MATERNAL AND CHILD HEALTH 9 Habib Somanje and Jameson Ndawala This chapter presents the MDHS findings in the following areas of importance to maternal and child health: health services use during and after pregnancy, characteristics of the newborn, childhood vaccinations, and common childhood illnesses and their treatment. Combined with information on childhood mortality, this information can be used to identify women and children who are at risk because of nonuse of health services and to provide information to assist in the planning of appropriate improvements in service access and delivery. The results presented in the following sections are based on data collected from mothers on all live births that occurred in the five years preceding the survey. Given the importance of malaria in Malawi, a special malaria data collection “module” was implemented in the 2000 MDHS survey. The survey results pertaining to reported fevers, treatment of febrile episodes, and other malaria control programme activities, including possession and use of bednets, are presented in a separate chapter (Chapter 13). 9.1 ANTENATAL CARE Table 9.1 shows the percent distribution of women who had a live birth in the five years preceding the survey by source of antenatal care (ANC) received during pregnancy, according to maternal and background characteristics. Although interviewers were instructed to record all persons a woman had consulted for care, only the provider with the highest qualifications is considered here (if more than one person was seen). Ninety-one percent of mothers received antenatal care from a doctor or trained nurse or midwife. This compares with 90 percent of births based on the 1992 MDHS data. Women received antenatal care from a traditional birth attendant (TBA) for only 3 percent of births and no antenatal care at all for 5 percent of births. Thus, most women receive some antenatal care, relying largely on a nurse or trained midwife (83 percent) or a doctor (8 percent). It should be considered, however, that the type and quality of antenatal services is not reflected in these figures. Maternal age at birth, the birth order of the child, and urban-rural residence are not strongly related to use of antenatal care. Older, higher parity women and women living in rural areas are, however, more likely to have seen no one for antenatal services than younger, lower parity women and women living in urban areas. The use of antenatal services is strongly associated with level of education. Women with no education are eight times more likely than women with some secondary education to have received no antenatal care and 23 percent less likely to have received care from a doctor. Access and use of antenatal services varies among Malawi’s districts. Lack of any antenatal care is as high as 7 percent in Lilongwe District and as low as 1 percent in Blantyre District. Variation among districts in the use of doctors for antenatal care should be viewed with caution because the definition among respondents of what constitutes a “doctor” is rather loose and may vary by locality. Maternal and Child Health * 105 Table 9.1 Antenatal care Percent distribution of women who had a live birth in the five years preceding the survey by source of antenatal care (ANC) during pregnancy, according to maternal and background characteristics, Malawi 2000 ____________________________________________________________________________________________________ Traditional Background Nurse/ Ward birth Other/ characteristic Doctor midwife attendant attendant No one Missing Total Number _____________________________________________________________________________________________________ Mother's age at birth <20 7.7 85.7 1.1 2.1 3.4 0.0 100.0 1,487 20-34 8.5 83.4 1.0 2.5 4.3 0.3 100.0 5,342 35-49 7.6 79.4 1.5 3.9 7.2 0.4 100.0 1,228 Birth order 1 8.3 86.1 0.6 1.9 3.1 0.0 100.0 1,703 2-3 8.8 83.1 1.2 2.5 4.1 0.2 100.0 2,780 4-5 8.2 84.0 0.7 2.5 4.4 0.3 100.0 1,664 6+ 7.3 80.3 1.7 3.7 6.7 0.4 100.0 1,909 Residence Urban 9.0 88.3 0.4 0.5 1.5 0.2 100.0 1,075 Rural 8.1 82.5 1.2 3.0 5.0 0.2 100.0 6,982 Region Northern 4.2 87.7 0.7 4.3 2.9 0.3 100.0 894 Central 9.1 81.1 0.9 2.6 6.1 0.3 100.0 3,407 Southern 8.4 84.1 1.4 2.3 3.6 0.2 100.0 3,757 Education No education 7.9 78.0 1.6 4.0 8.3 0.2 100.0 2,477 Primary 1-4 8.7 83.2 1.0 2.6 4.3 0.2 100.0 2,531 Primary 5-8 7.6 87.5 0.8 1.9 1.9 0.3 100.0 2,434 Secondary+ 10.2 87.8 0.4 0.6 1.0 0.0 100.0 615 Districts Blantyre 4.7 93.2 0.6 0.2 1.2 0.0 100.0 638 Karonga 2.8 85.2 0.5 9.1 2.4 0.0 100.0 157 Kasungu 5.5 86.3 1.6 1.3 5.0 0.3 100.0 316 Lilongwe 8.5 81.3 0.2 2.7 6.9 0.4 100.0 1,173 Machinga 14.0 78.6 1.5 3.3 2.6 0.0 100.0 314 Mangochi 9.8 80.2 5.0 2.8 1.9 0.3 100.0 412 Mulanje 2.1 91.7 0.5 2.7 2.7 0.4 100.0 368 Mzimba 3.5 89.6 0.8 2.5 3.2 0.5 100.0 382 Salima 18.7 73.0 1.2 2.7 3.9 0.6 100.0 189 Thyolo 3.7 91.1 0.6 2.4 2.0 0.2 100.0 397 Zomba 5.8 87.8 1.0 3.5 1.9 0.0 100.0 469 Other districts 10.1 79.7 1.1 2.8 6.1 0.2 100.0 3,242 Total 8.2 83.2 1.1 2.7 4.6 0.2 100.0 8,057 _____________________________________________________________________________________________________ Note: For women with two or more live births in the five-year period, data refer to the most recent birth. If more than one source of ANC care was mentioned, only the provider with the highest qualifications is considered in this tabulation. Antenatal care can be more effective in avoiding adverse pregnancy outcomes when it is sought early in the pregnancy and continues through to delivery. It is recommended in Malawi that women first attend an antenatal clinic in the first trimester of pregnancy and, barring signs of heightened risk, at least three more times during the pregnancy (i.e., a minimum of four times total). Information about the number and timing of visits made by pregnant women is presented in Table 9.2. For 56 percent of births, mothers made four or more antenatal care visits, indicating that many women are aware of the importance of regular attendance. Yet, the median number of antenatal care visits was 3.4, fewer than the 4.8 visits found in the 1992 MDHS survey. The median 106 * Maternal and Child Health number of antenatal visits per pregnancy is Table 9.2 Number of antenatal care visits and stage of slightly higher in urban areas (3.8 times) than in pregnancy rural areas (3.3 times) Percent distribution of women who had a live birth in the five years preceding the survey by number of antenatal By the start of the sixth month of preg- care (ANC) visits, and by the stage of pregnancy at the time of the first visit, according to urban-rural residence, nancy, 50 percent of Malawian women have not Malawi 2000 made a single antenatal visit—the median dura- _______________________________________________ tion of gestation at which the first antenatal Number and timing of ANC visits Urban Rural Total care visit was made was 5.9 months. This de- _______________________________________________ layed use of services, whether because of moth- Number of ANC visits ers’ poor access or poor knowledge, makes it None 1.5 5.0 4.6 difficult for the optimum benefits of antenatal 1 1.9 4.0 3.8 2-3 27.6 35.7 34.6 care to be realised. Urban women tend to attend 4+ 68.3 54.1 56.0 their first antenatal care (ANC) visit at a slightly Don't know/missing 0.7 1.2 1.1 earlier gestational age than rural women. Total 100.0 100.0 100.0 Unlike earlier DHS surveys, the 2000 Median number of visits MDHS survey asked questions about particular (for those with ANC) 3.8 3.3 3.4 services that were received during pregnancy at the ANC provider. These include whether infor- Number of months pregnant at time of mation about signs of pregnancy complications first ANC visit were provided, whether the woman’s blood No antenatal care 1.5 5.0 4.6 pressure was measured, whether urine and <4 months 7.5 6.4 6.5 4-5 months 50.6 41.3 42.6 blood samples were taken, whether the woman 6-7 months 37.9 43.3 42.6 received tetanus toxoid injections, and whether 8+ months 2.2 3.6 3.4 iron supplements and antimalarial (intermittent Don't know/missing 0.3 0.3 0.3 treatment) tablets were provided.