1. Nutrition Multiple Indicator Cluster Surveys Data dissemination and further analysis workshop

2. Overview of presentation Nutritional status Breastfeeding Micronutrients –Vitamin A –Iodized salt Low birthweight

3. Table NU.1: 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 above - 2 SD 1 - 3 SD 2 - 2 SD 3 - 3 SD 4 - 2 SD 5 - 3 SD 6 + 2 SD Sex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total 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 –refer to appendix

4. 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.1: 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 above - 2 SD 1 - 3 SD 2 - 2 SD 3 - 3 SD 4 - 2 SD 5 - 3 SD 6 + 2 SD Sex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total

5. MICS4 country example Table NU.1: 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 SexMale13.33.4-.8308533.413.6-1.429286.22.27.5.02954 Female12.03.0-.8298633.613.1-1.428785.51.97.6.02909 AreaUrban10.53.2-.7180028.014.0-1.217136.52.310.0.11713 Rural13.63.2-.9427135.813.1-1.540935.61.96.6.04150 Total 12.73.2-.8607133.513.3-1.458055.92.07.6.05863

6. Breastfeeding

7. Background Several documents provide guidance on indicators for assessing infant and young child feeding practices

8. Continuum of feeding practices Infant and young child feeding patterns from birth to two years * Excluding China, due to lack of data. Source: UNICEF global databases 2010, from MICS, DHS and other national surveys.

9. Table NU.2: 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 Region Residence Months since birth Assistance at delivery Place of delivery Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total Note denominator = women surveyed having a live birth within the 2 years prior to the survey

10. Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Country, Year Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed 1 Percent predomi- nantly breastfed 2 Num- ber of childre n Percent breastfed (Continued breastfeeding at 1 year) 3 Number of children Percent breastfed (Continued breastfeeding at 2 years) 4 Number of children Sex Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total 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. only breastmilk (exceptions for medicine, vitamins) breastmilk, water, non-milk liquids

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

12. Figure 4. Répartition en pourcentage des enfants de moins de 2 ans par type d'alimentation, par tranche d'âge, Tchad, 2010

13. MICS4 Survey Design Workshop

14. Table NU.4: 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 Sex Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Median Mean for all children (0-35 months)

15. Table NU.5: 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 appropriatel y breastfed 2 Number of children Sex Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total NEW! Assess appropriate breastfeeding practices throughout recommended period of birth to age 2 years of age

16. Table NU.6: 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 Sex Male Female Residence Urban Rural Total Children should start receiving food at 6 months of age New standard indicator – not comparable to previous indicator on complementary feeding NEW!

17. Table NU.7: Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Country, Year Currently breastfeedingCurrently not breastfeedingAll Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds 1 Percent receiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency 2 Number of children age 6-23 months Sex Age Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total Appropriate number of meals varies according to child’s age and breastfeeding status NEW!

18. Table NU.8: 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 Sex Age Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total

19. 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, 12- 15 mos, 20-23 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

20. Micronutrients Vitamin A and Salt Iodization

21. Table NU.10: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Country, Year Percentage who received Vitamin A according to: Percentage of children who received Vitamin A during the last 6 months 1 Number of children age 6- 59 months Child health book/card/vaccination card Mother's report Sex Region Residence Age Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total Not all countries have Vitamin A programmes While there may be some expectation of vitamin A deficiency in poor and rural areas, keep in mind that these are also the areas specifically targeted by campaigns. Either recorded in health book/ vaccination card or mother’s report Proxy measure of recommended 2 doses per year

22. Things to remember Survey data for vitamin A tend to be underreported as a result of - Timing: data collection may precede campaign - Recall error - Mothers’ don’t know if infant received supplement - Often not recorded on child health card May be discrepancies between data obtained through household surveys and those obtained from National Immunization Days and routine service statistics

23. MICS4 Country Example Table NU.10: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Percentage who received Vitamin A according to: Percentage of children who received Vitamin A during the last 6 months [1] Number of children aged 6- 59 months Child health book/ card/ vaccination cardMother's report Sex1 Male8.058.860.71760 2 Female7.559.561.21743 Wealth index quintiles1 Poorest9.555.158.9818 2 Second8.059.360.8669 3 Middle7.862.964.7669 4 Fourth5.663.363.8700 5 Richest7.756.056.7648 Total1.00 Total7.859.260.93504

24. Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Country, Year Percentage of households in which salt was tested Number of households Percent of households with Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM15+ PPM 1 Total Region Residence Wealth index quintile Total100.0 Take note of % households in which salt tested 15+ PPM is international standard

25. MICS4 Country Example Table NU.9: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Country, Year Percent of households in which salt was tested Number of households Percent of households with salt test result Total Number of households in which salt was tested or with no salt >0 and <15 PPM15+ PPM [1] Percent of households with no salt Not iodized 0 PPM AreaUrban 96.72,6122.740.515.341.5100.02,596 Rural 97.11,2092.334.315.348.1100.01,201 Wealth index quintiles Poorest 97.07802.439.715.941.9100.0776 Second 96.28113.441.816.238.6100.0807 Middle 96.07783.234.215.447.3100.0772 Fourth 97.37562.235.614.747.6100.0752 Richest 97.56961.641.614.042.8100.0691 Total 96.83,8212.638.515.343.6100.03,797

26. Low Birth Weight

27. Table NU.11: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Country, Year Percent of live births: Number of live births in the last 2 years Below 2500 grams 1 Weighed at birth 2 Region Residence Mother’s education Wealth index quintile Religion/Language/Ethnicity of household head Total

28. 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?????

29. 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). –Mother’s recall of the child’s size at birth (i.e. very small, smaller than average, larger than average, very large) –Mother’s recall of the child’s weight or the weight recorded on a health card if the child was weighed at birth

30. Methodological Issues Adjustment Procedure

31. Methodological Issues Heaping of Birth Weight, Tanzania 1999

32. 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 2500 grams -- this is based on empirical distributions from DHS surveys 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 4.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 5.Divide by the total number of live births to obtain the percentage with low birth weight

33. Example from Gambia MICS4 Survey Design Workshop

34. Methodological Issues Effect of Adjustment

35. Table NU.11: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth Percent of live births: Number of live births in the last 2 years Below 2500 grams Weighed at birth AreaUrban29.19.7602 Rural31.33.51889 Wealth index quintilesPoorest34.01.9464 Second33.02.3539 Middle28.42.7485 Fourth30.36.4490 Richest28.411.7513 Total 30.85.02491 Table NU.11: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, 1.00 Percent of live births: births Number of live births in last two years Below 2500 grams [1] Weighed at birth [2] Area1 Urban4.298.9997 2 Rural5.697.9657 Wealth index quintiles1 Poorest5.797.6354 2 Second4.297.6328 3 Middle5.598.4365 4 Fourth4.1100.0297 5 Richest3.899.3310 Total1.00 Total4.798.51654

36. Some ideas for further analyses Undernutrition is the result of a combination of factors: lack of food in terms of quantity and quality; inadequate water, sanitation and health services; and suboptimal care and feeding practices. Until improvements are made in these three aspects of nutrition, progress will be limited. As such, there is a desperate need to further understand and document relationships between WASH and undernutrition. Examine associations between early initiation of breastfeeding and skilled attendants at delivery or antenatal care with a skilled professional

37. 37 Thank you!