Photographs used on cover:

Afro - Caribbean girl from Bluefields, Southern Atlantic Coast. Survey interviewer in the municipality of San Miguelito. Young adults at the Central American University (UCA). A pregnant young adult receiving antenatal care at the health center in the municipality of Mulukuku in the Northern Autonomous Atlantic Region (RAAN). Doctors in the operation room in a hospital in Bluefields. A one - year old boy, in his mother’s arms, receiving a medical check-up at the health center at Mulukuku.

REPUBLIC OF NICARAGUA

Nicaraguan Demographic and Health Survey ENDESA 2006/07 Preliminary Report

National Institute for Development Information (INIDE) Ministry of Health (MINSA) Special thanks to: United Nations Population Fund (UNFPA) United Nations Children’s Fund (UNICEF) United Nations Development Programme (UNDP) World Bank (WB) United States Agency for International Development (USAID) Canadian Technical Assistance Program (CANTAP-3) Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. USA (Technical Assistance)

ENDESA Project National Institute for Development Information (INIDE) Ministry of Health (MINSA) Photographs and Cover: Fanix Urbina, Fátima Pérez Graphic Design: Raquel Martínez Internet site: www.inide.gob.ni Fax: 2681790, Telephone: 2666178, 2662825. Post Box: 4031. Managua, Nicaragua, September, 2008

CONTENTS Introduction ........................................................................................................................................1

Methodology .......................................................................................................................................2 Sample design and selection ..................................................................................................2 Data collection and processing ...............................................................................................3 Sample yield ...........................................................................................................................4

Characteristics of the Respondents .........................................................................................5

Fertility ...............................................................................................................................................7

Family Planning ...............................................................................................................................10 Maternal and Child Health .........................................................................................................13 Women’s Health ....................................................................................................................13 Prenatal care .........................................................................................................................13 Delivery assistance .................................................................................................................15 Child Health ..........................................................................................................................16 Nutrition ...............................................................................................................................17 Child Immunization ..............................................................................................................19 Childhood Illnesses ................................................................................................................20 Acute Respiratory Infections ...................................................................................................20 Diarrhea ..............................................................................................................................21

Infant and Child Mortality ..........................................................................................................23

HIV/AIDS ............................................................................................................................................26

Violence Against Women .............................................................................................................28

Annexes .............................................................................................................................................31 TABLES Table 1

RESULTS FROM HOUSEHOLD AND INDIVIDUAL INTERVIEWS Number of household and individual interviews and response rates, by residence, region and department .....................................................................................33

Table 2

CHARACTERISTICS OF WOMEN INTERVIEWED Percent distribution of women 15 to 49 years of age, by selected characteristics .......................................................................................................................34

Table 3a FERTILITY Age-specific and total fertility rates for the 5 years preceding the survey, by rural-urban residence ........................................................................................................35 Table 3b FERTILITY Age-specific and total fertility rates for the 5 years preceding the survey, ENDESA 1998, 2001 and 2006/07 .......................................................................................35 Table 4

FERTILITY, PARITY AND PREGNANCY Total fertility rate, mean number of children born alive among women 45 to 49 years of age and percent of women currently pregnant, by selected characteristics ..........................................................................................................36

Table 5

WANTED AND UNWANTED FERTILITY, PARITY, PREGNANCY, AGE OF FIRST SEX, UNION, AND BIRTH Wanted and Unwanted total fertility, mean number of live births of women 45-49, percent currently pregnant women and median age at first sexual relation, first union, and first birth, by selected characteristics .......................................................................................................................37

Table 6

ADOLESCENT FERTILITY Percent of adolescents (15-19) that are already mothers or are pregnant for the first time, by selected characteristics .................................................................................38

Table 7

CURRENT CONTRACEPTIVE USE OF WOMEN IN-UNION Percent distribution of women in-union by current contraceptive method, by select characteristics ..........................................................................................................39

Table 8

SOURCE OF MODERN CONTRACEPTIVE METHODS Percent distribution of users of contraceptive methods, by source of method ............................40

Table 9a PRENATAL CARE COVERAGE Percent of births for whom mothers received prenatal care (various indicators of care) and a tetanus toxoid vaccine prior to childbirth, live births between September 2001 and August 2006 ............................................................41 Table 9b DELIVERY OF BIRTHS Percent of live births (between September 2001 and August 2006), by type of assistance at birth..............................................................................................................42 Table 10 BREASTFEEDING STATUS OF CHILDREN Percent distribution of last child under 3 years of age, by breastfeeding status and age in months .......................................................................................................43 Table 11 INDICATORS OF MALNUTRITION Low and very-low height-for-age, weight-for-height, and weight-for-age among children under 5 years of age......................................................................................44 Table 12 CHILD IMMUNIZATION Percent children ages 18 to 29 months of age by each vaccine received (anytime) and full series of vaccines according to vaccination card or as reported by mother, by selected characteristics. .......................................................................45 Table 13 PREVALENCE AND TREATMENT OF ACUTE RESPIRATORY INFECTION AND DIARRHEA Percent of acute respiratory infection and diarrhea (during the two weeks prior to the survey) among children under 5 years of age and percent of ill children whose caretaker sought treatment and use of oral rehydration salts for diarrhea, by selected characteristics .................................................................................46 Table 14a INFANT AND CHILD MORTALITY IN 5-YEAR PERIOD PRIOR TO SURVEY Neonatal, post-neonatal, infant, and child mortality for 5-year period prior to survey,by selected ch aracteristics..............................................................................47 Table 14b INFANT AND CHILD MORTALITY IN 10-YEAR PERIOD PRIOR TO SURVEY Neonatal, post-neonatal, infant, and child mortality for 10-year period prior to survey, by selected characteristics...............................................................................48

Table 15 KNOWLEDGE OF HIV / AIDS Percent of women who have heard of HIV/AIDS, know that there are different ways to prevent transmission, and know that condoms can prevent transmission, by selected characteristics .....................................................................49 Table 16a LIFETIME PREVALENCE OF DIFFERENT TYPES OF VIOLENCE Percent of ever-married women who have experienced verbal, physical or sexual violence during their lifetime, by selected characteristics...............................................50 Table 16b PREVALENCE OF DIFFERENT TYPES OF VIOLENCE DURING THE LAST 12 MONTHS Percent of ever-married women who have experienced verbal, physical or sexual violence during the 12 months prior to the survey, by selected characteristics .......................................................................................................................51

LIST OF GRAPHS

Graph 1 Number of selected segments by department, ENDESAS 1998, 2001 and 2006/07 .................................................................................................................2 Graph 2 Marital status of women interviewed........................................................................................5 Graph 3 Education level of women in reproductive ages, ENDESAS 1997/98, 2001 and 2006/07 .................................................................................................................6 Graph 4 Age-specific fertility by area of residence ...................................................................................8 Graph 5 Age-specific fertility ENDESA 1997/98, 2001 and 2006/07 .....................................................8 Graph 6 Total fertility rate by department .............................................................................................9 Graph 7 Percent distribution of current contraceptive method use ........................................................10 Graph 8 Current contraceptive method use of women in union, by age group .......................................11

Graph 9 Current contraceptive method use of women in union, by level of education ............................11 Graph 10 Principal sources of modern contraceptive Methods ................................................................12 Graph 11 Use of prenatal care for birth in the 5 years prior to the survey by area of residence, wealth quintile and birth order ......................................... .................................13 Graph 12 Use of prenatal care from a qualified medical personnel for births in 5 years prior to survey by area of residence, wealth quintile and birth order ...................................... 14 Graph 13 Deliveries of birth in the 5 years prior to the survey in a health care facility, by department ............................................................................................. ..........................15 Graph 14a Trends in nutritional status of children, ENDESAS 1997/98, 2001 and 2006/07 ................. 18 Graph 14b Chronic malnutrition (Height for Age) of children by age ..................................................... 19 Graph 15 Infant and child mortality in the 5 years prior to the survey ................................................... 23 Graph 16 Trends in infant and child mortality in Nicaragua and neighboring countries ......................... 24 Graph 17 Infant mortality in the 5 years prior to the survey by area of residence and region .................. 25 Graph 18 Knowledge of HIV/AIDS of women ages 15-49 years (Spontaneous response) ......................... 26 Graph 19 Percent of women, who know that abstinence, use of condoms in all relationships, and fidelity of partners can prevent HIV/AIDS transmission ................................................... 27 Graph 20 Percent of women who have ever experienced verbal, physical and/or sexual abuse, by marital status and level of education ................................................................................. 28 Graph 21 Percent of women who have experienced verbal, physical and/or sexual violence in the last year ...................................................................................................................... 29

PRESENTATION

The National Institute for Development Information (Instituto Nacional de Información de Desarrollo – INIDE), as governing organization of the National Statistics System (SEN), in collaboration with the Ministry of Health (MINSA), guarantor of the health of the people, in fulfillment of its fundamental mission of providing reliable and timely information for management and planning of health officials, cooperating agencies and others who represent public and private interests of the Nicaraguan people, has the honor of presenting the Preliminary Report of the Nicaraguan Demographic and Health Survey 2006/07 (ENDESA 2006/07). ENDESA 2006/07 contributes important data for and on: 1) developing and pursuing a holistic approach to the health care of children in such areas as immunization, low birth weight, nutrition, and infant and child survival and development, 2) care for reproductive age women including prenatal care, and delivery assistance and postpartum care to prevent maternal mortality, 3) demand for family planning, 4) knowledge of HIV/AIDS, an epidemic which is still contained, and 5) family and partner violence. On this occasion, INIDE and MINSA wish to acknowledge the United States Agency for International Development (USAID); the United Nations Development Programme (UNDP); the United Nations Population Fund (UNFPA); the United Nations Children’s Fund (UNICEF); the World Bank through Agreement No, 4050 NI; the Canadian Technical Assistance Program (CANTAP-3) through the Inter-American Development Bank (I.A.D.B.); and the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia., USA. INIDE and MINSA are thankful for the efforts of the inter-institutional committees and technical personnel of ENDESA 2006/07, during the different stages of the survey. In addition, we acknowledge the self-sacrificing work of the field personnel in gathering the data, and especially thank the 14,221 women who provided the information asked for in the survey.

National Institute for Development Information

Ministry of Health

National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Introduction Demographic and reproductive health surveys are designed to provide information to family planning and reproductive health program administrators to assist them in the management and evaluation of their programs. In Nicaragua, Demographic and Health Surveys, known as ENDESAS, have been conducted by the National Institute for Development Information (INIDE) in collaboration with the Ministry of Health (MINSA) in 1997/98, 2001 and 2006/07. The 2006/07 survey received technical assistance from the Division of Reproductive Health of the U.S. Centers for Disease Control and Prevention in Atlanta, Georgia, and was funded by the United States Agency for International Development (USAID). Nicaragua’s demographic and health survey ENDESA 2006/07 is the fourth survey of its kind and provides updated statistical information for the purpose of identifying the reproductive behavior of women in the reproductive ages and assessing changes in fertility and mortality. Topics that are examined include, among others: 1. Fertility rates and trends (including adolescent fertility). 2. Child mortality rates and trends.

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3. Prenatal, delivery and postnatal assistance. 4. Nutritional status of women and children under 5 years of age. 5. The health status of children and the prevalence of certain illnesses, such as acute respiratory infection (ARI) and diarrhea, and vaccination coverage. 6. Status of functional development of children under 5 years of age (between 7 and 59 months). 7. Sexual and reproductive health of women, including a) Family planning. b) Marriage and exposure to pregnancy risks. c) Knowledge of HIV/AIDS, STIs, and high risk sexual activities. This preliminary report of ENDESA 2006/07 provides a brief description of these topics illustrated with graphics in the text and tables in an appendix. The report contains an overall description and updated assessment of the health condition of women and children in Nicaragua.

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Nicaraguan Demographic and Health Survey 2006/07

Methodology Sample design and selection ENDESA 2006/07 was designed to provide national, regional, and departmental estimates on the health behavior and status of women 15 to 49 years of age and of children less than 5 years of age. As a consequence sample size is based on the smallest geographical area (department) of interest and a minimum of 30 segments were selected from each department. For ENDESA 2006/07, a total of 638 census segments were selected which represents an increase of 27 and 37 segments over the number of segments selected in ENDESA 2001 and ENDESA 1997/98, respectively.

cartographic update of housing units prepared for the 2005 census.

The sample design for ENDESA 2006/07 was a multistage, stratified, probability sample, as in the previous ENDESAS.

To attain a representative sample for estimating key indicators with adequate precision in less populated departments, thirty segments per department were selected as a minimum. This resulted in more interviews in the departments of Río San Juan, Chontales, Boaco, and Madriz compared with previous surveys (see Graph 1).

While, the sampling frames for the 1998 and 2001 ENDESAS were based on the 1995 census, the frame for ENDESA 2006/07 was the residential

Sample selection for ENDESA 2006/07 was done in three stages. The first stage sampling units were census sectors (segments), stratified by department. Systematic random selection was used to choose a minimum of 30 segments from each of Nicaragua’s 17 departments with probability proportional to the size of segments (the number of housing units in a segment).

Graph 1 Number of selected segments by department, ENDESAS 1998, 2001 and 2006/07 80 70 60

Segments

50 40 30 20 10

Rí o

Sa n

Ju an M ad C ho ríz nt al es Bo ac G o ra na da Ri va s C ar az o N ue Est va elí Se go vi a RA A M N as ay Jin a ot eg a RA AS C Le hi ón na nd M ega at ag a M lpa an ag ua

0

1998

2

2001

2006/07

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National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Since departments with a large rural population were over-sampled while departments with greater population density were under-sampled, the use of weights is required to obtain national and regional estimates, and weighting factors were created to adjust for this unequal selection probability. The second stage sampling units were housing units. Thirty housing units were randomly selected from each of the 638 selected census sectors by randomly choosing a starting housing unit and selecting 29 consecutive housing units in a given direction, yielding a household sample of 19,140 housing units. The third stage sampling units were women of reproductive age living in the selected households. One woman from each selected household was chosen for the sample. If more than one woman 15-49 years of age resided in a household, a random selection procedure was used to identify the woman eligible for the sample. The number of women selected for the sample was 14,847. The probability of selection of any woman was inversely proportional to the number of women of reproductive age living in her household. Therefore, weighting factors equal to the number of women of reproductive age in the household were created to adjust for this unequal probability of selection. For interviewed women with children born since January of 2001, one child 0-5 years of age was randomly selected for administering a series of questions on postpartum care and the prevalence and treatment of respiratory infections and diarrhea, among other topics. The selection

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of only one child per household reduced the time required for reliable data collection and allows for construction of national level estimates for children under 5 years of age. To analyze the data for children, weights were created and applied to adjust for the unequal probability of selection of children. Data collection and processing Two instruments were used for data collection, the household questionnaire and the individual questionnaire. The former was designed to collect information on the characteristics of the household, including dwelling characteristics such as structural materials and basic services, and goods and services available in the household. A household roster collected basic sociodemographic information (age, marital status, educational level, relationship to head of household) on every member of the household. The household questionnaire also included a section dedicated to the selection of the eligible reproductive-age woman to be interviewed. The individual questionnaire was designed to collect information on the specific survey topics from the woman selected for interview. These topics included fertility history, knowledge and use of contraception, sexual and contraceptive behavior of young adults, knowledge and practices related to HIV/AIDS and STIs, maternal and child health practices, infant feeding practices, infant and child mortality, as well as social, economic, and demographic characteristics of the women interviewed. The individual questionnaire also included a section for recording the anthropometric information collected to assess the selected 3

Nicaraguan Demographic and Health Survey 2006/07

child’s nutrition status. The two questionnaires were pretested to assure appropriateness, comprehension, and logical sequencing of questions. A two-week training was conducted for field personnel to establish dominance of the questionnaire, use of the field manual, and standardization of field procedures and interview norms. Field supervisors were responsible for the anthropometric measurement of children and were trained separately in measurement techniques and nutrition data collection. Fieldwork began on September 20, 2006, and ended on April 18, 2007, with several interruptions due to presidential elections in the month of November, the Christmas and New Year holidays, and Holy Week. The fieldwork schedule allowed for up to five revisits to households where occupants were not at home or the selected woman was not available at the time of a visit. Extra visits were also conducted to correct inconsistencies found in questionnaires during review or data entry. Fieldwork was conducted by nine teams, each comprising four interviewers, one supervisor, one editor (to review and evaluate completed questionnaires in the field), and a driver. There were also two field coordinators and an overall supervisor at the central office to support fieldwork logistics and data collection. Respondents were assured of anonymity and confidentiality of the information they provided. An additional six persons reviewed the questionnaires in the central office and data entry

4

was carried out by eight data-entry personnel. CSPro software was used to create a data entry/ edit program that performed logic checks for skip patterns and range checks on all response entries. An extensive consistency check program was also used for data evaluation. Finally, double data entry was conducted to protect against data entry error. Sample yield Of the 19,140 housing units selected into the sample (see Table 1), 91.8 percent were found to be inhabited. The remaining 8.2 percent were unoccupied, destroyed, dwellings under construction, or structures converted to a nonresidential purpose. Of the 17,570 occupied dwellings, the household response rate was 97.9 percent (17,209 households). Nonresponse included a low refusal rate of 0.5 percent (91 households). The remaining 1.5 percent (270 households) of nonresponse was attributable to no capable adult being present at the time of the first and subsequent visits. Of the 17,209 households surveyed, 86.3 percent (14,847 households) had one or more women eligible for the individual interview. Of the 14,847 households with one or more women 15-49 years of age, 14,221 of the selected women completed an individual interview, for a response rate of 95.8 percent. The combined response rate (household response rate x individual response rate) was 93.8 percent, higher than obtained in previous ENDESA surveys.

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Characteristics of the Respondents Table 2 presents a profile of the respondents aged 15 to 49 years. One can observe that nearly 60 percent live in urban areas. By geographical region, higher percentages can be found in the Pacific region with 57 percent, North Central region with 30 percent, and 13 percent for the Northern and Southern Autonomous Regions (RAAN and RAAS, respectively) and the Department of Río San Juan that make up the Atlantic Coastal Region. Among departments, Managua has the largest share with 27 percent, Matagalpa with 9 percent, followed by León and Chinandega with 8 percent each, RAAS and Masaya with 6 percent each, and Jinotega with 5 percent; for each of the remaining departments

women in reproductive ages comprise less than 5 percent of the national total. A key sociodemographic factor related to fertility and reproductive health is marital status. Fiftysix percent of respondents were legally married or living in consensual unions, with the majority living in consensual unions (34 vs. 22 percent married). Twenty-eight percent of respondents had never been married, while approximately 16 percent stated that they had been previously married and were now either separated, divorced or widowed (see Graph 2).

Graph 2 Marital status of women interviewed

Single 28% Married 22%

Separated, Divorced and Widowed 16 %

Consensual Union 34%

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Nicaraguan Demographic and Health Survey 2006/07

Nicaraguan women are relatively well-educated as evidenced by the fact that slightly more than half had completed at least some secondary education or had taken university level courses. The share of women with some university education has steadily increased in the last decade, from 7 percent (ENDESA 1998) to 14 percent currently. The share of women ages 15 to 49 years with lower levels of education has decrease significantly, from near 30 percent with less than four years of instruction in 2001 to 24 percent in ENDESA 2006/07. Only 12 percent of the respondents had no formal education. Comparing the 2006/2007 survey results with those of the 1998 and 2001 surveys, it can be seen

in Graph 3 that the proportion of women with little or no formal education has decreased over time, while the proportion of women with university training has increased dramatically. Of the total 14,221 interviewed women, 59 percent were less than 30 years of age; these proportions are similar to previous ENDESAS, 57 percent for 2001 and 58 percent for 1998. Overall, 44 percent of the respondents were young adults (15-24 years of age), while nearly 18 percent were approaching the end of their reproductive lives (40-49 years of age).

Graph 3 Education level of women in reproductive ages, ENDESAS 1997/98, 2001 and 2006 / 07

ENDESAS

1997/98

2001

2006/07 10

20

30

40

50

60

70

80

90

100

Percent None

6

Primary 1-3

Primary 4-6

Secondary

Superior

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National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Fertility Different data sources for Nicaragua reveal that for the better part of the last three decades fertility has been declining. The evidence, from various sources, (Population censuses of 1995 and 2005, Family health survey 1992/93, ENDESA 1997/98 and ENDESA 2001) indicates that these decreases have been more intense during the current and last decade. ENDESA 2006/07 corroborates this downward trend. From a demographic perspective this behavior constitutes an unique opportunity, a “demographic window of opportunity,” in which birth rates decline, and changes occur in the population age structure with a reduction in the relative weight of younger age groups and a significant increase in the proportion of working aged persons (15 to 64 years of age), resulting in slower rates of population growth. This produces a general stability in the overall number of births with the potential for a decline in numbers of births and associated positive benefits for the educational sector, the environment, and health.

of live births and the date and sex of each birth. This information is used to estimate fertility rates by age within specific periods of time, as well as an overall estimate of fertility, the total fertility rate (TFR). The total fertility rate is a summary indicator of recent fertility that combines the agespecific fertility rates of a given time period. It is interpreted as the average number of births per woman at the completion of their reproductive life that would occur if women were to experience the age-specific rates of the current period over their lifetimes. Age-specific fertility rates from ENDESA 2006/07, indicate a TFR of 2.7 children per woman for the country as a whole. This overall rate combines very different geographic levels. In urban areas the TFR of 2.2 is now close to replacement level (2.1 births per woman), while in rural areas women have on average three and a half children, near 60 percent more than urban women.

This section of the report analyses the evolution and present state of fertility, as well as differentials by geographic area, the link between fertility rate and socioeconomic status (as indicated by quintiles of wealth, measured by household goods and services), the relationship between fertility and the use of family planning, women’s education and other characteristics. Information provided by survey respondents included detailed information on women’s reproductive behavior. For each respondent a birth history was obtained that included the number

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Nicaraguan Demographic and Health Survey 2006/07

Table 3a presents age-specific fertility rates, by place of residence. These rates give the annual number of live births per 1,000 reproductive age women in 5-year age groups for the 5-year period prior to ENDESA 2006/07. As seen in Table 3a and Graph 4, Nicaraguan women initiate childbearing at an early age. For both urban and rural women, peak fertility occurs at ages 20-24. Most of the difference between rural and urban fertility rates is due to higher age-specific fertility rates among rural residents aged 15-29 years.

over the past 10 years, and the decline has been concentrated principally among women aged 15-29 years. Table 4 shows differentials in the ENDESA 2006/07 TFRs, by area of residence, socioeconomic level, and completed education. On average, rural women have 1.3 more live births per woman than do urban women. Fertility differentials are largest when women are classified by educational and socioeconomic levels. The difference between Graph 5 Age-specific fertility ENDESA 1997/98, 2001 and 2006/07

200

Births per 1,000 women

Births per 1,000 women

Graph 4 Age-specific fertility by area of residence

150 100 50 0 15-19

20-24

25-29 30-34

35-39

40-44

45-49

250 200 150 100 50 0 15-19

20-24

25-29

Age Group Urban

Rural

Total

Graph 5 and Table 3b show the age-specific fertility rates for each of the surveys in Nicaragua. As can be seen, declines occurred with different intensity for all age groups. The TFR estimated from the ENDESA 2006/07 was 2.7 births per woman, which represents a decline of 0.6 births per woman from the TFR of 3.3 estimated in 2001 (ENDESA 2001), and a decline of 1.2 births from the TFR of 3.9 estimated in 1998. Thus, there has been a dramatic decline in fertility in Nicaragua

8

30-34 35-39

40-44

45-49

Age Group 2006/07

2001

1998

the highest and lowest categories of these characteristics was 2.8 and 2.7 births per woman, respectively. Department level estimates of the TFR ranged from 2.0 births per woman in Chontales to 4.5 in the RAAN (Graph 6). Departments with a TFR of 3.0 or greater include Nueva Segovia, Jinotega, Madriz, Matagalpa, Rio San Juan, the RAAN, and the RAAS. It should be noted that five departments are at or are approaching the fertility rate of replacement: Carazo, Chontales, Managua, León, and Estelí.

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Graph 6 Total fertility rate by department Total Nueva Segovia Jinotega Madríz Estelí Chinandega León Matagalpa Boaco Managua Masaya Chontales Granada Carazo Rivas Río San Juan RAAN RAAS

2.7 3 4.2 3 2.3 2.6 2.05 3.24 2.85 2.17 2.61 2.03 2.61 2.13 2.6 3.05 4.5 2.99

0

1

2

3

4

5

Number of children per Woman

Table 5 shows the total fertility rate disaggregated into wanted/mistimed or unwanted components. The unwanted TFR is computed the same as the overall observed TFR except that only births classified as “unwanted” are included in the numerator of the rate. The wanted TFR can be interpreted as the hypothetical TFR that would occur if all unwanted births had been avoided. The unwanted TFR is simply the difference between the observed TFR and the wanted TFR. As can be seen in the table, Nicaragua has a wanted TFR of 2.3 births per woman, 16 percent less than the observed TFR of 2.7 births per woman.

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The unwanted TFR for rural areas (0.5 births per woman) is 1.3 times greater than for urban areas (0.4 births per woman), while the unwanted TFR for women without formal education is 2.6 times greater than that for women with a university level education. It should be noted that the wanted TFR for urban areas and for the departments of Carazo, Granada, Chontales, Masaya, Managua, León, and Estelí is below the replacement level.

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Nicaraguan Demographic and Health Survey 2006/07

Family Planning The use of contraceptive methods is the most important proximate determinant of fertility, and constitutes the most effective practice to reduce unintended pregnancy in women of reproductive age. It is also an important factor in increasing infant and child survival. Knowledge of the level of use of contraceptive methods allows for the evaluation of the effectiveness of family planning programs and the identification of groups with poor access to services and women at risk of an unplanned or unwanted pregnancy. In Nicaragua, almost all women (99 percent) had heard of at least one method of contraception, a result which is similar to the 98 percent found in ENDESA 2001. Overall, 72 percent of in-union (married or consensual) women aged 15-49 years were using a contraceptive method in the 30 days prior to the interview. Corresponding percentages for ENDESA 2001 and ENDESA 1997/98 are 69 and 60 percent, respectively. Thus, in less than 10 years, contraceptive prevalence has increased by 12 percentage points, with most of the increase occurring between 1998 and 2001. In urban areas, current contraceptive use was 75 percent compared to 69 percent in rural areas, for a difference of 6 percentage points. As can be seen in Table 7, contraceptive prevalence was highest in the departments of Río San Juan (79 percent), Chontales (77 percent), and Managua (76 percent), while it was lowest in Jinotega (63 percent) and in the RAAN (57 percent).

10

Female sterilization was the most widely used method in the country (24 percent), followed by the hormone injection (23 percent), and the pill (13 percent). The use of traditional methods such as Rhythm/Billings and Withdrawal was very low – about 3 percent (see Graph 7).

Graph 7 Percent distribution of current contraceptive method use

Hormone injection 23%

Condom* 4%

LAM 1%

Periodic abstinence 2% Withdrawal 1%

IUD 3%

None 28%

Pill 13%

Female sterilization 25%

Female sterilization, injectables, and the pill, are very effective methods, and are used by 61 percent of in-union women, representing 85 percent of all contraceptive users. Female sterilization is the most prevalent method in the departments which constitute the Pacific region while injections are widely used in the North Central and Atlantic regions. Table 7 shows the use of birth control methods by age for women in union. Women in-union from

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ages 30-34 through 40-44 years have the highest rates of use (76 to 79 percent). The lowest levels of use occur among women in union with 15 to 19 and 45 to 49 years of age (61 and 62 percent, respectively). Over 70 percent of women in union ages 20 through 44 use some form of birth control. Use of birth control is relatively low among women in union who do not have living children (37 percent), but increases to 75 percent when women have one or two children and up to 83 percent when they have three or four children. As expected, women ages 15 to 29 years and women with less than three living children use

temporary birth control methods, with hormonal injection and the pill being the principal methods. Use of female sterilization increases with age, with 12 percent of women in-union ages 25 to 29 years using sterilization. As women reach 30 years of age or when they have at least three living children the importance of female sterilization increases, reaching 50 percent among women 40 to 44 years of age (see Graph 8). Few women use IUDs or condoms; overall, use of these two methods is less than 4 percent each. In general, the use of contraceptive methods increases as the socioeconomic and educational levels of the respondents increases (Table 7 and Graph 9).

Graph 9 Current contraceptive method use of women in union, by level of education

Graph 8 Current contraceptive method use of women in union, by age group

Superior

45-49

Education level

Age Group

40-44 35-39 30-34 25-29

Secondary Primary 4-6 Primary 1-3

20-24 No schooling

15-19 0

20

40

60

80

100

0

20

Sterilization

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Pill Injection LAM None

60

80

100

Percent

Percent Sterilization IUD Condom* Traditional

40

IUD Condom* Traditional

Pill Injection LAM None

11

Nicaraguan Demographic and Health Survey 2006/07

Contraceptive use among women in union in the lowest socioeconomic quintile or with no formal education is 65 and 66 percent, respectively, and gradually increases among intermediate groups, reaching 79 percent among women with higher education or socioeconomic status. Women in-union aged 15-49 years who used a modern method of contraception during the 30 days prior to interview were asked where they obtained their method. As shown in Table 8 and Graph 10, 67 percent obtained their method from a public sector entity, with health centers and public hospitals being the principal suppliers (35 and 30 percent, respectively). An additional 32 percent of the women obtained their method from the private sector, with pharmacies being the main

source (15 percent), followed by PROFAMILIA clinics. Less than 1 percent of the women stated that their source of contraceptives was from community groups (0.6 percent). With regards to sources of specific methods, certain sources standout. Seven out of 10 sterilized women had their tubal ligation performed in a public sector entity, principally a public hospital, while 28 percent of the procedures were performed in a private sector entity, notably at PROFAMILIA clinics (11 percent). The public sector is also the most utilized source for obtaining hormonal injections (78 percent) and oral contraceptives (54 percent). Private drugstores are the most common supplier of male condoms (68 percent) and the second most important source for oral contraceptives (36 percent) and hormonal injection (14 percent).

Graph 10 Principal sources of modern contraceptive methods

Social Security related Health Providers 4% Private Hospital or Clinic, 4% IXCHEN, 2 % PROFAM ILIA, 5 % Health Post 2 %

Pharmacy, 14% Others 4 %

Public Hospital 29 %

Health Center 36 %

12

Preliminary Report

National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Maternal and Child Health Women’s Health A number of factors can have a considerable impact on the health of a woman, the outcome of her pregnancy and the health of her baby, and as result the use of health care services related to pregnancy, the place and type of assistance at delivery, and postpartum behavior are all very important. The use of preventive health services such as the receipt of tetanus toxoid and childhood vaccinations can also save the lives of mothers and infants. These topics along with others are examined in this section. Prenatal care Prenatal care is important for preventing, identifying, and treating conditions that can affect the health of an expectant mother or her baby. For the optimal health of mother and child, it is recommended that every pregnant woman start seeing a health care provider for prenatal care examinations during her first trimester of pregnancy. The number of prenatal visits a woman should make during her pregnancy depends on the evolution of the pregnancy. In Nicaragua, a minimum of four visits is recommended by the Ministry of Health. The Ministry of Health also recommends that all pregnant women receive at least one dose of tetanus toxoid, even though a woman may have been vaccinated several times in the past.

Comparable percentages for ENDESA 2001 and ENDESA 1997/98 are 86 and 84 percent, respectively, indicating an important continued improvement in prenatal coverage. Nevertheless, there are significant differences observed by residential area, department, women’s level of education, socioeconomic status and birth order of a child (see Graph 11). Of pregnant women with higher education, less than 2 percent received no prenatal care, while among urban area residents only 5 percent did not; this percentage increases in rural areas to 13 percent. For women in the population’s highest socioeconomic quintile less than 2 percent had no prenatal visit while for those in the poorest quintile this percentage rises to 17. In summary, prenatal care in urban areas, departments of the Pacific region and Segovia (Madriz, Estelí and Nueva Segovia) was above 95 percent, while the departments of the Atlantic Graph 11 Use of prenatal care for birth in the 5 years prior to the survey by area of residence, wealth quintile and birth order

Total

91

Rural

87

Urban

95

Wealth Quintile 98

High

96

Medium - High Intermediate

93

Medium -Low

92 83

Low Birth Order

The data in Table 9a indicate that for live births born in the period September, 2001 through August, 2006, 91 percent of the pregnancies received at least one prenatal care examination.

Preliminary Report

1

95

2-3

92

4-5

86

6+

79 0

20

40

60 80 Percent

1 00

1 20

13

Nicaraguan Demographic and Health Survey 2006/07

region and Jinotega share levels similar or lower than that of rural areas, at 87 percent. As expected, the percentage of pregnancies receiving a prenatal examination increases as socioeconomic status and educational attainment increases. In contrast, the probability of receiving an examination decreases as birth order increases. Some achievements, and disparities, are not captured by a single simple indicator of prenatal coverage until other aspects of care are considered: timing of first prenatal visit, number of visits, and qualifications of practitioners providing care. ENDESA 2006/07 indicates that 90 percent of the prenatal visits were attended by a health professional (general medical doctor, gynecologist / obstetrician or nurse).

status and educational level of the respondents. The opposite is the case when birth order is examined. Of all pregnancies ending in live births in the period September 2001 through August 2006, 91 percent received at least one dose of tetanus toxoid. The percent who did not receive at least one dose of tetanus toxoid was greatest in the Atlantic region (81 percent) and among pregnant women with no formal education (84 percent). Graph 12 Use of prenatal care from a qualified medical personel for births in 5 years prior to survey by area of residence, wealth quintile and birth order Total

90

Rural

86

Urban

95

Wealth Quintile 97

High Medium - High

The likelihood of being attended by a health professional is greater in urban areas than in rural areas, and increases with socioeconomic status and educational attainment (Graph 12). As with prenatal coverage, the disparities widen when considering prenatal visits with a qualified health professional.

96

Intermediate

92

Medium - Low

92

Low

82

Birth Order 1

95

2-3

91

4-5

85

6+ 0

78 20

40

60

80

100

120

Percent

Seventy percent of pregnant women begin receiving prenatal care during the first trimester of pregnancy and nearly 78 percent receive four or more prenatal examinations. Urban women are more likely than their rural counterparts to begin prenatal care during the first trimester of pregnancy, and to receive four or more prenatal examinations. Similarly, receipt of early prenatal care and at least four or more examinations is directly associated with the socioeconomic

14

The proportion of women who received prenatal care during the first trimester of pregnancy and four or more examinations, and at least one dose of tetanus toxoid is 63 percent. This proportion varies from 72 percent in urban areas to 55 percent in rural areas, and from 80 percent in the department of Estelí to 37 percent in the RAAN. Satisfying all three of these norms is directly related to the socioeconomic status and educational level of the respondents. Preliminary Report

National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Delivery assistance Due to obstetric risks, every delivery should be attended by adequately trained personnel in order to have sufficient monitoring of the mother and baby during labor and delivery. For this reason delivery assistance is best at a health institution, with appropriate human and material resources. In Nicaragua, institutional delivery coverage has reached 74 percent (see Table 9b). Ninety-two percent of urban births were delivered in a medical facility compared to only 56 percent of rural births. Although coverage is relatively low in rural areas, the present coverage represents an important gain since the last ENDESA (2001), which reported 45 percent coverage. As shown in Graph 13, Managua has the highest percent of institutional deliveries (95 percent), followed by Estelí with 93 percent. In

other departments in the Pacific region (excluding Managua) between 81 and 86 percent of births are delivered in an institutional setting; in the North-Central region percentages range from 46 in Jinotega, to 64 in Boaco to between 70 and 77 in the remaining departments (excluding Estelí). The RAAN and RAAS has only 38 and 48 percent of births delivered in institutional settings, respectively. The department of Río San Juan has improved significantly in recent years and now 60 percent of births are institutional. While there has been a general improvement in institutional deliveries throughout the country, both Estelí and Río San Juan show rapid improvements in recent years while RAAS, Jinotega, and RAAN lag behind other departments.

Graph 13 Deliveries of births in the 5 years prior to the survey in a health care facility, by department

Total Rural Urban Departments Nueva Segovia Jinotega Madríz Estelí Chinandega León Matagalpa Boaco Managua Masaya Chontales Granada Carazo Rivas Río San Juan RAAN RAAS

74

56

92 77

46

70 81 70

63

93 86 95

81 72

38 0

Preliminary Report

10

20

30

40

86 85 84

60 48 50 Percent

60

70

80

90

100

15

Nicaraguan Demographic and Health Survey 2006/07

Considering other factors, it is worth noting that institutional deliveries are highest among women having their first child (85 percent) and among women with high school and higher education (above 90 percent). As noted above, advances in all categories and territories have been observed; however, women in high risk categories (low education, living in the poorest socioeconomic quintile households, ages above 35, and having 6 or more children) have persistently low proportions of institutional births. As can be seen in Table 9b, younger mothers were more likely to deliver in a medical facility than older mothers (75 vs. 64 percent). One can also appreciate that birth order influences the place of delivery. Medical facility deliveries drop from 85 percent among first births to 44 percent among sixth or higher order births. It is precisely these groups that could benefit the most from obstetric care during delivery. In its plan to reduce maternal mortality, the Pan American Health Organization (PAHO) has indicated that the percentage of all births in a country by cesarean section should range from 5 to 15 percent. If the percentage falls below 5 percent, this indicates lack of accessibility to the procedure, while if it is above 15 percent, this indicates abuse in the use of this procedure.

The cesarean rate is especially high among women with a university level education (51 percent) and among high socioeconomic status women (44 percent), indicating that many of their cesarean sections were performed for reasons related to convenience rather than for medical necessity. Child Health Since the early 1990s, there have been improvements in child survival in Nicaragua. Despite these improvements, much work remains to be done in reducing levels of infant and underfive mortality and morbidity. This section of the report covers a number of topics related to the health of the child, such as breastfeeding and weaning practices, the nutritional status of children less than 5 years of age, child immunizations, and the prevalence of acute respiratory infections and diarrhea during the two weeks prior to interview.

As shown in Table 9b, almost 20 percent of all deliveries were cesarean, the percentage increases to 28 percent in urban areas but decreases to 12 percent in rural areas. The highest cesarean rates (greater than 30 percent) are found in the departments of León, Managua, Granada, and Carazo, while the lowest rates (less than 10 percent) are found in Matagalpa, the RAAS, and the RAAN. 16

Preliminary Report

National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Nutrition Scientific evidence indicates that breastfeeding provides the greatest nutritional contribution for physical growth, mental and affective development of the child. Early initiation of breastfeeding permits the newborn to benefit immediately from colostrum, which is highly nutritious and contains the antibodies necessary to protect babies from infection before their immune systems are fully mature. In general, breastfeeding benefits are recognized as valuable for the psychic and physical health of the newborn, the mother and the family. The Ministry of Health of Nicaragua recommends that all infants be fed (on demand) exclusively on breast milk from birth to 6 months of age, and that supplementary breastfeeding continues until the child is two years of age. Table 10 shows the percent distribution of children less than three years of age, by foods other than breast milk that they received in the previous 24 hours, classified by current age. According to ENDESA 2006/07, there is a tendency of discontinuing any breastfeeding (exclusive or supplementary) at an early stage: when the child’s age reaches 4 or 5 months, 10 percent are no longer being breastfed at all. Only 46 percent of those less than 2 months old received breast milk exclusively. For the group 2-3 months of age, this percentage declines to 28 percent and then to 13 percent in the 4-5 month age group. Thus, the percentage of children who are being exclusively breastfed decreases rapidly as the age of the children increases. The most common supplements given among infants ages 0-1 month are other milks (38 percent) and water (12 percent). But already in the 4-5 month age group, solids and

Preliminary Report

semi-solids are common (46 percent). There has been little progress since 2001 in fostering the Health Ministry’s (MINSA’s) recommendations despite the programs promoted by the Ministry of Health. Nutrition status of children is the product of a series of social, environment, biological, and cultural factors. It is reflected in their growth in height and weight and is influenced by feeding practices and illness recurrence. In order to objectively assess the nutritional status of children, the height and weight of children under 5 years of age were measured in ENDESA 2006/07. These measurements, in conjunction with a child’s age, allow for the calculation of three standard measures of physical growth: height-for-age, weight-for-height, and weight-for-age. Each indicator provides insight into different aspects of nutritional status. The nutritional status of children as measured by these indices can be evaluated by comparing their distributions on a specific index to that of a well-nourished, healthy population of children. The reference population used is that developed by the U.S. National Center for Health Statistics (NCHS) and accepted by the World Health Organization (WHO) and used in previous ENDESA surveys. The ENDESA 2006/07 Final Report presents results based on the NCHS as well as the new reference developed by the World Health Organization. Height-for-age is a measure of physical growth over the child’s life. A child whose height is greater than 2 standard deviations below the mean of the NCHS reference population is considered stunted or very short for his or her age. Stunting is a 17

Nicaraguan Demographic and Health Survey 2006/07

condition that results from prolonged inadequate food intake or from recurrent episodes of illness and is often referred to as chronic malnutrition. Weight-for-height indicates the appropriateness of a child’s weight given his/her height. A child whose weight-for-height is more than 2 standard deviations below the NCHS reference mean is referred to as wasted or too thin. This condition may reflect a recent period of inadequate food intake or a recent episode of illness.

was 7 percent. Thus, the nutritional status of children in Nicaragua has improved since ENDESA 1998 was conducted (Graphs 14a and 14b). The percentage of children classified as stunted decreased by 8 percentage points, the percent classified as wasted by 1 percentage point, and the percentage classified as underweight by 5 percentage points.

Weight-for-age is a general indicator of a child’s nutritional status. A child who falls more than 2 standard deviations below the NCHS reference mean on this index is referred to as underweight. The child may have suffered from chronic malnutrition (stunting) or acute malnutrition (wasting), but the index does not distinguish between these two conditions.

Seventeen percent of children were classified as stunted. The percentage of children suffering from wasting was 1 percent, while the percentage of children found to be underweight

Graph 14a Trends in nutritional status of children, ENDESAS 1997/98, 2001 and 2006/07 25 20 Percent

Children are considered severely stunted, wasted, or underweight when their value for height-for-age, weight-for-height, or weight-forage is greater than 3 standard deviations below the mean value for the NCHS reference population. Table 11 shows the three indices of nutritional status for children less than 5 years of age. The statistics presented for each index is the total (> -2 sd) percentage and the severe (> -3 sd) percentage of children considered to be stunted, wasted, or underweight at the time the ENDESA 2006/07 was conducted.

Based on height for age (Graphs 14a and 14b), ENDESA 1998 revealed that 1 in 4 Nicaraguan children under 5 years of age were chronically malnourished (stunted). The ENDESA 2001 reported that 1 out of 5 children suffered with chronic malnutrition, and ENDESA 2006/07 reports that 1 in 6 is in that situation.

15 10 5 0 Height -for-Age

ENDESA 1997/98

18

Weight-for-Age

ENDESA 2001

Weight - for-Height

ENDESA 2006/07

Preliminary Report

National Institute for Development Information (INIDE) - Ministry of Health (MINSA)

Graph14b Chronic malnutrition (Height- for - Age) of children by age 30

Percent

25 20 15 10 5 0