Multiple Indicator Cluster Surveys Data Interpretation, Further Analysis and Dissemination Workshop Nutrition

Overview of presentation  Low birth weight  Nutritional status  Breastfeeding and dietary intake  Iodized salt 2

Low Birth Weight

4 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Country, Year Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live- born children in the last two years Very small Smaller than averageAverage Larger than average or very largeDK Below 2,500 grams 1 Weighed at birth 2 Total Mother's age at birth Birth order Region Area Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head

Methodological Issues Percentage of births NOT weighed *: Excluding China Note: Regional averages of births not weighed are not available for Latin America and Caribbean, East Asia and Pacific and Central and Eastern Europe/Commonwealth of Independent States (CEE/CIS), due to lack of data. Source: UNICEF global databases 2010, from MICS, DHS and other national surveys. How can we measure low birth weight when high proportion of children not weighted????? 5

Methodological Issues In MICS, two items in the questionnaire are used to estimate low birth weight based on an adjustment procedure was proposed by Boerma and colleagues (1996). 1.Mother’s subjective assessment of the child’s size at birth (i.e. very small, smaller than average, larger than average, very large) 2.Mother’s recall of the child’s weight or the weight recorded on a health card 6

Methodological Issues Adjustment Procedure 7

Methodological Issues Heaping of Birth Weight, Tanzania

Methodological Issues Adjustment steps 1.25 percent of children reported as weighing exactly 2500 grams are treated as weighing less than 2500 grams to adjust for heaping on 2,500 2.Tabulate children’s size by their weight for those weighed at birth to obtain proportion of births in each size category who weighed <2,500 grams 3.Multiply this proportion by the total number of children in size category to obtain estimated number of children by size category with low birth weight 9

Methodological Issues Adjustment steps (cont’d) 3.Sum the estimated number of children in each size category with low birth weight in order to obtain the total number of low birth weight children 4.Divide by the total number of live births to obtain the percentage with low birth weight 10

Example from Gambia 11

Methodological Issues Effect of Adjustment 12

Nutritional status

14 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Country, Year Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) percent below percent above - 2 SD SD SD SD SD SD SD Total Sex Region Residence Age Region Mother’s education Wealth index quintile Religion/Language/Ethni city of household head Reflects a child’s total body mass Cumulative deficient growth Recent nutritional deficiency Undernutrition indicators refer to children whose z-scores fall below -2 SDs (moderately and severely) and -3 SDs from the median of the reference population International reference population:  Note that the WHO Child Growth Standards is used for these calculations  Not comparable to the NCHS/CDC/WHO reference

15 Key data considerations  Note that if height and weight data are missing for more than 10% of children under-five, caution should be exercised in the interpretation of the results.  Accurate age reporting is also an essential component of anthropometric indicators (underweight and stunting)  Do not attempt to do any trend analysis with the wasting indicator due to seasonality of wasting prevalence Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Country, Year Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) WastedOverweight Mean Z- Score (SD) percent below percent below percent below percent above -2 -SD 1 -3 S -D SD SD SD SD SD Total Sex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head

MICS4 country example Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Underweight Weight for age: Stunting Height for age: Wasting Weight for height: % below - 2 sd [1] % below - 3 sd [2] Mean Z-Score (SD) Number of children % below - 2 sd [3] % below - 3 sd [4] Mean Z-Score (SD) Number of children % below - 2 sd [5] % below - 3 sd [6] % above +2 sd Mean Z-Score (SD) Number of children SexMale Female AreaUrban Rural Total

Breastfeeding and Dietary Intake

Background  Several documents provide guidance on indicators for assessing infant and young child feeding practices 18

Continuum of feeding practices Percent Birth 2 years and beyond * Excludes China

Table NU.3: Initial breastfeeding Percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Country, Year Percentage who were ever breastfed 1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last- born children in the two years preceding the survey Within one hour of birth 2 Within one day of birth Total Region Area Months since birth Assistance at delivery Place of delivery Mother’s education Wealth index quintile  Note: Denominator = women surveyed having a live birth within the 2 years prior to the survey 20

Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Country, Year Children age 0-5 months Children age months Children age months Percent exclusively breastfed 1 Percent predomi- nantly breastfed 2 Number of children Percent breastfed (Continued breastfeeding at 1 year) 3 Number of children Percent breastfed (Continued breastfeeding at 2 years) 4 Number of children Total Sex Region Area Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head  Indicators based on current status (24 hour recall period)  The prevalence of exclusively breastfed children should be less than or equal to the prevalence of children who are predominantly breastfed. Breastmilk, water, non-milk liquids Only breastmilk (exceptions for medicine, vitamins) 21

MICS4 country example  According to the 2010 Chad MICS, only 3% of children <6 months are exclusively breastfed. What’s going on? 22

Figure 4. Répartition en pourcentage des enfants de moins de 2 ans par type d'alimentation, par tranche d'âge, Tchad,

Figure 4. Répartition en pourcentage des enfants de moins de 2 ans par type d'alimentation, par tranche d'âge, Tchad, Breastmilk + water

25

Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Country, Year Median duration (in months) of Number of children age 0-35 months Any breastfeeding 1 Exclusive breastfeeding Predominant breastfeeding Median Sex Region Area Mother’s education Wealth index quintile Mean 26

Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Country, Year Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed 1 Number of children Percent currently breastfeeding and receiving solid, semi-solid or soft foods Number of children Percent appropriately breastfed 2 Number of children Total Sex Region Area Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head  Assess appropriate breastfeeding practices throughout recommended period of birth to age 2 years of age 27 Children age 0-5 months who are exclusively breastfed and children age 6-23 months who are currently breastfed and receiving any solid, semi- solid or soft foods (at least one food item).

Table NU.7: Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Country, Year Currently breastfeeding Currently not breastfeedingAll Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods 1 Number of children age 6-8 months Total Sex Area  Children should start receiving food at 6 months of age  New standard indicator – not comparable to previous indicator on complementary feeding 28

Recent addition to MICS 29 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Country, Year Currently breastfeedingCurrently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Min dietary diversity Min meal freq. Min accep table diet 1, Min dietary diversity Min meal freq. Min acceptab le diet 2 At least 2 milk feeds 3 Min dietary diversity 4 Min meal freq. 5 Min accepta ble diet Total Sex Age Region Area Mother’s education Minimum dietary diversity: Receiving foods from at least 4 of 7 food groups: 1)Grains, roots and tubers 2)Legumes and nuts 3)Dairy products (milk, yogurt, cheese) 4)Flesh foods (meat, fish, poultry and liver/organ meats) 5)Eggs 6)Vitamin-A rich fruits & vegetables 7)Other fruits &vegetables.

Recent addition to MICS 30 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Country, Year Currently breastfeedingCurrently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Min dietary diversity Min meal freq. Min accep table diet 1, Min dietary diversity Min meal freq. Min acceptab le diet 2 At least 2 milk feeds 3 Min dietary diversity 4 Min meal freq. 5 Min accepta ble diet Total Sex Age Region Area Mother’s education Minimum meal frequency Calculation depends on age of child and breastfeeding status

Recent addition to MICS 31 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Country, Year Currently breastfeedingCurrently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Min dietary diversity Min meal freq. Min accep table diet 1, Min dietary diversity Min meal freq. Min acceptab le diet 2 At least 2 milk feeds 3 Min dietary diversity 4 Min meal freq. 5 Min accepta ble diet Total Sex Age Region Area Mother’s education Minimum acceptable diet: Receiving the minimum dietary diversity and the minimum meal frequency

Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Country, Year Percentage of children age 0-23 months fed with a bottle with a nipple 1 Number of children age 0-23 months Total Sex Age Region Area Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head 32

Things to think about  “Current status approach” is used to calculate indicators – asks about feeding status within 24 hours of the survey.  Precision of indicators poor - The number of children in age ranges of interest (< 6 mos, 6-9 mos, mos, mos) are likely to be small, and therefore the precision of indicators may lower than that of others  While exclusive breastfeeding among infants remains uncommon in some countries, exclusive breastfeeding patterns are often similar for boys and girls and across household residence area and wealth quintile 33

Salt Iodization

 Take note of % households in which salt tested  15+ PPM is international standard 35 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Country, Year Percentage of households in which salt was tested Number of househ olds Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM 1 Total Region Area Wealth index quintiles

MICS4 Country Example Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Country, Year Percent of househol ds in which salt was tested Number of househol ds Percent of households with salt test result Total Number of househol ds in which salt was tested or with no salt >0 and <15 PPM 15+ PPM [1] Percent of househol ds with no salt Not iodized 0 PPM AreaUrban 96.72, ,596 Rural 97.11, ,201 Wealth index quintiles Poorest Second Middle Fourth Richest Total 96.83, ,797 36

Some ideas for further analyses  Undernutrition is the result of a combination of factors: lack of food in terms of quantity & quality; inadequate water, sanitation & health services; and suboptimal care and feeding practices.  Possible to look at relationships between  WASH and undernutrition.  Early initiation of breastfeeding and skilled attendance at delivery or antenatal care with a skilled professional  Create an infant feeding continuum 37

Thank you! 38 Holly’s daughter!