province (4 percent), followed by Mashonaland West and Mashonaland East (3 percent each), whilst the rest of the predominantly rural provinces had 2 percent each. Bulawayo and Harare provinces also had relatively low wasting prevalences of one percent each. Underweight prevalence was highest in Matabeleland North and Mashonaland West provinces (21 percent each) and lowest in Matabeleland South, Manicaland and Masvingo provinces (15 percent each). Bulawayo and Harare provinces had wasting prevalences of 13 percent and 12 percent, respectively. In addition, for all the provinces Harare had the highest proportion of overweight children (3 percent) whilst five provinces namely; Mashonaland East, Matabeleland North, Mashonaland Central, Matabeleland South and Mashonaland West had the lowest (one percent each). 37 5.1.3 Malnutrition According to the Mid-Upper-Arm Circumference (MUAC) According to the WHO: a MUAC of less than 11.4 centimetres indicates that a child is severely malnourished; 11.5-12.4 centimetres that a child is moderately malnourished; 12.5-13.4 centimetres that a child is at risk of malnutrition; and 13.5-95.0 centimetres that a child is well nourished. Nationally, 92 percent of the children aged 6-59 months were well nourished, 7 percent were at risk of malnutrition, 1 percent were moderately malnourished and an insignificant proportion were severely malnourished, see Table 5.3. Male children had a higher proportion who were well nourished (93 percent) than female ones (90 percent). Children in urban areas (93 percent) had a slightly higher proportion who were well nourished than in rural areas (91 percent). Table 5.3: Mid-Upper Arm Circumference (MUAC) Percentage Distribution of Children Age 6-59 Months by Classification of Mid-Upper Arm Circumference, MIMS, Zimbabwe, 2009 Background characteristic Percentage of children age 6-59 months Severely malnourished Moderately malnourished At risk of malnutrition Well nourished Total Percent Number of Children Sex Male 0.1 1.2 5.5 93.2 100.0 3 098 Female 0.4 1.4 7.8 90.4 100.0 3 061 Province Manicaland 0.1 1.0 6.9 91.9 100.0 857 Mashonaland Central 0.5 0.9 8.2 90.4 100.0 656 Mashonaland East 0.4 2.1 11.0 86.5 100.0 603 Mashonaland West 0.5 1.0 6.8 91.7 100.0 690 Matabeleland North 0.0 0.8 7.2 92.0 100.0 399 Matabeleland South 0.2 0.0 1.5 98.3 100.0 393 Midlands 0.6 2.2 7.1 90.1 100.0 746 Masvingo 0.0 0.9 5.8 93.4 100.0 728 Harare 0.0 2.1 4.9 93.0 100.0 816 Bulawayo 0.3 1.6 4.4 93.7 100.0 271 Area Urban 0.2 1.5 5.0 93.3 100.0 1 731 Rural 0.3 1.2 7.3 91.2 100.0 4 429 Age of child 6-11 months 1.7 3.0 14.7 80.5 100.0 630 12-23 months 0.2 3.6 12.6 83.7 100.0 1 402 24-35 months 0.2 0.8 5.8 93.2 100.0 1 318 36-47 months 0.0 0.1 2.7 97.1 100.0 1 409 48-59 months 0.0 0.0 1.6 98.4 100.0 1 401 Mother’s education None 0.4 0.7 6.0 92.9 100.0 303 Primary 0.5 1.5 7.2 90.8 100.0 2 328 Secondary 0.1 1.4 6.7 91.8 100.0 3 224 Higher 0.0 0.0 2.4 97.6 100.0 303 Missing/DK * * * * 100.0 2* Wealth quintile Lowest 0.6 1.0 8.4 90.0 100.0 1 480 Second 0.1 1.5 7.1 91.4 100.0 1 318 Middle 0.1 1.1 6.6 92.3 100.0 1 176 Fourth 0.2 2.1 6.2 91.5 100.0 1 192 Highest 0.2 1.0 4.0 94.8 100.0 995 Total 0.3 1.3 6.6 91.8 100.0 6 160 Note: MUAC less than 11.4 cm is severely malnourished, 11.5-12.4 cm is moderately malnourished, 12.5-13.4 cm is at risk of malnutrition and 13.5-95.0 cm is well nourished. 38 The proportion of well nourished children increased with age of child and generally with the education of the mother and household wealth. For the predominantly rural provinces, Matabeleland South had the highest proportion of well nourished children (98 percent) whilst Mashonaland East had the lowest (87 percent). Bulawayo and Harare provinces had 94 percent and 93 percent, respectively of their children aged 0-59 months well nourished according to the MUAC. 5.1.4 Oedema Prevalence The MIMS enumerators checked for bilateral pitting oedema and what grade the oedema was in children aged 0-59 months. The prevalence of oedema was very low with 98 percent of the children aged 0-59 months not having oedema, with no gender or urban rural differentials see Appendix Table A5.2. The prevalence of oedema did not vary significantly with education of mother and household wealth. All provinces had very high proportions of children with no oedema of at least 98 percent. 5.2 BREASTFEEDING The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. Breast-milk provides all the nutritional requirements for a new born baby for up to 6 months of age, and half of the nutritional requirements for the next 6 months. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop exclusive breastfeeding too soon and there are often pressures to switch to infant formula. Although, formula milk contains the required micronutrients, mothers from low income households may fail to supply the child with enough quantities and may sometimes over-dilute the milk and or use unsafe water for preparation, contributing to growth faltering and increasing the risk of diseases. WHO/UNICEF have the following feeding recommendations: - Breastfeeding be initiated within one hour of birth. - Exclusive breastfeeding for first six months. - Continued breastfeeding for two years or more. - Safe, appropriate and adequate complementary foods beginning at 6 months. - Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds. The Zimbabwe Ministry of Health and Child Welfare’s Baby Friendly Hospital Initiative promotes rooming-in of all new babies in maternity hospitals and breastfeeding immediately or within the first hour of birth to foster bonding and protect babies from harsh environments. It also promotes exclusive breastfeeding for under 6 months olds and continued breastfeeding combined with complementary foods up to 24 months. In Zimbabwe, the 12-24 month olds are recommended to have 3 meals plus 2 snacks per day as complementary feeding. Even with the HIV and AIDS pandemic and the risk of mother-to-child transmission through breastfeeding, exclusive breastfeeding for children under 6 months with prophylaxis is still the best, unless formula milk is affordable, feasible, accessible, sustainable and safe (AFASS). The indicators of recommended child feeding practices are as follows: - Timely initiation of breastfeeding (within 1 hour of birth). - Exclusive breastfeeding rate (less than 6 months and less than 4 months). - Timely complementary feeding rate (6-9 months). 39 - Continued breastfeeding rate (12-15 months and 20-23 months). - Frequency of complementary feeding (6-11 months). - Adequately fed infants (0-11 months). 5.2.1 Breastfeeding Initiation Figure 5.3 and Appendix Table A5.3 provide the proportion of women aged 15-49 years who gave birth in the last two years preceding the survey who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). About half (51 percent) of the women started breastfeeding within one hour of birth while 89 percent did so within one day of birth. There were no rural-urban differences for breastfeeding within one hour of birth whilst 90 percent of the rural compared to 86 percent of the urban women breastfed within one day of birth. There were no significant patterns linking initial breastfeeding practice to mother’s education or household wealth. In the ZDHS 2005/06, for children born in the five years preceding the survey, 69 percent were breastfed within one hour of birth while 93 percent were breastfed within one day of birth. Figure 5.3: Percentage of Mothers Who Started Breastfeeding Within One Hour and Within One Day of Birth, MIMS, Zimbabwe 2009 90 89 88 87 88 83 93 95 85 86 86 90 84 89 89 86 91 89 91 87 85 89 5151 53 51 49 5250 5250 44 515152 49 59 51 49 55 52 46 53 47 0 20 40 60 80 100 120 Pr ov in ce M an ic al an d M as ho na la nd C en tra l M as ho na la nd E as t M as ho na la nd W es t M at ab el el an d N or th M at ab el el an d So ut h M id la nd s M as vi ng o H ar ar e B ul aw ay o A re a U rb an R ur al M ot he r’ s e du ca tio n N on e Pr im ar y Se co nd ar y H ig he r W ea lth q ui nt ile s Lo w es t Se co nd M id dl e Fo ur th H ig he st Zi m ba bw e Pe rc en t Within one hour Within one day For the predominantly rural provinces, Masvingo (59 percent) had the highest proportion of women breastfeeding within one hour of birth, whilst Mashonaland East (46 percent) had the lowest proportion doing so. The predominantly urban provinces of Bulawayo and Harare had 52 percent and 49 percent, respectively of women breastfeeding within one hour of birth. Masvingo (95 percent) had the highest proportion of women breastfeeding within one day of 40 birth whilst Matabeleland South (83 percent) had the lowest proportion doing so. Bulawayo and Harare had 86 percent and 85percent, respectively, of women breastfeeding within one day of birth. 5.2.2 Exclusive Breastfeeding The MIMS collected information on the breastfeeding status based on reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Appendix Table A5.4 shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Exclusive breastfeeding refers to children who receive only breast milk. However, children on exclusive breastfeeding may be given vitamins, mineral supplements, or medicine. Exclusive breastfeeding for children under 4 months, although improving was still very low in Zimbabwe. Thirty eight (38) percent of children aged less than 4 months were exclusively breastfed, a level considerably lower than the ideal 100 percent. In the ZDHS 2005/06, 24 percent of children aged less than 4 months were exclusively breastfed. A higher proportion of children under 4 months (46 percent) in urban areas were exclusively breastfed compared to their rural counterparts (35 percent), see Figure 5.4 and Appendix Table A5.4. In addition, a higher proportion of male children (40 percent) were exclusively breastfed in the first 4 months of birth compared to their female counterparts (35 percent). Exclusive breastfeeding for children under 4 months improved with mother’s education and generally with wealth. Midlands province had the highest proportion (44 percent) of children under 4 months who were exclusively breastfed while Mashonaland Central province had the lowest proportion (21 percent) doing so. Harare province had 41 percent of children under 4 months being exclusively breastfed. Bulawayo province sample for children aged 0-3 months was small. Figure 5.4: Percent of Living Children According to Breastfeeding Status at Each Age Group by Rural/Urban Area, MIMS, Zimbabwe, 2009 46 29 91 72 12 35 25 89 88 24 38 26 89 83 21 0 10 20 30 40 50 60 70 80 90 100 0-3 months percent exclusively breastfed 0-5 months percent exclusively breastfed 6-9 months Percent receiving breastmilk and solid/mushy food 12-15 months Percent breastfed 20-23 Percent breastfed Pe rc en t Urban Rural Total Exclusive breastfeeding for children under 6 months similarly, although improving, was still very low in Zimbabwe. Twenty six (26) percent of children aged less than 6 months were exclusively breastfed, a level considerably lower than the ideal 100 percent. In the ZDHS 2005/06, 22 percent of children aged less than 6 months were exclusively breastfed. A higher proportion of children under 6 months (29 percent) in urban areas were exclusively breastfed compared to 41 their rural counterparts (25 percent). A higher proportion of male children (29 percent) were exclusively breastfed in the first 6 months of birth compared to their female counterparts (23 percent), see Figure 5.5 and Appendix Table A5.4. Figure 5.5: Percent of Living Children According to Breastfeeding Status at Each Age Group by Gender, MIMS, Zimbabwe, 2009 40 29 88 85 22 35 23 91 82 18 38 26 89 83 21 0 10 20 30 40 50 60 70 80 90 100 0-3 months percent exclusively breastfed 0-5 months percent exclusively breastfed 6-9 months Percent receiving breastmilk and solid/mushy food 12-15 months Percent breastfed 20-23 Percent breastfed Pe rc en t Male Female Total Exclusive breastfeeding for children under-6 months improved with mother’s education and generally with wealth, see Appendix Table A5.4. Masvingo province had the highest proportion (34 percent) of children under 6 months who were exclusively breastfed while Mashonaland Central province had the lowest proportion (15 percent) doing so. Bulawayo and Harare provinces had 40 percent and 26 percent, respectively, of children under-6 months being exclusively breastfed. 5.2.3 Timely Complementary Feeding Complementary feeding refers to children who receive breast milk and solid or semi-solid food. It is of concern that significant proportions of children under 6 months had been introduced to solids. Sixty three (63) percent of children aged 4-5 months, 41 percent aged 2-3 months and 12 percent aged 0-1 month, had been introduced to solids, see Appendix Table A5.5. Early introduction of complimentary foods is discouraged because breast milk is a complete meal on its own during the first 6 months. On the other hand formula milk has a high risk of food contamination which can result in diarrhoea and other health complications. In assessing timely complementary feeding, at age 6-9 months, 89 percent of the children were receiving breast milk and solid or semi-solid foods, see Appendix Table A5.4. A slightly higher proportion (91 percent) of children aged 6-9 months in urban areas were receiving complementary feeding compared to rural areas (89 percent). Female children aged 6-9 months had a higher proportion (91 percent) receiving complementary foods than their male counterparts (88 percent). While complementary feeding increased with mother’s education it had no relationship with household wealth status. Mashonaland Central province had the highest proportion (96 percent) of children aged 6-9 months who were receiving complementary feeding while Mashonaland West province had the lowest proportion (84 percent) who did so. Harare province had 90 percent of children aged 6-9 months receiving complementary feeding. Bulawayo province sample of children aged 6-9 months was small. 42 5.2.4 Continued Breastfeeding Continued breastfeeding was assessed using the following two indicators; proportions of children aged between 12-15 months and 20-23 months who were breastfed the day preceding the survey. By age 12-15 months, 83 percent of children were still being breastfed and by age 20-23 months, 21 percent were still doing so, see Appendix Table A5.4. Children living in rural areas had a higher proportion being breastfed up to 12-15 months and 20-23 months, than urban areas. Male children had a higher proportion being breastfed up to 12-15 months and 20- 23 months, than their female counterparts. Continued breastfeeding of children up to 12-15 months and 20-23 months declined with education and generally with household wealth. Mashonaland Central province had the highest proportion (91 percent) of children who had continued to breastfeed to age 12-15 months while Matabel

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