1. Multiple Indicator Cluster Surveys Data dissemination and further analysis workshop Maternal and Reproductive Health MICS4 Data Dissemination and Further Analysis Workshop

2. Overview of MICS4 contents Core modules –Childbearing among adolescents (3 tables) –Contraception (2 tables) –Antenatal care (3 tables) –Delivery care (2 tables) Other modules –Post-natal health care (6 tables) –Maternal mortality (1 table)

3. Table RH.1: Adolescent birth rate and total fertility rate, Country, 2010 Adolescent birth rate [1] (Age-specific fertility rate for women age 15-19) Total Fertility Rate AreaUrban302.3 Rural772.8 Mother's education None1132.9 Primary702.5 Second ary+ 293.0 Wealth index quintile Poorest1123.1 Second952.8 Middle973.0 Fourth362.4 Richest102.0 Total 592.6 Childbearing among adolescents Calculations based data from the child mortality module (Brass questions) or birth history Pay attention to sample sizes, especially for breakdowns by background variables NEW!

4. Table RH.1: Adolescent birth rate and total fertility rate, Country, 2010 Adolescent birth rate [1] (Age-specific fertility rate for women age 15-19) Total Fertility Rate AreaUrban302.3 Rural772.8 Mother's education None1132.9 Primary702.5 Second ary+ 293.0 Wealth index quintile Poorest1123.1 Second952.8 Middle973.0 Fourth362.4 Richest102.0 Total 592.6 Childbearing among adolescents Calculations based data from the child mortality module (Brass questions) or birth history Pay attention to sample sizes, especially for breakdowns by background variables Number of births to women age 15-19 years, divided by the average number of women age 15-19 (during the one year period preceding the survey) Average number of children to which a woman will have given birth by the end of her reproductive years if current fertility rates prevailed. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. NEW! ABR: Number of births per 1,000 adolescent girls aged 15–19.

5. Table RH.2: Early childbearing Percentage of women age 15-19 who have had a live birth or who are pregnant with the first child; percentage of women age 15-19 who have begun childbearing before age 15, and the percentage of women age 20-24 who have had a live birth before age 18, Country, 2010 Number of women age 15-19 Percentage of women age 20-24 who have had a live birth before age 18 [1] Number of women age 20-24 Have had a live birth Are pregnant with first child Have begun childbearing Have had a live birth before age 15 AreaUrban2.9.83.7.275310.3882 Rural11.83.515.3.7129918.01620 EducationNone20.34.825.11.454824.01158 Primary11.64.115.7.930422.7340 Secondary +2.41.03.4.012012.71004 Wealth index quintilesPoorest15.82.518.31.631621.1402 Second17.04.221.2.132317.7413 Middle13.25.418.61.533916.8499 Fourth4.61.46.0.044117.1614 Richest.8 1.5.06336.3574 Total 8.52.511.0.5205215.32502 [1] MICS indicator 5.2 Childbearing among adolescents NEW! Sum of the first two columns

6. Childbearing among adolescents Two indicators -- Note that each indicator has a different denominator Figures in the total row are based on women age 15-19 and 20-24 for live births before age 15 and age 18, respectively. Data from different cohorts provides trends NEW! Table RH.3: Trends in early childbearing Percentage of women who have had a live birth by age 15 and 18, by age groups, Country, 2010 UrbanRuralAll Percentage of women with a live birth before age 15 Number of women Percentage of women with a live birth before age 18 Number of women Percentage of women with a live birth before age 15 Number of women Percentage of women with a live birth before age 18 Number of women Percentage of women with a live birth before age 15 Number of women Percentage of women with a live birth before age 18 Numb er of wome n Age15-19.2753.0.71299.0.52052.0 20-24.688210.38821.5162018.016201.2250215.32502 25-291.498311.19832.3173818.117381.9272115.62721 30-341.872216.67222.3149718.114972.2221917.62219 35-392.653613.15362.0132015.913202.2185615.11856 40-442.438017.43801.4118113.511811.7156114.41561 45-492.419210.5192.791410.89141.0110610.81106 Total 1.4444812.936951.6957016.382711.61401815.21196 6

7. Adolescent childbearing – a comparison of indicators IndicatorValue Adolescent birth rate* (per 1000 women 15-19)59 2010-2011 MICS4 *Adolescent birth rate: Age-specific fertility rate for women aged 15–19

8. Adolescent childbearing – a comparison of indictors IndicatorValue Adolescent birth rate (per 1000 women 15-19)59 15-19 year old women who have had a live birth8.5% Example from MICS4

9. Adolescent childbearing – a comparison of indictors IndicatorValue Adolescent birth rate (per 1000 women 15-19)59 15-19 year old women who have had a live birth8.5% Live birth before age 18 (among 20-24 year olds)15.3% Example from MICS4

10. Overview of MICS4 contents Core modules –Childbearing among adolescents (3 tables) –Contraception (2 tables) –Antenatal care (3 tables) –Delivery care (2 tables) Other modules –Post-natal health care (6 tables) –Maternal mortality (1 table)

11. Contraception Table RH.4: Use of contraception Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a contraceptive method, Country, Year Not using any method Percent of women (currently married or in union) who are using: Number of women currentl y married or in union Fe-male sterili- zation Male sterili- zationIUD Injectab les Im- plantsPill Male con- dom Fe-male con- dom Dia- phragm/ Foam/J ellyLAM Periodic abstin- ence With- drawalOther Any mod- ern meth-od Any tradi- tional meth-od Any method 1 Any method is an MDG indicator Modern Traditional

12. How to define unmet need? Women with an unmet need for family planning are women who –are married or in union –are fecund –not using any method of contraception –report not wanting any more children or wanting to delay the birth of their next child for at least two years

13. We also consider the following to have unmet need: Women* who are pregnant, but whose current pregnancy unwanted or mistimed Postpartum amenorrheic women* (not using contraception) whose last birth was unwanted or mistimed *Married/in union How to define unmet need?

14. Key indicator elements Marital status Current use of contraception (any method) Fecundity Pregnant or amenorrheic Desire for last birth Desire for future births

15. Unmet need Table RH.5: Unmet need for contraception Percentage of women age 15-49 years currently married or in union with an unmet need for family planning and percentage of demand for contraception satisfied, Country, Year Met need for contraception Unmet need for contraception Number of women currently married or in union Percentage of demand for contraception satisfied Number of women currently married or in union with need for contraception For spacing For limitingTotal For spacing For limitingTotal 2 Region Urban-rural Age Education Wealth index quintiles Religion/Language/Ethnicity of household head Total 1 MICS indicator 5.3; MDG indicator 5.3 2 MICS indicator 5.4; MDG indicator 5.6 New MICS4 methodology – may make comparisons challenging Note that met need for contraception includes both traditional and modern methods

16. MICS4 country example of unmet need Met need for contra- ception - For spacing Met need for contra- ception - For limiting Met need for contra- ception - Total Unmet need for contra- ception – For spacing Unmet need for contra- ception – For limiting Unmet need for contra- ception - Total Number of women currently married or in union Percentage of demand for contra- ception satisfied Number of women currently married or in union with need for contra- ception 19.158.277.32.42.14.52,65394.42,171 Any method 77.2 Any modern method 58.8 Any traditional method 18.5 Periodic abstinence/Rhythm 12.0 Withdrawal 6.2 RH4: Use of contraception Note that met need for contraception includes both traditional and modern methods

17. Overview of MICS4 contents Core modules –Childbearing among adolescents (3 tables) –Contraception (2 tables) –Antenatal care (3 tables) –Delivery care (2 tables) Other modules –Post-natal health care (6 tables) –Maternal mortality (1 table)

18. Antenatal care Table RH.6: Antenatal care coverage Percent distribution of women age 15-49 who gave birth in the two years preceding the survey by type of personnel providing antenatal care, Country, Year Person providing antenatal care No antenatal care receivedTotal Any skilled personnel 1 Number of women who gave birth in the preceding two years Medical doctor Nurse/ Midwife Auxiliary midwife Traditional birth attendant Communit y health workerOther Key indicator: At least one ANC visit (MDG) Personnel categories Should have been modified in country MICS4 standard -- Skilled health personnel includes doctors, nurses, midwives, and auxiliary midwives. But double-check and document in final report text

19. Table RH.7: Number of antenatal care visits Percent distribution of women who had a live birth during the two years preceding the survey by number of antenatal care visits by any provider, Country, Year Percent distribution of women who had: Number of women who had a live birth in the preceding two years No ante- natal care visitsOne visit Two visits Three visits 4 or more visits 1 Total Region Urban-rural Mother's age at birth Education Wealth index quintile Religion/Language/Ethnicity of household head Total 100.0 1 MICS indicator 5.5b; MDG indicator 5.5 Antenatal care MDG indicator; for reporting ensure that 4+ can be derived from table Watch out for… Indicator definition (any provider) “don’t knows”

20. Table RH.8: Content of antenatal care Percentage of women age 15-49 years who had their blood pressure measured, urine sample taken, and blood sample taken as part of antenatal care, Country, Year Percentage of pregnant women who had: Number of women who had a live birth in the preceding two years Blood pressure measured Urine sample taken Blood sample taken Blood pressure measured, urine and blood sample taken 1 Region Urban-rural Mother's age at birth Education Wealth index quintile Religion/Language/Ethnicity of household head Total 1 MICS indicator 5.6 Antenatal care

21. Overview of MICS4 contents Core modules –Childbearing among adolescents (3 tables) –Contraception (2 tables) –Antenatal care (3 tables) –Delivery care (2 tables) Other modules –Post-natal health care (6 tables) –Maternal mortality (1 table)

22. Delivery Care Table RH.9: Assistance during delivery Percent distribution of women age 15-49 who had a live birth in the two years preceding the survey by person assisting at delivery and percentage of births delivered by C-section, Country, Year Person assisting at delivery No attend- antTotal Delivery assisted by any skilled atten- dant 1 Percent delivered by C-section 2 Number of women who had a live birth in preceding two years Medical doctor Nurse/ Midwife Auxiliary midwife Traditio nal birth attend- ant Com- munity health worker Relative /FriendOther MDG indicator: Skilled attendant at delivery MICS 4 standard -- Skilled health personnel includes doctors, nurses, midwives, and auxiliary midwives. But double-check and document in final report text New indicator! C-section should be within 5%-15% NEW!

23. Delivery Care Table RH.10: Place of delivery Percent distribution of women age 15-49 who had a live birth in two years preceding the survey by place of delivery, Country, Year Place of delivery Total Delivered in health facility 1 Number of women who had a live birth in preceding two years Public sector health facility Private sector health facilityHomeOther Region Urban-rural Mother's age at birth Number of antenatal care visits Education Wealth index quintiles Religion/Language/Ethnicity of household head Total 100.0 1 MICS indicator 5.8 Place of delivery categories should have been modified in country Possible to present additional categories

24. Continuum of reproductive and maternal health interventions Pre- preg Pregnancy (Antenatal Care) Delivery Care

25. Continuum of reproductive and maternal health interventions Pre- preg Pregnancy (Antenatal Care) Delivery Care Gap!

26. Overview of MICS4 contents Core modules –Childbearing among adolescents (3 tables) –Contraception (2 tables) –Antenatal care (3 tables) –Delivery care (2 tables) Other modules –Post-natal health care (6 tables) –Maternal mortality (1 table)

27. Post-natal Health Checks New MICS4 module 6 tables covering post-natal health checks for both mother and child –Post-partum stay in health facility –Post-natal health checks for newborns –Post-natal care (PNC) visits for newborns –Post-natal health checks for mothers –Post-natal care (PNC) visits for mothers –Post-natal health checks for mothers and newborns NEW!

28. The MICS4 Module Institutional deliveries Non-institutional deliveries With attendantWithout attendant While in facility or at home following birth Duration of post-partum stay in facility Health check in facility after birth - before discharge Health check from attendant before leaving mother & child after birth Postnatal care visit (with information on timing, location & provider) Health check after discharge Health check after attendant leaves home after birth Any health check Postnatal health check (global indicator) Health check in facility and/or health check after discharge (i.e. PNC visit within two days of delivery) Health check from birth attendant and/or a health check after attendant leaves home (i.e. PNC visit within two days of delivery) Health check (i.e. PNC visit within two days of delivery)

29. PNC Data from West African country MICS 2011 West African country MICS 2011; unpublished data Place of delivery (Last births in last 2 years) –Facility births: 67 percent 74 percent stay in facility for more than 12 hours 10 percent are discharged within 6 hours of delivery Survey data provide important programmatic insights – especially with detailed data on PNC visits

30. Health check following birth while in facility or at home PNC visit Same day 1 day following birth 2 days following birth 3-6 days following birth After first week following birth No PNC Visit Missing/ Don’t KnowTotal Global Indicator: PNHC Number of last births in the 2 years prior to survey Newborns Place of delivery Health facility 97.16.33.31.75.027.055.71.1100.097.21434 Home 47.412.67.31.35.38.564.30.8100.054.5793 Total 80.98.54.51.65.021.058.51.0100.083.32528 Mothers Place of delivery Health facility 97.53.21.40.94.016.773.40.4100.097.51703 Home 47.37.94.90.93.44.378.40.1100.051.6793 Total 81.14.82.50.93.812.874.90.3100.082.52528 PNC Data from West African country MICS 2011 Similar patterns for mothers, but mothers are less likely to receive a PNC visit Majority receive a health check while in facility or at home (much less for home deliveries) – similar figures for newborns and mothers 21 percent receive a first PNC visit more than one week after delivery Only 41 percent receive a PNC visit 15 percent receive a PNC visit on the same day, or one or two days following delivery

31. PNC Data from West African country MICS 2011 Health checks performed universally in facilities, but PNC visits may not be performed at all, or may be performed quite late In the case of home deliveries, less than half of birth attendants perform health checks on mothers and newborns More PNC visits for newborns than mothers – both for home and facility deliveries

32. PNC Data from West African country MICS 2011 Location of first PNC visitProvider of first PNC visit Home Public sector Private sectorOtherTotal Doctor/ nurse/ midwife Aux. Midwife Community health workerTBATotal Number of newborns/mother s of last births in 2 years prior survey with a PNC visit within first week of life Newborns Place of delivery Home68.431.50.10.0100.038.31.77.652.4100.0210 Health facility 12.373.614.10.0100.095.61.72.70.1100.0277 Total36.155.57.90.4100.070.81.75.022.5100.0495 Mothers Place of delivery Home66.633.20.20.0100.041.02.110.047.0100.0129 Health facility 17.271.011.80.0100.095.51.71.61.1100.0146 Total39.253.96.40.0100.070.51.85.522.2100.0280 Majority of home deliveries receive PNC visits at home; more than half have PNC visits with a TBA Very similar patterns for newborns and mothers Facility deliveries return to a facility for a PNC visit (88 %) Almost all are seen by a doctor/midwife/nurse

33. PNC Data from West African country MICS 2011 Possible to use MICS data to uncover differentials – for example: –80 percent of both mothers and newborns receive PNHC –Newborns in rural areas and poorest households lag behind, at 73 and 63 percent Per cent of both mothers and newborns receiving a health check in the facility or at home, or a PNC visit within two days of birth

34. To conclude Substantial increase in PNC data availability due to inclusion in MICS –18 surveys in 2009-2012 –Many more expected in MICS5 (2012-2014) More data will also mean better understanding of how the module is working

35. MICS4 – now recommends direct sisterhood method (survivorship of all siblings) Limitations include: –Reference period usually 7 years or 10 years before the survey –Confidence intervals are very wide –Studies indicate that both male and female mortality underestimated Maternal mortality

36. Table RH.17: Maternal mortality Direct estimates of maternal mortality for the 0-6 years preceding the survey, Country, Year Maternal deaths Exposure (years) Mortality rates (per 1000) Proportion of maternal deaths to female deaths Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total General fertility rate Maternal mortality ratio 1 1 MICS indicator 5.13; MDG indicator 5.1 Maternal mortality ratio is calculated as the maternal mortality rate divided by the general fertility rate The maternal mortality rate and general fertility rate are age-adjusted

37. Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia) Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010

38. Further use of the data

39. Coverage of interventions varies across the continuum of care Source: Countdown to 2015: The 2012 report

40. Tracking Progress on Child and Maternal Nutrition

41. Brainstorming Focus on adolescents – coverage of maternal health services Maternal health… –fertility desires by background characteristics HIV and maternal care (knowledge, testing during ANC) Malaria in pregnancy (provision of IPTp during ANC visits)

42. Thank you!