June 2010
Anthropometric and Retrospective Mortality Survey
Aweil East County, Northern Bahr el Ghazal State Southern Sudan
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 1 Acknowledgement
Action Against Hunger would like to express its deep gratitude for the support given during the Anthropometric and retrospective Mortality Survey 2010 in Aweil East County. We would like to thank ACF-USA staff, particularly the support team without which the survey wouldn’t have been possible. Furthermore, we would like to thank the survey teams, for their endurance, dedication and team spirit which enabled survey to reach the end successfully. Thanks also to all drivers who ensured timely and safe movement of the survey teams. A special thanks to the SSRRC of Aweil East County for providing vital information on the geographical areas. We finally like to say many thanks to the individual families who pleasantly allowed the survey teams measure their children and provided the survey team with the information required to make it a success.
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 2 Table of Contents
Executive Summary ...... 5 1. Introduction ...... 7 2. Objectives of the survey ...... 8 3. Survey Methodology ...... 8 3.1 Type of Survey ...... 8 3.2 Sampling methodology ...... 8 3.3 Training and Data Collection ...... 9 3.4 Anthropometric survey ...... 10 3.5 Mortality survey ...... 10 3.6 Food Security and Livelihood, Water and Sanitation ...... 10 3.7 Data Quality Control Assurance ...... 11 3.8 Field Exercise...... 11 3.9 Data Entry and Analysis ...... 11 4. Guidelines and Formulae used ...... 11 4.1 Acute Malnutrition ...... 11 4.2 Mortality ...... 12 5. Survey Constraints ...... 12 6. Results: Anthropometry and Retrospective Mortality ...... 12 6.1 Anthropometric analysis (WHO Standards, 2006) ...... 13 4.2 Vaccination Coverage ...... 14 4.4. Mortality ...... 14 3.5 Child Morbidity ...... 15 7. Results on Qualitative data ...... 15 7.1 Socio- demographic characteristics of the respondents ...... 15 7.2 Food Security and Livelihoods ...... 16 7.3 Health ...... 17 7.4 Water and Sanitation ...... 19 7.5 Maternal and Child Care Practices ...... 20 8. Discussion ...... 21 9. Conclusion and Recommendations ...... 22 10. Annexes ...... 23
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 3 Abbreviations
ACF-USA Action Contre la Faim- USA (Action Against Hunger-USA) BSFP Blanket Supplementary Feeding Program CMR Crude Mortality Rate ENA Emergency Nutrition Assessment EPI Expanded Program on Immunization FGD Focus Group Discussion GAM Global Acute Malnutrition GFD General Food Distribution IDP Internally Displaced People INGO International Non Governmental Organization IOM International Organization for Migration MAM Moderate Acute Malnutrition MOH Ministry of Health MUAC Mid Upper Arm Circumference NCHS National Center for Health Statistic OTP Outpatient Therapeutic Program PHCC Primary Health Care Center PHCU Primary Health Care Unit SAM Severe Acute Malnutrition SFP Supplementary Feeding Program SMART Standardized Monitoring and Assessment of Relief and Transitions SSRRC Southern Sudan Relief and Rehabilitation Commission TFP Therapeutic Feeding Program UNICEF United Nations Children’s Fund U5MR Under Five Mortality Rate WFH Weight for Height WFP World Food Program WHO World Health Organization WVI World Vision International
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 4 Executive Summary
Aweil County is located in Northern Bahr el Ghazal state of Southern Sudan. Aweil East County is one of the five counties that make up the state of Northern Bahr el Ghazal in Southern Sudan. Its borders include Gogrial West County to the east, Southern Kordofan to the north-east, Southern Darfur to the north, and Aweil South County to the south. The County consists of the seven administrative payams of Malualbai, Baac, Madhol, Mangartong, Mangok, Yargot and Wunlang running from north to south. The current population of Aweil East County is estimated at 180,948. According to April and May 2009 National Baseline Household Survey, the incidence of poverty (calculated at an income of 72.9 SDG per person per month) in Southern Sudan range from one fourth in Upper Nile to three fourths in Northern Bahr el Ghazal. This makes Northern Bahr el Ghazal is one of the poorest and most food insecure state in Southern Sudan. Aweil East/Northern Bahr el Ghazal is traditionally an agro-pastoralist region with cattle ownership being the primary determinant of wealth and status. The topography of Aweil East makes it prone to flooding during rainy seasons. The County lies in the western flood plain livelihood zone which is prone to seasonal flooding; especially in August and September. The flat terrain and sandy and clay soils contribute to this flooding pattern. The fact that sanitation and waste disposal is very poor in the region and especially in Aweil East, the population is always susceptible to Acute Watery Diarrhea. Poverty, food insecurity, insufficient heath services and high child morbidity, poor infant and child feeding practices, low immunization coverage and high vulnerability to Acute Watery Diarrhea aggravate each other subjecting Aweil East to a vicious cycle of malnutrition. An anthropometric and retrospective mortality survey was conducted between 13th and 25th June 2010. The survey was aimed at assessing the prevalence of acute malnutrition in children aged 6-59 months, estimating the crude and under five mortality rate, estimating the coverage of measles among targeted children and identifying some of the underlying causes/factors contributing to malnutrition in Aweil East. The sampling frame included all the 7 payams of Aweil East County. The survey used SMART methodology, 40 clustered were sampled in the survey that included 475 households for anthropometric data and 598 households for mortality data. The results are summarized by Table 1 below. Table 1: Results Summary, Aweil East, June 2010
INDEX INDICATOR RESULTS1 Global Acute Malnutrition 23.1% W/H< -2 z and/or oedema [17.9% - 28.3%] Z- scores Severe Acute Malnutrition 1.5% NCHS (1977) W/H < -3 z and/or oedema [0.6% - 2.5%] (n=649) Global Acute Malnutrition 13.9% W/H < 80% and/or oedema [9.6% - 18.2%] % Median Severe Acute Malnutrition 0.0 % W/H < 70% and/or oedema [0.0% - 0.2%] Global Acute Malnutrition 23.1% WHO (2006) W/H< -2 z and/or oedema [17.9% - 28.3%] Z-scores (n=649) Severe Acute Malnutrition 3.2% W/H < -3 z and/or oedema [1.6% - 4.8%]
1 Results in brackets are expressed at 95% Confidence Interval
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 5
Global Acute Malnutrition 9.0% MUAC Height >65 cm (<125mm) [6.8% -11.2%] (n=645) Severe Acute Malnutrition 1.9% (<115mm) [0.8% - 2.9%] Total crude retrospective mortality (last 91 days) 0.39 /10,000/day [0.18-0.82] Mortality Under five crude retrospective mortality (last 91 0.16 days) /10,000/day [0.02-1.17]
As shown by the findings of this survey, it is demonstrably rear that the population of Aweil East is in need of support and malnutrition is still at emergency level. A small improvement was seen when the result of this survey are compared to a similar survey that was done at the same time in the previous year. It is believed that effort of many agencies in the County working on health, food aid, food security and livelihoods and nutrition are privy to this progress. However, measured against the complexity of food security, health and nutrition challenges in the county, a double measure of effort is required to have meaningful impact on the population. Based on the findings of this survey, the following are recommended:
> Increased coverage of TFP. > Promotion of the importance of immunization of children. This can be achieved through health education sessions at OTP, PHCU, PHCC and community level. > Among other health interventions, provision of bed nets and promotion of their use to reduce the incidence of malaria is highly recommended. Malaria is persistently prevalent among children under the age of five years > The community in this location is used to continuous food distribution from agencies like WFP and partners. While this is done to save people from large-scale starvation, it is recommended that more focus be given to developing the capacity of the community to increase farming activities (supporting increased household food production) that will have a remarkable contribution to food security of the population and hence reduced prevalence of under-nutrition, especially among the <5 children, pregnant and lactating mothers of Aweil East. > Provision of seeds and tools, including agricultural training on improved farming techniques and plant protection as well as diversification of income sources through various income generating activities is highly recommended > Increase the number of adequate and safe water schemes through construction, rehabilitation and training on operation and maintenance, especially in highlands and lowlands which are lagging behind as all the boreholes are concentrated in the midlands only. > Recent effort in supporting the community in latrine construction and use at the household level and distribution of slabs for latrines has seen increased interest by some community members. This needs to continue in tandem with hygiene community hygiene promotion.
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 6
1. Introduction
Aweil East County is one of the five counties that make up the state of Northern Bahr el Ghazal in Southern Sudan. The county consists of the seven administrative Payams of Malualbaai, Baac, Madhol, Mangartong, Mangok, Yargot and Wunlang running from north to south. Population figures for the total population of the county are estimated at 180,948. Northern Bahr el Ghazal is traditionally an agro-pastoralist region, and cattle ownership remains the primary determinant of wealth and status. Livestock are sold for cash, traded for other products, form marriage dowries and act as a source of milk and meat. However, given that up to seventy percent of the population does not own any cattle, and over forty percent do not own any livestock at all, the majority of the population is reliant on a more diversified livelihoods base. Agriculture is commonly undertaken during the annual cropping season, although generally at a subsistence level that covers barely 3-6 months worth of the household’s staple food requirements. Very poor and poor households (those with no or few livestock) undertake a range of seasonal and year-round livelihoods activities including: grass and firewood collection; charcoal burning; casual labor; fishing; petty trade; and wild food collection as coping mechanisms. These households tend to be heavily reliant on cash income, wild food collection and daily purchasing to meet their needs as they lack the asset base to make long term investments. The population of Aweil East County has seen a high influx of returnees in the previous year, with an estimated 24% of all returnees in Northern Bahr El Ghazal State having settled in Aweil East. From March to May 2009 Northern Bahr el Ghazal State recorded 18,335 spontaneous returnees into the state. Additionally, an estimated 56% of Northern Bahr El Ghazal’s Internally Displaced People (IDP) population is currently settled in Aweil East. However, there had been no more report of returnees as per 2010 according to the SSRRC office in the County. According to the 2009/2010 Annual Needs and Livelihood Assessment, about 4 million people in south Sudan were found to be food insecure due to last year drought which didn’t make the crops do well. Again Aweil East was said to be among the 4 Counties which were said to be having severe hunger. One of these counties was Aweil East County. In addition, though regular market assessments by ACF have shown that currently food prices are not very high for staple food items and the cost of livestock. The situation is still hard. A rapid water and sanitation assessment in Aweil East County conducted in March 2009 by ACF showed that only 24% of the population has access to clean water. It also demonstrated that while some households show interest in having latrines, however they don’t have slabs for use on them; the sanitation coverage rate in Aweil East is almost negligible. The community is currently facing a very serious hunger gap due to the fact that last year’s harvest was poor yielding as a result of concurrent drought, floods and crop pest infestations. This early onset of the hunger season and an increased reliance on market purchases adds particular pressures onto the most vulnerable households who lack livestock and other assets. The delayed rains this year are also hampering planting which will result in a shorter growing season in which to plant or re-plant seeds in hopes of obtaining good yields. Aweil East County is a subject of chronic level of acute malnutrition, above the emergency threshold. The combination of food insecurity, lack of access to clean water and sanitation facilities, disease outbreaks, and poor child care practices and inadequate health facilities have a negative impact on the nutrition status of children under five years of age. Nutrition and retrospective mortality surveys are undertaken annually in Aweil East County by ACF in order to estimate malnutrition and mortality rates in this county so as to give early warning to the stakeholders. There are several UN agencies, international NGOs (INGO), and Ministries operating in Aweil East to help with basic infrastructural needs such as health clinics and schools, and to assist the general population in livelihoods and food security, water and sanitation, health and nutrition needs. Table 2 below shows some of the key partners working in Aweil East.
ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 7 Table 2: UN Agencies, NGOs and INGOS Operating in Aweil East County NGO/UN Agency Activity IOM Returnee monitoring, food security, WASH WFP G FD, BSFP, Food for Training UNICEF Nutrition, education, child survival, WASH FAO Food Security and surveillance World Vision International Nutrition, food aid, emergency response Save the Children Alliance Education, child protection vocational training IRC Medical treatment and child survival programs AMURT International Food security, education and WASH Mercy Corps Food security, economic recovery and development, cash for work VSF SWISS Livestock surveillance, vaccination, outbreak reporting, and restocking TearFund Health Christian Solidarity International Health
2. Objectives of the survey