PHYSICAL ENVIRONMENT

Transcription

1 FactorsDetermining health and diseases in Ethiopia PHYSIOGRAPHY, CIMATE NATURAL RESOURCES PHYSICAL ENVIRONMENT Economy Low GDP, dependence on biomass for fuel, subsistence living, unstable pastoral and nomadic existence, corruption, pollution ENVIRONMENTAL DAMAGE Culture/tradition Health & Diseases Education/politics Belief systems/religion, patriarchy, place of women in society/protection under the law, wars and their destabilizing effects on society, child abuse, child labor History

2 The Physical Environment, Health Care Services and Health Outcomes Excerpts from the topics listed in the content page of this online resource Citation : Aynalem Adugna Ethiopian Demography Updated October 2017

3 FACTORS AFFECTING THE NATION s HEALTH I. PHYSICAL / ENVIRONMENTAL Source : Aynalem Adugna Yemane Berhane, Damen Haile Mariam, Helmut Kloos (eds.) Epidemiology and Ecology of Health and Disease in Ethiopia. Shama Books. Addis Ababa. Ethiopia. Consideration of physical/biotic factors allows understandingof : o The Suitability of vector/agent habitat: vegetation, soil, rock- type, etc. for transmission of diseases o Toxicity and chemical composition of soil, rocks, and water. o The role of climatic and geologic events and disasters such as floods and draught. o The role of the physical environment in determining agricultural productivity, food security, etc. o Man-made changes to the environment and its impacts on the ecology of diseases and the carrying-capacity of land o The role of plants, and plant products in utilization of traditional medicine :

4 The Health Impacts of Topography Altitude and Geology o Living in highland plateaus over 2000 mt may be affecting hemoglobin content and Oxygensaturation o Depletion of fertile volcanic soil due to erosion caused by over population has triggered out-migration to the low lands with major health implications CLIMATE

5 o Kolla risk of heat- stroke, vector habitat o Dega and Woyna Dega acute respiratory diseases, vector/agent habitatintensity and duration o Temperature - Kolla C -Woyna Dega C - Dega C o Rainfall : Variability of rainfallhas contributed to frequent food shortages and famines that have been recorded for hundreds of years Variability in rainfall amounts makes the prediction of transmission patterns and intensity of malaria, trypanosomiasis meningiococcal meningitis, diarrhoea, and other water- related diseases difficult and at times impossible AIR QUALITY The use of fuel wood and dung in rural Ethiopia is responsible for very high levels of indoor pollution. Additionally, increasing automobile traffic and industrialization, together with persistent reliance.. on firewood for household use and Addis Ababa s location between mountains on three sides is largely responsible for high air pollution levels in this city

6 WATER AND SOIL o The 12 major river basins carry about 110 billion cubic meters of water in the highlands annually across deeply incised valleys towards the low-lying peripheries and neighboring countries o The gradients of most rivers andstreams is steep and their currents correspondingly strong, affecting the habitats of vectors. o Other water-related health issues include, contamination by human and animal waste, infection risks associated with standing water used in irrigation schemes, and the agricultural impacts of massive top-soil loss due to erosion of fertile volcanic soil from the highlands and its deposition in the lowlands, or in neighboring countries with serious consequences for land productivity, food security, and nutritional content.

7 Examples of the importance ofsoils in disease transmission include verisols in the highland plateaus of Ethiopia with a tendency toform deep cracks when dry making them an excellent habitat for phlebotomous flies transmitting leishmaniasis VEGETATION Long histories of settlement, massive deforestation, recurrent draughts, wars, villagization under the Derg regime, and resettlement have reduced Ethiopia s forest cover to only 3% of areas in the West and Southwest with serious implications for biodiversity, climate change, sustainabledevelopment and attendant health consequences. BIO DIVERSITY Introduction of genetically engineered grain crops from North America as part of food aid programs constitutes a potential threat to the biodiversity of Ethiopian crops and thereby, its food security.

8 BIO DIVERSITY Contd. The need to preserve aspects of of indigenous Ethiopian land use practices is increasingly being recognized with several advantages over recently introduced conservation measures. The advantages include its compatibility with local environment,land use, the farming system and objectives of the farming community but also its ease of implementation and gradual adoption by farmers on an incremental basis. II ECONOMY A country s level of economic development has significant impacts on the health of its citizens. Conversely, the health of its citizens determines the overall health of theeconomy. The impact on economy happens inthree important ways: 1. Loss of production by sick individuals as a result of decreased working capacity, and absenteeism. 2. The opportunity costs of people involved in caring for the sick 3. Countries with higher disease burden are forced to manage morbidities and disabilities by shifting resources that would have been invested in other productive activities

9 The country s per capita income of $590 is substantially lower than the regional average (source: Gross National Income, Atlas Method). The government aspires to reach lowermiddle income status over the next decade. The economy has experienced strong and broad-based growth over the past decade, averaging 10.8% per year in 2003/ /15 compared to the regional average of 5.4%. The expansion of services and the agricultural sector account for most of this growth, while manufacturing performance was relatively modest. Private consumption and public investment explain demand-side growth, with the latter assuming an increasingly important role in recent years. Economic growth brought with it positive trends in poverty reduction in both urban and rural areas. While 55.3% of Ethiopians lived in extreme poverty in 2000, by 2011, this figure was reduced to 33.5%, as measured by the international poverty line of less than $1.90 per day. The government is currently implementing the second phase of its Growth and Transformation Plan (GTP II). GTP II, which will run from 2015/16 to 2019/20, aims to continue improvements in physical infrastructure through public investment projects and transform the country into a manufacturing hub. The overarching goal is to turn Ethiopia into a lower-middle-income country by Growth targets are comparable to those under the previous plan, with annual average GDP growth of 11%; in line with the manufacturing strategy, the industrial sector is slated to grow by an average of 20%. Source: World Bank Adugna (retrieved 09/30/2017)

10 WATER Accessibility to Improved Water Sources Nearly all urban households in Ethiopia (97%) have access to an improved source of drinking water. Only 57% of rural households have such access. The phrase Improved sources of drinking water is a reference to the availability of piped water, stand pipes, public taps, boreholes, tube wells, protected dug wells and springs, and rainwater. Households using bottled water for drinking are classified as using an improved source only if the water they use for cooking and hand washing comes from an improved source. Some of the findings from the 2016 Demographic and Health Survey (DHS) on this subject include : o Fetching drinking water is an additional chore that could be of great cost to household members o More than half of rural households (53%) travel 30 minutes or longer round trip to fetch drinking water o In both rural and urban households, adult women are most likely to be responsible for fetching drinking water (17% in urban households and 68% in rural households). o In rural areas, female children under age 15 are three times more likely than male children in the same age group to fetch drinking water (13% versus 4%). Source : Aynalem Adugna DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

11 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July Source of Improved Water Urban Rural

12 Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July Time to Obtain Drinking Water (round trip) Urban Rural Water on premises Less than 30 minutes 30 minutes or longer Distance to source of water

13 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017 Availability of Water in Last two Weeks Urban Rural Not available for at least one day Available with no interruption of at least one day

14 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017 Person Who Usually Collects Drinking Water Water on premises Male child under age 15 Female child under age 15 Adult man Rural Urban Adult woman Percent

15 SANITATION Accessibility to Improved Sanitation Improved toilet facilities Include any non-shared toilet of the following types: flush/pour flush toilets to piped sewer systems, septic tanks, and pit latrines; ventilated improved pit (VIP) latrines; pit latrines with slabs; and composting toilets. DHS 2016, Page 10 Overall, 6% of Ethiopian households use improved toilet facilities (16% in urban areas and 4% in rural areas). More than half (56%) of rural households use unimproved toilet facilities. More than one-third (35%) of toilet facilities are shared in urban households, whereas only 2% of rural households share their toilet facilities with other households. One in three households in Ethiopia have no toilet facility (39% in rural areas and 7% in urban areas). DHS 2016 Page 10 Urban (households) Rural (houseeholds) Improved Unimproved sanitation Improved Unimproved sanitation Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia

16 Facility type Unimproved Sanitation Facilities by Type : Urban and Rural Households Rural households Urban households Other Hanging toilet/hanging latrine Flush/pour flush not to sewer/septic tank/ pit latrine Open defecation (no facility/bush/field) Pit latrine without slab/open pit Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

17 SANITATION Hand Washing Hand washing: Soap and water, the essential hand washing agents, were observed in 28% of urban households and 7% of rural households. On a regional basis, the availability of soap and water is highest in Addis Ababa (39%) and lowest in Amhara (5%). Page 9 80 Hand Washing : soap and Water Use by Wealth Quintile Lowest Second Middle Fourth Highest Soap and water Soap but no water No water no soap/other cleansing agent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

18 Hand Washing : Soap and Water Usage (percentage) by Region Soap and water Water only Soap but no water No water, no soap, no cleansing agent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia

19 HEALTH AND DISEASE IN ETHIOPIA HEALTH SERVICES and Health Indicators Health Policy : The country s national health policy is based on the principles of democratization and decentralization of the health cares system with primary focus on preventive, promotive and curative health services for the population. Private and nongovernmental organizations are encouraged to participation in the health sector. Five-year plans : The health sector follows five-year rolling plans which started in 1997/1998 with three consecutive plan phases completed so far. The country is and currently implementing the fourth comprehensive Health Sector Development Program (HSDP) with Wereda health offices managing and coordinating the operation of the Wereda health system under their jurisdiction. Source: : Adugna The health system has had a huge transformation over the past two decades, with a dramatically improved potential access to care through the accelerated expansion of health facilities. An innovative community-level health service, the Health Extension Programme was introduced by training and deploying female health extension workers and institutionalizing community health care at the health post level. Over the past decade, the Government of Ethiopiahas given priority to the expansion of health facilities, especially those of primary health care. In order to expand comprehensive obstetric care services further to the community level, the Government is planning an accelerated expansion of primary hospitals in each woreda. Source: : Adugna

20 The Ministry of Health has introduced a three-tier health care delivery system : I. Level one is a woreda health system comprised of a primary hospital (for people), health centres (for population) and their satellite health posts (for population), connected to each other by a referral system. The primary hospital, health centres and health posts form a primary health care unit. II. Level two is a general hospital for million people III. Level three is a specialized hospital for million people. Source: : Adugna Health Care Workforce For population, there are o <0.5 physicians, o 2 nursing and midwifery workers, o <0.5 dentistry workers, o <0.5 pharmaceutical personnel, o <0.5 environmental and public health workers, o 3 community health workers and o 2 hospital beds. [3] The shortage, uneven distribution, poor skill mix and high attrition of trained health professionals remain the major concerns. [1] The medicine supply system is unreliable and has long procurement procedures, resulting in low availability of medicines. Availability of essential medicines is 52% in the public sector and 88% in the private sector. Source: : Adugna

21 HEALTH PERSONNEL

22 DOCTORS : Age/Sex Distribution and Turnover There were 2,300 medical doctors in 5 regions and 2 city administrations in 6 years of observations [ ]. Of these, 553 (24.04%) medical doctors moved out of their duty stations and the remaining 1,747 (75.96%) were working actively. Of the actively working, the majority of the medical doctors, 1,407 (80.5%), were males, [of] which 889 (50.9%) were born after the year 1985, 997 (57%) had work experience of <3 years, and most, 1,471 (84.2%), were general practitioners. Within the observation period, physician turnover among specialists ranged from 21.4% in Dire Dawa to 43.3% in Amhara region. The capital, Addis Ababa, was the place of destination for 32 (82%) of the physicians who moved out to other regions Source : Aynalem Adugna Adugna Health Care Workforce The below facts, numbers, and graphs are based on a World Bank Report (2012) shown below. Direct quotes are placed within quotation marks. TheHealthWorkforce in Ethiopia. ADDRESSING THE REMAINING CHALLENGES, Berhanu Feysia, Christopher H. Herbst, Wuleta Lemma, and Agnes Soucat Editors

23 Health Care Workers Stock and Density of Health Care Workers : Selected Counties (2006/07/08/09) 250, , , , , Ghana Rwanda Benin Zambia Côte d Ivoire Ethiopia Thailand Health workera 46,040 13,133 9,323 12,219 19,784 65, ,577 Ratio per 1,000 population Source: World Bank Report, 2012 (full reference on slide 11)

24 Gender Distribution o Female health workers are underrepresented in the professional and mid-level categories in, even in nursing which is traditionally considered a female domain. o Just 11 percent of Ethiopia s physicians are women. o By design, the opposite is true for health extension workers (HEW where there are more females than men except in a few regions Alternative cadres in Ethiopia Health extension workers. HEWs are young women, with secondary education, paid and trained by the government, that woredas have identified to serve their local community. The training of the first cohort of health extension workers started in HEWs are trained to manage operations of health posts; conduct home visits and outreach services to promote preventive health actions; refer cases to health centers and follow up on referrals; identify, train, and collaborate with voluntary community health workers; and provide reports to district health offices. Health officers. Health officers provide clinical service at both health centers and primary hospitals, and manage district health offices. They hold skill sets and carry out tasks somewhere between a nurse and a doctor. The training of health officers started at Gonder University in 1954 dueto the shortage of physicians. Health officers hold bachelor s degrees and undergo a three-year training program plus one-year internship. Those who complete the master s degree provide advanced care, such as emergency surgery Source: World Bank Report, 2012 (full reference on slide 11)

25 12000 Health Personnel Excluding Man Power Outside of Ministry of Health (2010/2011) , , Doctors Health Officers Nurses Source : Aynalem Adugna Based on Central Statistical Authority, CSA, Statistical Abstract, 2012

26 12000 Health Personnel Excluding Man Power Outside of Ministry of Health (2010/2011) , , Doctors Health Officers Nurses

27 HEALTH INSTITUTIONS

28 Number of Health Posts 7000 Number of Health Posts by Region, 2010/ Series1, 0 Source : Aynalem Adugna Based on Central Statistical Authority, CSA, Statistical Abstract, 2012

29 Number of Hospitals Number of Government Hospital (MOH) and Others by Region, 2010/ Oromiya Snnp* Amhara Tigray Somalie Addis Ababa 0 4 Affar Harari Benishang ul Gumuz Gambella Others MOH Diredawa Source : Aynalem Adugna Based on Central Statistical Authority (CSA), Statistical Abstract, 2012

30 Number of Beds NUMBER OF HOSPITAL BEDS BY REGION Region Source : Aynalem Adugna Based on Central Statistical Authority (CSA), Statistical Abstract, 2012

31 HEALTH OUTCOMES Click HERE to access an interactive web map of health outcomes as measured by the Ethiopian Demographic and Health surveys

32 Source : Aynalem Adugna Based on Central Statistical Authority (CSA), Statistical Abstract, 2012

33 Source : Aynalem Adugna Based on Central Statistical Authority (CSA), Statistical Abstract, 2012

34 Maternal Health Care : Number of Child Delivery Services by Region (201/2011) Gambella Benshangul- Gumuz Harari Afar Dire Dawa Somali Tigray Addis Ababa 1,603 2,108 3,513 3,586 5,176 12,723 32,881 47,762 SNNP Amhara 76,200 87,319 Oromiya 206, , , , , ,000 Source : Aynalem Adugna Based on Central Statistical Authority (CSA), Statistical Abstract, 2012

35 2,000,000 Number of Childhood Vaccinations by Region, 2010/2011 : DPT and Measles D.P.T Measles 1,800,000 1,600,000 1,400,000 1,200,000 1,000, , , , ,000 0 Source : Aynalem Adugna Based on Central Statistical Authority (CSA), Statistical Abstract, 2012

36 The top 10 causes of hospital/health center visits show some regional variation SNNPR is shown below as an example

37 MATERNAL HEALTH CARE Key Findings of the 2016 Ethiopian Demographic and Health Survey o Antenatal care: There was an increase of 7 percentage points (from 27% in 2000 to 34% in 2011, and 62% in 2016) in the proportion of women age who received antenatal care (ANC) from a skilled provider; 32% percent of women had at least four ANC visits during their last pregnancy. o Overall, pregnant women are less likely to have their to have their urine sample taken or to have received nutritional counselling (66% for both) than to have their blood pressure measured (75%) or blood sample taken (73%). o Nearly 49% of women had their last birth protected against neonatal tetanus to ensure protection against neonatal tetanus. o Delivery: Home deliveries have decreased from 95% in 2000 to 90% in 2011, and 73% in During the same period, institutional deliveries increased from 5% in 2000 to 10% in 2011, and to 26% in o Postnatal care: The proportion of women and newborns who received a postnatal check within the first 2 days of birth was 17% and 13% respectively. o Problems in accessing maternal health care: There was a notable decrease in the proportion of women age who report having at least one of the specified problems in accessing health care decreased - from 96% in 2005, to 94% in 2011, and 70% in Source : Aynalem Adugna DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

38 Percent Antenatal Care by Skilled Providers for the Most Recent Birth by Age of Mothers at Child Birth, DHS Doctor Nurse/midwife Health extension worker No antenatal care < Mother's age at child birth Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

39 Percent Antenatal Care Provided by Skilled Providers for the Most Recent Birth by Birth Order, DHS Doctor Nurse/midwife Health extension worker No antenatal care Birth Order Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

40 Percent Antenatal Care Provided by Skilled Providers for the Most Recent Birth by Region, DHS 2016 Doctor Nurse/midwife Health extension worker No antenatal care Region Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

41 What the above slide showed o Tigray has significant nurse/midwife coverage (the highest in the county) : 71.4% o Dire Dawa also has significant nurse/midwife coverage (the second highest in the county) : 58.9% o Addis Ababa has the highest percentage of antenatal cared attended by doctors (the highest in the county) : 46.1% o Somali has a high percentage of women who did not receive any antenatal care (56% - the highest in the county) and Oromia has the second highest at 48.6% and Afar the third highest (48.4%). o Tigray has the second lowest percentage (after Addis Ababa) of women who did not received any antenatal care o SNNP and Benishangul-Gumuz have relatively high coverage of antenatal care attended by Health Extension Workers (20.7% and 17.9% respectively)

42 Education level Antenatal Care Provided by Skilled Providers for the Most Recent Birth by Mothers' Educational Attainment, DHS 2016 Doctor Nurse/midwife Health extension worker No antenatal care More than secondary Secondary Primary No education Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

43 Percent Antenatal Care Provided by Skilled Providers for the Most Recent Birth by Wealth Quintiles Lowest Second Middle Fourth Highest No antenatal care Health extension worker Nurse/midwife Doctor Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

44 Urban-rural Differences in Antenatal Care Provided by Skilled Providers, DHS 2016 Doctor/nurse/midwife Health extension worker No antenatal care Urban Rural Urban Rural Urban Rural Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

45 Number of months Number of Months Pregrant at Time of First Anenatal Care Visit by Urban-rural Residence, DHS, Rural Urban <4 No antenatal care Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

46 CHILD HEALTH CARE Key findings of the 2016 Ethiopian Demographic and Health Survey o Child size and birth weight: Birth weight information was obtained for a very small percentage of newborns (only 14%) of births. Of these babies 13% weighed less than 2.5 kg at birth. o o Vaccinations: Of children aged months at the time of the survey, close to two in every five (39%) received all of the basic vaccinations at some time, and 22% were vaccinated by the appropriate age. The proportion of children age months who are fully vaccinated increased by 15 percent, from 24 percent in 2011 to 39 percent in Symptoms of acute respiratory infection (ARI): In the two weeks before the survey, seven percent of children under the age of five had symptoms of ARI. Roughly 30% of these children sought treatment. o Fever: In the two weeks before the survey 14% percent of children under 5 were reported to have fever. Of these, only 35% sought treatment from a health facility or provider. o Diarrhoea: Of children under the age of 5, 12% percent had diarrhoea in two weeks before the survey; 44% percent of these sought and 46% received some form of ORT. Another 39% received ORT or increased liquids.

47 Percent 90 Percentage of Children Aged who were Vaccinated by Appropriate age at Any Time Before the 2016 Demographic and Health Survey Vaccine type Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

48 Percentage of Children aged Months who Ever Had Vaccination Cards by Region, DHS 2016 Affar 24.2 Somali Oromiya SNNPR Amhara Benishangul-Gumuz Gambela Harari Dire Dawa Tigray Addis Ababa Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

49 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

50 Wealth quintile Percentage of Children Months Old who Ever had Vaccination Cards by Wealth Quintiles, DHS 2016 Highest Fourth Middle Second Lowest Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

51 NUTRITION OF CHILDREN AND ADULTS Key Findings of the 2016 Demographic and Health Survey Nutritional status of children: More that one in three (38%) of children under 5 years of age are stunted (short for their age) and 10% are wasted (thin for their height). Nearly a quarter (24%) are underweight (thin for their age). Only 1% of children under 5 are overweight (heavy for their height). Breastfeeding: Nearly all infants and children (97%) are breastfed at some point. However, a low percentage (only 58%) of infants under 6 months of age are exclusively breastfed. Minimum acceptable diet: Only 7% of children age 6-23 months meet the minimum acceptable dietary standards for breast feeding practices, and only 14% of children had a sufficiently diverse diet. Anaemia: Anemia is wide spread among women and children. It affects more than half of children age 6-59 months (57%) and 24% of women age Salt iodisation: Iodised salt for cooking by 89% households. Maternal nutrition: More than one in five (22%) of women age are thin (BMI < 18.5), while eight percent are overweight or obese. Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017, Page 187

52 Source: Direct quote, EDHS 2016, Page 188 DEFINITION Stunting (assessed via height-for-age) Height-for-age is a measure of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted), or chronically undernourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Sample: Children under age 5 Wasting or weight-for-height The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered thin (wasted), or acutely undernourished. Children whose weight-for-height Z-score is below minus three standard deviations (-3 SD) from the median of the reference population are considered severely wasted. Sample: Children under age 5 Underweight or weight-for-age Weight-for-age is a composite index of height-for-age and weight-for-height that accounts for both acute and chronic undernutrition. Children whose weight-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age Z-score is below minus three standard deviations (-3 SD) from the median are considered severely underweight. Sample: Children under age 5 Overweight children Children whose weight-for-height Z-score is more than two standard deviations (+2 SD) above the median of the reference population are considered overweight. Sample: Children under age 5

53 Percent Percentage of Children Stunted, Underweight, and Wasted, DHS 2000, 2005, 2011, DHS2000 DHS2005 DHS2011 DHS2016 Stunted Under weight Wasted The percentage of children who are stunted has decreased substantially from 58% in 2000 to 38% in This translates into an average decline of more than 1 percentage point per year. The prevalence of underweight also decreased from 41% to 24% over the 16-year period but wasting has remained more or less constatnt Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017, Page 187

54 Stunting, Underweight, Wasting.contd. o For children under age 5 stunting increases sharply between the age of 6 to 23 months, and peaks at ages months reflecting a scenario of overall undernutrition in the first 1,000 days of life. o There is an association between child malnutrition, childbirth size, and maternal malnutrition in that children who were small at birth are more likely to be stunted, wasted, or underweight than children who were normal weight or larger weight at birth. o On the other hand, children of thin mothers (BMI <18.5) are more likely to be stunted, wasted, or underweight than children of mothers with normal BMI, or of mothers who are overweight or obese. o Children in rural areas show higher levels of stunting, underweight, and wasting than those in urban areas. o Mothers education and wealth are important correlates of children's nutritional status as represented by the proportions of children who are stunted and underweight which declines with increasing mother s education and increasing household wealth. Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017, Page 187

55 Pewrcent Breastfeading Status According to Age, DHS Breast- feeding and consuming comple- mentary foods Breast- feeding and consuming other milk Breast- feeding and consuming non milk liquids Breast- feeding and consuming plain water only Exclusively breast- feeding Not breast- feeding Age in months Contrary to the recommendation that children under the age of 6 months be exclusively breastfed, many infants are also fed with other liquids such as water (17%), non-milk liquids (5%), and other milks (5%) before reaching age 6 months (0-5 months). Moreover, 11% of infants begin complementary foods before 6 months of age, with more than one-fifth of children (21%) consuming complementary foods by age 4-5 months. Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017, Page 191

56 Region Nutritional Status of Women by Region, DHS 2016 Dire Dawa Addis Ababa Harari Gambela SNNPR Benishangul-Gumuz Somali Oromiya Amhara Affar Tigray Percent Normal ( ) Thin (<18.5) Mildly thin ( ) Severely thin (<17) Overweight or obese (>=25) Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

57 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Key findings of the 2016 Ethiopian Demographic and Health Survey Knowledge about HIV transmission and prevention: Comprehensive knowledge about the modes of HIV transmission and prevention was reported by 23% of women age and 38% of men age Knowledge of mother-to-child transmission of HIV: The fact that that HIV can be passed on to infants during pregnancy, labour/delivery, or breastfeeding is known to 57% percent of women and 55% of men Discriminatory attitudes: The opinion that children living with HIV should not be able to attend school with children who are HIV negative was voiced by 48%t of women and 35% of men; moreover, 47% of men and 55% of women would not purchase fresh vegetables from a shopkeeper who has HIV. Sexual partners: Having two or more sexual partners in the past 12 months was reported by less than 1% of women and 3% of men reported. Condom use: HIV has been present in Ethiopia over three decades. And yet, only 20% of women and 51% of men who had a non-cohabiting partner in the past 12 months said they used a condom during last sexual intercourse with such a partner. Coverage of HIV testing: On the plus side, 69% percent of women and 84% of men know the locations of HVI testing sites, and 40% women and 43% men have ever been tested for HIV and received the test results. Additionally, 20% of women and 19% of men had been tested for HIV and received the most recent test results within the 12 months before the 2016 survey. Male circumcision: The survey showed that, overall, 91% of men aged were circumcised. Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

58 Percent Percentage of Women and Men Aged Who Have Knowledge of HIV Prevention Methods 80 Men women Even though the percentage of adults with knowledge of HIV transmission methods has increased significantly between 2000 and 2016, the male-female knowledge gap has not narrowed that much. DHS2000 DHS2005 DHS2011 DHS2016 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

59 Percent Percentage of Women and Men Using Condoms by Region, DHS Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

60 Benishangul-Gumuz Percentage of Women Who Know Where to Obtain an HIV Test by Region, DHS 2016 Somali Oromiya Affar SNNPR Amhara Gambela Dire Dawa Harari Tigray Addis Ababa Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

61 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

62 Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

63 Percentage of Women Ever Tested for HIV Before Getting Married or Living With a Partner by Region, DHS 2016 Somali 2.9 Oromiya Benishangul-Gumuz SNNPR Affar 24.9 Harari Dire Dawa Amhara Gambela Tigray Addis Ababa Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

64 Region Percentage of Women Tested While Pregnant, DHS 2016 Somali 5.7 Oromiya Affar Gambela Benishangul-Gumuz SNNPR Harari Amhara 32.5 Dire Dawa 40.5 Tigray 46.6 Addis Ababa Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

65 What the above two slides showed o Oromia, a region with the highest population in the county, has the second lowest percentages of women who have been tested for HIV. o Governmental policy decisions, both federal and regional, can be redesigned to produce remedial results for the people. o Success is to be measured, among others, by health outcomes that protected the population from HVI and premature deaths. Click HERE to access an interactive web map of health outcomes as measured by the Ethiopian Demographic and Health Surveys

66 Percentage Distribution of Men by Circumcision Status and Provider of Circumcision, DHS 2016 Dire Dawa 14.9 Addis Ababa 30.4 Harari Gambela SNNPR 37.6 Benishangul-Gumuz Somali Oromiya Amhara Affar Health worker/ professional Traditional practitioner/ family friend Other/don t know Not circumcised Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

67 Adult and Maternal Mortality o o o Adult mortality: Women and men who have reached age 15 have a probability of dying before age 50 of 10% and 12%, respectively. Pregnancy-related mortality: The pregnancy related mortality ratio was 412 maternal deaths per 100,000 live births for the 7 years before the survey. The decline from the estimate of 871 for the 7 years before the 2000 EDHS or the estimate of 676 for the 7 years before the 2011 EDHS is statistically significant. Lifetime risk of pregnancy-related death: The lifetime risk of pregnancy-related death (a death related to pregnancy or childbirth) is 21 in 1,000 women in Ethiopia. Direct quote :DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017, page 249 Trends in Pregnancy-related Mortality Ratio (PRMR) with confidence intervals (Pregnancy-related deaths per 100,000 live births, 2000 to 2016) Upper limit Point estimate Lower limit 1, DHS DHS DHS DHS Source : DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

68 What the above slide showed o Estimates from Ethiopia s Demographic Health Surveys (EDHS) show significant declines in the pregnancy-related mortality ratio in since 2000, from 871 deaths per 100,000 live births in the 7 years before the 2000 EDHS to 673 deaths per 100,000 live births in the 7 years before the 2005 EDHS, 676 deaths per 100,000 live births in the 7 years before the 2011 EDHS, and 412 deaths per 100,000 live births in the 7 years before the 2016 EDHS survey. o The 2000 to 2016 and 2011 to 2016 declines are statistically significant. o Note : in accordance with the World Health Organization s definition, a pregnancy-related death is defined as the death of a woman while pregnant or during delivery, or in the 42 days after the delivery or within 42 days of termination of pregnancy, if the death is not due to an accident or violence. o However, the term maternal mortality used in previous EDHS surveys corresponds to pregnancy-related mortality.however, the data collected in previous EDHS surveys refer to deaths within 2 months after a birth rather than 42 days after a birth, and current estimates are comparable to estimates from previous EDHS surveys..

69 WOMEN S RIGHTS AND EMPOWERMNT : Implications for Health Key Findings: Ethiopian Demographic and Health Survey 2016 o Employment and earnings: Forty-eight percent women age who are currently married were employed in the 12 months before the survey, compared with 99% men age who are currently married. o More than half of the men (53%) and just under half of the women (49%) were not paid for their work. The percentage of women who were not paid for their work was highest in the age group (66%). o For 62% of currently married women who have cash earnings, decisions about how their earnings are used are usually made jointly with their husbands; 30% of women make most of these decisions on their own. o Ownership of a home and land: Half of all women own a house, either alone or jointly with someone, while just over one-third of women who own a house report that there is a title or deed for the house which includes their name. Similarly, 40 percent of women own land but only one in two of the women who own land say there is a title or deed in their name for the land o Decision to marry: The majority (61%) of ever-married women say their parents made the decision that they would get married the first time. Only 35% say they made the decision to marry by themselves Source : DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017, Page 255

70 Key findings.contd. o Schooling after marriage: A quarter of women were attending school at the time they first married, and the majority (three-quarters) of these women stopped going to school after getting married. o Participation in decision making: When measured on the basis of three specified household decisions (own health care, household purchases, and visits to their family), 71% of currently married women participate in all three decision, while 10% are not involved in any of these decisions. o Reproductive health: Overall, access to antenatal care, the use of contraception, delivery assistance, and postnatal care increase with women s empowerment. o Attitudes toward wife beating : Sixty three percent of Ethiopian women age believe that a husband is justified in beating his wife in at least one of the five specified circumstances listed below (compared with 28% of men) : 1. she burns the food, 2. she argues with him, 3. she goes out without telling him, 4. she neglects the children, and 5. she refuses to have sex with him Source : DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

71 Region Person who Decides How Wives (15-49) Cash Earnings are Used by Region, DHS 2016 Mainly wife Wife and husband jointly Mainly husband Dire Dawa 35 Addis Ababa 40 Harari 28.5 Gambela 44.5 SNNPR 35.3 Benishangul-Gumuz 8.5 Somali 55.7 Oromiya 22 Amhara 27 Affar 27.9 Tigray Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

72 Region Person who Decides how A Husbands (15-49) Earnings Should be Spent by Region, DHS 2016 Mainly wife Wife and husband jointly Mainly husband Dire Dawa Addis Ababa Harari Gambela SNNPR Benishangul-Gumuz Somali Oromiya Amhara Affar Tigray Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

73 Percente Percentage of Women who Use a Bank Account and Own Mobile Phones 100 Use a bank account Own a mobile phone Region Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

74 Percent Percentage of Women who Use a Bank Account and Own A Mobile Phone by Educational Attainment Use a bank account Own a mobile phone No education Primary Secondary More than secondary Level of education Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

75 Regional Percentage Distribution of Ever Married Women by Person Making a Decision on a Woman's First Marriage, DHS Myself Parents Other family/relative Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

76 Level of education Percentage of Ever MArried Women by Person Making a Decision on Woman's First Marriage by Educational Attainment, DHS 2016 Other family/relative Parents Myself More than secondary Secondary Primary No education Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

77 Percent Regional Percentage of Ever Married Women Who Stopped School After Marriage by Reason for Discontinuing School Graduated from school Too busy with life Husband refused Other Region Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

78 Region Regional Percentage of Women Whose Husbands Participate in Household Chores, DHS 2016 Somali Harari Affar Oromiya Dire Dawa Gambela SNNPR Benishangul-Gumuz Tigray Amhara Addis Ababa Percent Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

79 Percent Distribution of Currently Married Women by Person Who Usually Makes Decisions, DHS 2016 Visits to her family or relatives Major household purchases Own health care Major household Visits to her family or Own health care purchases relatives Mainly wife Wife and husband jointly Mainly husband Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

80 Percent Background characteristic Burns the food Percentage of women who agree that Husband is justified in hitting or beating his wife if she: Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percent of Women Who Agree With At Least One Specified Reason by Age Group, DHS 2016 Percentage who agree with at least one specified reason Nearly two-thirds of women agreed with at least one reason regardless of age, DHS Age group Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

81 Background characteristic Burns the food Percentage of women who agree that husband is justified in hitting or beating his wife if she: Argues with him Goes out without telling him Neglects the children Percent Who Agrees With At Least One Specified Reason by Urban-rural Residence Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason 69.80% 39.20% Urban Rural Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

82 Background characteristic Percentage of Women Who Agree that Husband is justified in hitting or beating his wife if she: Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Burns food Argues with him Goes out without telling him Percentage who agree with at least one specified reason Addis Ababa Somali Harari Dire Dawa Benishangul-Gumuz Gambela Amhara Tigray Oromiya Affar SNNPR Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July 2017

83 Background characteristic Percentage of Women Who Agree that Husband is justified in hitting or beating his wife if she: Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Percentage who agree with at least one specified reason Addis Ababa Somali Dire Dawa Harari Gambela Benishangul-Gumuz Amhara Oromiya SNNPR Affar Tigray Neglects children Refuses sex Agrees with at least one reason Source : Aynalem Adugna Based on DERAL DEMOCRATIC REPUBLIC OF ETHIOPIA : Demographic and Health Survey 2016, Central Statistical Agency Addis Ababa, Ethiopia The DHS Program ICF, Rockville, Maryland, USA, July

84 Place of Delivery : Health Facility Three Years Preceding the Survey (percent) Comparison with Egypt and Kenya Egypt Ethiopia Kenya Source : Aynalem Adugna Based on

85 Received All Eight Vaccinations (percent) Comparison with Egypt and Kenya Egypt Ethiopia Kenya Source : Aynalem Adugna Based on

86 Children Stunted (percent) Comparison with Egypt and Kenya Egypt Ethiopia Kenya Source : Aynalem Adugna Based on

87 Children Underweight (percent) Comparison with Egypt and Kenya Egypt Ethiopia Kenya Source : Aynalem Adugna Based on

88 Maternal Mortality Ratio Comparison with Kenya Maternal mortality ratio for the seven years preceding the survey expressed per 100,000 live births, calculated as the ageadjusted maternal mortality rate times 100 divided by the age-adjusted general fertility rate. Data are shown with lower and upper bounds of the confidence intervals showing the range of the estimate with 95% probability Ethiopia Kenya Source : Aynalem Adugna Based on

89 Women Circumcised FGM (percent) Comparison with Egypt and Kenya Egypt Ethiopia Kenya Source : Aynalem Adugna Based on