2014 Kigoma Reproductive Health Survey: Kigoma Region, Tanzania

Publication date: 2015

Introduction A 2014 Kigoma Reproductive Health Survey Kigoma Region, Tanzania US Department of Health and Human Services Centers for Disease Control and Prevention The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Suggested citation: Centers for Disease Control and Prevention. 2014 Kigoma Reproductive Health Survey: Kigoma Region, Tanzania. Atlanta, GA: Centers for Disease Control and Prevention; 2015. http://www.cdc.gov/reproductivehealth/Global/Publications/ Surveys/Africa/Kigoma-Tanzania/index.htm. Foreword This 2014 Kigoma Reproductive Health Survey (RHS) report presents findings from a population- based health survey conducted in collaboration with government agencies, nongovernmental organizations, and other public and private partners. The report includes key indicators that aim to inform the decisions of policy makers, program managers, and other stakeholders invested in supporting and improving reproductive health in Kigoma Region. The government of Tanzania values collaboration with its development partners to achieve shared goals for reproductive health. Through these partnerships, Bloomberg Philanthropies has supported country efforts to improve maternal and newborn health for more than 8 years. The Ministry of Health and Social Welfare (MoHSW) wishes to thank members of MoHSW Reproductive and Child Health who provided valuable contributions: Dr. Georgina Msemo, Dr. Koheleth Winani, Clement Kihinga, and Moris Hiza. MoHSW also acknowledges Kigoma Regional Medical Officer Dr. Leonard Subi and other members of Kigoma health management teams as critical to the success of the 2014 Kigoma RHS. We wish to express gratitude to Bloomberg Philanthropies for providing financial support via the CDC Foundation and contributions to the questionnaire content. The World Lung Foundation and EngenderHealth—nongovernmental organizations providing reproductive health and family planning interventions in Kigoma Region—also contributed to the questionnaire content. We recognize Abdallah Mwinchande, Patrick Kanyamwenge, and Fredrick Ananga at AMCA Inter-Consult Ltd., who trained field staff and organized and supervised survey implementation logistics. We also wish to thank the staff of the US Centers for Disease Control and Prevention, both in Tanzania and in Atlanta, for providing technical assistance in questionnaire design, field staff training, data analysis, and report writing. We are particularly grateful to the enumerators from Kigoma and Dar es Salaam whose hard work enabled the collection of quality data. Finally and most importantly, we would like to thank the women who agreed to participate in the survey and contribute important information to the evidence base for reproductive health in Kigoma Region. Dr. Neema Rusibamayila Director of Preventive Services Ministry of Health and Social Welfare United Republic of Tanzania Partners: Tanzania Ministry of Health & Social Welfare Kigoma Region Government Bloomberg Philanthropies EngenderHealth World Lung Foundation AMCA Inter-Consult Ltd. CDC Foundation US Centers for Disease Control and Prevention 2014 Kigoma Reproductive Health Survey Kigoma Region, Tanzania National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health Contents Key Findings and Conclusions from the Kigoma 2014 Reproductive Health Survey .1 Chapter 1: Introduction .5 1.1 Background and Purpose .5 1.2 Western Zone and Tanzania: Reproductive Health Indicators in Context .5 1.3 Survey Objectives .7 1.4 Survey Methods .8 1.5 Ethics Approval .10 Chapter 2: Households, Women, and Births Since January 2009 .11 2.1 Household Characteristics .11 2.2 Characteristics of Respondents .14 2.3 Characteristics of Births Since January 2009 .18 Chapter 3: Fertility .23 3.1 Fertility Levels .23 3.2 Fertility Preferences and Planning Status of Previous Pregnancies .28 3.3 Future Fertility Preferences .31 Chapter 4: Family Planning .35 4.1 Contraceptive Knowledge .35 4.2 Ever Use of Contraception .37 4.3 Current Use of Contraception .39 4.4 Number of Living Children at First Use of Contraception .45 4.5 Source of Modern Contraception Methods .46 4.6 Time to Source of Modern Contraception Methods .49 4.7 Availability of Family Planning Services at Government Facilities .50 4.8 Payment for Contraceptive Methods .50 4.9 Preferred Contraceptive Method Among Current Users .51 4.10 Contraceptive Decision Making Among Current Users .53 4.11 Reasons for Non-Use of Contraception .54 4.12 Future Intentions of Non-Users and Preferred Method .56 4.13 Unmet Need for Contraception . 59 Chapter 5: Maternal and Perinatal Health .63 5.1 Antenatal Care .63 5.2 Use of Local Herbs During Pregnancy .68 5.3 Delivery .70 5.4 Postnatal .88 Chapter 6: Infant, Child, and Perinatal Mortality .99 Chapter 7: Opinions About Contraception and Family Planning .105 7.1 Opinions About Family Planning .105 7.2 Family Planning Information .111 Chapter 8: Early Sexual Activity .121 8.1 Relationship to First Partner .121 8.2 Wantedness of First Sex .123 8.3 Contraceptive Use at First Sex .124 Chapter 9: Summary of Findings and Implications .129 9.1 Reproductive Health .129 9.2 Fertility Levels and Unmet Need for Family Planning Services .130 9.3 Family Planning .130 Abbreviations .132 Appendices A and B: Household and Individual Questionnaires .133 Key Findings and Conclusions 1 Key Findings and ConClusions From the 2014 Kigoma reproduCtive health survey The 2015 Kigoma Reproductive Health Survey assesses many reproductive health indicators for women of reproductive age (15-49 years). Key findings and actionable conclusions include: Pregnancy Health Finding: Although almost all women receive antenatal care (ANC) during their pregnancies, very few (17%) begin receiving this care during the first trimester, the time when health problems can be detected early. Furthermore, during ANC care visits, fewer than half of women reportedly receive instruction on pregnancy complications or have their blood pressure checked. Conclusion: Community mobilization is needed to encourage ANC visits in the first trimester. At each ANC visit, providers should review pregnancy complications, measure blood pressure, and advise women to receive at least four ANC visits. Finding: Distance to health services is a barrier for many women accessing care, particularly in rural areas. The cost of transportation prevents many women from delivering in facilities, even if they have made transportation plans. Conclusion: Increased geographic coverage of quality health service providers is needed. In addition, transport voucher programs and community transport funds could help to offset the transportation costs (which are higher in rural areas). Labor, Delivery, and Postpartum Care and Counseling Finding: Half of births occur at home. Women who are older, have less education, and are of lower socioeconomic status are more likely than other women to deliver at home, a decision they often report having made themselves. Conclusion: Since almost all women receive ANC at some point during their pregnancies, ANC providers should use those opportunities to discuss delivery in health facilities with skilled birth attendants, show the facility amenities, and encourage women to have a birth plan. Finding: Although most (86%) newborns receive a well-baby (postnatal) check within 2 months of birth, very few women (13%) attend a postnatal check for their own health. Conclusion: Women’s postnatal health could benefit from more attention and resources; maternal health and family planning services could be combined with well-baby care. Finding: It is advisable for all women to receive family planning counseling before, during, and after delivery. In Kigoma, 74% of women receive such counseling during pregnancy, but very few (2%) receive it at the time of delivery, and only 28% receive counseling postpartum. Conclusion: Health facility staff should routinely provide family planning counseling before women leave the facility after giving birth. 2 Key Findings and Conclusions Child Health and Mortality Finding: Vital registration is low in Kigoma; for women’s most recent live births, only 3% of babies born at home and 10% of those born at a facility are reported to have a birth certificate. Conclusion: Strengthening vital registration is a government priority and an essential strategy in monitoring efforts to improve the health of the population. The barriers to vital registration in facilities and in the communities need to be examined and addressed. Finding: Child mortality rates have fallen, but fertility rates remain high. Kigoma has not yet gone through a demographic transition. Conclusion: Increased use of family planning to reduce the number of births and increase the time between births could lower rates of both child and maternal mortality. Family Planning Finding: Fertility rates in Kigoma are higher than those of Tanzania as a whole, and both knowledge of and use of contraceptive methods are lower in Kigoma. Although most women have heard of short-term methods such as injectables and the pill, fewer have heard of the long-acting reversible methods such as the IUD and implants. Conclusion: Informational campaigns should improve awareness of long-acting methods among women. Providers’ training could ensure that health workers are skilled to both provide counseling and insert IUDs and implants. Family planning logistic management efforts should address shortages and unavailability of products. Finding: Most women have favorable opinions about family planning, but only 16% of women in union are currently using a modern contraceptive method. Conclusion: Family planning information and counseling should be provided during pregnancy and well-child visits, including an emphasis on the health benefits to both women and their children. Greater availability of implants and IUDs in health facilities would enable increased use of these long-acting, reversible methods. Finding: The injectable is the most popular method among women currently using contraception (9% of women in union are using the injectable, or more than half of modern method users). It is also by far the most popular method among women not currently using a method who thought they might in the future; almost half (47%) said they would choose the injectable. Conclusion: Since women using the injectable must return to dispensaries periodically for supplies, these visits could be used to educate women about all methods of contraception, including the long-acting, more effective methods. Finding: About half of women are not aware that modern contraceptive methods are effective at preventing pregnancy or are safe for their health. Conclusion: Community outreach efforts, including information about family planning and contraceptive methods are urgently needed, especially targeting rural women and young women aged 15-19, whose levels of knowledge are lower. Key Findings and Conclusions 3 Finding: Among women who are not currently using contraception, the leading reasons for non- use are their desire to become pregnant and their fear of side effects. Contraceptive side effects are generally not well understood; nearly two-thirds of all women mistakenly think that using birth control pills or injectables would reduce their ability to get pregnant in the future. Conclusion: More education is needed about the health benefits and effectiveness of contraceptive methods and about their side effects. Finding: Almost all young, sexually active women aged 15-24 years did not use contraception the first time they had sexual intercourse. Nearly half (45%) of these women did not use contraception because they wanted to become pregnant, but 17% did not because they did not know about contraception at the time. Conclusion: Family planning education is needed for young women in particular. Finding: Overall, 39% of women who are married or in union have an unmet need for family planning. Most of this need (32%) is for spacing births (women in Kigoma prefer birth spacing intervals of at least 2 years), and 7% of the need is for limiting births. Conclusion: Improving the use of reliable and reversible methods of contraception is the best approach to reducing unmet need for spacing. As rural women and women with low levels of education have the highest levels of such unmet need, efforts to increase and meet demand for family planning should be particularly focused on those groups. Finding: Two-thirds of women prefer to get information on family planning from clinic health workers. More than half of women said that receiving information about family planning in religious settings or on the radio was acceptable. Conclusion: Health facility visits are a good opportunity for trained health workers to educate women about family planning and maternal health services. Radio seems to be an acceptable source, and religious settings appear to be accepted venues. Introduction 5 Chapter 1: introduCtion 1.1. Background and Purpose The Ministry of Health and Social Welfare in Tanzania has developed national strategies to reduce maternal deaths and improve reproductive health through strengthening antenatal care provision, expanding emergency obstetric care services, and increasing knowledge and use of contraception. The ministry also has collaborated with multiple nongovernmental partners to achieve shared goals for improving reproductive health. For more than 8 years, Bloomberg Philanthropies has supported efforts to improve maternal and newborn health by upgrading facilities to better provide comprehensive emergency obstetric and neonatal care (CEmONC) services in Kigoma, Pwani, and Morogoro Regions. Bloomberg is now expanding activities in Kigoma Region to integrate family planning and comprehensive post-abortion care into various health facilities, including the health centers that have already been upgraded to provide CEmONC services. Evaluating the impact of such interventions is vital to achieving Tanzania’s reproductive health goals, including maternal mortality reduction. The 2014 Kigoma Reproductive Health Survey (RHS) was designed to provide a reliable baseline assessment of demographic indicators related to maternal and newborn health outcomes, knowledge and use of maternal health services, knowledge and use of contraception, and exposure to health promotion programs. When the follow-up survey is conducted in several years, the evaluators plan to assess the impact of the planned expansion of services. Secondary survey objectives include understanding women’s fertility and health care service utilization preferences, attitudes about family planning, and access to media and cell phone coverage, with a goal of informing health promotion programming. This report presents the findings from the 2014 Kigoma RHS. This introductory chapter provides an overview of the current status of reproductive health among women of reproductive age in Tanzania’s Western Zone, including comparisons with Tanzania as a whole. In addition, it describes details of the survey methodology. Subsequent chapters of this report detail topic-specific findings. 1.2 Western Zone and Tanzania: Reproductive Health Indicators in Context The 2014 Kigoma RHS was conducted throughout Tanzania’s Kigoma Region. One of 30 regions in Tanzania, Kigoma is located in the northwest corner of the country (Figure 1.1), bordering Lake Tanganyika, the Democratic Republic of Congo, and Burundi. It covers 45,066 square kilometers, 27% of which consist of arable and grazing land; the remaining area consists of forest and water. Administratively, the region is divided into eight districts. According to the 2012 National Census of Population and Housing, Kigoma Region had a population of 2,127,930 with 374,479 households, an average household size of 5.7, and an annual population growth rate of 2.4%. Approximately 83% of households in Kigoma are classified as rural.2 6 Chapter 1 Figure 1.1: Kigoma’s Location in Tanzania Map: Grounds for Health.1 Prior to this 2014 survey in Kigoma, the most recent survey was the 2010 Tanzania Demographic and Health Survey (DHS)2; findings were presented down to the zone level, using the classifications employed by the Reproductive and Child Section of the Ministry of Health and Social Welfare. Administrative areas were collapsed into seven geographic zones; Kigoma, Tabora, and Shinyanga Regions make up the Western Zone. The 2010 DHS was not designed to be representative at the regional level, and the 2014 Kigoma RHS was borne out of Bloomberg Philanthropies’ desire for more detailed population-based reproductive health information specific to Kigoma Region. Thus, all zone- and national-level indicators discussed in this chapter come from the 2010 DHS. The 2010 DHS data indicated that fertility, contraceptive use, access to obstetric care services, and mortality rates varied by zone.2 Regarding fertility, the overall total fertility rate in Tanzania was 5.4 births per woman. The Western Zone, however, had the highest total fertility rate in the country (7.2 births per woman), and the highest percentage of women aged 15-49 years who were pregnant when interviewed (13%). Nationwide, fertility was strongly associated with both the educational attainment and wealth status of the mother. The poorest women, for example, had more than twice as many children as women living in the wealthiest households (7.0 vs 3.2 children per woman, respectively). Use of contraception varied by zone, despite widespread knowledge of contraception. Results from the 2010 DHS showed that both nationally and in the Western Zone, 99% of women aged 15-49 years knew of at least one modern contraceptive method.2 Use of any contraceptive method, however, was lower in the Western Zone than in the nation overall (20% and 34%, respectively), as was use of any modern method (15% and 27%, respectively). The 2010 DHS also showed that use of modern family planning varied by residence nationwide; modern methods were used by 34% of married women in urban areas, compared with 25% in rural areas. Access to obstetric care services varied substantially within Tanzania. A smaller proportion of deliveries took place in health facilities in the Western Zone (37%) than in the nation as a whole (52%). Women in the Western Zone also had fewer deliveries by a skilled provider (38% and 51%, respectively) and fewer deliveries by cesarean section than did women nationwide (3% and 5%, respectively). Furthermore, the 2010 DHS data document higher mortality in the Western Zone than in the nation overall2; infant mortality was 56 deaths per 1,000 live births compared with 51 deaths per 1,000 live births nationwide, and child (younger than 5 years old) mortality was 98 deaths per 1,000 live births compared with 81 deaths per 1,000 live births nationwide. Introduction 7 Table 1.1 compares additional reproductive health indicators between the 2010 DHS (nation and Western Zone) and 2014 RHS (Kigoma Region). Table 1.1: Key Reproductive Health Indicators for Tanzania, the Western Zone, and Kigoma Region Indicator DHS-2010 RHS-2014  Tanzania Western Zone Kigoma Region Fertility Currently married/in union 63.2% 68.0% 63.7% Currently pregnant 9.6% 12.9% 10.4% Total fertility rate 5.4 7.2 6.7 Family planning Knows any contraceptive methods 98.0% 98.9% 96.3% Knows any modern contraceptive method 97.9% 98.9% 96.0% Currently using any contraceptive method (women in union) 34.4% 20.1% 20.6% Currently using a modern method (women in union) 27.4% 14.6% 15.6% Currently using pill (women in union) 6.7% 2.6% 1.4% Currently using injectable (women in union) 10.6% 5.4% 8.9% Currently using IUD (women in union)  0.6% 0.5% 0.3% Currently using female sterilization (women in union) 3.5% 3.0% 2.1% Currently using condom (women in union) 2.3% 1.9% 0.9% Currently using periodic abstinence (women in union) 3.1% 1.8% 2.2% Want no more children 29.7% 20.1% 19.4% Want to delay birth at least 2 years 43.5% 52.5% 51.7% Ideal family size 4.9 5.8 6.5 Child mortality (rates per 1,000 live births during previous 5 years) Perinatal mortality 36 29 29 Neonatal mortality 26 25a 16 Infant mortality 51 56a 30 Mortality under age 5 years 81 98a 56 Maternal and perinatal health At least four antenatal care visits 42.8% N/A 42.1% Delivered in health facility 50.2% 36.5% 47.0% Delivered by C-section 4.5% 2.8% 3.5% Delivered by skilled provider 50.6% 37.5% 48.3% Postnatal check-up (mother) 35.4% 29.1% 12.5% Abbreviations: DHS-2010, 2010 Tanzania Demographic and Health Survey; IUD, intrauterine device; RHS-2014, 2014 Kigoma Reproductive Health Survey. a Rate per 1,000 live births during previous 10 years. Sources: DHS-2010, RHS-2014. 1.3 Survey Objectives Objectives for the survey of Kigoma Region included the following: 1. To assess baseline knowledge and use of key maternal health services, including family planning, antenatal care, delivery care, and postnatal services among women of reproductive age. 2. To measure contraceptive prevalence rates and related parameters. 3. To measure key demographic indicators that are affected by use of family planning and maternal and newborn services. 4. To obtain data on reproductive health knowledge, attitudes, and behavior of young women aged 15-24 years, and to assess their exposure to sex education and family planning health promotion programs. 8 Chapter 1 1.4 Survey Methods The 2014 RHS employed a regionally representative probability sample and consisted of face-to-face interviews with women aged 15-49 years, regardless of marital status. This baseline survey was conducted in Kigoma Region during August-September 2014. This baseline survey aimed to produce data that will be comparable to the next survey in Kigoma Region, which is currently scheduled for June-July 2016. Sample Design This sample was selected to be representative of the Kigoma Region and to allow separate urban and rural estimates for key population and health indicators. The number of households included in the sample was calculated to yield approximately 4,000 interviews with women aged 15-49 years. The survey employed a multistage sampling design that used the 2012 Tanzania National Census of Population and Housing as the sampling frame.3 A two-stage selection process was used. The first stage involved systematic selection of 120 primary sampling units, using probability proportional to size sampling. The primary sampling units for the survey were enumeration areas (EAs), defined by the Tanzania National Bureau of Statistics. In June 2014, prior to the second stage, a complete household listing (described below) was created in all selected EAs. In the second stage, 35 households were selected for most EAs (88 of 120). One household was randomly selected as the starting point within each EA; interview teams visited that household and the next 34 from the household listing. For the 16 EAs with fewer than 35 total households, all households were interviewed. To compensate, 9-10 additional households were visited in the 16 sampled EAs that had experienced the fastest population growth since the 2012 Census. All women aged 15-49 years who were living in the selected households were eligible to be interviewed, and all who consented to participate were interviewed. Data were weighted at the household and the individual levels to account for changes in EA size since the 2012 Census and to yield the same distribution of the weighted sample by age group and rural/urban residence as in the 2012 Census.4 Cartography and Household Listing The survey team obtained maps for Kigoma Region that were based on the 2012 Census from the National Bureau of Statistics.3 The survey cartography team went to the field in June 2014 to update the maps and create lists of all households in the selected EAs. Response Rate Table 1.2 displays household and individual response rates for the 2014 RHS. A total of 4,202 households was selected and visited. Up to three visits were made to each household if eligible respondents were not at home during the initial household visit, resulting in 3,838 completed household interviews (a response rate of 91%). A total of 4,091 (859 urban and 3,232 rural) eligible women of reproductive age were residing in those 3,838 households. Of these, 3,916 women were successfully interviewed, resulting in an individual response rate of 96% (94% urban and 96% rural). Only 0.3% of women of reproductive age refused to be interviewed. Introduction 9 Table 1.2: Response Rate for 2014 Kigoma Reproductive Health Survey Households Responding (%) Individual Women Responding, by Residence (%) Urban Rural Total Completed 91.3 94.1 96.2 95.7 Not at home 4.1 2.8 1.6 1.9 Refused 0.6 0.8 0.2 0.3 Dwelling not a household (Household only) 3.7 NA NA NA Incapacitated (Women only) NA 0.7 1.1 1.0 Other 0.2 1.6 1.0 1.1 Total 100.0 100.0 100.0 100.0 Number of cases 4,202 859 3,232 4,091 Survey Instruments Two Swahili-language questionnaires were administered. The first was a relatively short household questionnaire (see Appendix A for English language version) which listed the usual residents of each household, described the demographic characteristics of each, and identified all women of reproductive age who lived there. The household questionnaire also included multiple questions regarding the characteristics of the household itself (e.g., water supply, number of rooms, roofing materials, durable goods owned by the family, etc.), which were later used to describe the relative wealth status of each household. The second questionnaire was the questionnaire for individual women (see Appendix B), administered confidentially to each woman aged 15-49 years who agreed to be interviewed, and who resided in a selected household. Individual interviews took 30-60 minutes to complete. The questionnaire focused on women’s knowledge and use of key maternal and child health services. It also included questions used to calculate key demographic indicators, such as the total fertility rate; unmet need for contraception; age at first union (marriage or informal union); age at first birth; and perinatal, neonatal, infant, and child mortality. The specific topics included in the individual woman’s questionnaire were: • Characteristics (age, education, literacy, religiosity, marital status). • Pregnancy history (lifetime pregnancies, pregnancy outcome, date, sex and survival status of live births, age at death for children who died). • Antenatal care (source, timing of first visit, number of visits, content of care). • Delivery (place, skilled birth attendance, type of delivery, delays, problems encountered, transport, referrals). • Postpartum (care, use of family planning, amenorrhea, abstinence). • Breastfeeding (initiation, duration). • Family planning (knowledge, ever use, current use, source, counseling, attitudes). • Fertility desires (timing of next pregnancy, preferred family size). • Male involvement in maternal and child health issues such as family planning and delivery decisions. • Exposure to family planning media messages and awareness campaigns at the community level. Pilot Test and Survey Team Training Training was first conducted in Kigoma Region during June 2014 with the specific goal of piloting the survey tools. For 5 days, the twelve-member survey pilot team was oriented to the details of the study data collection. The questionnaires were pilot tested in EAs that were not selected for the survey. Although the study data collection tools were translated into Swahili to ensure excellent communication with survey respondents, both English and Swahili were employed in the pilot test training. The clarity of the translations of all data collection tools was assessed at this stage. 10 Chapter 1 Training for the final survey administration took place during 2 weeks in July and August 2014. Training consisted of lectures, discussions, and practice opportunities. Topics covered included survey logistics, survey questions, interviewing techniques, and both principles and practice of confidentiality. Six survey teams were selected, including one supervisor and three interviewers per team. Data Collection Data collection took place in August and September 2014. Each supervisor confirmed that his or her team went to each selected EA and visited all of the sampled households. Before administering household questionnaires, interviewers explained to a member of each household what the study was about and obtained permission to conduct the household interview. Similarly, the study was explained to the women aged 15-49 years who lived in the household and who were at home. They were asked to participate, and their verbal and written consent was obtained prior to interview. Interviewers then administered the questionnaires confidentially with each woman who consented. Supervisors reviewed the completed survey questionnaires in the field to ensure completeness, and then sent them to Kigoma for daily data entry. Data entry clerk supervisors recorded receipt of the questionnaires from the field and assigned the questionnaires to the data clerks, who entered all survey responses into CSPro version 5.0 (US Census Bureau). All completed and entered questionnaires were stored in a secure location in the data entry room in Kigoma and were transported to Dar es Salaam at the end of field data collection activities to be stored in a secure location. Data cleaning took place in Dar es Salaam in the first 2 weeks of October 2014 and analysis was conducted using SAS statistical software, version 9.3 (SAS Institute, Inc., Cary, North Carolina). 1.5 Ethics Approval The protocol for the baseline Kigoma Reproductive Health Survey received ethical approval from the US Centers for Disease Control and Prevention (CDC), CDC-Tanzania, and the Tanzania National Health Research Ethics Review Committee. References 1. Grounds for Health. Available at: http://www.groundsforhealth.org. 2. The United Republic of Tanzania National Bureau of Statistics (NBS), ORC Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: National Bureau of Statistics, ORC Macro; 2011. 3. NBS, Office of Chief Government Statistician. 2012 Population and Housing Census: Population Distribution by Administrative Areas. Dar es Salaam and Zanzibar, Tanzania: NBS, Office of Chief Government Statistician; 2013. 4. NBS, Office of Chief Government Statistician. Population Distribution by Age and Sex. Dar es Salaam and Zanzibar, Tanzania: NBS, Office of Chief Government Statistician; 2013. Households, Women, and Births Since January 2009 11 Chapter 2: households, women, and Births sinCe January 2009 The 2014 Kigoma Reproductive Health Survey assessed reproductive health outcomes for women of reproductive age (15-49 years). To provide context for these outcomes, this chapter summarizes the basic characteristics of the sampled households, respondents, and births since January 2009. In this report, key indicators are stratified according to these characteristics. 2.1 Household Characteristics A household was defined as a person or group of persons who usually live together in the same dwelling and share food. The Household Questionnaire collected information on household composition, amenities, and goods. Household Members and Eligible Women The total population of usual residents within all surveyed households was 20,811, with an average household size of 5.4 persons. Each completed household interview yielded an average of 1.1 women of reproductive age, for a total of 4,091 eligible women. Figure 2.1 shows the distribution of households by number of persons in them, both for Kigoma Region and for Tanzania nationally.1 Kigoma Region has a much greater percentage of households having six or more residents than Tanzania as a whole (48% vs 36%, respectively). Eighty-one percent of households were in rural areas, according to the National Bureau of Statistics.2 Figure 2.1: Household Size, Kigoma Region vs Tanzania (Percent Distribution) Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. 5.9 8.8 11.2 13.1 13.0 14.3 12.8 8.8 12.2 8.6 10.3 14.3 16.2 14.7 11.5 9.4 5.6 9.5 0 2 4 6 8 10 12 14 16 18 1 2 3 4 5 6 7 8 9+ Pe rc en t Number of Persons in Household Kigoma Region Tanzania 12 Chapter 2 Figure 2.2 shows the age and sex distribution of the Kigoma Region population. The wide base of the pyramid indicates a large number of children relative to the number of adults in the population, normally an indication of high recent fertility. There are large differences in the percentages of women aged 10-14 years compared with those aged 15-19 years, as well as those aged 45-49 years compared with those aged 50-54 years. This may be due to age displacement, a phenomenon in surveys of women of reproductive age whereby interviewers may misclassify respondents’ ages just outside of reproductive age categories (e.g., 10-14 and 50-54 years instead of 15-49 years) to reduce interviewer workloads. To correct for age displacement, all woman-level analyses have been weighted so that the distribution of the sample by age groups is the same as the age distribution of Kigoma women of reproductive age in the 2012 National Census of Population and Housing.2 Figure 2.2: Surveyed Household Population in Kigoma Region, by Age and Sex Source: 2014 Kigoma Reproductive Health Survey. 10 8 6 4 2 0 2 4 6 8 10 10-14 15-19 0-4 5-9 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Percent A ge (y ea rs ) Male Female Households, Women, and Births Since January 2009 13 Assets To determine the wealth of households in Kigoma Region, information was collected on dwelling characteristics and household assets (i.e., electricity, paraffin lamp, radio, television, mobile phone, iron, refrigerator, watch, bicycle, motorized vehicle, ownership of a bank account). Table 2.1 shows the percent distributions of dwelling characteristics collected for each household. Forty-one percent of households had access to protected water (piped, 31.1%; covered well, 10.2%), and the vast majority (93.7%) have access to a latrine (flush/pour toilets, 4%; pit latrine, 89.7%). More than half (57.4%) of households have a cell phone. Ten percent of households in Kigoma have electricity (urban, 31.0%; rural, 5.3%). Table 2.1: Availability of Basic Household Services, by Urban vs Rural Residence (Percent Distribution) All Households with Completed Interviews Service Urban (%) Rural (%) Total (%) Drinking water source Piped 37.9 29.5 31.1 Open well 10.1 17.2 15.8 Covered well 11.2 10.0 10.2 Surface water 36.0 43.0 41.6 Other 4.8 0.4 1.2 Toilet facility Flush/pour toilet 16.4 1.1 4.0 Pit latrine 80.6 91.8 89.7 Other 0.2 0.1 0.1 None 2.8 7.0 6.2 Electricity Yes 31.0 5.3 10.1 No 69.0 94.7 89.9 Cell phone Yes 68.0 54.9 57.4 No 32.0 45.1 42.6 Total 100.0 100.0 100.0 Number of households 753 3,085 3,838 Source: 2014 Kigoma Reproductive Health Survey. 14 Chapter 2 2.2 Characteristics of Respondents Age Table 2.2 shows the percent distribution of women interviewed by age at the time of interview. Nearly one quarter (24.1%) of women were in the youngest age group (15-19 years) (urban, 25.8%; rural, 23.7%). Most women (60.3%) were aged 15-29 years (urban, 62.2%; rural, 59.9%), but the proportion of women in each age group decreased with increasing age, again indicating Kigoma’s relatively young population composition and high rate of childbearing. Table 2.2: Characteristics of Selected Women, by Urban vs Rural Residence (Percent Distribution) Women of Reproductive Age (15-49 Years) Characteristic Kigoma (RHS-2014) Tanzania (DHS-2010) Urban (%) Rural (%) Total (%) Number of Women Total (%) Number of Women Residence Urban 100.0 0.0 19.7 808 28.5 2,892 Rural 0.0 100.0 80.3 3,108 71.5 7,247 Age group (yr) 15-19 25.8 23.7 24.1 865 21.4 2,221 20-24 20.2 19.8 19.9 716 18.8 1,860 25-29 16.2 16.4 16.3 637 16.5 1,613 30-34 13.1 13.2 13.2 525 14.0 1,389 35-39 10.9 11.4 11.3 487 12.7 1,249 40-44 8.0 9.0 8.8 416 9.2 983 45-49 5.9 6.6 6.4 270 7.3 824 Education level No education 15.8 26.9 24.7 958 19.1 1,940 Some primary 16.2 16.7 16.6 627 14.6 1,482 Completed primary 46.1 49.1 48.5 1,926 50.0 5,071 Attended secondary or higher 21.9 7.3 10.2 405 16.2 1,646 Swahili literacy Illiterate 21.9 33.1 30.9 1,196 27.4 N/A Partially literate 5.0 8.0 7.4 288 5.3 N/A Literate 73.0 59.0 61.7 2,432 67.0a N/A Current union status Married 46.7 49.5 48.9 1,974 58.3 5,917 In union 10.5 15.8 14.8 570 5.0 393 Widowed 2.4 2.1 2.2 92 2.9 255 Divorced 1.3 1.0 1.1 46 8.8b 856b Separated 5.7 4.9 5.1 206 Never in union 33.3 26.7 28.0 1,028 25.1 2,718 Total 100.0 100.0 100.0 3,916 100.0 10,139 Abbreviations: DHS-2010, 2010 Tanzania Demographic and Health Survey; RHS-2014, 2014 Kigoma Reproductive Health Survey. Sources: DHS-2010, RHS-2014. a Includes women who attended secondary school or higher (assumed literate), as well as women who attended up to primary school and who could read a whole sentence. b Divorced/separated. Households, Women, and Births Since January 2009 15 Education and Literacy Nearly half (48.5%) of women reported that primary school was the highest level of school they completed (urban, 46.1%; rural, 49.1%), and 24.7% reported that they had received no formal education (urban, 15.8%; rural, 26.9%) (Table 2.2, Figure 2.3). A larger proportion of women in urban areas (21.9%) had attended secondary school or higher than had women in rural areas (7.3%). Figure 2.3: Educational Attainment of Women Aged 15-49 Years, by Urban/Rural Residence—Kigoma Region (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. Literacy was determined by assessing each woman’s ability to read all, some, or none of a Swahili sentence. About 62% of women were Swahili literate (urban, 73.0%; rural, 59.0%), 31% were illiterate (urban, 21.9%; rural, 33.1%), and 7.4% were partially literate (urban, 5.0%; rural, 8.0%) (Table 2.2). Partnership Status For the 2014 Kigoma Reproductive Health Survey, women who were in union with a man were in a steady relationship with a man, either married via legal or customary matrimony, or living together as if married. Sixty-four percent of women were in union at the time of the interview (married, 48.9%; unmarried, 14.8%), 8.4% had previously been in union with a man (widowed, 2.2%; divorced, 1.1%; separated, 5.1%), and 28.0% had never been in union with a man (Table 2.2). A greater proportion of women in rural areas (65.3%) were currently in union with a man (married, 49.5%; unmarried, 15.8%) than were those living in urban areas (57.2% [married, 46.7%; unmarried, 10.5%]). Wealth An index of relative wealth was created using principal components analysis, which assigned a weight to each household asset and dwelling characteristic. Each household received an asset score comprising the total of the asset weights in that household. Each household member was assigned the weighted asset score of the household. Based on this score, all individuals in the sample were then ranked and divided into three wealth terciles: low, middle, and high. A designation of high wealth, therefore, did not indicate being a wealthy household; rather, it meant that the household had a higher asset score than households classified as having low and middle wealth. 15.8 16.2 46.1 21.9 26.9 16.7 49.1 7.3 24.7 16.6 48.5 10.2 0 10 20 30 40 50 60 None Some primary Completed primary Attended secondary or higher Pe rc en t Education Level Urban Rural Total 16 Chapter 2 Table 2.3 shows the results of the relative wealth classification for all women interviewed. A greater percentage of women in urban households were classified in the high wealth tercile, whereas more women in rural households were classified in the low or middle wealth terciles. Table 2.3: Relative Socioeconomic Classification (in Terciles) of Selected Women, by Urban vs Rural Residence (Percent Distribution) Women of Reproductive Age (15–49 Years) Characteristic Urban (%) Rural (%) Total (%) Number of Women Wealth tercile Low 17.9 35.1 31.7 1,235 Middle 16.7 37.5 33.4 1,277 High 65.4 27.5 34.9 1,404 Total 100.0 100.0 100.0 3,916 Source: 2014 Kigoma Reproductive Health Survey. Economic Empowerment Index An index of economic empowerment of women of reproductive age was created using a set of five questions3 inquiring whether the respondent had received money or goods for work outside the home (or outside of household chores), had her own cash savings, owned land, or owned any other assets that could generate income. Table 2.4 shows that one-third (32.8%) of these women earned money for work outside the home; 2.9% were paid in goods for work outside the home; 11.1% had individual cash savings; 25.4% owned land; and 14.5% owned income-generating assets. The women’s economic empowerment index was then assessed by tallying answers to the five questions described above, so that each yes answer scored 1 point. A respondent’s economic empowerment index score was the sum of those points (0-5), and a high score implied a respondent’s greater control over assets. Table 2.4 shows the distribution of the summary score by urban/rural residence. Scores of 5 were so rare that they were combined with the scores of 4. Scores were generally similar between urban and rural populations, with the majority (76.1%) of respondents demonstrating scores of only 1 or 0. Table 2.4: Components of Economic Empowerment Index, by Urban vs Rural Residence (Percent) Women of Reproductive Age (15–49 Years) Urban (%) Rural (%) Total (%) Indicator Received money for work outside home (last 12 months) 38.2 31.5 32.8 Received goods for work outside home (last 12 months) 3.9 2.7 2.9 Has her own cash savings 17.4 9.5 11.1 Owns land 17.5 27.3 25.4 Has assets that could help her generate income 13.0 14.9 14.5 Economic empowerment index 0 46.9 48.0 47.8 1 28.2 28.4 28.3 2 15.5 15.7 15.7 3 6.7 5.6 5.8 4-5 2.6 2.2 2.3 Number of women 808 3,108 3,916 Source: 2014 Kigoma Reproductive Health Survey. Households, Women, and Births Since January 2009 17 Household Decision Making To measure women’s autonomy, a household decision-making index was created.4 Women reported which member of the household was usually responsible for six possible decisions: the respondent’s health care, large household purchases, household purchases for daily needs, how to use the money that the respondent brought into the household, how to use the money that her partner brought into the household, and whether the respondent was allowed to work to earn money. Women could indicate one of six possible decision makers for each decision: respondent only, husband/partner only, both respondent and husband/partner, husband/partner’s parents, respondent’s parents, or someone else. In addition, a score of 1 was assigned to each decision the respondent made herself or jointly with her husband/ partner. The household decision-making index created a cumulative score (0-6) for the six decisions, where a low score (0) indicated less empowerment, and a high score (6) indicated greater empowerment within the household. Table 2.5 demonstrates the distribution of women by this index. Interestingly, greater percentages of women scored either 6 (17.4%) or 0 (16.8%). More rural women than urban women scored 0 or 1 (29.0% and 20.5%, respectively). More urban women than rural women scored mid-to-high (2-5) (62.2% and 53.6%, respectively). Table 2.5: Household Decision-Making Index: Scale 0 (Low) to 6 (High), by Selected Characteristics (Percent Distribution) Women in Union Aged 15-49 Years Characteristic Household Decision-Making Score (%) Number of Women0 1 2 3 4 5 6 Total Residence Urban 12.5 8.0 15.3 16.7 13.2 17.0 17.4 100.0 475 Rural 17.7 11.3 13.6 13.8 12.8 13.4 17.3 100.0 2,069 Age group (yr) 15-19 27.1 14.8 13.5 8.4 7.3 6.8 22.1 100.0 146 20-24 19.1 14.1 13.9 12.9 11.3 12.2 16.6 100.0 440 25-29 16.1 13.5 14.7 16.5 13.8 12.2 13.2 100.0 534 30-34 17.2 7.2 16.0 16.0 14.6 13.1 15.9 100.0 437 35-39 14.5 8.7 12.6 16.7 12.5 17.9 17.0 100.0 416 40-44 12.9 7.4 14.3 11.7 14.3 17.3 22.1 100.0 348 45-49 14.1 8.4 9.9 11.8 13.4 19.1 23.3 100.0 223 Education level No education 23.1 12.4 11.8 12.8 11.3 10.9 17.6 100.0 741 Some primary 15.4 11.8 12.7 16.6 13.1 17.3 13.1 100.0 373 Completed primary 14.3 10.0 15.9 14.7 13.8 14.9 16.4 100.0 1,280 Attended secondary or higher 9.2 5.3 11.0 12.2 12.6 14.2 35.4 100.0 150 Total 16.8 10.7 13.9 14.3 12.9 14.0 17.4 100.0 2,544 Source: 2014 Kigoma Reproductive Health Survey. The percentage of women with low scores decreased with increasing age. The greatest percentage of women in the two youngest age groups scored low (0), whereas the greatest percentage of women in the two oldest age groups scored high (6). The percentage of women with low scores (0 or 1) also decreased with rising education level. The percentage of women scoring 6 increased sharply with secondary education or more (attended secondary or higher, 35.4%; all other education levels, 13.1%-17.6%). 18 Chapter 2 Access to Media and Communication To assess exposure to media, respondents were asked how often they listened to the radio or watched television in a typical week. Table 2.6 shows that 33.8% of women of reproductive age listened to the radio almost every day (urban, 39.5%; rural, 33.8%), whereas 33.5% did not listen to the radio at all (urban, 26.7%; rural, 35.2%). The majority (81.7%) did not watch television at all. Owning a mobile phone can increase access to health education and to health care and financial services. One-third (33.4%) of women of reproductive age owned a mobile phone, though this proportion differed by residence (urban, 48.3%; rural, 29.7%). Table 2.6: Media Access and Religious Service Attendance, by Urban vs Rural Residence (Percent Distribution) Women of Reproductive Age (15-49 Years) Characteristic Urban (%) Rural (%) Total (%) Number of Women Listens to radio Almost every day 39.5 32.4 33.8 1,355 At least once a week 24.4 20.6 21.3 812 Less than once a week 9.4 11.8 11.3 436 Not at all 26.7 35.2 33.5 1,313 Watches TV Almost every day 21.0 1.5 5.3 226 At least once a week 11.7 6.7 7.7 291 Less than once a week 5.5 5.3 5.3 204 Not at all 61.8 86.6 81.7 3,195 Personal cell phone ownership Yes 48.3 29.7 33.4 1,352 No 51.7 70.3 66.6 2,564 Religious service attendance At least daily 12.2 12.5 12.4 498 At least weekly 75.3 70.4 71.3 2,785 At least monthly 3.1 4.6 4.3 171 Occasionally 2.4 2.6 2.6 101 None 6.7 9.9 9.3 358 Refused a a a 3 Total 100.0 100.0 100.0 3,916 Source: 2014 Kigoma Reproductive Health Survey. a Fewer than 25 cases. Participation in Religious Services Participation in religious activities outside the home can facilitate information-sharing within communities. Table 2.6 shows that 83.7% of women of reproductive age in Kigoma Region attended religious services at least weekly. Slightly more urban women attended at least daily or weekly (87.5%) than did rural women (82.9%). Only 9.3% did not attend any religious services. 2.3 Characteristics of Births Since January 2009 Mothers’ Characteristics Table 2.7 shows maternal characteristics for births since January 2009. As most selected households were located in rural areas, the majority of births (84.2%) occurred among women residing in rural areas. Fifteen percent of births were to women younger than age 20 at the time of birth (Figure 2.4). Nearly half of births occurred among women who completed only primary education (47.6%), and almost one-third (32.5%) of births occurred among women with no education. Fifteen percent of births during this period occurred among women who completed only up to some primary education, and 4.5% occurred among women who attended secondary school or more. Households, Women, and Births Since January 2009 19 Table 2.7: All Births (Live Births/Stillbirths) Occurring Since January 2009, by Selected Characteristics (Percent Distribution) Births to Women Aged 15-49 Years Since January 2009 Characteristic Urban (%) Rural (%) Total (%) Number of Births Residence Urban 100.0 0.0 15.8 671 Rural 0.0 100.0 84.2 3,450 Mother’s age at birth 15-19 16.2 14.2 14.5 535 20-24 26.7 27.3 27.2 1,062 25-29 25.5 23.1 23.5 960 30-34 17.1 17.4 17.3 746 35-39 10.7 12.9 12.6 586 40-44 3.6 4.8 4.6 217 45-49 0.2 0.4 0.3 15 Education level No education 18.9 35.0 32.5 1,316 Some primary 19.7 14.6 15.4 617 Completed primary 48.1 47.5 47.6 1,999 Attended secondary or higher 13.3 2.9 4.5 189 Wealth tercile Low 22.9 38.8 36.3 1,486 Middle 19.5 38.8 35.7 1,472 High 57.6 22.4 28.0 1,163 Birth order 1 23.9 18.7 19.5 755 2 18.4 15.6 16.1 631 3 17.0 14.7 15.0 604 4 13.9 13.0 13.1 545 5 9.0 10.5 10.3 435 6 6.8 8.9 8.6 372 7 5.0 7.1 6.8 297 8 3.0 5.6 5.2 230 9 2.2 3.1 3.0 136 10+ 0.9 2.7 2.5 116 Year of birth 2009 17.2 16.4 16.5 695 2010 17.7 16.7 16.9 708 2011 14.4 17.2 16.8 697 2012 17.9 17.6 17.6 726 2013 19.6 18.3 18.5 746 2014a 13.2 13.8 13.7 549 Total 100.0 100.0 100.0 4,121 Source: 2014 Kigoma Reproductive Health Survey. a January-September only. 20 Chapter 2 Figure 2.4: Mother’s Age at Time of Birth, All Births (Live Births/Stillbirths) Since January 2009 (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. Birth Order Table 2.8 demonstrates the distribution of births by birth order and characteristics of the mother. Overall, 19.5% of births were first births and nearly half (49.4%) were fourth or higher order births. A high birth order (fourth or higher) was significantly less common among women who attended secondary school or higher (6.4% for women with secondary or higher versus 46.4%-57.1% for women with less education). Table 2.8: Birth Order of All Births (Live Births/Stillbirths) Since January 2009, by Mothers’ Characteristics (Percent Distribution) Births to Women Aged 15-49 Years Since January 2009 Characteristic Birth Order (%) Number of Births1 2 3 4+ Total Residence Urban 23.9 18.4 17.0 40.7 100.0 671 Rural 18.7 15.6 14.7 51.0 100.0 3,450 Education level No education 12.4 14.1 16.4 57.1 100.0 1,316 Some primary 20.5 19.3 13.9 46.4 100.0 617 Completed primary 20.6 15.6 14.7 49.1 100.0 1,999 Attended secondary or higher 56.1 24.1 13.3 6.4 100.0 189 Wealth tercile Low 19.0 16.2 15.0 49.8 100.0 1,486 Middle 17.7 16.1 15.9 50.3 100.0 1,472 High 22.6 15.9 13.9 47.6 100.0 1,163 Total 19.5 16.1 15.0 49.4 100.0 4,121 Source: 2014 Kigoma Reproductive Health Survey. 14.5 27.2 23.5 17.3 12.6 4.6 0.3 0 5 10 15 20 25 30 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Pe rc en t Age (Years) Households, Women, and Births Since January 2009 21 References 1. The United Republic of Tanzania National Bureau of Statistics (NBS), ORC Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: National Bureau of Statistics, ORC Macro; 2011. 2. NBS, Office of Chief Government Statistician. Population Distribution by Age and Sex. Dar es Salaam and Zanzibar, Tanzania: NBS, Office of Chief Government Statistician; 2013. 3. CARE USA. Women’s Empowerment: Multidimensional Evaluation of Agency, Social Capital & Relations (WE– MEASR): a Tool to Measure Women’s Empowerment in Sexual, Reproductive and Maternal Health Programs. Atlanta, GA: CARE USA; 2014, p. 14. 4. CARE USA. Women’s Empowerment: Multidimensional Evaluation of Agency, Social Capital & Relations (WE– MEASR): a Tool to Measure Women’s Empowerment in Sexual, Reproductive and Maternal Health Programs. Atlanta, GA: CARE USA; 2014, pp. 20-22. 22 Chapter 2 Fertility 23 Chapter 3: Fertility Chapter 3 provides an overview of fertility levels and differentials for population subgroups within the Kigoma Region and considers future fertility preferences of reproductive age women. For selected indicators, the Kigoma Region was compared with Tanzania as a whole using data from the 2010 Tanzania Demographic and Health Survey (DHS). Data on fertility were collected in several ways. Each woman interviewed was asked about the number of children who live with her, the number of children who live somewhere else, and the number who were born alive but later died. Together, these answers provide the number of live births each woman ever had. A complete pregnancy history for every woman was then recorded, which included all pregnancies, regardless of outcome (live births, stillbirths, multiple births, miscarriages/abortions, and ectopic pregnancies). For each pregnancy, information was recorded on the outcome, date of outcome, and duration of the pregnancy. For live births, additional information was recorded on sex of the child, whether the child was alive, and age at death for those children who had died. Fertility is conventionally defined in terms of live births per woman, and stillbirths are not included; this convention is used here to calculate fertility levels. There are several tables in this chapter, however, that take into account stillbirths as well as live births. 3.1 Fertility Levels Fertility during a period of time can be measured using age-specific fertility rate (ASFR), the total fertility rate (TFR), and the general fertility rate (GFR). For this report the 3-year period from August 2011 through July 2014 was used to measure recent fertility. Table 3.1 shows the ASFR, TFR, and GFR for this 3-year period in Kigoma Region for the total population of the region and for population subgroups. The ASFRs give the annual number of live births per 1,000 women in each age group during that period. The TFR expresses the average number of births per woman if a group of women conformed to the observed ASFRs over their reproductive age span (15- 49 years). The GFR is defined as the average annual number of births per 1,000 women aged 15-44 years. The Kigoma TFR was 6.7 live births per woman, which was considerably higher than the national TFR of 5.4, based on the 2010 DHS. There were sizable differences in the TFR for the population characteristics considered. Rural women experienced, on average, almost two more births per women than did urban women, and women with no education experienced three more births per woman than did women with at least some secondary education. Considering wealth status, women in the highest tercile of households experienced a TFR of 5.3 births per woman compared with 7.5 and 7.3 for the lowest and middle terciles, respectively. 24 Chapter 3 Table 3.1: Age-Specific Fertility Rates, Total Fertility Rate, and General Fertility Rate—August 2011-July 2014 Women Aged 15-49 Years Age Group TFR Number of Women GFR15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban 105 228 242 192 192 62 6 5.1 808 166 Rural 117 308 308 290 223 129 28 7.0 3,108 221 Education Level None 143 335 326 321 233 140 44 7.7 958 256 Some Primary 148 323 282 265 161 127 40 6.7 627 215 Completed primary 112 308 287 252 228 105 11 6.5 1,926 202 Attended secondary or higher 57 165 212 195 174 108 0 4.6 405 122 Wealth tercile Low 150 358 308 293 218 142 26 7.5 1,235 238 Middle 110 323 313 310 239 134 39 7.3 1,277 228 High 84 211 259 220 197 78 6 5.3 1,404 167 Total – Kigoma 115 293 295 270 218 117 24 6.7 3,916 210 Tanzania 116 260 249 207 161 72 22 5.4 -- 188 Abbreviations: GFR, general fertility rate (annual live births per 1,000 women, 15-44); TFR,total fertility rate (the average number of live births per woman if a group of women conformed to the observed age-specific fertility rates over their reproductive age span). Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. The GFR of 210 births per 1,000 women aged 15-44 years indicates that in 1 year about one-fifth of all reproductive age women had a live birth. This can be compared with the ASFRs, which varied between 22 per 1,000 for women aged 45-49 years and 295 per 1,000 for women aged 25-29 years. With the exceptions of the youngest and oldest age groups, Kigoma Region had notably higher ASFRs than did the country as a whole (Figure 3.1). Figure 3.1: Age-Specific Fertility Rates for Kigoma (2011-2014) and Tanzania (2007-2010) Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. 115 293 295 270 218 117 24 0 50 100 150 200 250 300 350 15-19 20-24 25-29 30-34 35-39 40-44 45-49 A nn ua l B irt hs p er 1 00 0 W om en Age Group Kigoma (2011-2014) Tanzania (2007-2010) 116 260 249 207 161 72 22 Fertility 25 Table 3.2 presents the distribution of all women and of currently married women by the number of children ever born, according to 5-year age groups. In addition, it shows the mean number of children ever born per woman and the mean number of children alive per woman in each age group. Overall, 28.6% of all reproductive age women did not report any live births, and only 6.7% of women currently in union had not had any live births. Among women aged 35-49 years, more than 90% had more than two births during their lifetimes. While just 2.7% of women in all age groups reported 10 or more births, almost one-fifth (17.5%) of women aged 45-49 years had 10 or more. Table 3.2: Number of Children Ever Born (Percent Distribution) All Women Aged 15-49 Years, and Women in Union Aged 15-49 Years Age Group Number of Childen Ever Born (%) Total Number of Women Mean Children Ever Born Mean Children Surviving0 1 2 3 4 5 6 7 8 9 10 or more All Women 15-19 85.9 11.7 1.9 0.4 . . . . . . . 100.0 865 0.17 0.16 20-24 29.4 33.9 22.3 11.5 2.2 0.6 0.2 . . . . 100.0 716 1.26 1.19 25-29 5.9 10.7 21.1 24.1 23.6 12.4 1.4 0.6 0.2 . . 100.0 637 2.96 2.75 30-34 3.1 4.1 6.3 17.2 19.0 21.3 15.9 8.1 2.6 2.2 0.2 100.0 525 4.45 4.05 35-39 3.9 1.5 4.0 7.2 12.0 14.9 18.0 17.7 14.1 3.6 3.2 100.0 487 5.63 5.08 40-44 1.1 1.2 3.2 4.4 5.9 10.3 14.3 18.0 14.0 13.5 14.2 100.0 416 6.89 6.11 45-49 1.7 0.6 2.9 4.6 6.5 10.4 11.3 13.6 15.8 15.0 17.5 100.0 270 7.11 6.02 Total 28.6 12.2 10.1 10.1 9.1 8.2 6.4 5.6 4.2 2.8 2.7 100.0 3,916 3.06 2.76 Women Currently in Union 15-19 45.9 43.3 8.8 2.0 . . . . . . . 100.0 146 0.67 0.62 20-24 11.6 36.5 31.2 16.6 3.2 0.7 0.3 . . . . 100.0 440 1.66 1.58 25-29 3.1 8.6 19.8 26.1 26.0 13.7 1.6 0.8 0.3 . . 100.0 534 3.17 2.95 30-34 1.6 1.7 5.1 15.5 19.5 24.0 17.3 9.4 3.1 2.6 0.2 100.0 437 4.76 4.35 35-39 2.4 1.2 3.4 5.4 10.5 15.4 19.1 18.9 15.9 4.3 3.7 100.0 416 5.93 5.35 40-44 0.3 1.1 2.3 2.5 4.6 9.9 15.0 18.3 15.3 14.6 16.0 100.0 348 7.20 6.42 45-49 2.1 0.8 1.4 3.7 6.8 10.0 10.6 11.7 17.2 15.9 19.7 100.0 223 7.32 6.19 Total 6.7 12.4 12.7 13.1 12.3 11.6 8.9 7.8 6.2 4.1 4.1 100.0 2,544 4.23 3.82 Source: 2014 Kigoma Reproductive Health Survey. The average number of children ever born among 45- to 49-year-olds was 7.1. This is only slightly greater than the TFR of 6.7 derived from recent ASFRs, indicating only a very slight recent decline in fertility for younger cohorts of women. 26 Chapter 3 Figure 3.2 and Table 3.3 illustrate young ages of initiation into sexual activity, entry into marriage, and childbearing. Twenty-nine percent of 15- to 19-year-olds were sexually active, and 14.1% had had at least one birth. By ages 25-29, 98.2% had ever had sex, and 94.1% had ever given birth. Figure 3.2: Women Who Ever Had Sexual Relations, Were Ever Married, or Ever Had a Birth, by Current Age (Percent) Source: 2014 Kigoma Reproductive Health Survey. Table 3.3: Women Who Ever Had Sexual Relations, Ever Were Married, or Ever Had a Birth, by Current Age (Percent) All Women Aged 15-49 Years Age Group Ever Had Sex Ever Married or in Union Ever Had a Birth Number of Women 15-19 29.0 19.1 14.1 865 20-24 84.2 68.8 70.6 716 25-29 98.2 92.9 94.1 637 30-34 99.4 96.1 96.9 525 35-39 99.3 97.2 96.1 487 40-44 99.4 97.4 98.9 416 45-49 100.0 99.3 98.3 270 Total 79.2 72.0 71.4 3,916 Source: 2014 Kigoma Reproductive Health Survey. 0 10 20 30 40 50 60 70 80 90 100 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Pe rc en t Age Group Ever had sex Ever in a union Ever had a birth Fertility 27 Fertility can also be described in terms of the length of time between two births. Research has shown that short birth intervals are associated with subsequent child mortality and poor health status of children. For non-first births that occurred after January 2009 and before the survey in 2014, Table 3.4 shows the percentage of births that occurred within 18, 24, 36, 48, and 60 months of the previous births. Both live births and stillbirths have been included in this analysis. For all of Kigoma Region, 7.4% of births occurred after a very short interval of less than 18 months, and 22.5% occurred less than 24 months after the previous births. A strong relationship exists between mother’s age, child’s birth order, and the length of the interval before the birth. Thirty-five percent of non-first births to women younger than 25 years occurred within 24 months of the previous birth, compared with just 14.8% of births at ages 35-49 (Figure 3.3). Thirty-one percent of second births occurred within 24 months of the previous birth, compared with just 19.5% of sixth or higher order births. There was little difference in the occurrence of short intervals by mother’s education level or household’s wealth. The 2010 Tanzania DHS showed that just 15.6% of births nationally occurred after intervals of less than 24 months, compared with 22.5% in Kigoma Region, again reflecting the higher level of fertility there. Figure 3.3: Births Within 18, 24, 36, 48, and 60 Months of a Previous Birth, by Age of Mother at the Birth, Since January 2009 (Percent) Source: 2014 Kigoma Reproductive Health Survey. 12.4 34.9 80.2 93.8 98.1 5.7 18.5 63.2 83.3 92.0 4.8 14.8 52.6 75.4 86.9 0 20 40 60 80 100 120 <18 months <24 months <36 months <48 months <60 months Pe rc en t Time Since Previous Birth Age at birth < 25 Age at birth 25-34 Age at birth 35-49 28 Chapter 3 Table 3.4: Non-First Births Since January 2009, that Occurred Within 18, 24, 36, 48, and 60 Months After the Previous Birth (Percent)a Non-First Births Since January 2009 Time Since Previous Birth (%) Number of Births<18 Months <24 Months <36 Months <48 Months <60 Months Age at birth < 25 12.4 34.9 80.2 93.8 98.1 887 25-34 5.7 18.5 63.2 83.3 92.0 1,627 35-49 4.8 14.8 52.6 75.4 86.9 809 Birth order 2 11.4 31.0 70.3 85.1 92.5 622 3 6.6 22.1 66.7 84.5 90.8 595 4 7.1 22.3 66.7 86.0 93.4 541 5 5.7 17.7 60.9 83.8 93.0 427 6+ 6.4 19.5 64.1 84.1 93.2 1,138 Residence Urban 7.7 21.4 53.3 74.9 86.4 516 Rural 7.4 22.7 68.1 86.4 93.7 2,807 Education level No education 6.7 24.2 69.0 86.8 93.6 1,143 Some primary 10.6 22.7 63.5 84.6 94.5 494 Completed primary 7.0 21.4 64.6 83.4 91.5 1,604 Attended secondary or higher 7.8 18.3 58.5 77.6 88.2 82 Wealth tercile Low 6.3 21.5 67.9 86.7 94.6 1,198 Middle 8.2 23.4 69.1 86.9 93.3 1,217 High 7.9 22.6 58.7 78.9 89.1 908 Total - Kigoma 7.4 22.5 65.8 84.7 92.6 3,323 Tanzania 4.5 15.6 55.4 75.6 85.8 6,472 Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. a Excludes 755 first births and 43 births missing information on previous interval length. 3.2 Fertility Preferences and Planning Status of Previous Pregnancies Information on fertility preferences provides family planning programs with greater understanding of the potential demand for family planning services. The 2014 Kigoma Reproductive Health Survey included questions about planning status of previous pregnancies, desire to have additional children, preferred waiting time to the next birth, and what women considered the ideal number of children they would like to have. For each live birth or stillbirth since January 2009, survey respondents were asked, “Just before you got pregnant, did you want to get pregnant then, did you want to get pregnant later, or did you not want to get pregnant then or any time in the future?” Table 3.5 and Figure 3.4 show the percent distribution of births since January 2009 by responses to this question. Because of post hoc rationalization of attitudes with behavior, these results should be interpreted with care. The results do, however, provide insight into the extent to which women are able to control their fertility. Fertility 29 Table 3.5: Planning Status of Births (Percent Distribution) All Births Since January 2009 Planning Status of Birth Total Number of Births Wanted Then Wanted Later Wanted No More Not Sure Age at birth < 25 74.8 18.7 5.6 0.9 100.0 1,597 25-34 70.1 23.8 5.1 0.9 100.0 1,706 35-49 67.9 21.2 10.1 0.8 100.0 818 Birth order 1 82.5 9.6 7.2 0.7 100.0 755 2 74.6 20.9 3.7 0.8 100.0 631 3 69.3 26.5 3.4 0.8 100.0 604 4 73.7 20.1 4.8 1.4 100.0 545 5 66.6 27.6 5.5 0.4 100.0 435 6+ 64.1 25.3 9.6 1.1 100.0 1,151 Residence Urban 70.4 20.6 8.2 0.8 100.0 671 Rural 71.9 21.4 5.8 0.9 100.0 3,450 Education level No education 72.9 19.9 6.0 1.3 100.0 1,316 Some primary 71.3 22.1 6.3 0.4 100.0 617 Completed primary 71.8 21.7 5.6 0.8 100.0 1,999 Attended secondary or higher 63.1 23.4 13.5 0.0 100.0 189 Wealth tercile Low 72.8 21.1 5.4 0.7 100.0 1,486 Middle 71.2 22.6 5.5 0.7 100.0 1,472 High 70.8 19.7 8.1 1.4 100.0 1,163 Total - Kigoma 71.7 21.2 6.2 0.9 100.0 4,121 Tanzania 73.6 22.1 3.7 0.6 100.0 9,145 Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. Considering all births during this period of time, 71.7% of women wanted the birth at the time it occurred, 21.2% wanted it later, and just 6.2% did not want it then or later. The results for Kigoma Region were similar to results for all of Tanzania, according to the 2010 DHS (wanted then, 73.6%; wanted later, 22.1%; unwanted, 3.7%). The percentage who wanted no more was greater for women aged 35-49 at the time of the birth (10.1%) than for births before age 25 (5.6%). There was a U-shaped association with birth order; 7.2% of first births were classified as unwanted, compared with just 3.4% of third births and 9.6% of sixth and higher order births. There were no appreciable differences in reported planning status of recent births by area of residence or by wealth status of the household. Women with a secondary or higher level of education were more likely to classify births as not wanted (13.5%) than women with less education (5%-6%). Table 3.6 shows total wanted and total unwanted fertility rates. These were calculated in the same manner as the TFR, which was labelled “observed TFR,” except that the wanted TFR included just those live births classified as “wanted then” or “wanted later.” The unwanted TFR included only live births classified as “wanted no more.” Overall, the wanted TFR was 6.1, or about half a birth less than the observed TFR of 6.7. The discrepancy between the wanted TFR and the observed TFR was greater for women with less education (no education, 0.7 births for women; attended secondary or higher, 0.3). 30 Chapter 3 Figure 3.4: Planning Status of Births Since January 2009, by Birth Order of the Birth (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. Table 3.6: Total Wanted and Unwanted Fertility Rates During August 2011-July 2014 All Women Aged 15-49 Years All Women Aged 15-49 Years Women Aged 40-49 Years Wanted TFR Unwanted TFR Observed TFR Number of Women Mean Number Children Ever Born Number of Women Residence Urban 4.5 0.7 5.1 808 5.9 146 Rural 6.5 0.5 7.0 3,108 7.2 540 Education level None 7.1 0.7 7.7 958 7.1 194 Some Primary 6.2 0.5 6.7 627 7.2 94 Completed primary 6.1 0.5 6.5 1,926 7.0 381 Attended secondary or higher 4.2 0.3 4.6 405 3.6 17 Wealth tercile Low 7.0 0.5 7.5 1,235 7.2 224 Medium 6.8 0.6 7.3 1,277 7.3 219 High 4.7 0.6 5.3 1,404 6.4 243 Total - Kigoma 6.1 0.5 6.7 3,916 7.0 686 Tanzania 4.7 0.7 5.4 -- 6.0 -- Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. 82.5 74.6 69.3 73.7 66.6 64.1 9.6 20.9 26.5 20.1 27.6 25.3 7.2 3.7 3.4 4.8 5.5 9.6 0 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6+ Pe rc en t Birth Order Pregnancy wanted then Pregnancy wanted later No more births wanted Not sure Fertility 31 3.3 Future Fertility Preferences Table 3.7 presents data on future fertility preferences among women currently married or in an informal union. Survey respondents were asked whether they would like to have any more children and, if they did want more, were asked how long they would like to wait until the birth of another child. Pregnant women were asked if they wanted more children after the current pregnancy and how long they would want to wait after the birth of the child they were expecting. The upper panel classifies women by the number of living children and the lower panel classifies them by current age group. While 69.2% of married women said they wanted additional children, only 10.6% wanted the next birth to occur in less than 2 years. Table 3.7: Desire for More Children, by Current Number of Living Children and Woman’s Age (Percent Distribution) Women Aged 15-49 Years, Currently Married or in Union Kigoma Regiona Tanzaniab Number of Living Children Total0 1 2 3 4 5 6 or more Desire for more children More soon (<2 years) 30.1 11.8 11.7 12.2 9.8 8.4 4.5 10.6 21.3 More later 54.7 74.8 69.7 62.5 53.7 49.9 23.2 51.7 43.5 More, unsure when 9.2 8.2 6.3 7 7.9 7.3 5.2 6.9 1.2 No more childrenc 0.6 0.3 4.2 8.6 16.2 21.4 49.1 19.4 30.0 Unable to get pregnant 0.6 0.5 0.6 0.5 1 1.6 3.1 1.4 2.1 God’s will/fate 3.7 3.8 5.7 8.6 9.3 9.4 12.4 8.4 N/A Not sure 1.1 0.6 1.8 0.6 2.1 2.1 2.5 1.7 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 172 316 348 342 356 302 708 2,544 6,412 Age Group Total Tanzaniab 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Desire for more children More soon (<2 years) 17.5 9.2 11.2 9.9 13 9.5 5.8 10.6 21.3 More later 68.2 76 67.4 55.7 36.1 17 10.3 51.7 43.5 More, unsure when 10.7 5.9 7.5 7.6 7.6 6.4 2.5 6.9 1.2 No more childrenc . 1.7 5.3 14 31.3 48.8 59.7 19.4 30.0 Unable to get pregnant . 0.2 0.2 0.4 0.6 3.4 8.8 1.4 2.1 God’s will/fate 1.9 5.6 7 10.2 9.9 13.4 9.8 8.4 N/A Not sure 1.6 1.3 1.5 2.3 1.3 1.5 3 1.7 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 146 440 534 437 416 348 223 2,544 6,412 a 2014 Kigoma Reproductive Health Survey. b 2010 Tanzania Demographic and Health Survey. c Includes sterilized women. Nineteen percent of women stated they wanted no more children, 1.4% said they were unable to get pregnant, and 10.1% were not sure or said it was up to fate or God’s will. Responses varied considerably by the number of living children and age of the woman. While 30.1% of married women with no living children wanted a birth in the next 2 years, only 4.5% of women with six or more living children wanted a birth soon (Figure 3.5). The percentage of women wanting no more children increased from 8.6% among women with three children to 49.1% among those with six or more. Overall, in Tanzania, 71.8% of women with six or more living children want no more children. Similarly, the percentage of women wanting no more children increased with age from 1.7% among those aged 20-24 years to 59.7% among those aged 45-49 years. 32 Chapter 3 Figure 3.5: Women in Union Who Wanted to Wait Less Than 2 Years vs More Than 2 Years Until Next Birth, by Number of Living Children (Percent) Source: 2014 Kigoma Reproductive Health Survey. Table 3.8 details the percentage of women wanting no more children, according to various characteristics (women’s residence, education level, and wealth tercile). The percentage of urban and rural women wanting no more children was the same, but it differed by the number of children that urban and rural women had. Among women with the same number of children, a larger percentage of urban women than rural women wanted no more children. This is reflected in the fact that fewer urban women reach higher parities. Furthermore, a threshold of 20% of women wanting no more children differed according to parity and education level: women with no education reached this threshold when they had six or more children, whereas women with some primary education reached this threshold when they had five or more children. Table 3.8: Women Who Wanted No More Children, by Number of Living Children (Percent) Women Aged 15-49 Years, Currently Married or in Union Number of Living Children Total0 1 2 3 4 5 6 or more Residence Urban 0.0 0.0 4.1 10.5 28.0 33.3 55.9 19.4 Rural 0.7 0.4 4.3 8.0 13.8 19.4 48.1 19.4 Education level No education 0.0 1.5 3.9 6.9 16.1 13.7 48.5 19.2 Some primary 0.0 0.0 4.6 4.3 10.1 24.9 47.9 17.6 Completed primary 1.2 0.0 3.5 10.1 15.9 26.5 49.5 21.1 Attended secondary or higher 0.0 0.0 9.1 a a a a 9.5 Wealth tercile Low 0.0 0.0 3.9 5.6 9.7 16.0 46.3 16.4 Middle 0.0 1.0 3.2 5.2 14.1 17.5 49.2 19.0 High 1.7 0.0 5.7 15.8 25.7 35.4 52.0 23.0 Total - Kigoma 0.6 0.3 4.2 8.6 16.2 21.4 49.1 19.4 Tanzania 0.7 3.4 11.3 22.5 35.4 51.9 71.8 30.0 Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. a Fewer than 25 cases. 30.1 11.8 11.7 12.2 9.8 8.4 4.5 54.7 74.8 69.7 62.5 53.7 49.9 23.2 0.6 0.3 4.2 8.6 16.2 21.4 49.1 0 10 20 30 40 50 60 70 80 0 1 2 3 4 5 6 or more Pe rc en t Number of Living Children Next birth less than 24 months Next birth after 24 months No more children Fertility 33 Women were also asked about their ideal family size. Women without any children were asked how many children they would ultimately like to have; women with living children were asked about the number they would choose if they could start their childbearing over again. Table 3.9 shows the percent distribution of women by their ideal number of children, as well as the percentage of women who already had their ideal family size. Overall, 24.3% of women indicated that their ideal family size consisted of eight or more children. Twenty- one percent responded that it was “up to God” or fate to determine the ideal family size. Six percent of women said their ideal family size was three or fewer children, and only 4.3% felt they had exceeded their ideal number of children. Overall, the average ideal number for Kigoma women was 6.5 children, higher than that of Tanzania as a whole (4.9 children).1 Table 3.9: Ideal Number of Children, Mean Ideal Number, and Percent Who Had More than Ideal Number, by Number of Living Childrena (Percent Distribution) Women Aged 15-49 Years Number of Living Children (%) Total0 1 2 3 4 5 6 7 8 or More Ideal number of children 0 0.5 0.0 0.0 0.0 0.4 0.0 0.0 0.5 1.2 0.3 1 0.3 0.0 0.1 0.1 0.6 0.0 0.5 0.7 0.0 0.2 2 1.7 1.1 1.1 0.0 0.3 0.0 0.0 0.0 0.0 0.8 3 7.3 9.6 4.2 2.5 2.6 1.3 0.7 0.5 0.0 4.7 4 11.9 14.6 10.1 13.2 6.9 1.5 3.5 2.1 3.2 9.5 5 19.8 20.8 23.8 15.8 5.9 8.0 4.8 4.9 6.4 15.4 6 14.0 17.7 15.1 18.1 20.7 11.9 10.5 4.2 3.9 14.3 7 8.0 7.7 7.3 5.1 11.6 10.5 12.5 7.2 4.0 8.2 8 or more 16.5 12.7 19.6 25.9 27.8 38.2 40.9 44.1 42.2 24.3 God’s will/fate 18.0 14.5 17.9 17.9 22.5 27.4 25.6 35.7 38.1 21.0 Not sure 1.9 1.0 0.7 1.2 0.7 1.2 0.7 0.0 1.0 1.2 Other 0.2 0.3 0.0 0.1 0.0 0.0 0.3 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of cases 1,063 486 435 416 409 337 293 235 242 3,916 Mean ideal numberb 5.7 5.6 6.1 6.6 6.9 7.8 7.9 8.6 8.6 6.5 Percent with more than ideal numberb 0.0 0.0 0.2 0.2 5.5 4.6 14.1 19.2 35.0 4.3 Tanzania mean ideal numberc 4.0 4.1 4.4 5.0 5.5 5.9 6.8 4.9 Sources: 2010 Tanzania Demographic and Health Survey, 2014 Kigoma Reproductive Health Survey. a 2014 Kigoma Reproductive Health Survey. b Does not include women with non-numeric responses. c 2010 Tanzania Demographic and Health Survey. The average ideal number of children increased according to women’s actual number of children: women with no children wanted 5.7 children, and women with eight or more children wanted 8.6 children. Less than 5% of women with fewer than six children had exceeded their ideal family size, compared with 35% of women with eight or more children. Table 3.10 provides more information on the average ideal family size, as well as the percentage of women who had exceeded their ideal family size. There is little difference in either indicator according to area of residence or wealth tercile. The average ideal size decreased with educational attainment, however (no education, 7.2 children; attended secondary or higher, 4.7 children). Additionally, the average ideal number of children increased with women’s ages (15-29 years, 6 children; 40-49 years, 8 children). 34 Chapter 3 Table 3.10: Mean Ideal Number of Children and Percentage of All Women Who Have More than Their Ideal Number, by Age All Women Aged 15-49 Years Average Ideal Number of Childrena Percent with More than Ideal Numbera Age Group Total Age Group Total 15-29 30-39 40-49 15-29 30-39 40-49 Residence Urban 5.3 6.4 6.9 5.7 0.5 4.3 16.2 3.2 Rural 6.2 7.3 8.3 6.7 0.7 7.8 16.4 4.6 Education level No education 6.9 7.3 8.2 7.2 1.4 11.4 15.7 6.7 Some primary 6.4 7.4 8.4 6.8 0.3 3.4 12.4 2.3 Completed primary 5.9 7.2 7.9 6.6 0.7 6.1 18.2 4.7 Attended secondary or higher 4.7 4.6 4.7 4.7 0.0 3.6 6.6 0.5 Wealth tercile Low 6.5 7.7 8.3 7.0 0.3 6.7 16.8 4.1 Middle 6.2 7.3 8.3 6.7 1.0 9.3 17.7 5.1 High 5.4 6.5 7.4 5.9 0.7 5.5 14.8 3.7 Total 6.0 7.1 8.0 6.5 0.7 7.1 16.4 4.3 Source: 2014 Kigoma Reproductive Health Survey. a Does not include women with non-numeric responses. In summary, the indicators on planned status of births and ideal numbers of children showed a general agreement between fertility desires and fertility levels. Only 4.3% of women exceeded their ideal number of children. Discrepancies between past behavior and reported preferences occurred only for women who had six or more children. Twenty-one percent of past births were classified as wanted later, and just 6.2% of births were not wanted at all. This could be contrasted with responses to questions about current fertility desires of married women: 19.4% of married women stated they wanted no more children, and 51.7% indicated that they did want more children but preferred to wait at least 2 years before the next birth. In general, women in Kigoma Region have very high actual and desired fertility, with no indication of strong desires to reduce fertility significantly. However, there was some evidence of desire to increase spacing between births. Chapter 4 addresses the use of contraception to avoid and delay pregnancy. It also includes an analysis of unmet demand for contraception that combines information about contraceptive use with questions about current fertility desires. Reference 1. The United Republic of Tanzania National Bureau of Statistics, ORC Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: National Bureau of Statistics, ORC Macro; 2011. Family Planning 35 Chapter 4: Family planning Contraceptive use has important and direct control over fertility levels, and using contraception to limit, delay, or space births can have positive effects on the health of both women and children. 4.1 Contraceptive Knowledge Lack of knowledge about modern methods of contraception is a significant barrier to using family planning services. Women who are not aware of modern contraceptive methods may not know where to obtain them, may not understand how to use them correctly, and are more likely to have an unmet need for family planning than those who have been exposed to this information. Modern contraceptive methods include the long-acting methods of the intrauterine device (IUD), hormonal implants, and sterilization; shorter acting methods such as injectable and oral contraceptives; and barrier methods such as the condom and the diaphragm. The 2014 Kigoma Reproductive Health Survey (RHS) asked women whether they had heard of 14 specific methods of contraception. Table 4.1 shows that women of reproductive age in Kigoma appeared to be well aware of family planning; virtually all women (96.3%) had heard of at least one modern method of contraception, though fewer (51.1%) were aware of at least one traditional method. The best known methods were oral contraceptives (91.9%), hormonal injectables (91.3%), and male condoms (89.1%). Contraceptive implants were known of by 82.1% of women, while about two-thirds of women were familiar with IUDs (69.2%), female sterilization/tubal ligation (67.4%), and female condoms (63.3%). About half the respondents had heard of male sterilization/vasectomy, but few knew of the diaphragm, contraceptive foam or jelly, lactational amenorrhea, or emergency contraception. Of the traditional methods, the best known was the rhythm/calendar method (41.7%). Less than a third know of withdrawal (31.8%). As might be expected, familiarity with each method was greater among women who were in union, but even women not in union had substantial knowledge of many methods. There was still a sizeable gap, however, in knowledge about long-acting reversible methods of contraception; only about half of women who were not in union had heard of the IUD. Emergency contraception was virtually unknown. Contraceptive knowledge increased with wealth, but the differences were generally small. For injectables and implants, women in the lowest wealth tercile were nearly as knowledgeable as were those in the highest. The greatest gap between the lowest and highest wealth tercile was for the rhythm or calendar method; 53.4% of women in the highest wealth tercile knew of it, compared with 30.6% of those in the lowest. Although knowledge of contraception was widespread in Kigoma Region, knowledge of most contraceptive methods was slightly lower there than it was nationally (according to the 2010 Tanzania Demographic and Health Survey [DHS]). The exceptions to this were the implant, which was as well known in Kigoma Region as it was elsewhere, and vasectomy, which was known of by almost half of women in Kigoma but by only about a third of women nationally. 36 Chapter 4 Ta bl e 4. 1: K no w le dg e of C on tra ce pt iv e M et ho ds , b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) Al l W om en A ge d 15 -4 9 Ye ar s Kn ow le dg e of Co nt ra ce pt iv e M et ho ds Co nt ra ce pt iv e M et ho ds Nu m be r o f W om en Modern Traditional Any Tubal Ligation Vasectomy IUD Injectable Implant Pill Male Condom Female Condom Diaphragm Foam or Jelly LAM Rhythm, Calendar, BOM Withdrawal Emergency Contraception Other Re si de nc e Ur ba n 96 .3 58 .1 96 .3 69 .2 50 .8 73 .0 92 .4 83 .0 91 .5 92 .1 74 .8 16 .6 8. 7 17 .2 50 .7 37 .1 6. 2 1. 7 80 8 Ru ra l 95 .9 49 .4 96 .2 67 .0 48 .2 68 .3 91 .0 81 .8 92 .0 88 .3 60 .5 14 .1 7. 0 16 .2 39 .5 30 .6 3. 8 1. 7 3, 10 8 Cu rr en t u ni on s ta tu s In u ni on 97 .9 55 .4 98 .1 75 .0 57 .3 79 .1 96 .1 89 .5 95 .9 91 .0 66 .6 18 .2 8. 7 18 .7 43 .3 37 .7 4. 7 1. 8 2, 54 4 No t i n un io n 92 .7 43 .6 93 .0 54 .1 33 .6 51 .9 83 .0 68 .9 84 .8 85 .8 57 .4 8. 4 4. 9 12 .5 38 .9 21 .5 3. 5 1. 5 1, 37 2 Ed uc at io n le ve l No e du ca tio n 95 .1 41 .7 95 .4 64 .7 46 .0 67 .8 90 .4 82 .0 91 .4 85 .9 54 .3 10 .6 4. 2 12 .2 30 .2 27 .3 2. 3 1. 2 95 8 So m e pr im ar y 92 .5 41 .4 93 .3 59 .6 39 .2 60 .0 86 .3 75 .0 87 .2 84 .1 55 .9 11 .2 6. 2 13 .8 31 .5 26 .6 3. 3 1. 6 62 7 Co m pl et ed p rim ar y 97 .5 54 .4 97 .6 71 .4 53 .1 72 .4 93 .5 84 .8 93 .6 91 .6 66 .9 16 .9 8. 3 18 .0 44 .9 34 .3 4. 6 1. 7 1, 92 6 At te nd ed s ec on da ry o r hi gh er 96 .5 73 .9 96 .9 68 .0 49 .8 72 .8 90 .9 80 .7 92 .7 93 .2 80 .1 19 .2 12 .0 23 .2 71 .2 39 .8 8. 9 3. 1 40 5 W ea lth te rc ile Lo w 95 .0 40 .4 95 .4 64 .3 44 .7 64 .3 89 .8 80 .6 90 .9 85 .6 56 .3 12 .8 6. 0 14 .1 30 .6 24 .2 2. 4 1. 2 1, 23 5 M id dl e 96 .1 51 .0 96 .5 67 .0 49 .9 69 .3 91 .8 82 .1 92 .3 89 .3 63 .5 13 .6 6. 8 15 .1 39 .6 33 .4 4. 3 1. 6 1, 27 7 Hi gh 96 .8 60 .8 96 .8 70 .6 51 .2 73 .7 92 .2 83 .4 92 .4 92 .1 69 .5 17 .3 9. 0 19 .7 53 .8 37 .3 5. 9 2. 2 1, 40 4 To ta l 96 .0 51 .1 96 .3 67 .4 48 .7 69 .2 91 .3 82 .1 91 .9 89 .1 63 .3 14 .6 7. 3 16 .4 41 .7 31 .8 4. 3 1. 7 3, 91 6 Ta nz an ia 97 .9 67 .1 98 .0 83 .4 37 .2 72 .5 94 .5 81 .8 96 .1 94 .5 72 .5 8. 3 9. 3 32 .8 54 .3 49 .9 11 .8 11 .3 10 ,1 39 Ab br ev iat io ns : B OM , B ill in gs O vu lat io n M eth od ; D HS -2 01 0, 2 01 0 Ta nz an ia De m og ra ph ic an d He alt h Su rv ey ; I UD , i nt ra ut er in e d ev ice ; L AM , l ac tat io na l a m en or rh ea m eth od . So ur ce s: 20 14 K ig om a R ep ro du cti ve H ea lth S ur ve y, DH S- 20 10 . No te: Tr ad iti on al m eth od s i nc lu de rh yth m /c ale nd ar /B OM , w ith dr aw al, an d ot he r. M od er n m eth od s i nc lu de th e r em ain in g m eth od s l ist ed . Family Planning 37 4.2 Ever Use of Contraception For the RHS, if a woman responded that she had heard of a particular contraceptive method, she was asked whether she had ever used it. Figure 4.1 and Table 4.2 shows that although almost all women had heard of modern contraceptive methods, only 28.6% of all women in Kigoma had ever used one. Ever use of a contraceptive method was quite low for each method except the injectable, which has been used by a fifth of women (20.3%). The second most popular method, oral contraception (pill), has been used by only 6.9%, and male condoms by 5.4%. Although more than two-thirds of women had heard of the IUD, fewer than 1% had ever used one (0.6%); similarly, tubal ligation was little used (1.5%). Implants have been used by 2.9% of women. Among traditional methods, relatively few women had ever used rhythm (4.7%) or withdrawal (5.5%). Figure 4.1: Knowledge and Ever Use of Methods of Contraception Amoung All Women Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. 41.7 31.8 69.2 67.4 82.1 89.1 91.9 91.3 96.0 96.3 4.7 5.5 0.6 1.5 2.9 5.4 6.9 20.3 28.6 33.0 0.0 20.0 40.0 60.0 80.0 100.0 Rhythm/calendar Withdrawal IUD Tubal ligation Implant Male condom Oral contraceptive Injectable Any modern method Any method Percent Ever use Knowledge 38 Chapter 4 Ta bl e 4. 2: E ve r U se o f C on tra ce pt iv e M et ho ds , b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) Al l W om en A ge d 15 -4 9 Ye ar s Ev er U se o f Co nt ra ce pt iv e M et ho ds (% ) Ev er U se o f C on tra ce pt iv e M et ho ds b y M et ho d (% ) Nu m be r of W om en Modern Traditional Any Tubal Ligation Vasectomy IUD Injectable Implant Pill Male Condom Female Condom Diaphragm Foam or Jelly LAM Rhythm, Calendar, BOM Withdrawal Emergency Contraception Other Re si de nc e Ur ba n 37 .2 11 .3 41 .3 2. 0 0. 1 0. 7 24 .3 5. 7 10 .3 10 .4 0. 6 0. 0 0. 0 1. 0 7. 5 5. 9 0. 0 0. 2 80 8 Ru ra l 26 .5 8. 2 31 .0 1. 4 0. 0 0. 6 19 .3 2. 2 6. 1 4. 2 0. 2 0. 0 0. 0 0. 2 4. 0 5. 4 0. 1 0. 1 3, 10 8 Cu rr en t u ni on s ta tu s In u ni on 36 .0 11 .8 42 .3 2. 1 0. 1 0. 8 26 .7 3. 5 8. 9 5. 1 0. 3 0. 1 0. 0 0. 5 6. 2 7. 5 0. 1 0. 2 2, 54 4 No t i n un io n 15 .6 3. 6 16 .8 0. 4 0. 0 0. 3 9. 0 1. 8 3. 4 5. 9 0. 2 0. 0 0. 0 0. 2 2. 0 2. 1 0. 1 0. 1 1, 37 2 Ed uc at io n le ve l No e du ca tio n 25 .4 4. 2 28 .2 1. 6 0. 0 0. 4 19 .0 2. 4 3. 8 2. 2 0. 3 0. 0 0. 0 0. 1 1. 0 3. 7 0. 0 0. 1 95 8 So m e pr im ar y 26 .3 6. 2 29 .8 1. 2 0. 0 0. 5 19 .0 2. 1 7. 2 4. 3 0. 4 0. 1 0. 0 0. 2 2. 3 5. 1 0. 0 0. 2 62 7 Co m pl et ed p rim ar y 31 .1 10 .3 36 .6 1. 7 0. 1 0. 6 22 .7 3. 1 8. 6 5. 7 0. 2 0. 0 0. 0 0. 3 5. 6 6. 2 0. 1 0. 1 1, 92 6 At te nd ed s ec on da ry or h ig he r 28 .3 16 .8 33 .2 0. 8 0. 0 0. 9 14 .0 4. 0 6. 0 13 .7 0. 3 0. 0 0. 0 1. 5 13 .4 7. 4 0. 3 0. 2 40 5 W ea lth te rc ile Lo w 23 .7 4. 9 26 .3 0. 9 0. 0 0. 4 16 .7 2. 0 4. 5 3. 9 0. 3 0. 1 0. 0 0. 1 1. 5 3. 7 0. 0 0. 1 1, 23 5 M id dl e 27 .7 8. 8 33 .3 1. 2 0. 1 0. 3 20 .8 2. 6 6. 0 4. 0 0. 3 0. 0 0. 0 0. 2 3. 6 6. 8 0. 1 0. 1 1, 27 7 Hi gh 33 .9 12 .2 38 .9 2. 3 0. 0 1. 0 23 .0 3. 9 10 .0 8. 1 0. 3 0. 0 0. 0 0. 8 8. 6 6. 0 0. 2 0. 2 1, 40 4 To ta l 28 .6 8. 8 33 .0 1. 5 0. 0 0. 6 20 .3 2. 9 6. 9 5. 4 0. 3 0. 0 0. 0 0. 4 4. 7 5. 5 0. 1 0. 1 3, 91 6 Ab br ev iat io ns : B OM , B ill in gs O vu lat io n M eth od ; I UD , i nt ra ut er in e d ev ice ; L AM , l ac tat io na l a m en or rh ea m eth od . So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. No te: Tr ad iti on al m eth od s i nc lu de rh yth m /c ale nd ar /B OM , w ith dr aw al, an d ot he r. M od er n m eth od s i nc lu de th e r em ain in g m eth od s l ist ed . Family Planning 39 Rates of ever use of contraception were higher among women in union for all methods except the male condom, where use was slightly higher among women not in union. Ever use of a modern method was higher in urban areas (37.2%) than in rural areas (26.5%), even for the injectable (urban, 24.3%; rural, 19.3%). Use of implants, IUDs, and male condoms increased with education level. For pills and injectables, use rose with education and then dropped among those with secondary education, especially for the injectable. Considerably more women with any secondary education had used male condoms and the rhythm method than had women with less education. For all methods, both modern and traditional, ever use increased with wealth. The difference was greatest for the rhythm method (highest wealth tercile, 8.6%; lowest, 1.5%). The proportion of all women in Kigoma who had ever used contraception was smaller than the nationwide ever use rates from the 2010 DHS, especially for the pill and condom. Injectable ever use, however, was as high in Kigoma as it was in the nation as a whole. 4.3 Current Use of Contraception The level of current use of contraceptive methods, especially for women in union, is one of the most important indicators used to assess the success of family planning program activities, and is one of the key determinants of control over fertility. Current contraceptive use among all women in Kigoma was very low, at only 15.5% of women (modern, 12.1%; traditional, 3.4%) (Figure 4.2, Table 4.3). Figure 4.2: Current Use of Contraception, by Method Type and Union Status, Among Women Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. 15.5 20.6 6.4 12.1 15.6 5.9 3.4 5.0 0.5 0 5 10 15 20 25 All Women Women in Union Women Not in Union Pe rc en t Any method Modern methods Traditional methods 40 Chapter 4 Ta bl e 4. 3: C ur re nt U se o f C on tra ce pt iv e Ty pe o f M et ho ds , b y Ty pe o f M et ho d an d Se le ct ed C ha ra ct er is tic s (P er ce nt D is tri bu tio n) Al l W om en A ge d 15 -4 9 Ye ar s Ch ar ac te ris tic Cu rr en t C on tra ce pt iv e Us e (% ) Cu rr en t U se o f C on tra ce pt iv e M et ho ds b y M et ho d (% ) To ta l Nu m be r o f W om en Modern Traditional Any Female Sterilization, Tubal Ligation Male Sterilization, Vasectomy IUD Injectables Implant Pill Male Condom LAM Rhythm, Calendar, BOM Withdrawal Other Traditional Method Currently Not Using Re si de nc e Ur ba n 16 .3 4. 0 20 .3 2. 0 0. 1 0. 3 8. 0 3. 1 1. 7 1. 1 0. 0 2. 6 1. 4 0. 1 79 .7 10 0. 0 80 8 Ru ra l 11 .1 3. 2 14 .3 1. 4 0. 0 0. 2 6. 6 1. 2 0. 8 0. 8 0. 0 1. 3 1. 9 0. 0 85 .7 10 0. 0 31 08 Ag e gr ou p (y r) 15 -1 9 2. 5 0. 8 3. 4 0. 0 0. 0 0. 0 1. 3 0. 3 0. 1 0. 8 0. 0 0. 6 0. 2 0. 0 96 .6 10 0. 0 86 5 20 -2 4 13 .2 4. 0 17 .1 0. 1 0. 0 0. 2 8. 1 2. 2 1. 1 1. 3 0. 1 1. 3 2. 7 0. 0 82 .9 10 0. 0 71 6 25 -2 9 13 .8 6. 3 20 .1 0. 6 0. 0 0. 0 8. 0 3. 2 1. 2 0. 8 0. 0 2. 7 3. 6 0. 0 79 .9 10 0. 0 63 7 30 -3 4 19 .7 2. 6 22 .3 1. 0 0. 0 0. 5 13 .2 2. 5 1. 6 0. 9 0. 0 1. 0 1. 6 0. 0 77 .7 10 0. 0 52 5 35 -3 9 17 .5 4. 3 21 .8 2. 2 0. 3 0. 6 10 .2 1. 2 1. 7 1. 2 0. 0 2. 5 1. 8 0. 0 78 .2 10 0. 0 48 7 40 -4 4 17 .2 4. 5 21 .7 6. 8 0. 0 0. 5 7. 1 1. 3 0. 9 0. 6 0. 0 2. 8 1. 4 0. 3 78 .3 10 0. 0 41 6 45 -4 9 8. 3 1. 8 10 .1 6. 0 0. 2 0. 0 1. 6 0. 0 0. 5 0. 0 0. 0 0. 9 0. 9 0. 0 89 .9 10 0. 0 27 0 Ed uc at io n le ve l No e du ca tio n 10 .8 1. 6 12 .4 1. 6 0. 0 0. 2 6. 7 1. 4 0. 4 0. 5 0. 0 0. 4 1. 1 0. 1 87 .6 10 0. 0 95 8 So m e pr im ar y 11 .1 2. 7 13 .7 1. 2 0. 0 0. 3 5. 6 1. 3 1. 4 1. 3 0. 0 0. 7 1. 9 0. 1 86 .3 10 0. 0 62 7 Co m pl et ed p rim ar y 13 .2 4. 2 17 .3 1. 7 0. 1 0. 2 8. 0 1. 6 0. 9 0. 6 0. 0 1. 8 2. 3 0. 0 82 .7 10 0. 0 1, 92 6 At te nd ed s ec on da ry o r h ig he r 11 .6 5. 0 16 .6 0. 8 0. 0 0. 3 3. 9 2. 4 1. 8 2. 4 0. 0 4. 4 0. 6 0. 0 83 .4 10 0. 0 40 5 W ea lth te rc ile Lo w 9. 9 2. 2 12 .0 0. 9 0. 0 0. 3 6. 3 1. 1 0. 5 0. 8 0. 1 0. 8 1. 3 0. 0 88 .0 10 0. 0 1, 23 5 M id dl e 12 .3 3. 4 15 .8 1. 2 0. 1 0. 0 7. 4 1. 6 1. 0 1. 0 0. 0 1. 2 2. 3 0. 0 84 .2 10 0. 0 1, 27 7 Hi gh 13 .9 4. 4 18 .3 2. 3 0. 0 0. 4 6. 8 2. 1 1. 4 0. 9 0. 0 2. 6 1. 7 0. 0 81 .7 10 0. 0 1, 40 4 To ta l 12 .1 3. 4 15 .5 1. 5 0. 0 0. 2 6. 9 1. 6 1. 0 0. 9 0. 0 1. 6 1. 8 0. 0 84 .5 10 0. 0 3, 91 6 Ab br ev iat io ns : B OM , B ill in gs O vu lat io n M eth od ; I UD , i nt ra ut er in e d ev ice ; L AM , l ac tat io na l a m en or rh ea m eth od . So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. No te: Tr ad iti on al m eth od s i nc lu de rh yth m /c ale nd ar /B OM , w ith dr aw al, an d ot he r. M od er n m eth od s i nc lu de th e r em ain in g m eth od s l ist ed . Family Planning 41 All Women Among all women of reproductive age in Kigoma, injectable contraception was the most widely used method (6.9%), with each of the other modern methods being used by fewer than 2% of women (Figure 4.3, Table 4.3). Current use of any contraceptive method was higher in urban areas (20.3%) than in rural areas (14.3%). Additionally, current use increased with age until it peaked at ages 30-34 (22.3%) and declined in older women. Any current contraceptive use increased with wealth. Figure 4.3: Current Use of Specific Methods of Contraception Among All Kigoma Women Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. Women in Union Current contraceptive use among women in union was low (20.6% [modern, 15.6%; traditional, 5.0%]) (Table 4.4). As among all women (Figure 4.4), the most popular method was the injectable, which was used by 8.9% of women in union. No other method was used by more than 3% of women in union. The second most popular modern method among women in union was tubal ligation (2.1%), which was favored by women over the age of 40. The highly effective reversible methods were used by very few women (implant, 1.8%; IUD, 0.3%). The traditional methods of withdrawal (2.8%) and rhythm (2.2%) were used by more women than was any modern method except the injectable. 6.9 1.5 1.6 1.0 0.9 0.2 0.0 1.8 1.6 0 1 2 3 4 5 6 7 8 Inj ec tab le Tu ba l li ga tio n Im pla nt Pil l Ma le co nd om IU D Va se cto my W ith dra wa l Rh yth m Pe rc en t Method 42 Chapter 4 Ta bl e 4. 4: C ur re nt U se o f C on tra ce pt iv e M et ho ds , b y Ty pe o f M et ho d an d Se le ct ed C ha ra ct er is tic s (P er ce nt D is tri bu tio n) W om en in U ni on A ge d 15 -4 9 Ye ar s Ch ar ac te ris tic Cu rr en t C on tra ce pt iv e Us e (% ) Cu rr en t U se o f C on tra ce pt iv e M et ho ds b y M et ho d (% ) To ta l Nu m be r o f W om en Modern Traditional Any Female Sterilization, Tubal Ligation Male Sterilization, Vasectomy IUD Injectables Implant Pill Male Condom LAM Rhythm, Calendar, BOM Withdrawal Other Traditional Method Currently Not Using Re si de nc e Ur ba n 23 .2 6. 5 29 .6 3. 3 0. 1 0. 6 11 .8 3. 4 2. 5 1. 4 0. 0 4. 0 2. 4 0. 1 70 .4 10 0. 0 47 5 Ru ra l 14 .0 4. 7 18 .7 1. 8 0. 1 0. 3 8. 3 1. 5 1. 2 0. 8 0. 0 1. 8 2. 9 0. 0 81 .3 10 0. 0 2, 06 9 Ag e gr ou p (y r) 15 -1 9 5. 2 2. 3 7. 5 0. 0 0. 0 0. 0 4. 3 0. 0 0. 4 0. 4 0. 0 1. 1 1. 2 0. 0 92 .5 10 0. 0 14 6 20 -2 4 14 .7 6. 2 20 .9 0. 2 0. 0 0. 4 9. 4 1. 7 1. 5 1. 3 0. 2 1. 9 4. 3 0. 0 79 .1 10 0. 0 44 0 25 -2 9 13 .8 7. 1 20 .9 0. 7 0. 0 0. 0 7. 3 3. 5 1. 5 0. 7 0. 0 2. 9 4. 3 0. 0 79 .1 10 0. 0 53 4 30 -3 4 20 .5 3. 2 23 .7 1. 2 0. 0 0. 5 13 .9 2. 3 1. 6 1. 0 0. 0 1. 2 2. 0 0. 0 76 .3 10 0. 0 43 7 35 -3 9 19 .6 5. 0 24 .6 2. 5 0. 4 0. 7 11 .6 1. 0 2. 0 1. 4 0. 0 2. 9 2. 1 0. 0 75 .4 10 0. 0 41 6 40 -4 4 19 .0 5. 4 24 .4 7. 2 0. 0 0. 5 8. 2 1. 6 1. 1 0. 5 0. 0 3. 3 1. 7 0. 4 75 .6 10 0. 0 34 8 45 -4 9 8. 4 2. 2 10 .5 5. 7 0. 2 0. 0 1. 9 0. 0 0. 6 0. 0 0. 0 1. 1 1. 1 0. 0 89 .5 10 0. 0 22 3 Ed uc at io n le ve l No e du ca tio n 11 .8 2. 1 13 .9 2. 0 0. 0 0. 3 6. 9 1. 5 0. 5 0. 6 0. 0 0. 6 1. 4 0. 1 86 .1 10 0. 0 74 1 So m e pr im ar y 14 .3 4. 6 18 .9 1. 9 0. 0 0. 4 7. 3 1. 4 2. 1 1. 2 0. 0 1. 1 3. 3 0. 1 81 .1 10 0. 0 37 3 Co m pl et ed p rim ar y 17 .2 6. 0 23 .2 2. 2 0. 2 0. 3 10 .7 1. 9 1. 3 0. 5 0. 1 2. 5 3. 6 0. 0 76 .8 10 0. 0 1, 28 0 At te nd ed s ec on da ry o r h ig he r 25 .8 12 .4 38 .3 2. 1 0. 0 1. 0 8. 8 4. 2 4. 7 5. 0 0. 0 10 .7 1. 7 0. 0 61 .7 10 0. 0 15 0 W ea lth te rc ile Lo w 12 .5 3. 0 15 .5 1. 1 0. 0 0. 4 8. 1 1. 3 0. 7 0. 9 0. 1 1. 0 1. 9 0. 1 84 .5 10 0. 0 1, 23 5 M id dl e 14 .9 5. 0 19 .9 1. 7 0. 2 0. 0 8. 8 1. 8 1. 4 1. 0 0. 0 1. 6 3. 4 0. 0 80 .1 10 0. 0 1, 27 7 Hi gh 19 .8 7. 3 27 .0 3. 6 0. 1 0. 6 10 .0 2. 4 2. 2 0. 9 0. 0 4. 1 3. 1 0. 1 73 .0 10 0. 0 1, 40 4 To ta l 15 .6 5. 0 20 .6 2. 1 0. 1 0. 3 8. 9 1. 8 1. 4 0. 9 0. 0 2. 2 2. 8 0. 0 79 .4 10 0. 0 2, 54 4 Ta nz an ia ( DH S- 20 10 ) 27 .4 7. 0 34 .4 3. 5 N/ A 0. 6 10 .6 2. 3 6. 7 2. 3 1. 3 3. 1 2. 9 0. 9 65 .6 10 0. 0 6, 41 2 Ab br ev iat io ns : B OM , B ill in gs O vu lat io n M eth od ; D HS -2 01 0, 2 01 0 Ta nz an ia De m og ra ph ic an d He alt h Su rv ey ; I UD , i nt ra ut er in e d ev ice ; L AM , l ac tat io na l a m en or rh ea m eth od . So ur ce s: 20 14 K ig om a R ep ro du cti ve H ea lth S ur ve y, DH S- 20 10 . No te: Tr ad iti on al m eth od s i nc lu de rh yth m /c ale nd ar /B OM , w ith dr aw al, an d ot he r. M od er n m eth od s i nc lu de th e r em ain in g m eth od s l ist ed . Family Planning 43 Figure 4.4: Current Use of Specific Methods of Contraception Among Women in Union, Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. Among women in union, use of most methods increased with age, peaking among women aged 30–39 years and decreasing in older women. Overall, modern method use remained low, particularly for the long-acting reversible methods; more women were using the traditional (and less effective) methods of withdrawal and rhythm than were using IUDs, implants, or tubal ligation. A larger percentage of urban women than rural women used all methods except withdrawal, and use also rose with education level (Figure 4.5). Figure 4.5: Current Use of Contraception by Residence and Education Level Among Women in Union, Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. Sexually Active Women Not in Union A larger percentage of sexually active women who were not in union used contraception (any method, 35.3%; modern, 30.6%) than did women in union (Table 4.5). Similar to women in union, injectables were the most popular method for this group (13.7%). However, use of the male condom was considerably higher (7.7%) than it was among women in union (0.9%). Eight percent of women not in union also used the implant, but oral contraception was rarely used (0.8%). 8.9 2.1 1.8 1.4 0.9 0.3 0.1 2.8 2.2 0 1 2 3 4 5 6 7 8 9 10 Inj ec tab le Tu ba l li ga tio n Im pla nt Pil l Ma le co nd om IU D Va se cto my W ith dra wa l Rh yth m Pe rc en t Method 29.6 18.7 13.9 18.9 23.2 38.3 23.2 14.0 11.8 14.3 17.2 25.8 6.5 4.7 2.1 4.6 6.0 12.4 0 5 10 15 20 25 30 35 40 45 Urban Rural None Some primary Completed primary Attended secondary school or higher Pe rc en t Any Modern Traditional 44 Chapter 4 Ta bl e 4. 5: C ur re nt U se o f C on tra ce pt iv e M et ho ds , b y Ty pe o f M et ho d an d by S el ec te d Ch ar ac te ris tic s (P er ce nt D is trr ib ut io n) Se xu al ly A ct iv e W om en A ge d 15 -4 9 Ye ar s No t i n Un io n Cu rr en t C on tra ce pt iv e Us e (% ) Cu rr en t U se o f C on tra ce pt iv e M et ho ds b y M et ho d (% ) Nu m be r of W om en M od er n Tr ad iti on al An y Fe m al e St er ili za tio n, Tu ba l L ig at io n IU D In je ct ab le Im pl an t Pi ll M al e Co nd om Rh yt hm , Ca le nd ar , BO M Cu rr en tly No t U si ng To ta l Re si de nc e Ur ba n 31 .2 5. 0 36 .2 1. 2 0. 0 12 .1 12 .6 0. 0 5. 3 5. 0 63 .8 10 0. 0 45 Ru ra l 30 .4 4. 5 34 .8 0. 0 0. 5 14 .4 5. 6 1. 1 8. 8 4. 5 65 .2 10 0. 0 10 2 Ag e gr ou p (y r) 15 -2 4 34 .4 6. 6 40 .9 0. 0 0. 0 0. 0 10 .9 0. 0 12 .5 6. 6 59 .1 10 0. 0 68 25 -3 4 33 .5 3. 8 37 .3 0. 0 0. 0 23 .4 5. 4 2. 3 2. 5 3. 8 62 .7 10 0. 0 51 35 -4 9 12 .3 0. 0 12 .3 2. 4 2. 1 2. 6 2. 6 0. 0 2. 5 0. 0 87 .7 10 0. 0 28 W ea lth te rc ile Lo w 24 .3 4. 0 28 .3 0. 0 0. 0 17 .9 1. 5 0. 0 4. 9 4. 0 71 .7 10 0. 0 41 M id dl e 42 .4 3. 3 45 .7 0. 0 0. 0 22 .1 7. 0 2. 8 10 .6 3. 3 54 .3 10 0. 0 35 Hi gh 27 .4 5. 8 33 .2 0. 8 0. 7 6. 3 12 .0 0. 0 7. 6 5. 8 66 .8 10 0. 0 71 To ta l 30 .6 4. 6 35 .3 0. 4 0. 3 13 .7 7. 8 0. 8 7. 7 4. 6 64 .7 10 0. 0 14 7 Ab br ev iat io ns : B OM , B ill in gs O vu lat io n M eth od ; I UD , i nt ra ut er in e d ev ice . So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. No te: Tr ad iti on al m eth od s i nc lu de rh yth m /c ale nd ar /B OM , w ith dr aw al, an d ot he r. M od er n m eth od s i nc lu de th e r em ain in g m eth od s l ist ed . Family Planning 45 4.4 Number of Living Children at First Use of Contraception Few women in Kigoma use contraception to delay their first birth; they appear to be more inclined to use it to space births. Among women who had ever used a method to control their fertility, only 8.2% used contraception before giving birth to their first child (Table 4.6, Figure 4.6). First-time contraceptive use was highest after the first birth; 31.7% of users began their contraceptive use when they had one living child. An additional one-fifth of women (20.2%) began contraceptive use when they had two children. Thus, the majority (60.1%) of women who had ever used contraception began their use before they had three children. Table 4.6: Number of Living Children at First Use of Contraception, by Selected Characteristics (Percent Distribution) Women Aged 15-49 Years Who Have Ever Used Contraception Characteristic Number of Living Children at First Contraceptive Use (%) Total Number of Women0 1 2 3 4 5 6+ Does Not Remember Residence Urban 12.9 35.4 19.9 14.9 8.0 2.5 5.6 0.8 100.0 331 Rural 6.7 30.5 20.3 14.3 10.7 6.8 10.4 0.2 100.0 1,005 Age group (yr) 15-19 55.4 41.8 1.6 1.2 0.0 0.0 0.0 0.0 100.0 56 20-24 19.0 51.6 24.9 4.6 0.0 0.0 0.0 0.0 100.0 225 25-29 5.4 35.5 25.5 22.2 9.1 1.8 0.0 0.4 100.0 281 30-34 2.8 22.8 24.3 19.8 14.0 8.6 7.7 0.0 100.0 256 35-39 0.8 26.4 15.1 14.9 14.5 8.4 19.3 0.6 100.0 242 40-44 0.0 18.3 15.1 12.9 14.4 10.2 27.2 1.8 100.0 187 45-49 1.6 15.9 11.4 13.8 19.1 17.6 20.6 0.0 100.0 89 Education level No education 2.1 18.9 23.0 20.9 13.4 7.6 13.2 0.9 100.0 268 Some primary 7.7 27.7 23.5 17.0 11.9 5.8 6.4 0.0 100.0 190 Completed primary 6.9 33.8 20.0 13.1 9.7 6.1 10.2 0.3 100.0 739 Attended secondary or higher 28.8 52.8 11.0 5.2 1.8 0.0 0.0 0.4 100.0 139 Wealth tercile Low 7.2 23.5 21.8 18.2 9.8 8.1 11.4 0.0 100.0 330 Middle 5.4 29.8 22.9 15.2 11.9 5.7 8.9 0.2 100.0 440 High 11.2 38.2 17.1 11.6 8.6 4.4 8.2 0.8 100.0 566 Total 8.2 31.7 20.2 14.5 10.0 5.7 9.2 0.4 100.0 1,336 Source: 2014 Kigoma Reproductive Health Survey. 46 Chapter 4 Figure 4.6: Number of Living Children at First Use of Contraception Among Women Aged 15-49 Who Have Ever Used Contraception (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. 4.5 Source of Modern Contraception Methods Almost half of the women using modern contraception obtained their supplies from dispensaries (47.8%). Smaller percentages of women went to hospitals (17.4%), health centers (14.6%), or pharmacies (8.0%) (Table 4.7, Figure 4.7). Rural women, in particular, were more likely to obtain contraception from dispensaries (56.0%; urban, 25.2%). Urban women, however, preferred to obtain contraception from hospitals (38.5%; rural, 9.8%). A greater percentage of women who were older, had attended secondary school, or were in the highest wealth tercile got their supplies from hospitals. Women with secondary education were more likely than others to go to religious or private health facilities, pharmacies, or markets/shops for their contraceptive supplies. 8.2 31.7 20.2 14.5 10.0 5.7 9.2 0.4 0 5 10 15 20 25 30 35 0 1 2 3 4 5 6+ Does not remember Pe rc en ta ge o f w om en Number of Living Children Family Planning 47 Ta bl e 4. 7: S ou rc e of M od er n Co nt ra ce pt iv es C ur re nt ly U se d, b y Se le ct ed C ha ra ct er is tic s (P er ce nt D is tri bu tio n) W om en A ge d 15 -4 9 Ye ar s W ho A re C ur re nt ly U si ng a M od er n M et ho da Ch ar ac te ris tic So ur ce o f C on tra ce pt iv e M et ho d (% ) Go ve rn m en t F ac ili ty Religious/ Private Health Facility Pharmacy NGO VCT Center CBD/ Village Health Worker Family, Friend, Neighbor Market, Shop, Bar Other Facility Not in Kigoma Region Does Not Remember/ Missing Total Nu m be r of W om en Hospital Health Center Dispensary Re si de nc e Ur ba n 38 .5 20 .3 25 .2 3. 0 7. 1 0. 0 0. 0 1. 2 0. 0 3. 2 0. 8 0. 8 0. 0 10 0. 0 12 6 Ru ra l 9. 8 12 .5 56 .0 5. 3 8. 3 1. 1 0. 2 0. 9 0. 6 0. 3 0. 5 3. 5 1. 0 10 0. 0 35 6 Ag e gr ou p (y r) 15 -1 9 b b b b b b b b b b b b b 10 0. 0 22 20 -2 4 14 .8 20 .1 39 .6 3. 7 13 .5 0. 0 0. 0 0. 0 0. 0 0. 9 1. 0 4. 7 1. 7 10 0. 0 89 25 -2 9 13 .4 16 .1 53 .5 6. 4 4. 4 2. 0 0. 0 2. 5 0. 0 1. 7 0. 0 0. 0 0. 0 10 0. 0 89 30 -3 4 18 .3 15 .5 54 .3 1. 4 6. 0 0. 0 0. 0 2. 0 0. 0 0. 0 0. 0 2. 5 0. 0 10 0. 0 10 2 35 -3 9 18 .7 5. 6 49 .4 6. 5 8. 1 1. 6 0. 0 0. 6 0. 0 1. 9 2. 3 3. 9 1. 4 10 0. 0 83 40 -4 4 18 .3 14 .7 53 .4 6. 9 0. 9 0. 0 1. 4 0. 0 0. 0 1. 7 0. 0 1. 8 0. 9 10 0. 0 72 45 -4 9 47 .0 10 .4 33 .9 3. 8 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 4. 8 0. 0 10 0. 0 25 Ed uc at io n le ve l No e du ca tio n 13 .0 14 .3 57 .9 1. 2 5. 7 2. 1 0. 8 0. 0 0. 0 0. 0 1. 0 1. 9 2. 2 10 0. 0 10 2 So m e pr im ar y 17 .9 22 .8 38 .0 3. 1 9. 9 2. 1 0. 0 1. 3 1. 3 0. 0 0. 0 3. 7 0. 0 10 0. 0 69 Co m pl et ed p rim ar y 17 .4 12 .8 49 .9 6. 3 6. 9 0. 0 0. 0 1. 5 0. 5 1. 0 0. 7 2. 5 0. 4 10 0. 0 26 4 At te nd ed s ec on da ry o r hi gh er 26 .9 12 .0 28 .9 6. 3 15 .7 0. 0 0. 0 0. 0 0. 0 5. 4 0. 0 4. 8 0. 0 10 0. 0 47 W ea lth te rc ile Lo w 4. 8 14 .0 59 .4 2. 2 10 .3 2. 0 0. 0 0. 9 0. 0 0. 0 1. 7 3. 2 1. 4 10 0. 0 12 2 M id dl e 13 .7 9. 1 55 .7 5. 8 8. 8 0. 0 0. 5 1. 9 0. 6 0. 6 0. 5 2. 8 0. 0 10 0. 0 15 9 Hi gh 28 .7 19 .6 33 .6 5. 3 5. 8 0. 7 0. 0 0. 3 0. 7 2. 1 0. 0 2. 5 0. 9 10 0. 0 20 1 To ta l 17 .4 14 .6 47 .8 4. 7 8. 0 0. 8 0. 2 1. 0 0. 5 1. 0 0. 6 2. 8 0. 7 10 0. 0 48 2 Ab br ev iat io ns : C BD , c om m un ity -b as ed d ist rib ut io n; N GO , n on -g ov er nm en tal o rg an iza tio n; V CT , v ol un tar y c ou ns eli ng an d tes tin g. So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. a E xc lu de s l ac tat io na l a m en or rh ea m eth od . b F ew er th an 2 5 ca se s. 48 Chapter 4 Figure 4.7: Source of Contraceptive Method Among All Current Modern Method Users (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. Contraceptive source decisions were influenced by the type of contraceptive available and by which method the woman was currently using. Dispensaries were the most common source among women who used injectables (59.4%), implants (46.9%), pills (33.6%), and other modern methods (44.3%) (Table 4.8, Figure 4.8). Over half of condom users (56.0%) got their supplies from pharmacies. The majority of women who used tubal ligation as their method (2.1% of women in union) had the procedure done at a government hospital (52.4%), while an additional quarter went to a government dispensary (26.5%). Dispensaries were not usually able to perform tubal ligation. Thus, many of these procedures were likely done at refugee camps or other dispensaries functioning at a higher-than-normal level, such as those with donor funding or with outreach programs. Table 4.8: Source of Modern Contraceptives, by Type of Method (Percent Distribution) Women Aged 15-49 Years Who Are Currently Using a Modern Methoda Current Contraceptive Method Used (%) Total Female Sterilization Injectable Implant Pill Male Condom Other Modern Source of Contraception Government hospital 52.4 11.3 17.4 17.0 3.5 b 17.4 Government health center 12.4 13.9 28.1 14.2 0.0 b 14.6 Government dispensary 26.5 59.4 46.9 33.6 12.5 b 47.8 Religious/private health facility 5.0 5.0 6.0 3.2 0.0 b 4.7 Pharmacy 0.0 3.8 0.0 21.2 56.0 b 8.0 Other 0.0 4.1 0.0 8.1 24.5 b 4.8 Facility not in Kigoma Region 3.7 2.6 1.6 2.7 3.6 b 2.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 70 266 62 42 31 11 482 Source: 2014 Kigoma Reproductive Health Survey. a Excludes lactational amenorrhea method. b Fewer than 25 cases. 17.4% 14.6% 47.8% 4.7% 8.0% 0.8% 4.0% 2.8% Government hospital Government health center Government dispensary Religious/private facility Pharmacy NGO Other Outside Kigoma Region Family Planning 49 Figure 4.8: Source of Supply for Specific Methods of Contraception Among All Current Users of Each Method (Percent) Source: 2014 Kigoma Reproductive Health Survey. 4.6 Time to Source of Modern Contraception Methods Difficulty in getting to the source of contraceptive supply is often a major barrier to continued use of supply methods, or to initiating a long-acting reversible method. It is not, however, the only factor. Although in Kigoma the male condom was the quickest method to obtain (61.2% of condom users needed less than half an hour to get to their source of supply), the injectable was the most popular method. Three-quarters (74.6%) of injectable users were able to get to their source of supply in less than an hour; the implant and pill were equally convenient, with 79.6% and 74.8% of users, respectively, able to reach supplies in less than an hour (Table 4.9). Overall, three-quarters of supply-based contraceptive users were able to travel to their source of supply in under an hour (74.5%), and only 6.1% needed 2 hours or more to get their contraceptive (Figure 4.9). Table 4.9: Time to Reach Source of Contraceptive Supplier, Among Supply-Based Methoda Users by Type of Method (Percent Distribution) Women Aged 15-49 Who Are Currently Using Supply-Based Contraceptive Methods Current Contraceptive Method Used TotalIUD Injectable Implant Pill Male Condom Length of Time <30 min b 28.5 27.8 46.7 61.2 32.2 30-59 min b 46.1 51.8 28.1 9.6 42.3 1-2 hr b 18.6 12.3 23.5 19.6 18.6 2-3 hr b 4.8 6.5 1.7 2.0 4.8 3+ hr b 1.6 1.6 0.0 0.0 1.3 Unsure/don’t know b 0.4 0.0 0.0 7.6 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of womenc 9 263 62 42 29 405 Source: 2014 Kigoma Reproductive Health Survey. a Includes all modern contraceptive methods except sterilization and lactational amenorrhea method. b Fewer than 25 cases. c Five missing cases, source”other” or “unknown.” 52.4 11.3 17.4 17.0 12.4 13.9 28.1 14.2 26.5 59.4 46.9 33.6 12.7 6.0 32.5 3.7 2.7 1.6 2.7 0 20 40 60 80 100 Tubal Ligation Injectable Implant Oral Contraceptive Percent M et ho d Government hospital Government health center Government dispensary Other Outside of Kigoma 50 Chapter 4 Figure 4.9: Time to Reach Source of Contraceptive Supplies Among Women Aged 15-49 Years Who Were Current Users of a Supply-Based Methoda (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. a All modern contraceptive methods except sterilization and lactational amenorrhea method. 4.7 Availability of Family Planning Services at Government Facilities Among women who currently used supply-based contraceptive methods and obtained them from government facilities, most (71.1%) said that family planning services were available at any time from such facilities (Table 4.10.) The remaining 28.8% of women said that services were only available at certain times; 18.4% of women found the times to be inconvenient. Table 4.10: Availability and Convenience of Family Planning Services at Kigoma Government Facilities (Percent Distribution) Women Aged 15-49 Years Who Were Currently Using a Supply-Based Contraceptive Methoda Obtained at a Government Facility Availability (%) Government Family Planning Services Available at any time 71.1 Certain times: Convenient 10.4 Certain times: Inconvenient 18.4 Total 100.0 Number of women 319 Source: 2014 Kigoma Reproductive Health Survey. a All modern contraceptive methods except sterilization and lactational amenorrhea method. 4.8 Payment for Contraceptive Methods The great majority of current contraceptive users in Kigoma received their contraceptive supplies free of charge. Overall, only 19.1% of users (or their partners) paid for their method, and 80.6% did not (Table 4.11). More than nine of ten implant users (92.9%) and most users of the injectable (85.3%) or the pill (74.0%) did not have to pay for their method. For the small number of male condom users, 79.1% paid for the condoms, and 20.9% obtained them free of charge. 32.2 42.3 18.6 4.8 1.3 0.9 0 5 10 15 20 25 30 35 40 45 <30 min 30-59 min 1-2 hr 2-3 hr 3+ hr Unsure/don't know Pe rc en t Time Family Planning 51 Table 4.11: Payment for Contraceptive Method Among Supply-Based Methoda Users, by Type of Method (Percent Distribution) Women Aged 15-49 Years Who Are Currently Using Supply-Based Contraceptive Methods Current Contraceptive Method Used (%) TotalIUD Injectable Implant Pill Male Condom Paid for Contraceptive Method Yes b 14.3 7.1 26.0 79.1 19.1 No b 85.3 92.9 74.0 20.9 80.6 Unsure b 0.4 0.0 0.0 0.0 0.3 Total b 100.0 100.0 100.0 100.0 100.0 Number of womenc 9 263 62 42 29 405 Source: 2014 Kigoma Reproductive Health Survey. a Includes all modern contraceptive methods except sterilization and lactational amenorrhea method. b Fewer than 25 cases. c Five missing cases, source “other” or “unknown.” 4.9 Preferred Contraceptive Method Among Current Users The vast majority of contraceptive users (87.0%) was satisfied with their method and did not wish to change (Table 4.12). Almost half of all contraceptive users (48.7%) preferred the injectable, and 14.2% preferred implants (Figure 4.10). One-tenth of users preferred the traditional rhythm method (10.7%), and another tenth preferred withdrawal (10.1%). Smaller percentages preferred the pill (5.2%) or condoms (5.7%). Given that these preferences were very similar to the percentages among all contraceptive users and given the high rates of satisfaction, it would appear that despite low levels of contraceptive use, most current contraceptive users have found a method that suits them. Table 4.12: Preferred Family Planning Method Among Current Usersa (Percent Distribution) Women Aged 15-49 Who Are Currently Using Contraception Total (%) Prefer Current Method No 13.0 Yes 87.0 Preferred Method Female sterilization, tubal ligation 1.1 IUD 3.4 Injectables 48.7 Implant 14.2 Pill 5.2 Male condom 5.7 LAM 0.4 Rhythm 10.7 Withdrawal 10.1 Other modern method 0.2 Other traditional method 0.3 Total 100.0 Number of women 550 Abbreviations: IUD, intrauterine device; LAM, lactational amenorrhea method. Source: 2014 Kigoma Reproductive Health Survey. a Excludes 72 users of male/female sterilization. 52 Chapter 4 Figure 4.10: Preferred Family Planning Method Among Women Who Were Current Contraceptive Usersa (Percent Distribution) Abbreviations: IUD, intrauterine device; LAM, lactational amenorrhea. Source: 2014 Kigoma Reproductive Health Survey. a Excludes 72 users of male or female sterilization. Of the 13% of current contraceptive users who would like to change to a different method, the largest percentage (28.2%) would like to switch to injectables, and 23.3% would like implants (Figure 4.11, Table 4.13). An additional 14.5% were interested in the IUD, and 8.6% were interested in tubal ligation. Some women (16.3%) would prefer a traditional method. Table 4.13: Preferred Family Planning Method, Among All Current Usersa Who Would Prefer a Different Method (Percent Distribution) Women Aged 15-49 Years Who Are Contraceptive Users and Would Like to Use a Different Method Total (%) Preferred Method Female sterilization, tubal ligation 8.6 IUD 14.5 Injectables 28.2 Implant 23.3 Pill 4.8 Male condom 2.8 LAM 1.4 Rhythm 9.6 Withdrawal 4.4 Other modern method 1.6 Other traditional method 0.9 Total 100.0 Number of women 75 Abbreviations: IUD, intrauterine device; LAM, lactational amenorrhea method. Source: 2014 Kigoma Reproductive Health Survey. a Excludes users of male/female sterilization. 1.1 3.4 48.7 14.2 5.2 5.7 0.4 10.7 10.1 0.2 0.3 0 10 20 30 40 50 60 Tu ba l li ga tio n IU D Inj ec tab les Im pla nt Pil l Ma le co nd om LA M Rh yth m W ith dra wa l Ot he r m od ern m eth od Ot he r tr ad itio na l m eth od Pe rc en t Method Family Planning 53 Figure 4.11: Preferred Method Among Current Contraceptive Users Aged 15-49a Years Who Would Prefer a Different Method (Percent) Abbreviations, IUD, intrauterine device; LAM, lactational amenorrhea. Source: 2014 Kigoma Reproductive Health Survey. a Excludes users of male/female sterilization. 4.10 Contraceptive Decision Making Among Current Users In Kigoma, decisions about contraception were largely joint decisions made by both wife and husband; 73.0% of women in union who were currently using a modern method (except tubal ligation) reported that they and their husband or partner decided together about contraception (Figure 4.12, Table 4.14). About one-quarter of women said that contraceptive decisions were mostly their own (23.4%), and only 3.6% of women reported that contraceptive decisions were made mainly by their husband or partner. Figure 4.12: Decision Making About Contraceptive Use Among Women Aged 15-49 Years Who Were Current Modern Method Usersa (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. a Excludes users of male/female sterilization. 8.6 14.5 28.2 23.3 4.8 2.8 1.4 9.6 4.4 1.6 0.9 0 5 10 15 20 25 30 Tu ba l li ga tio n IU D Inj ec tab les Im pla nt Pil l Ma le co nd om LA M Rh yth m W ith dra wa l Ot he r m od ern m eth od Ot he r tr ad itio na l Pe rc en t Method 23.4% 3.6% 73.0% Mainly respondent Mainly husband/partner Joint decision 54 Chapter 4 Table 4.14: Decision Making Regarding Contraceptive Method Use (Percent Distribution) Women in Union Aged 15-49 Years Who Are Currently Using a Modern Methoda Who Decides to Use a Modern Method of Contraception (%) Mainly Respondent Mainly Husband/Partner Joint Decision Total Number of Women Residence Urban 24.0 3.7 72.2 100.0 82 Rural 23.2 3.5 73.3 100.0 251 Age group (yr) 15-19 b b b 100.0 8 20-24 19.6 5.4 75.0 100.0 61 25-29 20.7 3.4 75.9 100.0 70 30-34 27.3 2.7 70.0 100.0 82 35-39 26.1 3.6 70.2 100.0 66 40-44 23.7 3.8 72.6 100.0 40 45-49 b b b 100.0 6 Education level No education 26.5 10.4 63.0 100.0 68 Some primary 23.5 2.7 73.8 100.0 44 Completed primary 25.0 0.8 74.2 100.0 188 Attended secondary or higher 8.0 5.1 86.9 100.0 33 Current contraceptive use IUD b b b 100.0 7 Injectables 26.1 3.7 70.1 100.0 221 Implant 21.1 4.2 74.7 100.0 46 Pill 27.3 0.0 72.7 100.0 39 Male Condom b b b 100.0 19 LAM b b b 100.0 1 Total 23.4 3.6 73.0 100.0 333 Abbreviations: IUD, intrauterine device; LAM, lactational amenorrhea method. Source: 2014 Kigoma Reproductive Health Survey. a Excludes users of male/female sterilization. b Fewer than 25 cases. This decision-making pattern was true for all leading contraceptive methods, although a larger percentage of women using injectables and pills as compared with implants reported that the decision was mainly their own (injectables, 26.1%; pills, 27.3%; implants, 21.1%). 4.11 Reasons for Non-Use of Contraception The majority of all women of reproductive age in Kigoma (84.5%) were not using any method of contraception. Among women in union, nearly 80% were not using any contraception, modern or traditional. Many women in union were not using contraception because they wished to get pregnant (23.4%) or had other health or medical reasons (6.8%)(Table 4.15, Figure 4.13). However, for nearly a quarter of women in union (22.8%) who were not using contraceptives, the most important reason was their fear of side effects. Other commonly mentioned reasons were that the woman opposed contraceptives (7.8%) or that her husband/partner opposed them (11.4%), and that the woman lacked information on methods (5.3%). Family Planning 55 Ta bl e 4. 15 : R ea so ns fo r N on -U se o f C on tra ce pt iv es (P er ce nt ) W om en A ge d 15 -4 9 Ye ar s at R is k of P re gn an cy a a nd N ot C ur re nt ly U si ng C on tra ce pt io nb Wants to Get Pregnant Health/Medical Reasons She Opposes Contraceptives Partner Opposes Contraceptives Partner Wants Her to Become Pregnant Health Concerns Fear of Side Effects Source Far Away Lack of Knowledge of Methods Lack of Knowledge of Source Lack of Access/Too Far Cannot Afford Cost Provider/Pharmacist Will Not Give to Them Religion Against Fatalistic Other Not Sure Number of Women Re si de nc e Ur ba n 14 .0 5. 9 1. 5 3. 2 3. 0 1. 9 14 .7 0. 1 3. 8 0. 5 0. 0 0. 0 0. 0 2. 7 2. 6 5. 5 0. 8 43 0 Ru ra l 14 .5 3. 8 5. 5 7. 8 1. 8 1. 5 15 .4 0. 4 4. 2 0. 1 0. 2 0. 1 0. 3 3. 0 2. 3 5. 5 3. 0 1, 54 4 Ag e gr ou p (y r) 15 -1 9 6. 5 0. 3 1. 2 0. 9 0. 7 0. 0 3. 1 0. 5 3. 0 0. 5 0. 0 0. 0 0. 0 1. 3 0. 6 6. 1 3. 1 53 3 20 -2 4 14 .1 2. 9 4. 6 7. 9 3. 0 0. 8 14 .3 0. 0 5. 1 0. 0 0. 3 0. 0 0. 8 3. 0 2. 2 4. 2 2. 5 37 7 25 -2 9 20 .3 5. 8 5. 8 11 .2 3. 8 2. 1 23 .5 1. 0 4. 8 0. 0 0. 0 0. 0 0. 3 1. 6 4. 3 5. 1 0. 6 29 4 30 -3 4 26 .2 5. 2 5. 8 11 .1 2. 0 2. 2 24 .7 0. 4 3. 0 0. 0 0. 3 0. 0 0. 0 4. 0 1. 7 5. 3 1. 6 24 2 35 -3 9 16 .8 10 .7 5. 7 8. 2 1. 8 3. 7 23 .7 0. 0 3. 7 0. 0 0. 4 0. 0 0. 0 3. 5 5. 2 5. 8 2. 0 22 9 40 -4 4 12 .4 7. 7 8. 5 10 .0 1. 8 4. 4 18 .2 0. 6 5. 9 0. 0 0. 0 0. 9 0. 0 4. 5 2. 3 6. 2 5. 6 20 3 45 -4 9 15 .9 6. 3 11 .3 5. 9 1. 6 1. 2 20 .8 0. 0 4. 9 0. 0 0. 0 0. 0 0. 0 10 .6 2. 5 8. 4 3. 0 96 Cu rr en t u ni on s ta tu s Cu rr en tly in u ni on 23 .4 6. 8 7. 8 11 .4 3. 5 2. 6 22 .8 0. 4 5. 3 0. 0 0. 2 0. 1 0. 2 3. 6 3. 3 5. 6 2. 3 1, 14 7 No t c ur re nt ly in u ni on 2. 9 0. 9 0. 7 1. 0 0. 1 0. 2 5. 5 0. 3 2. 6 0. 3 0. 0 0. 0 0. 2 2. 1 1. 1 5. 4 2. 8 82 7 Ed uc at io n le ve l No e du ca tio n 17 .9 4. 9 6. 8 9. 2 2. 6 0. 9 20 .2 0. 4 6. 5 0. 0 0. 0 0. 0 0. 1 3. 6 4. 1 6. 7 1. 8 48 0 So m e pr im ar y 14 .3 2. 8 4. 4 6. 9 1. 8 1. 4 16 .3 0. 9 4. 5 0. 3 0. 0 0. 0 0. 5 3. 1 2. 0 5. 7 1. 9 30 9 Co m pl et ed p rim ar y 13 .8 4. 9 4. 6 7. 1 1. 8 1. 9 14 .2 0. 3 3. 6 0. 1 0. 3 0. 2 0. 2 2. 9 1. 7 4. 7 3. 2 94 4 Se co nd ar y or h ig he r 10 .4 2. 3 1. 3 1. 3 1. 9 1. 5 8. 1 0. 0 0. 6 0. 4 0. 0 0. 0 0. 0 1. 6 1. 8 6. 5 2. 1 24 1 W ea lth te rc ile Lo w 14 .5 4. 0 5. 0 9. 5 2. 1 1. 0 17 .7 1. 0 5. 1 0. 0 0. 3 0. 2 0. 6 3. 7 3. 2 6. 5 2. 8 63 9 M id dl e 14 .0 4. 0 6. 2 7. 2 1. 3 1. 7 16 .4 0. 1 4. 6 0. 1 0. 0 0. 0 0. 0 2. 7 2. 5 4. 6 3. 1 62 3 Hi gh 14 .7 4. 6 3. 1 4. 1 2. 6 1. 9 11 .9 0. 0 2. 7 0. 3 0. 1 0. 0 0. 0 2. 5 1. 4 5. 6 1. 6 71 2 To ta l 14 .4 4. 2 4. 7 6. 8 2. 0 1. 6 15 .2 0. 4 4. 1 0. 2 0. 1 0. 1 0. 2 2. 9 2. 3 5. 5 2. 5 1, 97 4 So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. a At ri sk o f p re gn an cy d efi ne d as fe cu nd , s ex ua lly ac tiv e w om en w ho ar e n ot cu rre nt ly pr eg na nt /a m en or rh eic . b Fo ur ca se s m iss in g. 56 Chapter 4 Figure 4.13: Main Reasons for Not Using Contraception Among Women In Union Aged 15-49 Years at Risk of Pregnancy Who Were Not Using Contraception (Percent) Source: 2014 Kigoma Reproductive Health Survey. 4.12 Future Intentions of Non-Users and Preferred Method Fecund women who were not using contraception at the time of the survey were asked if they thought they might use a method at some time in the future. Nearly half (47.0%) said they would not, and 15.2% said they were not sure (data not shown). Thirty-eight percent of women, however, indicated they thought they would use a method at some point (Table 4.16). Interestingly, more women with one to four children indicated an intention to use contraception than women who had more children (five+ children); more than 40% of women with one to four children intended to use contraception, whereas fewer than 40% of women with five or more children planned to use contraception (Figure 4.14). Only 29.3% of childless women intended to use contraception in the future. Figure 4.14: Intended Future Use of Contraception by Number of Living Children Among Women Aged 15-49 Years Who Were Fertile Current Non-Users (Percent) Source: 2014 Kigoma Reproductive Health Survey. 2.3 3.6 5.3 5.6 6.8 7.8 11.4 22.8 23.4 0 5 10 15 20 25 Not sure Religion against Lack of knowledge of methods Other Health/medical reasons She opposes contraceptives Partner opposes contraceptives Fear of side effects Wants to get pregnant Percent 29.3 48.4 46.8 42.1 44.9 36.2 37.2 39.7 30.6 0 10 20 30 40 50 60 0 1 2 3 4 5 6 7 8 or more M ea n pe rc en ta ge Number of living children Family Planning 57 Table 4.16: Intended Future Use of Contraception, by Number of Living Children (Percent) Women Aged 15-49 Years Who Are Fecund, Current Non-Contraceptive Users Thinks She Will Use Contraception in the Future (%) Number of Women Number of Living Children 0 29.3 1,001 1 48.4 377 2 46.8 318 3 42.1 280 4 44.9 295 5 36.2 234 6 37.2 188 7 39.7 166 8 or more 30.6 150 Total 37.8 3,009 Source: 2014 Kigoma Reproductive Health Survey. Among those women who were currently not using contraception but intended to at some time in the future, the decided preference was for the injectable, which was preferred by nearly half (47.0%) of them (Table 4.17). Intended injectable use was particularly favored by those in the lowest wealth tercile and women in their 20s and early 30s. Current non-users of contraception were also interested in the implant (12.6%) and the pill (10.7%). There was some interest in tubal ligation (4.9%) and in the traditional method of rhythm (6.3%, with women in the highest wealth tercile having more interest than those in the other terciles). 58 Chapter 4 Ta bl e 4. 17 : P re fe rr ed M et ho d of F ut ur e Co nt ra ce pt io n, b y Se le ct ed C ha ra ct er is tic s (P er ce nt D is tri bu tio n) W om en A ge d 15 -4 9 Ye ar s W ho A re F ec un d, C ur re nt N on -C on tra ce pt iv e Us er s an d W ho T hi nk T he y W ill U se a M et ho d in th e Fu tu re Pr ef er re d M et ho d (% ) To ta l Nu m be r o f W om en Tubal Ligation Vasectomy IUD Injectables Implant Pill Male Condom Female Condom Foam/Jelly Rhythm Withdrawal Other Modern Method Other Traditional Method Undecided Re si de nc e Ur ba n 2. 8 0. 0 2. 2 43 .9 13 .2 9. 3 2. 8 0. 0 0. 0 12 .2 1. 6 0. 6 0. 5 10 .8 10 0. 0 23 7 Ru ra l 5. 5 0. 2 1. 4 47 .8 12 .4 11 .0 1. 9 0. 1 0. 1 4. 8 1. 6 0. 0 0. 6 12 .5 10 0. 0 88 5 Ag e gr ou p (y r) 15 -1 9 0. 0 0. 0 1. 3 41 .2 11 .1 17 .2 4. 2 0. 0 0. 0 8. 3 1. 3 0. 0 0. 0 15 .4 10 0. 0 24 9 20 -2 4 1. 4 0. 0 1. 1 50 .9 14 .3 9. 3 2. 9 0. 0 0. 2 5. 5 1. 3 0. 5 0. 4 12 .2 10 0. 0 27 3 25 -2 9 1. 6 0. 0 1. 9 53 .2 15 .7 7. 1 1. 3 0. 0 0. 0 7. 2 2. 0 0. 0 1. 2 8. 7 10 0. 0 22 0 30 -3 4 3. 1 0. 6 2. 8 52 .7 13 .3 5. 6 0. 4 0. 0 0. 0 4. 4 2. 1 0. 0 0. 7 14 .4 10 0. 0 16 2 35 -3 9 21 .8 0. 7 1. 5 38 .4 8. 0 9. 7 0. 0 0. 0 0. 0 7. 7 1. 7 0. 0 0. 8 9. 7 10 0. 0 14 3 40 -4 4 24 .1 0. 0 1. 0 36 .2 6. 8 17 .9 0. 0 1. 8 0. 0 0. 7 2. 5 0. 0 1. 8 7. 1 10 0. 0 63 45 -4 9 a a a a a a a a a a a a a a 10 0. 0 12 Ed uc at io n le ve l No e du ca tio n 5. 2 0. 0 3. 4 48 .5 12 .1 11 .2 1. 3 0. 4 0. 0 2. 6 1. 0 0. 0 1. 2 13 .2 10 0. 0 25 0 So m e pr im ar y 5. 3 0. 0 0. 4 51 .8 16 .1 10 .2 4. 4 0. 0 0. 0 2. 7 0. 3 0. 0 1. 4 7. 4 10 0. 0 15 7 Co m pl et ed p rim ar y 6. 1 0. 3 1. 0 49 .3 10 .7 10 .5 1. 6 0. 0 0. 1 4. 6 2. 4 0. 3 0. 3 12 .9 10 0. 0 55 6 Se co nd ar y or h ig he r 0. 0 0. 0 1. 8 31 .3 16 .2 10 .9 2. 7 0. 0 0. 0 22 .3 1. 6 0. 0 0. 0 13 .1 10 0. 0 15 9 W ea lth te rc ile Lo w 5. 3 0. 0 1. 7 55 .1 10 .5 11 .7 1. 3 0. 3 0. 2 1. 3 0. 5 0. 0 0. 6 11 .5 10 0. 0 33 6 M id dl e 6. 4 0. 5 1. 3 47 .9 11 .9 10 .6 2. 2 0. 0 0. 0 4. 8 2. 6 0. 0 0. 7 11 .1 10 0. 0 37 9 Hi gh 3. 3 0. 0 1. 6 39 .1 15 .0 9. 8 2. 6 0. 0 0. 0 12 .1 1. 7 0. 4 0. 5 13 .7 10 0. 0 40 7 To ta l 4. 9 0. 2 1. 6 47 .0 12 .6 10 .7 2. 1 0. 1 0. 1 6. 3 1. 6 0. 1 0. 6 12 .2 10 0. 0 1, 12 2 Ab br ev iat io n: IU D, in tra ut er in e d ev ice . So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. a F ew er th an 2 5 ca se s. Family Planning 59 4.13 Unmet Need for Contraception Fecund women who indicated that they either 1) wanted no more children or 2) wanted to wait 2 or more years before having a(nother) child, but were not currently using any method of contraception, were considered to have an unmet need for family planning services. Current users of any method of contraception were considered to have a met need for family planning services. Women with unmet need, combined with those with met need, constituted the total demand for family planning. In this report, the definition of unmet need corresponds to the standard DHS definition.1 Table 4.18 presents levels of unmet and met need, total demand, and satisfied demand for family planning among women in union surveyed in Kigoma Region. In total, 39.2% of women in union had an unmet need for family planning services, including 32.3% for spacing and 6.8% for limiting. As shown in Table 4.4, 20.6% of women in union were currently using contraception and, therefore, had met their need for family planning services. Approximately 60% of women in union in Kigoma had a need for family planning services, but only 34% of that demand was satisfied. Among women classified by the number of living children, the percentage of demand that was satisfied increased from just 7.6% among women with no children to a maximum of 42.0% among women with three living children, after which it declined with increases in the number of living children. Rural women had a higher level of unmet need for family planning services than did urban women (40.7% rural vs 32.0% urban), and women in the lowest wealth tercile had a higher level of need than did women in the middle and highest terciles, even though most contraceptives could be obtained free of charge. 60 Chapter 4 Ta bl e 4. 18 : U nm et N ee d, M et N ee d, a nd D em an d fo r F am ily P la nn in g Se rv ic es , b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) W om en in U ni on A ge d 15 -4 9 Ye ar s Un m et N ee d fo r F am ily P la nn in g M et N ee d fo r F am ily P la nn in g To ta l D em an d fo r F am ily P la nn in g Sa tis fie d De m an da Nu m be r o f W om en Sp ac in g Li m iti ng To ta l Sp ac in g Li m iti ng To ta l Sp ac in g Li m iti ng To ta l To ta l Re si de nc e Ur ba n 26 .6 5. 3 32 .0 21 .0 8. 6 29 .6 47 .6 14 .0 61 .6 48 .1 47 5 Ru ra l 33 .6 7. 1 40 .7 13 .8 4. 9 18 .7 47 .3 12 .1 59 .4 31 .5 2, 06 9 Ed uc at io n le ve l No e du ca tio n 34 .1 6. 8 40 .9 10 .0 3. 9 13 .9 44 .1 10 .7 54 .8 25 .4 74 1 So m e pr im ar y 32 .4 8. 2 40 .6 14 .2 4. 7 18 .9 46 .6 12 .9 59 .4 31 .8 37 3 Co m pl et ed p rim ar y 31 .5 6. 9 38 .4 16 .4 6. 8 23 .2 47 .9 13 .7 61 .6 37 .7 1, 28 0 Se co nd ar y or h ig he r 29 .9 2. 9 32 .8 32 .5 5. 8 38 .3 62 .4 8. 7 71 .1 53 .9 15 0 W ea lth te rc ile Lo w 35 .4 7. 6 42 .9 12 .2 3. 3 15 .5 47 .6 10 .9 58 .5 26 .5 84 7 M id dl e 31 .6 5. 7 37 .3 15 .7 4. 2 19 .9 47 .3 9. 9 57 .2 34 .8 88 7 Hi gh 29 .9 7. 3 37 .2 17 .4 9. 6 27 .0 47 .3 16 .9 64 .2 42 .1 81 0 Ag e gr ou p (y r) 15 -1 9 37 .3 1. 9 39 .1 7. 5 0. 0 7. 5 44 .7 1. 9 46 .6 16 .1 14 6 20 -2 4 32 .9 2. 7 35 .6 20 .4 0. 5 20 .9 53 .2 3. 2 56 .5 37 .0 44 0 25 -2 9 37 .3 3. 4 40 .7 18 .6 2. 3 20 .9 56 .0 5. 7 61 .7 33 .9 53 4 30 -3 4 37 .8 5. 1 42 .8 20 .3 3. 3 23 .7 58 .1 8. 4 66 .5 35 .6 43 7 35 -3 9 29 .5 11 .0 40 .5 14 .1 10 .6 24 .6 43 .6 21 .5 65 .1 37 .8 41 6 40 -4 4 24 .3 17 .0 41 .3 8. 0 16 .5 24 .4 32 .3 33 .4 65 .7 37 .1 34 8 45 -4 9 19 .5 11 .0 30 .6 0. 0 10 .5 10 .5 19 .5 21 .6 41 .1 25 .5 22 3 Nu m be r o f l iv in g ch ild re n 0 27 .6 1. 5 29 .1 2. 4 0. 0 2. 4 30 .1 1. 5 31 .5 7. 6 17 2 1 32 .2 1. 6 33 .8 15 .9 0. 0 15 .9 48 .1 1. 6 49 .7 32 .0 31 6 2 35 .3 2. 4 37 .7 23 .5 2. 0 25 .5 58 .8 4. 4 63 .2 40 .3 34 8 3 35 .1 4. 1 39 .2 24 .4 4. 0 28 .4 59 .6 8. 0 67 .6 42 .0 34 2 4 35 .8 6. 9 42 .7 14 .0 7. 4 21 .4 49 .8 14 .3 64 .1 33 .4 35 6 5 34 .3 4. 1 38 .4 17 .3 5. 4 22 .7 51 .6 9. 5 61 .1 37 .2 30 2 6 27 .8 12 .0 39 .8 13 .0 11 .8 24 .8 40 .8 23 .8 64 .6 38 .4 26 7 7 33 .5 15 .5 49 .0 7. 7 9. 2 16 .9 41 .2 24 .7 65 .9 25 .6 21 8 8 or m or e 22 .5 21 .3 43 .8 2. 5 14 .8 17 .3 25 .0 36 .1 61 .1 28 .3 22 3 To ta l 32 .3 6. 8 39 .2 15 .1 5. 6 20 .6 47 .4 12 .4 59 .8 34 .4 2, 54 4 Ta nz an ia 15 .9 9. 5 25 .3 20 .7 13 .6 34 .4 36 .6 23 .1 59 .7 57 .5 6, 41 2 So ur ce s: 20 14 K ig om a R ep ro du cti ve H ea lth S ur ve y, 20 10 Ta nz an ia De m og ra ph ic an d He alt h Su rv ey . a S ati sfi ed d em an d = to tal m et ne ed d ivi de d by to tal d em an d fo r f am ily p lan ni ng se rv ice s. Family Planning 61 Reference 1. The United Republic of Tanzania National Bureau of Statistics, ORC Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: National Bureau of Statistics, ORC Macro; 2011. 62 Chapter 4 Maternal and Perinatal Health 63 Chapter 5: maternal and perinatal health High quality maternal and perinatal health services are essential to reducing maternal and neonatal mortality. This chapter presents findings related to maternal and perinatal health in Kigoma including information on the use of antenatal, maternity, and postnatal care services. This information is derived from the reports of survey respondents as recorded in their lifetime pregnancy histories and the detailed histories of their health care utilization for all births carried to term since January 2009. The findings from this section can be used to identify problem areas; determine needed interventions; and set program priorities, targets, and goals to improve maternal and perinatal health outcomes. 5.1 Antenatal Care Antenatal care (ANC) is essential for preventing and treating conditions that may cause complications in pregnancy and affect the health of the mother and her fetus. The World Health Organization (WHO) recommends all pregnant women have at least four ANC assessments by a skilled attendant, starting as early in pregnancy as possible.1 These visits should, at a minimum, include advising on warning signs in pregnancy; assessing the woman’s risk factors; screening and treatment for health conditions; educating the woman and her partner on various topics, such as nutrition and self-care; preparing a birth plan; and counseling on family planning. The 2010 Kigoma Reproductive Health Survey (RHS) collected information on ANC attendance, timing, and location, and the content of the services provided for 4,121 live births and stillbirths that took place between January 2009 and the date of the RHS interview in August or September 2014. Antenatal Care Coverage Overall, coverage of ANC was almost universal in Kigoma Region, with only 0.8% of women reporting no ANC (Table 5.1). Differences in coverage based upon location of residence, age, and level of education were negligible. While coverage of ANC was high, only 17.0% of women began care in the first trimester, as recommended by the WHO guidelines. Overall, about two-thirds of women sought their first ANC visit during the second trimester (67.6%), with little difference by residence, wealth status, or education. Greater proportions of women with higher education and in the highest wealth tercile sought care in the first trimester (33.1% and 20.4%, respectively) than did women with less education or lower wealth status (Figure 5.1, Table 5.1). There were no discernable changes in timing of first visits based on year of birth since 2009. Fewer than half of all women (42.1%) attended four or more antenatal visits, as recommended by the WHO, although attendance was higher among women living in urban settings (47.2%), those who attended secondary school or higher (60.4%), and those with higher wealth status (51.3%). 64 Chapter 5 Figure 5.1: Timing of First Antenatal Care Visit Among Women Aged 15-49 Years, for Births Since January 2009 (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. Table 5.1: Receipt of Any Antenatal Care and 4+ Visits (Percent) and Timing of First Visit (Percent Distribution) Births Since January 2009, of Women Aged 15-49 Years     ANC (%)   Timing of First ANC (%)       Received Any ANC 4+ ANC Visitsa   First Trimester Second Trimester Third Trimester DNR Trimester No ANC Total   Number of Births Residence                     Urban 99.7 47.2   20.0 66.8 12.7 0.2 0.3 100.0   671 Rural 99.1 41.1   16.4 67.7 14.3 0.7 0.9 100.0   3,450 Age group (yr) at birth                       < 25 99.4 39.2   18.4 67.0 13.7 0.3 0.6 100.0   1,597 25-34 99.1 45.7   16.2 68.5 13.4 1.0 0.9 100.0   1,706 35-49 99.1 40.7   15.5 66.8 16.2 0.6 0.9 100.0   818 Education level                       No education 98.5 40.7   13.9 68.1 15.9 0.7 1.5 100.0   1,316 Some primary 99.1 42.3   19.5 63.9 15.3 0.5 0.9 100.0   617 Completed primary 99.7 41.2   16.7 68.9 13.3 0.7 0.3 100.0   1,999 Attended secondary or higher 100.0 60.4   33.1 63.0 3.9 0.0 0.0 100.0   189 Wealth tercile                       Low 98.8 36.8   14.6 67.3 16.4 0.4 1.2 100.0   1,486 Middle 99.4 40.3   16.6 68.1 13.7 0.9 0.6 100.0   1,472 High 99.6 51.3   20.4 67.3 11.3 0.6 0.4 100.0   1,163 Year pregnancy ended                       2009 99.2 40.5   15.1 69.1 14.2 0.8 0.8 100.0   695 2010 99.5 44.7   16.1 70.3 12.1 1.0 0.5 100.0   708 2011 98.7 42.0   17.8 65.2 15.1 0.6 1.3 100.0   697 2012 99.0 42.8   15.5 68.9 14.0 0.7 1.0 100.0   726 2013 99.5 46.1   20.0 66.6 12.7 0.1 0.5 100.0   746 2014 99.4 34.5   17.1 64.9 16.8 0.6 0.6 100.0   549 Total 99.2 42.1   17.0 67.6 14.0 0.6 0.8 100.0   4,121 Tanzania 98.0 42.8   15.1 N/A N/A 0.0 2.0 100.0   5,519 Abbreviations: ANC, antenatal care; DNR, did not remember.  Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey.  a Thirty women receiving ANC were unsure about the number of visits. 17.0 20.0 16.4 13.9 19.5 16.7 33.1 67.6 66.8 67.7 68.1 63.9 68.9 63.0 14.0 12.7 14.3 15.9 15.3 13.3 3.9 0 20 40 60 80 100 Total Urban Rural No education Some primary education Completed primary education Attended secondary school or higher Pe rc en t 1st trimester 2nd trimester 3rd trimester No ANC Don't remember Maternal and Perinatal Health 65 In urban settings, more than half of women used dispensaries for ANC (59.4%), and an even higher percentage did so in rural settings (88.1%) (Figure 5.2, Table 5.2). Only 1% of women received ANC at a facility outside of Kigoma Region. A greater percentage of women in urban settings and those with higher wealth status went to hospitals and health centers for ANC. Figure 5.2: Location of Antenatal Care Among Women Aged 15-49 Years, for Births Since January 2009, by Residence (Percent Distribution) a Other includes home, community-based distribution, community health worker, traditional birth attendant, other. Source: 2014 Kigoma Reproductive Health Survey. 19.0 20.4 59.4 1.4 0.1 2.5 7.7 88.1 0.9 0.9 5.1 9.7 83.6 1.0 0.8 0 20 40 60 80 100 Hospital Health center Dispensary Facility outside of Kigoma Othera Pe rc en t Type of Facility Urban Rural Total 66 Chapter 5 Table 5.2: Place Antenatal Care Received, by Selected Characteristics (Percent) Births Since January 2009 Receiving Antenatal Care, of Women Aged 15-49 Years   Hospital Health Center Dispensary Facility Outside Kigoma Home/CBD/ CHW/TBA/ Other Number of Births Residence             Urban 19.0 20.4 59.4 1.4 0.1 668 Rural 2.5 7.7 88.1 0.9 0.9 3,415 Age group (yr) at birth             < 25 4.8 11.0 82.1 1.2 0.9 1,587 25-34 6.0 9.6 83.0 0.9 0.8 1,687 35-49 3.7 6.9 88.5 0.7 0.3 809 Education level             No education 1.5 8.1 88.7 0.4 1.3 1,294 Some primary 5.0 12.4 79.8 2.4 0.5 611 Completed primary 5.3 9.6 83.9 0.8 0.4 1,989 Attended secondary or higher 28.1 12.9 56.2 1.5 1.8 189 Wealth tercile             Low 1.2 6.6 89.8 1.0 1.3 1,462 Middle 3.4 7.2 88.1 0.6 0.7 1,464 High 12.2 16.7 69.8 1.4 0.3 1,157 Year pregnancy ended             2009 6.3 10.8 81.5 0.6 0.7 689 2010 4.2 9.9 83.4 1.7 0.7 705 2011 4.9 8.1 85.3 1.1 0.6 687 2012 4.6 10.4 83.5 0.7 1.0 718 2013 5.3 9.2 84.1 0.8 0.8 739 2014 5.3 9.7 83.5 0.8 0.8 545 Total 5.1 9.7 83.6 1.0 0.8 4,083 Abbreviations: CBD, community-based distribution; CHW, community health worker; TBA, traditional birth attendant. Source: 2014 Kigoma Reproductive Health Survey. Antenatal Care Components It is important to evaluate the quality of ANC services provided to pregnant women, given the crucial role such care can play in preventing pregnancy complications. To assess one aspect of quality, the Kigoma RHS collected information about services the women received in ANC visits for their most recent birth. Specifically, women were asked whether their ANC visits included an evaluation of their blood pressure, planning for delivery (birth plan, transport, money, blood donation, and skilled attendant), information on pregnancy complications, and family planning education. Results showed that most women were advised to develop a birth plan (78.4%); urban women (84.8%), those with some secondary education (86.8%), and those with higher wealth status (84.5%) reported doing this more frequently than others (Table 5.3). Almost three-quarters of women were told about family planning (71.8%). Women in urban settings and those of higher wealth status reported this most frequently (79.5% and 76.2%, respectively). Nearly two-thirds of women reported they discussed plans to save money for delivery (62.2%). The number was higher in urban settings (71.4%), particularly among women who attended secondary school (84.8%) and those of higher wealth status (75.4%). Only half of all women reported having their blood pressure checked (51.1%), and only one-third reported being advised to identify transportation to a facility for delivery (31.6%). Few women reported discussion of identifying a birth attendant (10.2%) or blood donor (6.4%). Overall, women in urban settings reported more coverage of each of the components of ANC assessed (Figure 5.3). Maternal and Perinatal Health 67 Figure 5.3: Content of Antenatal Care Received for Most Recent Birth Since January 2009, of Women Aged 15-49 Years, by Residence (Percent) Source: 2014 Kigoma Reproductive Health Survey. Table 5.3: Content of Antenatal Care Received, by Selected Characteristics (Percent) Most Recent Births Since January 2009 Receiving Antenatal Care, of Women Aged 15-49 Years   Blood Pressure Checked Told About Signs of Pregnancy Complications Told About Family Planning Advised to Develop Birth Plan Identified Transport Saved Money for Delivery Identified a Blood Donor Identified a Skilled Attendant for Delivery   Number of Births Residence                     Urban 68.5 61.1 79.5 84.8 47.8 71.4 8.6 12.3   431 Rural 47.4 49.6 70.1 77.0 28.2 60.2 5.9 9.7   1,959 Age group (yr) at birth                   < 25 48.7 50.6 65.7 77.1 34.6 66.1 5.0 9.5   835 25-34 51.7 52.9 76.0 80.0 30.4 60.6 7.6 9.9   963 35-49 54.3 51.1 74.4 77.8 28.7 58.2 6.4 11.8   592 Education level                     No education 41.5 44.5 67.1 71.3 23.7 51.2 5.8 8.3   686 Some primary 48.7 52.9 66.3 75.3 30.8 60.4 5.3 8.6   366 Completed primary 54.6 53.2 76.0 82.6 33.9 66.6 6.3 10.8   1,192 Attended secondary or higher 76.6 70.3 73.8 86.8 54.5 84.8 12.5 18.7   146 Wealth tercile                     Low 41.8 46.0 69.0 71.5 19.8 50.1 5.9 8.8   820 Middle 46.5 50.8 70.7 79.9 29.1 62.5 4.0 9.1   827 High 67.0 59.0 76.2 84.5 47.9 75.4 9.5 13.0   743 Total 51.1 51.6 71.8 78.4 31.6 62.2 6.4 10.2   2,390 Source: 2014 Kigoma Reproductive Health Survey. Malaria poses a great risk to pregnant women. To prevent malaria in pregnancy, the WHO has recommended that ANC clinics (or other public or private facilities) provide insecticide-treated bed nets to women as early in the pregnancy as possible.2 The WHO also recommends that pregnant women receive intermittent prophylactic treatment with sulfadoxine-pyrimethamine (IPTp-SP) starting in the second trimester, with at least 1 month between doses, during pregnancy. Tanzania has adopted this practice and recommends at least two doses of IPTp-SP provided along with subsidized bed nets. 68.5 47.4 51.1 61.1 49.6 51.6 84.8 77 78.4 79.5 70.1 71.8 47.8 28.2 31.6 0 20 40 60 80 100 Urban Rural Total Pe rc en t Residence Blood pressure checked Told about signs of pregnancy complications Advised to develop birth plan Told about family planning Identified transport 68 Chapter 5 In September 2012, the WHO Malaria Policy Advisory Committee reviewed the most recent evidence on efficacy and effectiveness of IPTp-SP and issued new policy recommendations that promote the increased use of IPTp-SP in all areas of Africa with moderate-to-high transmission of Plasmodium falciparum malaria, such as Kigoma Region. The WHO’s recent policy update confirms the critical importance of scaling-up IPTp-SP use as part of routine ANC services. In Kigoma Region, the majority (84.4%) of women reported sleeping under a bed net during their last pregnancy that resulted in a birth since 2009 (Table 5.4). Similarly, almost three-quarters of women (71.4%) recounted taking an antimalarial drug for prevention during pregnancy, with most taking IPTp-SP (96.0%; data not shown). Reported usage of both bed nets and IPTp-SP increased with age, education, and wealth. Although reported bed net use was similar among rural and urban women, a greater percentage of urban women reported taking antimalarial drugs (81.5%; rural, 69.3%). Table 5.4: Use of Insecticide-Treated Bed Nets and Antimalarial Drugs During Pregnancy, by Selected Characteristics (Percent) Most Recent Births Since January 2009, of Women Aged 15-49 Years   Usually Slept Under ITN (%) Took Antimalarial Drugs (%) Number of Births Residence       Urban 85.3 81.5 432 Rural 84.3 69.3 1,978 Age group (yr) at birth       < 25 83.9 67.6 838 25-34 84.1 72.6 972 35-49 86.0 75.8 600 Education level       No education 81.6 65.5 697 Some primary 82.3 65.5 369 Completed primary 86.4 75.6 1,198 Attended secondary or higher 87.7 82.9 146 Wealth tercile       Low 79.9 62.3 834 Middle 85.6 72.6 829 High 88.3 80.5 747 Total 84.4 71.4 2,410 Abbreviation: ITN, insecticide-treated bed net. Source: 2014 Kigoma Reproductive Health Survey. 5.2 Use of Local Herbs During Pregnancy Women were asked whether they took local herbs during their pregnancy. Previous research has found that herbal medications are commonly administered to pregnant women with complications before childbirth in Kigoma. These medications are believed to increase contractions and assist the women in delivering faster. Though the RHS did not ask which herbs were taken specifically, women with a birth since 2009 were asked if they took herbal remedies during their last pregnancy, and why. Overall, 14.8% of women reported taking herbal remedies (Table 5.5). Rural women (15.4%), women aged 15-24 years (18.4%), and women with either no education (16.7%) or some primary education (22.8%) were the most frequent users of herbal medications. Reports of herb use declined as wealth levels increased (from 18.2% among women in the lowest wealth tercile to 10.3% among those in the highest). Women most commonly reported taking these medications to treat stomach pain (40.7%), to avoid miscarriage (25.8%), for the health of the child (16.0%), to induce labor (11.2%), and for vaginal bleeding (9.4%) (Table 5.6). Maternal and Perinatal Health 69 Table 5.5: Use of Local Herbs During Pregnancy, by Selected Characteristics (Percent) Most Recent Births Since January 2009, of Women Aged 15-49 Years   Took Local Herbs (%) Number of Births Residence     Urban 12.0 432 Rural 15.4 1,978 Age group (yr) at birth     < 25 18.4 838 25-34 12.2 972 35-49 13.6 600 Education level     No education 16.7 697 Some primary 22.8 369 Completed primary 12.1 1,198 Attended secondary or higher 6.6 146 Wealth tercile     Low 18.2 834 Middle 15.4 829 High 10.3 747 Total 14.8 2,410 Source: 2014 Kigoma Reproductive Health Survey. Table 5.6: Reasons for Taking Local Herbs During Pregnancy, by Selected Characteristics (Percent) Most Recent Births Since January 2009 Where the Mother Took Herbs During Pregnancy, of Women Aged 15-49 Years   Reasons for Taking Herbs During Pregnancy (%)  Number of Births To Induce Labor Malaria Cold/ Flu Headache Vaginal Bleeding Stomach Pain For the Health of the Child To Avoid Miscarriage Other Residence                   Urban 9.3 0.0 0.0 1.5 14.9 42.4 18.9 13.6 13.4 49 Rural 11.5 1.0 0.0 1.6 8.5 40.4 15.6 27.8 7.5 293 Age group (yr) at birth                   < 25 10.5 0.5 0.0 1.7 12.8 40.4 12.5 25.6 12.4 149 25-34 10.4 1.0 0.0 0.0 2.8 44.5 19.1 25.2 6.9 117 35-49 14.0 1.5 0.0 3.9 12.4 35.2 19.3 27.1 1.5 76 Education level                   No education 9.9 1.9 0.0 1.5 8.9 36.8 16.3 30.3 9.0 113 Some primary 7.2 1.1 0.0 3.4 10.9 47.1 19.1 24.3 6.3 82 Completed primary 14.6 0.0 0.0 0.6 8.5 40.4 14.1 22.9 9.2 139 Attended secondary or higher a a a a a a a a a 8 Wealth tercile                   Low 11.3 0.6 0.0 0.7 11.1 47.2 15.6 23.7 4.6 150 Middle 10.6 0.8 0.0 0.7 8.7 40.0 12.3 31.8 9.9 119 High 11.9 1.6 0.0 4.8 7.2 28.8 23.2 19.6 13.4 73 Total 11.2 0.9 0.0 1.6 9.4 40.7 16.0 25.8 8.4 342 Source: 2014 Kigoma Reproductive Health Survey.  a Fewer than 25 women responded. 70 Chapter 5 5.3 Delivery Place of Delivery The WHO recommends that all obstetric deliveries be conducted by skilled birth attendants.3 In Tanzania, skilled birth attendants are usually found in hospitals, health centers, and dispensaries. However, the RHS found that since 2009, about half of deliveries occurred at home (49.6%) (Figure 5.4). This was most common among women aged 35-49 years (53.5%), women with no education (61.9%), and women in the lowest wealth tercile (61.4%) (Table 5.7). Relatively few deliveries in Kigoma Region occurred in hospitals (14.4%), health centers (13.2%), or dispensaries (17.2%). Only 2.2% of women delivered outside of Kigoma Region. Women in urban settings reported a higher frequency of delivery at hospitals or health centers than at dispensaries or home. Women younger than age 25 years, those with some secondary education, and those in the highest wealth tercile were more likely to deliver in hospitals and health centers. Women in rural settings had the highest percentage of home deliveries (53.7%) and were more likely to deliver in a dispensary (18.9%) than at a hospital (10.9%) or health center (10.8%). Of women who lived more than 2 hours from the nearest health facility, 70.1% delivered at home. Figure 5.4: Place of Delivery of Births Since January 2009 of Women Aged 15-49 Years, by Residence (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. a 3.0% delivered en route to a facility; 0.4% had missing data for delivery location. 33.1 25.8 8.5 27.6 10.9 10.8 18.9 53.7 14.4 13.2 17.2 49.6 0 10 20 30 40 50 60 Hospital Health center Dispensary Home Pe rc en t Place of Delivery Urban Rural Totala Maternal and Perinatal Health 71 Table 5.7: Place of Delivery, by Selected Characteristics (Percent Distribution) Births Since January 2009, of Women Aged 15-49 Years   Place of Delivery (%)  Total  Number of Births Kigoma Hospitals Kigoma Health Centers Kigoma Dispensaries Facilities Outside Kigoma En Route to Facility Own/Other Home Other/ Missing Residence                   Urban 33.1 25.8 8.5 3.5 1.5 27.6 0.0 100.0 671 Rural 10.9 10.8 18.9 2.0 3.2 53.7 0.5 100.0 3,450 One-way travel time to nearest health facility              Less than 30 min 20.2 17.5 24.4 2.6 1.6 32.9 0.8 100.0 825 30 min to 1 hour 15.8 16.0 18.9 1.9 3.1 43.9 0.4 100.0 1,397 1 to 2 hours 14.1 11.6 15.6 1.2 4.3 52.8 0.3 100.0 1,141 2+ hours 6.8 6.8 10.1 3.9 2.1 70.1 0.3 100.0 758 Age group (yr) at birth                   < 25 16.1 14.4 17.8 3.1 2.5 45.8 0.3 100.0 1,597 25-34 13.0 12.6 17.5 1.8 3.1 51.7 0.3 100.0 1,706 35-49 13.5 11.8 15.4 1.1 3.8 53.5 0.9 100.0 818 Education level                   No education 8.6 10.3 14.9 1.7 2.4 61.9 0.2 100.0 1,316 Some primary 13.0 13.7 13.3 2.4 1.8 55.0 0.8 100.0 617 Completed primary 16.4 14.2 20.4 2.0 4.0 42.5 0.5 100.0 1,999 Attended secondary or higher 39.6 21.7 14.7 7.4 0.5 16.0 0.0 100.0 189 Wealth tercile                   Low 8.0 8.8 16.0 2.0 3.3 61.4 0.6 100.0 1,486 Middle 12.6 11.4 20.3 1.7 3.2 50.4 0.3 100.0 1,472 High 25.0 21.1 14.9 3.2 2.2 33.2 0.3 100.0 1,163 Year pregnancy ended                 2009 16.3 10.6 16.9 2.5 2.0 51.6 0.2 100.0 695 2010 11.8 12.4 18.1 2.2 3.2 51.8 0.6 100.0 708 2011 13.7 13.6 15.9 1.8 2.2 52.1 0.8 100.0 697 2012 13.2 15.3 17.6 2.0 3.9 47.9 0.2 100.0 726 2013 14.6 13.7 18.2 3.2 3.2 46.6 0.6 100.0 746 2014 17.4 13.4 16.7 1.5 3.4 47.5 0.1 100.0 549 Total 14.4 13.2 17.2 2.2 3.0 49.6 0.4 100.0 4,121 Source: 2014 Kigoma Reproductive Health Survey. Table 5.8 shows the one-way travel time to the nearest health facility by place of delivery for births since 2009. As expected, about 90% of women delivering in Kigoma facilities lived within 2 hours of a health facility. For those delivering at home, 27.9% lived more than 2 hours from a facility, but 41.5% lived within 1 hour. 72 Chapter 5 Table 5.8: One-Way Travel Time to Nearest Health Facility, by Place of Delivery (Percent Distribution) Births Since January 2009, of Women Aged 15-49 Years   Less than 30 Min 30 Min - 1 Hr 1-2 Hrs 2+ Hrs Total Number of Births Place of delivery             Kigoma hospital 26.6 35.8 28.2 9.4 100.0 594 Kigoma health center 25.2 39.5 25.2 10.2 100.0 570 Kigoma dispensary 26.8 35.7 26.0 11.5 100.0 724 Facility outside Kigoma 22.3 27.8 15.7 34.2 100.0 94 En route to a facility 10.1 34.2 41.5 14.3 100.0 119 Own/other home 12.6 28.9 30.6 27.9 100.0 2,002 Other/missing a a a a a 18 Total 18.9 32.6 28.7 19.8 100.0 4,121 Source: 2014 Kigoma Reproductive Health Survey.  a Fewer than 25 women responded.  Facility Referrals An estimated 15% of pregnancies and childbirths need emergency obstetric care because of complications that are difficult to predict.4 Since many of these pregnancies require referral to higher level facilities for treatment, referrals are a critical component of emergency obstetric care. Overall, in Kigoma, 12.0% of all institutional births since January 2009 involved referrals to higher levels of care. Referrals were more common among women in rural settings (12.9%), women aged 35-49 years (15.3%), and women in the lowest wealth tercile (13.6%) (Table 5.9). A greater percentage of births to women with no education (13.2%) or some primary education (15.0%) were referred, compared with births to women who had completed primary school or higher (10.8%). Table 5.9: Births Involving a Referral to a Facility, by Selected Characteristics (Percent) All Institutional Births (Including in Transit) Since January 2009, of Women Aged 15-49 Yearsa Referral % Number of Births Residence     Urban 8.9 471 Rural 12.9 1,630 Age group (yr) at birth     < 25 11.7 883 25-34 11.0 834 35-49 15.3 384 Education level     No education 13.2 507 Some primary 15.0 278 Completed primary 10.8 1,153 Attended secondary or higher 10.8 163 Wealth tercile     Low 13.6 576 Middle 12.2 736 High 10.6 789 Total 12.0 2,101 Source: 2014 Kigoma Reproductive Health Survey.  a Information is missing for five women. Maternal and Perinatal Health 73 Cesarean Section Deliveries The RHS found that 3.5% of all deliveries were by cesarean section (C-section), with higher C-section rates among women residing in urban settings (6.0%), those who attended secondary school or higher (13.2%), and those in the highest wealth tercile (5.2%). The frequency of C-sections decreased with maternal age (Figure 5.5, Table 5.10). Figure 5.5: Births Since January 2009 Delivered by Cesarean Section, of Women Aged 15-49 Years, by Selected Characteristics (Percent) Source: 2014 Kigoma Reproductive Health Survey. 0 2 4 6 8 10 12 14 Attended secondary or higher Completed primary Some primary No education 35-49 25-34 < 25 Rural Urban Education level Age at birth (yr) Residence Percent 74 Chapter 5 Table 5.10: Births Delivered by Cesarean Section, by Selected Characteristics (Percent) All Births Since January 2009, of Women Aged 15-49 Years Cesarean Delivery (%) Number of Births Residence     Urban 6.0 671 Rural 3.1 3,450 Age group (yr) at birth     < 25 4.3 1,597 25-34 3.2 1,706 35-49 2.6 818 Education level     No education 1.9 1,316 Some primary 4.1 617 Completed primary 3.5 1,999 Attended secondary or higher 13.2 189 Wealth tercile     Low 3.0 1,486 Middle 2.8 1,472 High 5.2 1,163 Year pregnancy ended     2009 3.2 695 2010 3.4 708 2011 3.8 697 2012 3.4 726 2013 3.7 746 2014 3.6 549 Total 3.5 4,121 Tanzania 4.5 8,176 Sources: 2014 Kigoma Reproductive Health Survey, 2010 Tanzania Demographic and Health Survey. Maternal and Perinatal Health 75 Mode and Cost of Travel to Facilities for Delivery Distances from health care can be long in Kigoma Region, posing a significant challenge to women seeking obstetric care. Looking exclusively at women who delivered in health facilities since January 2009, the RHS found that the majority of women (80.1%) indicated a travel time of less than 2 hours to the health facility where they delivered (Table 5.11, Figure 5.6). In rural areas, however, fewer women were able to travel to a facility for delivery in less than 2 hours (78.4%) than were women in urban settings (85.3%). As education levels and wealth terciles increased, the percentage of women who traveled more than 2 hours decreased. In addition, the percentage of women who traveled 2 hours or more was greater among those referred to higher level facilities (39.2%) than among those not referred (17.3%). Table 5.11: One-Way Travel Time to Delivery Facility, by Selected Characteristics (Percent Distribution) All Institutional Births Since January 2009, of Women Aged 15-49 Yearsa   One-Way Travel Time to Delivery Facility (%)  Number of Births Less Than 30 Minutes 30 Min - 1 Hour 1-2 Hours 2+ Hours Total Residence             Urban 25.2 40.8 19.3 14.7 100.0 455 Rural 19.6 31.9 26.9 21.6 100.0 1,480 Age group (yr) at birth             < 25 18.2 33.4 26.2 22.2 100.0 823 25-34 22.9 36.4 23.8 16.9 100.0 771 35-49 23.9 30.1 25.1 20.9 100.0 341 Education level             No education 14.9 34.9 25.9 24.3 100.0 458 Some primary 18.4 31.2 25.5 24.9 100.0 256 Completed primary 22.1 33.6 26.5 17.9 100.0 1,059 Attended secondary or higher 35.7 39.5 12.6 12.1 100.0 162 Wealth tercile             Low 15.5 34.0 26.7 23.8 100.0 514 Middle 15.5 30.1 31.2 23.2 100.0 672 High 29.6 37.6 18.4 14.3 100.0 749 Cesarean section delivery           No 21.5 34.5 25.4 18.6 100.0 1,798 Yes 13.4 28.6 20.8 37.2 100.0 137 Referral             No 22.5 35.3 24.9 17.3 100.0 1,704 Yes 9.9 24.7 26.2 39.2 100.0 231 Birth order             1 20.0 29.9 24.9 25.1 100.0 479 2 20.3 38.9 22.0 18.9 100.0 309 3 23.4 36.3 26.6 13.7 100.0 283 4+ 20.9 33.8 25.8 19.4 100.0 864 Total 21.0 34.0 25.1 19.9 100.0 1,935 Source: 2014 Kigoma Reproductive Health Survey. a Forty-seven women did not remember travel time. 76 Chapter 5 Figure 5.6: One-Way Travel Time to Delivery Facility for Births Since January 2009 of Women Aged 15-49 Years, by Residence (Percent Distribution)a Source: 2014 Kigoma Reproductive Health Survey. a Among women who remembered travel time. Women were asked how they traveled to facilities for their delivery. Overall, 42.1% of women reported walking, and 34.2% traveled by car or truck (Figure 5.7, Table 5.12). More than half of women who resided in urban settings used cars or trucks for transport to a facility for delivery (55.3%). As education level and wealth increased, the use of cars or trucks increased. Figure 5.7: Type of Transportation Used to Delivery Facility for Births Since January 2009 of Women Aged 15-49 Years, by Residence (Percent) Source: 2014 Kigoma Reproductive Health Survey. 35.0 4.2 5.1 55.3 44.3 13.5 16.4 27.7 42.1 11.3 13.7 34.2 0 10 20 30 40 50 60 Walked Bicycle Motorcycle Car/truck Pe rc en t Type of Transportation Urban Rural Total 26.2 40.3 19.0 14.5 21.8 31.0 26.2 21.0 22.8 33.2 24.5 19.5 0 5 10 15 20 25 30 35 40 45 <30 minutes 30-59 minutes 1-2 hours 2+ hours Pe rc en t One-Way Travel Time Urban Rural Total Maternal and Perinatal Health 77 Table 5.12: Type of Transportation Used to Delivery Facility, by Selected Characteristics (Percent) All Institutional Births Since January 2009, of Women Aged 15-49 Years Walk Bicycle Motorcycle Car/Truck Boat Other Number of Births Residence               Urban 35.0 4.2 5.1 55.3 1.9 0.0 461 Rural 44.3 13.5 16.4 27.7 0.5 0.6 1,521 Age group (yr) at birth               < 25 38.5 11.7 15.6 35.0 1.1 0.7 844 25-34 45.0 11.9 11.6 32.7 0.7 0.3 785 35-49 45.3 8.2 13.5 35.8 0.0 0.2 353 Education level               No education 41.5 16.8 13.1 28.7 1.5 0.1 475 Some primary 43.1 11.7 15.5 30.2 1.3 0.4 265 Completed primary 44.2 9.8 14.5 33.3 0.5 0.6 1,080 Attended secondary or higher 27.8 3.2 6.8 64.2 0.0 0.8 162 Wealth tercile               Low 44.9 16.6 16.9 23.5 1.6 0.6 530 Middle 48.5 12.0 15.6 25.3 0.5 0.3 691 High 34.3 6.9 9.7 49.9 0.5 0.4 761 Total 42.1 11.3 13.7 34.2 0.8 0.4 1,982 Source: 2014 Kigoma Reproductive Health Survey.         There are often costs associated with childbirth. Almost half of all women who delivered in a facility (44.7%) reported paying for transportation to their delivery facility (Table 5.13). More women in urban settings (54.4%), in the highest wealth tercile (51.1%), and among those who delivered in Kigoma Hospital (72.2%) reported paying for transport. Some women also reported payment for facility-related expenses, including delivery care, supplies, medications, and food (14.8%, 8.1%, 4.7%, and 3.6%, respectively). Supplies for delivery were the most common expense, with more than half of women (59.2%) reporting paying for supplies brought from home, and 8.1% paying for them at the facility. Some women also paid for accommodations near the facility (4.6%) and for dependent care (7.0%). A small percentage of women (5.9%) reported paying informal fees (bribes) for their delivery-related care. This was highest among women in the lowest wealth tercile (7.8%) and those delivering outside of Kigoma Region (14.7%). 78 Chapter 5 Ta bl e 5. 13 : T yp es o f E xp en di tu re s In cu rr ed (i n TZ S) a D ur in g La bo r a nd C hi ld bi rth , b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) M os t R ec en t I ns tit ut io na l B irt hs S in ce Ja nu ar y 2 00 9, o f W om en A ge d 15 -4 9 Ye ar sb   Tr an sp or t De liv er y Ca re In fo rm al Fe es (B rib es ) Su pp lie s (a t F ac ili ty ) Su pp lie s (B ro ug ht fro m H om e) M ed ic at io ns Ac co m m od at io n Fo od at th e Fa ci lit y De pe nd en t Ca re An y Ot he r Ex pe ns e Nu m be r of B irt hs Re si de nc e                       Ur ba n 54 .4 9. 7 5. 8 5. 9 67 .8 6. 2 4. 9 2. 8 12 .2 7. 2 30 1 Ru ra l 41 .4 16 .5 5. 9 8. 8 56 .2 4. 2 4. 6 3. 8 5. 3 7. 6 92 4 W ea lth te rc ile                       Lo w 41 .5 14 .1 7. 8 9. 4 56 .3 5. 7 3. 6 5. 6 6. 4 8. 3 30 6 M id dl e 38 .6 16 .1 5. 6 9. 0 57 .5 3. 9 5. 8 2. 7 4. 5 7. 8 39 5 Hi gh 51 .1 14 .2 5. 0 6. 6 62 .1 4. 8 4. 4 3. 0 9. 3 6. 9 52 4 Pl ac e of d el iv er y                     Ki go m a ho sp ita l 72 .2 7. 9 6. 3 7. 0 61 .3 4. 6 11 .0 4. 4 9. 0 12 .0 40 2 Ki go m a he al th ce nt er 43 .6 18 .0 3. 2 10 .6 57 .4 5. 4 2. 1 2. 9 7. 7 6. 4 35 5 Ki go m a di sp en sa ry 17 .4 17 .8 6. 5 6. 7 59 .6 3. 9 1. 0 3. 5 5. 1 5. 1 41 3 Fa ci lit y ou ts id e Ki go m a 57 .5 22 .3 14 .7 9. 5 50 .1 7. 9 1. 9 1. 6 3. 1 0. 0 55 To ta l 44 .7 14 .8 5. 9 8. 1 59 .2 4. 7 4. 6 3. 6 7. 0 7. 5 1, 22 5 Ab br ev iat io n: T ZS , T an za ni an sh ill in gs . So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. a E xc ha ng e r ate as o f S ep tem be r 2 01 4: 1 U SD = 1 60 0 TZ S. b B etw ee n 7- 29 u nk no wn re sp on se s f or ea ch ex pe nd itu re . A to tal o f f ou r c as es o f i n- kin d pa ym en t w er e r em ov ed fr om an aly sis . Maternal and Perinatal Health 79 Overall expenditures related to the last delivery were an average of Tanzanian shillings (TZS) 12,768 ($7.98 USD, as of September 2014) (Table 5.14). In comparison with any facility in Kigoma, expenditures associated with delivery outside of Kigoma Region were higher (average TZS 20,824). Average expenditures within Kigoma Region increased according to level of facility; average expenditures were lowest at dispensaries and highest at hospitals. Only 13.2% of deliveries in health facilities did not incur any expenditure. The greatest expenditures were for supplies brought from home (average TZS 3,770), transport (average TZS 3,681), and delivery care (average TZS 2,648) (Table 5.15.) Table 5.14: Expenditures Incurred (In TZS)a During Labor and Childbirth (Percent Distribution) and Total Expenditures Related to Last Institutional Delivery (Mean) Most Recent Institutional Births Since January 2009, of Women Aged 15-49 Yearsb   Expenditure Category (%)     Mean Total Expenditures Related to Last Institutional Delivery Since January 2009 (Average in TZS) Number of Births  None 1-4,999 TZS 5,000- 9,999 TZS 10,000- 19,999 TZS 20,000+ TZS Total Residence                   Urban 8.7 13.0 29.3 28.2 20.8 100.0   12,562 301 Rural 14.7 14.9 29.5 23.6 17.3 100.0   12,838 924 Wealth tercile                   Low 12.5 14.3 30.1 28.9 14.2 100.0   12,138 306 Middle 15.1 14.9 30.3 20.1 19.7 100.0   12,627 395 High 12.1 14.2 28.4 26.0 19.3 100.0   13,244 524 Place of delivery                   Kigoma hospital 5.7 14.1 29.5 28.8 21.8 100.0   14,805 402 Kigoma health center 16.4 10.9 26.9 24.6 21.2 100.0   13,882 355 Kigoma dispensary 18.0 17.9 32.5 21.0 10.7 100.0   8,763 413 Facility outside Kigoma 11.7 12.9 21.8 24.9 28.7 100.0   20,824 55 Total 13.2 14.4 29.4 24.8 18.2 100.0   12,768 1,225 Abbreviation: TZS, Tanzanian shillings. Source: 2014 Kigoma Reproductive Health Survey. a Exchange rate as of September 2014: 1 USD = 1600 TZS. b Between 7-29 unknown responses for each expenditure. Total of four cases of in-kind payment removed from analysis. For unknown/in-kind expenditures, assumption of zero expenditures in that category. 80 Chapter 5 Ta bl e 5. 15 : E xp en di tu re s In cu rr ed (M ea n, in T ZS )a b y Ty pe o f E xp en di tu re D ur in g La bo r a nd C hi ld bi rth M os t R ec en t I ns tit ut io na l B irt hs S in ce J an ua ry 2 00 9, o f W om en A ge d 15 -4 9 Ye ar sb     Ex pe nd itu re C at eg or y M ea n To ta l Ex pe nd itu re s Re la te d to L as t In st itu tio na l De liv er y Si nc e Ja nu ar y 20 09 (A ve ra ge in T ZS ) Nu m be r of B irt hs Tr an sp or t De liv er y Ca re In fo rm al Fe es Su pp lie s (a t Fa ci lit y) Su pp lie s (B ro ug ht fro m H om e) M ed ic at io ns Ac co m m od at io n Fo od at th e Fa ci lit y De pe nd en t Ca re An y Ot he r Ex pe ns e Re si de nc e                         Ur ba n 3, 40 7 1, 23 5 20 1 2 45 4, 81 4 53 5 7 7 1 22 1 ,4 94 43 2 12 ,5 62 30 1 Ru ra l 3, 77 3 3, 12 7 46 8 3 83 3, 41 6 31 9 1 74 2 94 5 03 38 2 12 ,8 38 92 4 W ea lth te rc ile                         Lo w 3, 71 6 2, 73 2 42 3 3 92 3, 30 1 38 7 1 09 2 84 4 56 33 7 12 ,1 38 30 6 M id dl e 3, 57 4 2, 93 7 46 2 4 06 3, 42 2 24 0 1 37 2 52 5 18 67 8 12 ,6 27 39 5 Hi gh 3, 74 1 2, 37 9 34 0 2 78 4, 30 9 46 7 1 82 2 28 1 ,1 07 21 4 13 ,2 44 52 4 Pl ac e of d el iv er y                       Ki go m a ho sp ita l 5, 95 3 1, 68 3 33 0 2 24 3, 66 4 57 9 2 13 3 30 1 ,2 84 54 5 14 ,8 05 40 2 Ki go m a he al th ce nt er 3, 64 6 4, 10 6 17 7 4 77 3, 95 9 27 8 8 5 1 69 6 43 34 3 13 ,8 82 35 5 Ki go m a di sp en sa ry 1, 18 4 1, 89 3 42 3 3 75 3, 56 9 19 6 1 56 2 51 3 71 34 5 8 ,7 63 41 3 Fa ci lit y ou ts id e Ki go m a 5, 89 6 6, 26 4 2, 13 0 2 50 4, 87 4 79 5 3 8 1 59 4 17 0 20 ,8 24 55 To ta l 3, 68 1 2, 64 8 40 0 3 48 3, 77 0 37 3 1 49 2 50 7 54 39 5 12 ,7 68 1, 22 5 Ab br ev iat io n: T ZS , T an za ni an sh ill in gs . a E xc ha ng e r ate as o f S ep tem be r 2 01 4: 1 U SD = 1 60 0 TZ S. b B etw ee n 7- 29 u nk no wn re sp on se s f or ea ch ex pe nd itu re . T ot al of fo ur ca se s o f i n- kin d pa ym en t r em ov ed fr om an aly sis . F or u nk no wn /in -k in d ex pe nd itu re s, as su m pt io n of ze ro ex pe nd itu re s i n th at ca teg or y. Maternal and Perinatal Health 81 Reasons for Not Delivering in a Health Facility Women who did not deliver in a health facility were asked the reason(s) they did not. The two most common reasons were the distance (22.8%) and that the baby came earlier than expected (36.2%) (Figure 5.8, Table 5.16). Not surprisingly, women living 2 or more hours from the nearest health facility identified distance as a reason nearly half the time (48.9%). Distance was also most commonly identified as a major reason by women younger than age 25 years, those in the lowest wealth tercile, or those with either no education or some secondary education. The ”baby came earlier than expected” was reported most frequently by women who were aged 35-49 years. Surprisingly, 10.1% of urban women reported that they did not deliver in a facility because transport was unavailable, and 6.3% of urban women said they did not deliver in a facility because it was not open. Overall, costs related to the impact on the family were also a consideration. For instance, 8.5% reported that not being able to find alternative care for their family was a reason for not delivering in a health facility. Other barriers included belief that facility delivery was unnecessary (9.1%) or not customary (7.6%), the husband’s not allowing it (2.2%), fear of abuse or disrespect at the facility (2.1%), and lack of a female care provider (1.6%). Figure 5.8: Reasons Mentioned for Not Delivering in a Health Facilitya for Births Since January 2009, of Women Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. a Births in transit not included. Only responses ≥ 3.5% shown here. 36.2 22.8 9.6 9.1 8.5 7.6 4.6 4.5 3.5 0 5 10 15 Percent 20 25 30 35 40 Baby came early Facility far away Transport not available Not necessary Lack of alternative care for family Not customary Transportation expensive Facility not open Facility delivery expensive 82 Chapter 5 Ta bl e 5. 16 : R ea so ns M en tio ne d fo r N ot D el iv er in g in a H ea lth F ac ili ty , b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) Al l N on in sti tu tio na l B irt hs (E xc lu di ng in Tr an sit ) S in ce Ja nu ar y 2 00 9, o f W om en A ge d 15 -4 9 Ye ar s Ch ar ac te ris tic Re as on s fo r N ot D el iv er in g in a F ac ili ty (% )   Nu m be r of B irt hs Cost Facility Not Open Distance Transport Unavailable Transport Expensive Do Not Trust Facility Expect Poor Quality Service/Care Fear of Abuse/ Disrespect at Facility Lack of Alternative Care for Family Lack of Accommodations Near Facility No Female Provider at Facility Baby Came Earlier Than Expected Husband/Family Did Not Allow Unnecessary Not Customary Other Re si de nc e                                   Ur ba n 3. 4 6. 3 25 .0 10 .1 4. 6 0. 5 1. 2 0. 6 8. 2 0. 0 4. 1 36 .1 1. 5 8. 8 3. 9 5. 1 20 0 Ru ra l 3. 6 4. 3 22 .5 9. 6 4. 6 1. 2 1. 0 2. 2 8. 5 0. 7 1. 4 36 .2 2. 2 9. 1 8. 0 5. 2 1, 81 3 On e- w ay tr av el ti m e to n ea re st h ea lth fa ci lit y                             Le ss th an 3 0 m in 5. 1 5. 8 6. 5 4. 4 3. 2 0. 6 0. 2 4. 9 6. 1 0. 9 2. 7 44 .9 1. 3 13 .6 6. 6 7. 1 27 7 30 m in - 1 hr 3. 0 7. 3 7. 6 5. 1 2. 8 1. 1 2. 0 1. 0 7. 3 0. 0 1. 8 41 .4 3. 3 10 .5 9. 2 9. 4 61 6 1- 2 hr s 3. 6 3. 3 19 .9 7. 2 1. 4 1. 2 1. 3 2. 7 11 .3 1. 0 1. 7 38 .7 1. 7 8. 6 10 .3 3. 7 60 3 2+ h rs 3. 3 2. 3 48 .9 19 .2 10 .5 1. 4 0. 1 1. 3 7. 6 0. 9 0. 9 24 .3 1. 9 6. 1 3. 6 1. 7 51 7 Ag e gr ou p (y r) a t b irt h                                 < 25 5. 0 4. 9 26 .9 11 .5 4. 4 0. 8 0. 8 1. 6 9. 1 0. 9 1. 6 35 .9 2. 5 7. 7 4. 2 5. 2 71 1 25 -3 4 2. 1 4. 4 20 .5 9. 6 4. 9 1. 7 1. 4 2. 6 8. 6 0. 5 2. 1 34 .7 2. 0 10 .4 8. 7 5. 4 87 0 35 -4 9 3. 9 3. 8 19 .5 5. 7 4. 1 0. 5 0. 9 2. 0 6. 9 0. 4 0. 7 40 .5 1. 8 9. 0 12 .0 4. 8 43 2 Ed uc at io n le ve l                                   No e du ca tio n 4. 1 4. 0 27 .2 12 .1 6. 4 0. 8 0. 8 2. 3 9. 3 0. 5 0. 9 30 .9 2. 2 8. 9 7. 2 5. 1 80 8 So m e pr im ar y 4. 2 6. 6 22 .0 8. 5 4. 1 0. 5 2. 0 2. 7 7. 0 0. 9 0. 9 36 .3 2. 1 11 .3 7. 3 3. 6 33 8 Pr im ar y co m pl et e 2. 7 4. 1 18 .4 7. 7 3. 1 1. 8 1. 0 1. 7 8. 1 0. 8 2. 7 41 .6 2. 3 8. 3 8. 3 5. 9 84 1 At te nd ed s ec on da ry or h ig he r 5. 6 3. 1 29 .8 5. 0 0. 0 0. 0 0. 0 0. 0 11 .1 0. 0 0. 0 34 .3 0. 0 11 .9 4. 1 7. 1 2 6 W ea lth te rc ile                                   Lo w 4. 0 4. 0 28 .3 11 .5 4. 6 0. 6 0. 8 1. 3 9. 2 0. 6 0. 8 33 .2 2. 2 9. 2 8. 4 5. 0 90 7 M id dl e 4. 1 4. 6 19 .0 8. 2 5. 0 1. 9 1. 3 2. 0 8. 7 0. 9 2. 3 39 .7 2. 6 8. 2 7. 6 5. 4 73 5 Hi gh 1. 3 5. 4 16 .7 7. 9 3. 6 1. 0 1. 3 4. 4 6. 3 0. 4 2. 3 36 .9 1. 2 10 .5 5. 7 5. 5 37 1 To ta l 3. 5 4. 5 22 .8 9. 6 4. 6 1. 1 1. 1 2. 1 8. 5 0. 7 1. 6 36 .2 2. 2 9. 1 7. 6 5. 2 2, 01 3 So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y.  Maternal and Perinatal Health 83 Delivery Location Decision Making Figure 5.9 shows the percent distribution of who decided where to deliver the most recent birth. For home deliveries, the woman was most often the decision maker (43.1%), though the husband/partner decided 25.8% of the time, and the couple decided together 22.0% of the time. For facility deliveries, the husband/partner was more likely to be the decision maker (32.3%), though the woman decided 28.3% of the time, and they decided together 26.2% of the time (Table 5.17). Figure 5.9: Person Who Decides Where to Deliver the Baby, for Births Since January 2009 of Women Aged 15-49 Years (Percent Distribution) Source: 2014 Kigoma Reproductive Health Survey. a “Other” category includes specified family members or friends. Table 5.17: Person Who Decided Where to Deliver the Baby, by Place of Delivery (Percent Distribution) Most Recent Births Since January 2009, of Women Aged 15-49 Years   Person Who Decided Place of Delivery (%)  Number of Births Pregnant Woman Herself Husband/ Partner Both Woman & Husband/ Partner Husband/ Partner’s Parent Pregnant Woman’s Parent Other Total Place Of Delivery Health facility 28.3 32.3 26.2 2.8 5.3 5.0 100.0 1,225 Home 43.1 25.8 22.0 2.3 3.7 3.0 100.0 1,094 In transit/other/missing 36.5 18.4 37.5 1.0 3.2 3.3 100.0 91 Total 35.5 28.8 24.7 2.5 4.5 4.0 100.0 2,410 Source: 2014 Kigoma Reproductive Health Survey.             35.5 28.8 24.7 7.0 4.5 Woman Husband/Partner Both Parents Othera 84 Chapter 5 Delivery Attendance The most common birth attendants were nurse midwives, who assisted at 40.0% of all deliveries and at 82.0% of facility deliveries (Table 5.18). Overall, women reported deliveries by traditional birth attendants (30.3%) and relatives/friends (20.3%) for a combined total exceeding 50% (Figure 5.10). Traditional birth attendants and relatives/friends were more commonly reported in rural settings (33.0% and 23.7%, respectively), by women in the lowest wealth tercile (36.0% and 26.7%, respectively), and by those without education (34.5% and 26.0%, respectively). Traditional birth attendants were the most common category of persons assisting with home deliveries (56.4%). Figure 5.10: Categories of Persons Assisting with Births Since January 2009, of Women Aged 15-49 Years (Percent) Source: 2014 Kigoma Reproductive Health Survey. 4.7 40.0 0.1 30.3 21.6 1.3 2.2 0 5 10 15 20 25 30 35 40 45 Doctor/assistant medical officer Nurse/ midwife Maternal and child health aide Traditional birth attendant Relative/friend Other No one Pe rc en t Category of Persons Assisting with Birth Maternal and Perinatal Health 85 Ta bl e 5. 18 : C at eg or y of P er so nn el A ss is tin g w ith B irt hs , b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) B irt hs S in ce Ja nu ar y 2 00 9, o f W om en A ge d 15 -4 9 Ye ar s Ch ar ac te ris tic Ca te go ry o f P er so nn el A ss is tin g w ith B irt hs (% ) Nu m be r of B irt hs Doctor/ AMO Clinical Officer ACO Nurse/ Midwife MCH Aide Medical Attendant Nurse Assistant Village Health Worker TBA Relative/ Friend Other No One Does Not Know Any Skilled Attendant at Birtha Re si de nc e                               Ur ba n 6. 7 1. 4 2. 2 64 .3 0. 4 4. 3 3. 4 0. 5 16 .1 10 .8 1. 2 1. 3 0. 0 72 .2 6 71 Ru ra l 4. 3 1. 5 1. 2 35 .4 0. 1 3. 4 3. 1 0. 2 33 .0 23 .7 1. 4 2. 4 0. 0 43 .8 3 ,4 50 Ag e gr ou p (y r) a t b irt h                               < 25 5. 3 1. 9 1. 0 42 .4 0. 2 3. 9 3. 6 0. 2 28 .1 21 .1 0. 8 0. 8 0. 0 52 .2 1 ,5 97 25 -3 4 4. 5 0. 9 1. 7 39 .0 0. 2 3. 5 2. 7 0. 4 31 .5 22 .4 1. 4 2. 5 0. 0 46 .1 1 ,7 06 35 -4 9 3. 6 1. 8 1. 2 36 .4 0. 0 2. 8 3. 1 0. 2 32 .8 20 .9 2. 6 4. 9 0. 0 43 .8 8 18 Ed uc at io n le ve l                               No e du ca tio n 2. 6 1. 0 1. 0 29 .9 0. 2 2. 9 2. 4 0. 1 34 .5 26 .0 1. 8 3. 3 0. 0 36 .7 1 ,3 16 So m e pr im ar y 4. 6 0. 8 0. 9 35 .1 0. 2 4. 4 1. 0 0. 2 34 .3 23 .7 1. 7 1. 8 0. 0 43 .0 6 17 Co m pl et ed p rim ar y 4. 8 2. 1 1. 7 45 .4 0. 1 3. 8 4. 4 0. 4 28 .1 19 .2 1. 1 1. 8 0. 0 54 .5 1 ,9 99 At te nd ed s ec on da ry o r h ig he r 18 .7 0. 3 1. 6 72 .6 0. 0 1. 6 3. 2 0. 0 10 .2 8. 2 0. 0 0. 0 0. 4 83 .9 1 89 W ea lth te rc ile                               Lo w 3. 2 1. 1 1. 0 29 .4 0. 2 1. 7 2. 1 0. 3 36 .0 26 .7 1. 9 3. 2 0. 0 35 .9 1 ,4 86 M id dl e 4. 2 2. 0 1. 3 37 .8 0. 0 4. 9 3. 8 0. 3 31 .5 22 .8 1. 3 2. 1 0. 0 47 .3 1 ,4 72 Hi gh 7. 3 1. 3 1. 7 56 .5 0. 2 4. 1 3. 8 0. 3 21 .4 13 .5 0. 6 1. 0 0. 0 65 .5 1 ,1 63 Pl ac e of d el iv er y                               He al th fa ci lit y 10 .0 3. 1 2. 8 82 .0 0. 3 7. 0 6. 2 0. 2 2. 3 1. 3 0. 1 0. 0 0. 0 98 .5 1 ,9 82 Ho m e 0. 0 0. 0 0. 0 2. 3 0. 0 0. 2 0. 3 0. 3 56 .4 39 .0 2. 5 4. 3 0. 0 2. 9 2 ,0 02 In tr an si t/o th er /m is si ng 0. 0 0. 5 0. 0 8. 2 0. 0 2. 8 2. 9 0. 9 37 .0 49 .9 1. 6 1. 9 0. 0 14 .4 1 37 Ye ar p re gn an cy e nd ed                               20 09 3. 8 1. 2 0. 5 39 .8 0. 1 3. 2 2. 4 0. 4 33 .0 19 .5 1. 4 2. 4 0. 0 46 .8 6 95 20 10 4. 7 0. 9 1. 4 39 .2 0. 2 3. 6 2. 7 0. 3 28 .8 25 .0 0. 9 2. 0 0. 0 46 .6 7 08 20 11 4. 8 2. 2 1. 3 38 .5 0. 2 3. 6 3. 4 0. 0 32 .5 21 .1 1. 3 1. 7 0. 0 47 .0 6 97 20 12 4. 5 1. 2 2. 0 40 .8 0. 2 3. 7 3. 4 0. 2 28 .7 21 .3 1. 7 3. 0 0. 1 49 .5 7 26 20 13 4. 7 1. 2 1. 7 40 .9 0 3. 5 3. 8 0. 4 29 .9 21 .2 1. 2 1. 9 0 49 .8 7 46 20 14 5. 8 2. 3 0. 9 40 .8 0. 2 3. 6 3. 3 0. 3 29 .1 21 .8 1. 7 2. 3 0 49 .9 5 49 To ta l 4. 7 1. 5 1. 3 40 .0 0. 1 3. 5 3. 2 0. 3 30 .3 21 .6 1. 3 2. 2 0. 0 48 .3 4 ,1 21 Ta nz an ia 4. 9 1. 9 b 42 .1 1. 7 N/ A N/ A N/ A 14 .7 29 .1 0. 9 3. 4 1. 3 50 .6 8, 17 6 Ab br ev iat io ns : AC O, as sis tan t c lin ica l o ffi ce r; AM O, as sis tan t m ed ica l o ffi ce r; M CH ai de , m ate rn al an d ch ild h ea lth ai de ; T BA , t ra di tio na l b irt h att en da nt . So ur ce s: 20 14 K ig om a R ep ro du cti ve H ea lth S ur ve y, Co m pa ris on : 2 01 0 Ta nz an ia De m og ra ph ic an d He alt h Su rv ey . a A ny sk ill ed at ten da nt in clu de s: AC O; A M O; cl in ica l o ffi ce r; do cto r; M CH ai de ; m ed ica l a tte nd an t; nu rs e a ss ist an t; TB A; o r t ra in ed n ur se /m id wi fe. b T he 2 01 0 Ta nz an ia De m og ra ph ic an d He alt h Su rv ey co m bi ne d th e c ate go rie s o f c lin ica l o ffi ce r a nd A CO . R es ul ts fo r b ot h ca teg or ies ar e s ho wn u nd er cl in ica l o ffi ce r. 86 Chapter 5 Birthweight Globally, about 16% of all babies born in 2013 were classified as low birthweight (<2.5kg).4 Low birthweight is an important newborn health indicator, as it may be a sign of reduced blood flow or poor nutrition in the womb, both of which can increase the risk of death in the early months and years of a child’s life. Low birthweight infants who survive may have impaired immune function and increased risk of disease, are likely to remain undernourished, and may have physical and developmental delays.5 Women in Kigoma were asked whether their most recently born (since January 2009) baby was weighed at birth and if they remembered his or her birthweight. Among the 86.3% reporting a known birthweight, only 5.8% were reported as low birthweight (Table 5.19). Consistent with other studies, a greater percentage of babies with a low birthweight were girls. Additionally, a greater percentage of low birthweight babies were born to first-time mothers or to women who had attended some or no primary school. Interestingly, a higher percentage of urban women reported low birthweight babies weighing < 2.5kg (7.5%) than did rural women (5.5%). Maternal and Perinatal Health 87 Table 5.19: Children with Low Birth Weight, by Selected Characteristics (Percent) Most Recent Live Births (with a Known Birth Weight)a Since January 2009, of Women Aged 15-49 Years  Characteristic Births Weighing Less Than 2.5 Kg (%) Number of Births Sex of baby     Boy 4.8 1,034 Girl 6.9 1,058 Residence     Urban 7.5 402 Rural 5.5 1,690 Age group (yr)   < 25 6.4 738 25-34 5.2 844 35-49 6.1 510 Education level     No education 6.1 571 Some primary 8.0 309 Completed primary 5.3 1,071 Attended secondary or higher 4.1 141 Wealth tercile     Low 6.3 677 Middle 5.9 715 High 5.4 700 Order of Live Births     1 8.5 376 2 5.9 308 3 4.7 289 4 6.4 286 5 5.6 226 6 4.7 191 7 5.1 147 8 2.6 123 9 2.9 80 10 or more 7.6 66 Total 5.8 2,092 Source: 2014 Kigoma Reproductive Health Survey. a 86.3% of births reported a known birthweight. 88 Chapter 5 Vital Registration Vital registration allows countries to track all births and deaths and to identify the most pressing health issues. While many countries have estimates of births and deaths, accurate and complete vital registration is critical to truly understanding countries’ health situations. The Kigoma RHS asked women about birth certificates issued for their most recent live birth since January 2009. Only 6.4% of all babies were reported to have a birth certificate (Table 5.20). Birth certificates were more common for boys (7.0%), as well as for babies born to women who resided in urban settings (14.9%), had attended secondary education or higher (28.1%), were in the highest wealth tercile (13.3%), and delivered in a health facility (10.1%). Table 5.20: Birth Registration, by Selected Characteristics (Percent) Most Recent Live Births Since January 2009, of Women Aged 15-49 Years   Child Has Birth Certificate (%) Number of Births Sex of baby     Boy 7.0 1,204 Girl 5.8 1,224 Residence     Urban 14.9 438 Rural 4.6 1,990 Age group (yr) at birth     < 25 5.7 842 25-34 7.8 992 35-49 5.1 594 Education level     No education 3.7 705 Some primary 4.6 369 Completed primary 6.1 1,207 Attended secondary or higher 28.1 147 Wealth tercile     Low 3.4 840 Middle 3.4 836 High 13.3 752 Place of delivery     Health facility 10.1 1,234 Home 2.8 1,104 In transit/other/missing 3.4 90 Total 6.4 2,428 Source: 2014 Kigoma Reproductive Health Survey. 5.4 Postnatal The postnatal period, from delivery of the placenta to 42 days (6 weeks) after birth, is an important time period for the health of the mother and the infant. Annually, an estimated 125,000 women and 870,000 newborns worldwide die in the first week after birth.6 Postnatal care is important for identifying and treating complications arising from delivery and for providing the mother with information on how to care for herself and her infant. This critical time period is also when health coverage and programs are often least available compared with antenatal and pregnancy care. Maternal and Perinatal Health 89 Breastfeeding Early initiation of breastfeeding is essential to the health of the newborn. WHO and the United Nations Children’s Fund (UNICEF) recommend exclusive breastfeeding for the first 6 months, and continued breastfeeding, with complementary foods, up to 2 years of age or beyond. In addition, WHO and UNICEF recommend that breastfeeding be initiated within the first hour of life. Nearly all women in Kigoma (98.8%) reported having ever breastfed with their most recent live birth (Table 5.21). The percentage of women who breastfed their newborn during the first day of life was also very high (97.1%), though it was lower for breastfeeding within 1 hour of birth (81.2%). Women with secondary education or higher had the lowest frequency of breastfeeding within the first hour (68.0%). Table 5.21: Breastfeeding, by Selected Characteristics (Percent) Most Recent Live Births Since January 2009, of Women Aged 15-49 Years   Ever Breastfed Most Recent Live Birth (%)  Number of Births Breastfeeding Initiation, Among Ever Breastfed (%) Number of BirthsWithin an Hour Within a Day Sex of baby           Boy 99.0 1,204 78.8 97.2 1,191 Girl 98.6 1,224 83.5 97.1 1,207 Residence           Urban 98.8 438 80.4 96.3 433 Rural 98.8 1,990 81.3 97.3 1,965 Age group (yr) at birth           < 25 98.5 842 81.7 96.7 831 25-34 98.8 992 80.2 97.4 979 35-49 99.1 594 82.0 97.3 588 Education level           No education 99.1 705 82.2 97.5 699 Some primary 98.1 369 80.6 97.5 362 Completed primary 98.7 1,207 82.3 97.2 1,191 Attended secondary or higher 99.5 147 68.0 93.7 146 Wealth tercile           Low 99.0 840 80.9 96.5 832 Middle 98.3 836 83.4 98.0 822 High 99.0 752 78.9 96.8 744 Place of delivery           Health Facility 98.7 1,234 81.1 96.1 1,218 Home 98.9 1,104 82.0 98.1 1,092 In transit/other/missing 98.1 90 72.4 98.0 88 Total 98.8 2,428 81.2 97.1 2,398 Source: 2014 Kigoma Reproductive Health Survey.       90 Chapter 5 Postnatal Care In Tanzania clinical practice, it is recommended that all postpartum women have postnatal checks at 48 hours, 7 days, 28 days, and 42 days. However, only 12.5% of all respondents indicated they received any postnatal checkup within 41 days of delivery (Table 5.22). Women in urban centers (19.7%), those who delivered in a facility (17.1%), those with secondary education or higher (23.5%), and those in the highest wealth tercile (17.6%) reported receiving postnatal checkups more frequently. Women with no education (10.4%), those in the lowest wealth tercile (9.0%), and those who gave birth at home (7.7%) received postnatal checkups least often. Table 5.22: Women’s Postnatal Checkups, by Selected Characteristics (Percent) Births Since January 2009, of Women Aged 15-49 Years Characteristic Received Postnatal Checkup Within 41 Days (%) Number of Births Residence     Urban 19.7 671 Rural 11.1 3,450 Age group (yr) at birth     < 25 12.8 1,597 25-34 13.0 1,706 35-49 10.5 818 Education level     No education 10.4 1,316 Some primary 12.9 617 Primary complete 12.7 1,999 Attended secondary or higher 23.5 189 Wealth tercile     Low 9.0 1,486 Middle 12.0 1,472 High 17.6 1,163 Place of delivery     Health facility 17.1 1,982 Home 7.7 2,002 In transit/other/missing 19.5 137 Total 12.5 4,121 Tanzania 35.4 5,519 Source: 2014 Kigoma Reproductive Health Survey, Comparison: 2010 Tanzania Demographic and Health Survey. Maternal and Perinatal Health 91 Of women who had a postnatal checkup within 41 days of delivery, the checkup was often done within 48 hours of delivery (41.3%), particularly for women with no education (49.5%) compared with women having secondary education or more (23.2%) (Table 5.23). Overall, dispensaries were the most frequent site for postnatal checkups (42.4%) (rural, 48.9%; urban, 22.5%) (Table 5.24). Women with no education, those in the lowest wealth tercile, and those who had home deliveries used dispensaries most frequently (44.8%, 54.9%, and 48.6%, respectively). Table 5.23: Timing of Women’s Postnatal Checkups, According to Selected Characteristics (Percent Distribution) Births Since January 2009, of Women Aged 15-49 Years Receiving a Postnatal Checkup   Postnatal Checkup: Time After Delivery (%)  Number of BirthsWithin 48 Hrs 48 Hrs - 6 Days 7-27 Days 28-41 Days Total Residence             Urban 40.5 15.1 31.5 12.9 100.0 129 Rural 41.6 21.7 29.7 7.0 100.0 397 Age group (yr) at birth             < 25 42.9 16.3 32.0 8.7 100.0 211 25-34 39.8 23.0 29.3 7.9 100.0 226 35-49 41.0 22.5 27.2 9.3 100.0 89 Education level             No education 49.5 22.8 22.5 5.2 100.0 138 Some primary 45.5 17.2 30.9 6.4 100.0 84 Completed primary 38.5 19.9 32.6 9.0 100.0 259 Attended secondary or higher 23.2 17.5 39.6 19.7 100.0 45 Wealth tercile             Low 38.7 23.4 28.3 9.7 100.0 136 Middle 47.8 20.4 25.7 6.0 100.0 183 High 37.4 17.5 35.3 9.7 100.0 207 Place of delivery             Health facility 34.6 18.4 36.1 10.9 100.0 347 Home 49.2 24.6 21.5 4.7 100.0 153 In transit/other/missing 77.4 14.4 8.2 0.0 100.0 26 Total 41.3 20.1 30.2 8.4 100.0 526 Source: 2014 Kigoma Reproductive Health Survey. 92 Chapter 5 Table 5.24: Place of Woman’s Postnatal Checkup, by Selected Characteristics (Percent Distribution) Births Since January 2009, of Women Aged 15-49 Years Receiving a Postnatal Checkup Characteristic Postnatal Checkup Place  Number of Births Kigoma Hospital Kigoma Health Center Kigoma Dispensary Home Other Not in Kigoma Region Total Residence                 Urban 45.1 23.7 22.5 3.0 0.0 5.8 100.0 129 Rural 15.5 15.5 48.9 16.1 0.2 3.7 100.0 397 Age group (yr) at birth                 < 25 24.0 22.4 34.6 11.9 0.0 7.0 100.0 211 25-34 21.1 16.0 47.3 12.9 0.3 2.4 100.0 226 35-49 24.6 8.2 50.4 15.3 0.0 1.5 100.0 89 Education level                 No education 14.8 19.3 44.8 18.5 0.0 2.5 100.0 138 Some primary 23.1 18.1 42.6 11.0 0.0 5.2 100.0 84 Completed primary 22.2 17.4 45.6 11.9 0.2 2.7 100.0 259 Attended secondary or higher 52.2 12.2 15.5 3.4 0.0 16.8 100.0 45 Wealth tercile                 Low 8.6 13.1 54.9 19.0 0.0 4.4 100.0 136 Middle 17.2 14.9 47.0 18.4 0.3 2.1 100.0 183 High 37.4 22.9 30.0 3.9 0.0 5.9 100.0 207 Place of delivery                 Health facility 33.8 21.9 37.7 0.5 0.0 6.0 100.0 347 Home 3.8 7.0 48.6 39.3 0.0 1.2 100.0 153 In transit/other/missing 0.0 25.1 62.6 10.1 2.2 0.0 100.0 26 Total 22.9 17.6 42.4 12.8 0.1 4.2 100.0 526 Source: 2014 Kigoma Reproductive Health Survey. Maternal and Perinatal Health 93 Tanzanian national guidelines also require all neonates to have a checkup within 2 months of birth. Overall, 85.6% of babies had a postnatal checkup within the advised 2-month timeframe (Table 5.25). Boys (86.7%), babies in rural settings (86.1%), and those born to women with secondary education or higher (90.3%) were found to have slightly higher frequencies of postnatal checkups. Table 5.25: Child Received Postnatal Checkup, by Selected Characteristics (Percent) Most Recent Live Births Since January 2009 Where the Baby Survived, of Women Aged 15-49 Years Characteristic Baby Received Postnatal Checkup Within 2 Months of Birth (%) Number of Births Sex of baby     Boy 86.7 1,196 Girl 84.6 1,214 Residence     Urban 83.4 434 Rural 86.1 1,976 Age group (yr) at birth     < 25 86.1 838 25-34 84.5 984 35-49 87.0 588 Education level     No education 83.2 701 Some primary 82.6 365 Completed primary 87.5 1,199 Attended secondary or higher 90.3 145 Wealth tercile     Low 84.1 834 Middle 87.6 829 High 85.1 747 Place of delivery     Health facility 84.1 1,226 Home 86.7 1,095 In transit/other/missing 91.8 89 Total 85.6 2,410 Source: 2014 Kigoma Reproductive Health Survey.   Pregnancy and Delivery Complications Complications from pregnancy and delivery, such as infection, bleeding, and preeclampsia, can occur during the postnatal period. Rapid identification and treatment are critical to saving the life of the mother and preventing morbidity and long-term disability. The Kigoma RHS asked women to list any complications they had in the 6 weeks following delivery. Table 5.26 provides an overview of the complications by key demographic variables. The most frequent complications included pelvic pain (17.5%), high fever (15.2%), painful urination (11.8%), and severe bleeding (11.1%). 94 Chapter 5 Ta bl e 5. 26 : C om pl ic at io ns E xp er ie nc ed W ith in 6 W ee ks o f B irt h, b y Se le ct ed C ha ra ct er is tic s (P er ce nt ) M os t R ec en t B irt hs S in ce Ja nu ar y 2 00 9, o f W om en A ge d 15 -4 9 Ye ar s Ch ar ac te ris tic Se ve re Bl ee di ng Ba d- Sm el lin g Va gi na l Di sc ha rg e In fe ct io n of S ur gi ca l W ou nd Fa in t/ Co m a Hi gh Fe ve r (3 9- 40 C) Pa in fu l Ur in at io n Pa in fu l Ut er us (P el vi c Pa in ) Br ea st In fe ct io n Co nt in uo us L ea ki ng fro m V ag in a Ot he r Nu m be r o f Bi rth s of U rin ea of F ec es a Re si de nc e                         Ur ba n 9. 4 4. 2 1. 2 2. 6 16 .4 12 .3 19 .7 1. 8 0. 7 0. 0 1. 6 43 2 Ru ra l 11 .5 6. 7 0. 8 1. 9 14 .9 11 .7 17 .1 2. 8 0. 8 0. 3 1. 0 1, 97 8 Ag e gr ou p (y r) a t b irt h                        < 25 9. 5 6. 2 1. 4 1. 6 17 .0 14 .3 16 .8 3. 5 0. 7 0. 3 0. 8 83 8 25 -3 4 11 .7 6. 6 0. 7 2. 2 14 .5 11 .3 19 .2 2. 2 1. 0 0. 1 1. 3 97 2 35 -4 9 12 .8 5. 7 0. 4 2. 6 13 .3 8. 3 15 .8 2. 1 0. 6 0. 2 1. 5 60 0 Ed uc at io n le ve l                         No e du ca tio n 12 .4 6. 4 0. 5 1. 9 13 .2 10 .5 17 .3 2. 3 1. 3 0. 2 0. 9 69 7 So m e pr im ar y 12 .8 8. 5 0. 7 3. 6 18 .3 12 .9 21 .4 3. 2 0. 5 0. 2 0. 8 36 9 Co m pl et ed p rim ar y 10 .4 5. 8 0. 9 1. 5 14 .9 11 .2 15 .8 3. 0 0. 5 0. 2 1. 4 1, 19 8 At te nd ed s ec on da ry or h ig he r 6. 6 3. 1 3. 0 2. 9 19 .3 20 .1 22 .9 0. 0 1. 6 1. 0 1. 1 14 6 W ea lth te rc ile                         Lo w 12 .5 7. 5 0. 2 2. 1 16 .3 12 .8 16 .7 2. 5 0. 9 0. 3 0. 7 83 4 M id dl e 12 .5 6. 2 1. 0 2. 3 15 .6 10 .8 18 .4 3. 5 0. 9 0. 3 1. 4 82 9 Hi gh 8. 0 4. 8 1. 4 1. 7 13 .4 11 .8 17 .4 1. 9 0. 6 0. 1 1. 4 74 7 Pl ac e of d el iv er y                         He al th fa ci lit y 11 .5 5. 9 1. 7 2. 8 15 .7 13 .3 17 .9 1. 8 1. 1 0. 2 1. 1 1, 22 5 Ho m e 10 .4 6. 3 0. 0 1. 4 14 .9 10 .4 17 .2 3. 6 0. 5 0. 2 1. 2 1, 09 4 In tr an si t/o th er / m is si ng 14 .4 9. 3 0. 0 0. 0 10 .8 8. 7 16 .2 1. 3 0. 0 0. 0 0. 0 91 To ta l 11 .1 6. 3 0. 9 2. 0 15 .2 11 .8 17 .5 2. 7 0. 8 0. 2 1. 1 2, 41 0 So ur ce : 2 01 4 Ki go m a R ep ro du cti ve H ea lth S ur ve y. a Le ak in g fro m va gi na , i nd ica tin g th at th e w om an h ad an o bs tet ric fi stu la th at wa s c au se d by p ro lo ng ed la bo r. Maternal and Perinatal Health 95 Family Planning Counseling (Receipt, Location, Timing) Family planning is an essential reproductive health service. According to WHO, “Family planning allows spacing of pregnancies and can delay pregnancies in young women at increased risk of health problems and death from early childbearing, and can prevent pregnancies among older women who also face increased risks. Family planning enables women who wish to limit the size of their families to do so. Evidence suggests that women who have more than four children are at increased risk of maternal mortality.” 7 Overall, 74.1% of women reported receiving family planning counseling during their most recent pregnancy or postpartum period. A higher percentage of women in urban (81.4%) than rural settings (72.5%) reported receiving family planning counseling (Table 5.27). Women younger than age 25, those with less education, and those in the lowest wealth tercile reported receiving counseling less frequently. Table 5.27: Family Planning Counseling During Pregnancy (Including After Delivery), by Selected Characteristics (Percent) Most Recent Births Since January 2009, of Women Aged 15-49 Years Characteristic Received Family Planning Counseling (%) Number of Births Residence     Urban 81.4 432 Rural 72.5 1,978 Age group (yr) at birth     < 25 67.8 838 25-34 78.2 972 35-49 77.4 600 Education level     No education 68.9 697 Some primary 69.0 369 Completed primary 78.5 1,198 Attended secondary or higher 76.6 146 Wealth tercile Low 70.2 834 Middle 74.3 829 High 78.3 747 Place of delivery     Health facility 77.3 1,225 Home 70.1 1,094 In transit/other/missing 80.2 91 Total 74.1 2,410 Source: 2014 Kigoma Reproductive Health Survey. 96 Chapter 5 Women who received family planning counseling were asked to recount when they received the counseling: during ANC, at the time of delivery, or at the postpartum checkup. Women could select all time periods that were applicable. The majority of women received family planning counseling during ANC (82.0%), more than a quarter received counseling in the postpartum checkup (28.1%), and a very low percentage of women (2.0%) received counseling at the time of delivery (Table 5.28). More rural than urban women reported receiving family planning counseling during the antenatal period (84.0% and 73.9%, respectively); more women aged 35-49 years (84.1%) reported receiving such counseling compared with younger women (79.7%). Conversely, as wealth increased, family planning counseling in the antenatal setting declined. A greater percentage of urban women reported receiving postpartum family planning counseling (40.8%), compared with rural women (25.1%). This was also true for women delivering in health facilities (32.6%) compared with those who delivered at home (23.6%). Table 5.28: Timing of Family Planning Counseling Received During Pregnancy or After Delivery, by Selected Characteristics (Percent) Most Recent Births Since January 2009 that Received Family Planning Counseling During Pregnancy, of Women Aged 15-49 Yearsa Characteristic Timing of Counseling Received (%) Number of BirthsAntenatal Care Time of Delivery Postpartum Checkup Residence         Urban 73.9 1.5 40.8 348 Rural 84.0 2.1 25.1 1,454 Age group (yr) at birth         < 25 79.7 2.0 29.0 579 25-34 82.8 1.5 27.7 758 35-49 84.1 2.7 27.5 465 Education level         No education 85.4 1.6 23.3 485 Some primary 80.0 2.4 29.9 261 Completed primary 82.3 2.1 28.7 943 Attended secondary or higher 69.8 1.5 40.7 113 Wealth tercile         Low 86.0 1.2 24.2 592 Middle 83.2 2.9 27.1 621 High 76.8 1.7 33.1 589 Place of delivery         Health Facility 78.4 2.5 32.6 947 Home 85.2 1.5 23.6 783 In transit/other/missing 94.7 0.0 18.9 72 Total 82.0 2.0 28.1 1,802 Source: 2014 Kigoma Reproductive Health Survey. a Excludes three women who did not remember the timing. Maternal and Perinatal Health 97 Among women who reported receiving postnatal family planning counseling for their most recent births since 2009, the most common location for both urban and rural women (44.0% and 78.2%, respectively) was a dispensary (Table 5.29). However, many urban residents received postnatal family planning counseling at Kigoma Region hospitals (34.3%) and health centers (22.8%). Women with secondary education or higher and those in the highest wealth tercile tended to receive postnatal family planning counseling at hospitals, and women in the lower educational and wealth terciles tended to receive counseling at dispensaries. Table 5.29: Place Where Postpartum Family Planning Counseling Was Received, by Selected Characteristics (Percent) Most Recent Births Since January 2009 that Received Postpartum Family Planning Counseling, of Women Aged 15-49 Yearsa   Kigoma Hospital (%) Kigoma Health Center (%) Kigoma Dispensary (%) Total Number of Births Residence         Urban 34.3 22.8 44.0 134 Rural 11.6 10.1 78.2 393 Age group (yr) at birth         < 25 21.0 1

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