The DHS Program

Majuro, Marshall Islands. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national level as well as in the urban and rural areas. A long-term objective of the survey is to strengthen the technical capacity of government organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the RMI 2007 DHS provides national, rural and urban estimates on population and health that are comparable to data collected in similar surveys in other Pacific DHS pilot countries and other developing countries.

INTRODUCTION CONTINUED
The RMI 2007 DHS was carried out under the ADB/SPC Pacific Regional Pilot DHS Project which was executed by EPPSO in collaboration with the Ministry of Health. Macro International Inc. provided technical assistance through its MEASURE DHS project. The survey was funded by the Asian Development Bank.

The survey was designed to obtain completed interviews of 1,070 women age 15-49. In addition, males age 15-59 in every second household were interviewed. To take non-response into account, a total of 608 households countrywide were selected, 295 in urban areas and 313 in rural areas. Three questionnaires were administered for the RMI 2007 DHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. These questionnaires were adapted to reflect the population and health issues relevant to Republic of the Marshall Islands at a series of meetings with various stakeholders from government ministries and agencies, NGOs and international donors.

A total of 1,141 households were selected for the sample, of which 1,131 were found to be occupied during data collection. Of these existing households, 1,106 were successfully interviewed, giving a household response rate of 98 percent.

POLICY NOTES

1. Reproductive Health Policy Note:
Notwithstanding apparent good antenatal coverage, TT immunization appears not to be available to the majority of Marshallese women, with 2 in 10 women reporting to have received two or more injections during their last pregnancy.

With most births in Majuro and Kwajalein taking place in health facilities, 3 in 10 births in the outer islands do not take place in a health facility.

With 2 in 10 women reporting no postpartum checkup, it is unclear from the survey if this is caused by a lack of access of lack of service uptake; either way, it would appear to be good sexual and reproductive health practice to bring coverage close to 100 percent.

With the vast majority of Marshallese women (80%) reporting some problem with health care access, it appears prudent to take note of reported service deficiencies.


2. Fertility and Family Planning Policy Note:
Considerable improvements have taken place in lowering RMI fertility from 7.2 to 4.5 live births per woman over the past 20 years.

Notwithstanding these developments, teenage fertility has remained virtually unchanged (and high by regional standards) over this time period; one in four girls and young women aged15-19 at the time of the survey either was pregnant or had already given birth to their first child. This high proportion overall, plus marked differentials between rural (43%) and (20%) Marshallese could warrant some closer policy attention.

The fact that this feature ahs remained constant for almost 20 years seems indicative of some kind of cultural acceptance’ this has remained virtually unchanged despite the rapid emergence of HIV/AIDS education does not seem to get message across very effectively. This is also illustrated in the fact that while widespread amongst women and men, and most women and men claim to have used some sort of family planning in the past, less than half of all married women, and only one in four (sexually active) unmarried women currently use contraceptive.

3. Infant and Child Mortality Policy Note:
Trends over the past 5 years show positive developments, yet mortality levels still remain higher than 10 to 15 years ago. An analysis of cause of death is advisable as a matter of urgency, to target program interventions.

There is a need to improve on current low rates of complete vaccination coverage.

Considering the importance of the age of the mother, education, and other socio-economic differentials, it is important to maintain high standards of health education: key messages need to focus on intensive and increase care of infants (<1 month old) and on the dangers of high risk fertility behavior.

4. Child Health Policy Note:
Improvement in child health appears to hinge on improving standards of service provision (immunization coverage) and a more community involved approach to health education.

The fact that only 1 in 3 children between one and two years of age, and 1 in 4 infants (children under 1 year) has received full immunization coverage represents a big challenge for RMI health authorities. The fact that 75% of all children have immunization cards shows most children are known to health personnel of children to be vaccinated appears a sensible, cheap and effective policy option to improve child health.

Some rural-urban differentials in service delivery, including regular supply of and access to all vaccines, need to be addressed urgently.

A low reported understanding of appropriate child feeding practices ( including intake of liquids) during bouts of diarrhea, with half of all others reporting no knowledge about oral rehydration (and even fewer teenage mothers), and most children’s stool left contained, highlights the importance of more targeted community-level health education.

5. Child and Maternal Nutrition Policy Note:
Breastfeeding is nearly universal in the Marshall Islands, with 95 percent of mothers reporting to have breastfed their infant at some time, with the median duration of breastfeeding amounting to 15.4 months, and about half of all children getting breastfed until 2 years of age.

Given this widespread acceptance of breastfeeding, it is surprising that only 1 in 4 infants are exclusively breastfed until six months of age- the recommended WHO gold standard to achieve optimal growth and development. Considering earlier remarks about infant and child health, it seems that more concerted policy attention to increase this percentage has the potential to make substantive contributions to both child health and house hold wealth (by saving on expenditure on milk formula), with minimum implications for the health budget.

While the survey provided a generally healthy nutritional picture for women in terms of food consumptions and micronutrient intake by mothers, the same cannot be said for children, with 17% showing some indication of malnutrition. The latter, not surprisingly, is strongly linked to house hold wealth, with some 20 percent of children in the middle and two lowest wealth quintiles in this category.

6. HIV and AIDS Policy Note:
As referred to earlier regarding fertility and family planning, there appears to be a substantial disconnect between knowledge and practice: While the reported knowledge about HIV/AIDS transmission is almost universal amongst men (96.6%) and women (96.8%) the prevalence of unprotected sex remains very high. This is most pronounced amongst women, with nearly twice as many women not using condoms during last sex, during high risk sex, or during first sex.

Considering that the vast majority of Marshallese young men (73%) and young women (60%) have had sex before they turned 18, and only 10 percent and 16 percent of 15-24 year old men and women, respectively, reported using a condom during their first sexual intercourse, this should be of considerable public health concern.

It appears from these figures that awareness of HIV/AIDS is quite high while comprehensive knowledge and corresponding behavior are still very low, despite many years of sexual and reproductive health education. It appears that different strategies and greater focus on behavior change are urgently needed.

7. Gender and Development Policy Note:
Where women are financially dependent on men, their control over their own lives and bodies can be greatly diminished, as illustrated by the belief of almost a third of Marshallese men that although a wife is free to refuse to have to have sex with her husband, an appropriate response is to sleep with another woman or withhold financial support. This also puts both women and men at greatly increased risk of contracting HIV and other STIs, with serious social and financial implications for society as a whole.

Lingering attitudes toward male control over family decision-making similarly leave Marshallese women vulnerable to personal and financial insecurity, an issue that could be addressed by improving education, raising awareness and building skills for women of all ages.

Likewise there is a clear need for women to be empowered regarding their own health. This should involve greater emphasis on health education and awareness for women and girls in both urban and rural areas, including information on general and reproductive health issues and on accessing health care advice, facilities and services.

8. Domestic Violence Policy Note:
Domestic violence is a serious, widespread and often hidden human rights abuse with wide-ranging implications for survivors, their families and society at large. Governments have a legal duty under international law to take all appropriate steps to eliminate domestic violence by any person and to protect people from it, including through passing appropriate laws, educating communities, providing appropriate medical and other services, punishing perpetrators, and compensating survivors.

Concerted efforts to eradicate domestic violence need to be taken by government in both urban and rural areas, in collaboration with civil society organizations and communities. Domestic violence legislation should be enacted, enforced and widely advertised in RMI in compliance with the UN Convention of the Elimination of All Forms of Discrimination Against Women. Judicial and law enforcement officers and other public officials need regular training on domestic violence issues, including the legal obligations to investigate and prosecute cases geld by both women and men, which condone violence against women, limit women to stereotypical roles or are based on the inferiority of women vis-à-vis-men, need to be taken, including through media campaigns, community awareness initiatives and educational curricula. Communities and government officials should be educated to understand the need to eliminate domestic violence and empowered to contribute to its elimination, and services for survivors, including legal, medical and counseling services made available and widely advertised.

Given that domestic violence is hidden and that women suffering such violence are much more likely in RMI to either stay quite or report it to family and friends than to go to government authorities or medical personnel, it is critical that whole communities be involved in eradicating domestic violence and understanding the help and services available to survivors. These services must be easily accessible and have high standards of confidentiality to improve the likelihood of help-seeking behavior. (Released February 25, 2009}

- Economic Policy, Planning and Statistics Office (EPPSO), Republic of the Marshall Islands