Bangladesh - Demographic and Health Survey - 1994

Publication date: 1994

Demographic and Health Survey 1993-1994 NIPIIII~T National Institute of Population Research and Training (NIPORT) Ministry of Health and Family Welfare lib Mitra and Associates ®DHS Demographic and Health Surveys Macro International Inc. Bangladesh Demographic and Health Survey 1993-1994 S. N. Mitra M. Nawab Ali Shahidul Islam Anne R. Cross Tulshi Saha National Institute of Population Research and Training (NIPORT) Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh Macro International Inc. Calverton, Maryland USA December 1994 This report summarizes the findings of the 1993-94 Bangladesh Demographic and Health Survey (BDHS) conducted by Mitra and Associates under the authority of the National Institute of Population Research and Training (NIPORT) under the Ministry of Health and Family Welfare, Government of Bangladesh. Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development office m Dhaka (USAID/Bangladesh) and the Government of Bangladesh. The BDHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information about the Bangladesh survey may be obtained from Mitra and Associates at 2/17 Iqbal Road, Block A, Mohammadpur, Dhaka, Bangladesh (Telephone: 818-065; Fax: c/o 832-915) or from NIPORT, Azimpur, Dhaka, Bangladesh (Telephone: 507-866; Fax: 863- 362). Additional information about the DHS program may be obtained by writing to: DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (Telephone: 301-572-0200; Fax: 301-572-0999). Recommended citation: Mitra, S.N., M. Nawab Ali, Shahidul Islam, Anne R. Cross, and Tulshi Saha. 1994. Bangladesh Demographic and Health Survey, 1993-1994. Calverton, Maryland: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc. CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv 1993-94 BDHS Technical Review Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Map of Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi CHAPTER 1.1 1.2 1.3 1.4 1.5 1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Geography and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Population, Family Planning and Maternal and Child Health Policies and Programs . . 3 Objectives of the 1993-94 Bangladesh Demographic and Health Survey . . . . . . . . . . . . 5 Survey Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 CHAPTER 2 2.1 2.2 2.3 CHARACTERIST ICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . . . 9 Characteristics of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Background Characteristics of Women Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . 18 CHAPTER 3 FERT IL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.2 Fertility Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.3 Fertility Differentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.4 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.5 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.6 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3.7 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.8 Teenage Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 CHAPTER 4 4.1 4.2 4.3 4.4 4.5 4.6 FERT IL ITY REGULAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Knowledge of Contraception and Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Ever Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Number of Children at First Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Family Planning Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Problems with Current Method of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 iii Page 4.7 Reasons for Selecting Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.8 Pill Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 4.9 Condom Brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 4.10 Timing of Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 4. I 1 Sterilization Regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 4.12 Source of Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.13 Contraceptive Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4.14 Nonuse of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 4.15 Family Planning Outreach Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 CHAPTER 5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 OTHER PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . . 71 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Marital Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Postpartum Amenorrhea and Insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 CHAPTER 6 6.1 6.2 6.3 6.4 FERTILITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 CHAPTER7 7.1 7.2 7.3 7.4 7.5 INFANT AND CHILD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Levels and Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Socioeconomic Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . 94 Demographic Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . 95 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 CHAPTER 8 8.1 8.2 8.3 8.4 8.5 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Childhood Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Childhood Illness and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Infant Feeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 15 iv CHAPTER 9 9.1 9.2 9.3 9A Page RESULTS OF THE HUSBANDS SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Background Characteristics of Husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Knowledge and Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Couples' Attitudes Towards Family Planning Use . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Fertility Preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 CHAPTER 10 AVAILABIL ITY OF HEALTH AND FAMILY PLANNING SERVICES . . . 119 10.1 Community Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 CHAPTER 11 11.1 11.2 11.3 11.4 IMPL ICAT IONS FOR POL ICY AND STRATEGIES . . . . . . . . . . . . . . . . . . . 133 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Family Planning Services Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 APPENDIX A SURVEY IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 APPENDIX B EST IMATES OF SAMPL ING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 APPENDIX C C.1 C.2 C.3 DATA QUAL ITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Age Reporting and Completeness of Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 APPENDIX D QUEST IONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 V TABLES Table 1.1 Table 2.1 Table 2.2 Table 2.3 Table 2A. 1 Table 2.4.2 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 2.11 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 Table 3.11 Table 3.12 Table 3.13 Table 3.14 Table 3.15 Table 4.1 Table 4.2 Page Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Educational level of the male household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Educational level of the female household population . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Employment status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Household durable goods and agricultural land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Trends in current fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Trends in total fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Trends in fertility by division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Percent pregnant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Age-specif ic fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Trends in children ever bom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Teenage pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Children born to teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Knowledge of contraceptive methods and source for methods . . . . . . . . . . . . . . . . . . . . 39 Trends in knowledge of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 vii Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 4.19 Table 4.20 Table 4.21 Table 4.22 Table 4.23 Table 4.24 Table 4.25 Table 4.26 Table 4.27 Table 4.28 Table 4.29 Table 4.30 Table 4.31 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Page Differentials in knowledge of contraceptive methods and source for methods . . . . . . . . 41 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Trends in ever use of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Current use of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Trends in current use of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Current use of family planning by background characteristics . . . . . . . . . . . . . . . . . . . . 47 Trends in current use of family planning methods by division . . . . . . . . . . . . . . . . . . . . 49 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Family planning decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Problems with current method of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Reason for using current method of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Use of pill brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Use of social marketing brand pills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Quality of pill use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Action taken if forgot to take the pill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Cost of pills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Use of condom brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 T iming of sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Sterilization regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Reasons for discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Preferred method of contraception for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Exposure to family planning messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Acceptability of media messages on family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Contact with family planning field workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Satellite clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Trends in proportion never married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Marital exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 viii Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 7.1 Table 7.2 Table 7.3 Table 7A Table 7.5 Table 8.1 Table 8.2 Table 8.3 Table 8A Table 8.5 Table 8.6 Table 8.7 Table 8.8 Table 8.9 Table 8.10 Table 8.11 Table 8.12 Table 8.13 Table 8.14 Table 8.15 Page Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Recent sexual activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Postpartum amenorrhea, abstinence and insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . 77 Median duration of postpartura insusceptibility by background characteristics . . . . . . . 78 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . . . . 89 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Trends in infant mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . 94 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . 96 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Number of antenatal care visits andstage of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 101 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . . . . . . 111 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Treatment with vitamin A capsules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Breastfeeding and supplementation by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 ix Table 9.1 Table 9.2 Table 9.3 T~ble 9A T~ble 9.5 T,~ ble 9.6 Ttble 9.7 T~ble 9.8 Table 9.9 Table 9.10 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table A. 1 Table B. 1 Table B.2 Table B.3 Table BA Table B.5 Table B.6 Table B.7 Table B.8 Table B.9 Table C.I Table C.2 Table C.3 Table C.4 Table C.5 Table C.6 Table C.7 Page Background characteristics of husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Age differences between spouses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Knowledge of family planning methods among married couples . . . . . . . . . . . . . . . . . 122 Current use of family planning among husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Comparison of reported contraceptive use by spouses . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Attitudes of couples towards family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Spouses' perceptions of approval of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Fertility preferences of husbands by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Desire for more children among couples by number of living children . . . . . . . . . . . . . 127 Spouses' agreement on ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Distance to public services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Presence of income-generating organizations in cluster . . . . . . . . . . . . . . . . . . . . . . . . 130 Preserce of health and family planning field workers and services in the community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Presence of government and non-governmental family planning field workers . . . . . . 132 Sample implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 List of selected variables for sampling errors, Bangladesh 1993-94 . . . . . . . . . . . . . . . 153 Sampling errols National sample, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . 154 Sampling errors Urban sample, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sampling errols Rural sample, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Sampling errors Barisal, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Sampling errors Chittagong, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Sampling errors Dhaka, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Sampling errors - Khulna, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Sampling errors - Rajshahi, Bangladesh 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Births by Westem calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Births by Bangla calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 FIGURES Figure2.1 Hguro2.2 ~gure2.3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 5.1 Figure 6.1 Figure 6.2 Figure 6.3 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7,4 Figure 8.1 Figure 8.2 Page Population Pyramid, Bangladesh, 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Distribution of De Facto Household Population by Single Year of Age . . . . . . . . . . 11 Percentage of Males and Females Who Have No Formal Education by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Age-Specific Fertility Rates By Urban-Rural Residence . . . . . . . . . . . . . . . . . . . . . . 25 Total Fertility Rates by Selected Background Characteristics . . . . . . . . . . . . . . . . . . 26 Age-Specific Fertility Rates 1989, 1991, and 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . 28 Trends in the Total Fertility Rate From Selected Sources, Bangladesh, 1980-1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Trends in the Total Fertility Rate from Matlab (Treatment and Comparison Areas) and the BDHS, 1982-1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Trends in Contraceptive Use among Currently Married Women 10-49, from Selected Sources, Bangladesh, 1975 to 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Trends in Modem Contraceptive Use among Currently Married Women 10-49, from Selected Sources, Bangladesh, 1975 to 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . 46 Current Use of Contraception among Currently Married Women 10-49 by Selected Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Trends in Market Share of Specific Pill Brands among Current Pill Users, Selected Sources, 1975 to 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Percent Distribution of Current Users of Modem Methods by Most Recent Source of Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Trends in Proportion of Women Never Married for Age Groups 15-19 and 20-24, Selected Sources, Bangladesh, 1975 to 1993-94 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Fertility Preferences of Currently Married Women 10-49 . . . . . . . . . . . . . . . . . . . . . 82 Fertility Preferences of Married Women by Number of Living Children . . . . . . . . . 83 Percentage of Married Women with 2 Children Who Want No More Children, by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Trends in Infant and Child Mortality Bangladesh, 1979-1993 . . . . . . . . . . . . . . . . . . 92 Infant Mortality Rates from Selected Sources, Bangladesh, 1981-1991 . . . . . . . . . . 93 Under-Five Mortality by Selected Background Characteristics . . . . . . . . . . . . . . . . . 95 Under-Five Mortality by Selected Demographic Characteristics . . . . . . . . . . . . . . . . 96 Percent Distribution of Births by Number of Antenatal Care Visits and Timing of First Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Vaccination Coverage Among Children Age 12-23 Months . . . . . . . . . . . . . . . . . . 107 xi Figure 8.3 Figure 8.4 Figure 9.1 Figure C.1 Page Percentage of Children Age 12-23 Months Who Are Fully Immunized, by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Percentage of Children under 3 Who Received Various Treatments for Diarrhea in the Two Weeks Preceding the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Percent Distribution of Couples by Fertility Desires . . . . . . . . . . . . . . . . . . . . . . . . 127 Births by Calendar Year, Bangladesh, 1983-1993 . . . . . . . . . . . . . . . . . . . . . . . . . . 170 xii Secretary, Ministry of Health & Family Welfare Government of the People's Republic of Bangladesh FOREWORD The Contraceptive Prevalence Surveys conducted during the period from 1979 to 1991 provided rapid feedback to policymakers and program managers on the status of implementation of programs. This information helped to formulate corrective measures on current program issues and to develop future policies and plans. A more comprehensive study, the Bangladesh Demographic and Health Survey (BDHS) was conducted in 1993-94. This study provides information on basic national indicators of social progress, including fertility, mortality, contraceptive behavior, and matemal and child health. BDHS data indicate a steady decline in fertility and infant mortality and a steady increase in contraceptive knowledge and use. In addition, results show that a substantial number of Bangladeshi women are either currently spacing or limiting their births or desire to do so. A small family norm thus appears to have taken root in Bangladesh. Policymakers, program managers, and family planning personnel at the grass roots level can take great pride in this achievement. Mitra and Associates, a private Bangladeshi research firm, was given the responsibility for conducting the Demographic and Health Survey 1993-94 under the auspices of the National Institute of Population Research and Training (NIPORT). I am happy to note that they have completed the task with professional excellence. A Technical Review Committee was constituted by the Govemment of Bangladesh through NIPORT. The Technical Review Committee included representatives from the Govemment, nongovernmental organiza- tions (NGOs), USAID/Bangladesh, and prominent Bangladeshi researchers---another example of the close cooperation between the Government, NGOs, donors and research communities in the health and family planning sector. I thank all parties for this excellent report, the findings of which will be useful in setting the direction and priorities of future programs. (Syed Ahmed) xiii PREFACE I am pleased to introduce the final report of the Bangladesh Demographic and Health Survey (BDHS), 1993-94. The BDHS is the first of this kind of study conducted in Bangladesh. It provides rapid feedback on key demographic and programmatic indicators to monitor the strengths and weaknesses of the national family planning/MCH program. The wealth of information collected through the 1993-94 B DHS will be of immense value to the policymakers and program managers in order to strengthen future program policies and strategies. The Technical Review Committee t'TRC) was composed of members with professional expertise in the field of population/family planning research. Its membership was drawn from the Govemment, non- governmental organizations, donor agencies and individual researchers. The professional contribution of the TRC members in major phases of the study helped to ensure the collection of relevant information that is needed to highlight the present status of programs and to provide future program directions. The preliminary results of the 1993-94 BDHS, with its major findings, were released in a dissemina- tion seminar held in July 1994. This final report contains more detailed information about both demographic and programmatic issues. On behalf of the BDHS Technical Review Committee, I express my heartfelt thanks to all officers of Mitra and Associates and also to the professional staffof NIPORT for their hard work in completing this study on time and with professional excellence. A.K.M. Rafiquz-Zaman Director General National Institute of Population Research and Training (NIPORT) Ministry of Health and Family Welfare October 1994 XV 1993-94 BDHS TECHNICAL REVIEW COMMITTEE Mr. A.K.M. Rafiquz-Zaman, Director General, NIPORT Mr. B.R. Chaudhury, Ex-Director General, N1PORT Mr. Khairuzzaman Chowdhury, Director General, Directorate of Family Planning Mr. Muhd. Azizul Karim, Joint Chief, Ministry of Health and Family Welfare Mr. M. Nawab Ali, Director (Administration), Directorate of Family Planning Dr. Ahmed A1-Sabir, Director (Research), NIPORT Mrs. Farkunda Akhter, Director (MIS), Directorate of Family Planning Mr. Md. Bazlur Rahman, Director (PDEU), IMED, Planning Commission Mr. Md. Shahadat Hossain, Director, HDS, BBS Dr. Syed Jahangeer Haider, Executive Director, READ Dr. Barkat-e-Khuda, Director, MCH-FP Extension Project, ICDDR,B Dr. M. Alanddin, Country Representative, Pathfinder International Dr. Abbas Bhuiyan, Demographer, ICDDR,B Dr. M. Kabir, Professor~ Department of Statistics, Jahangeernagar University Dr. Lokky Wai, Director, Monitoring Unit, CIDA Mr. S.N. Mitra, Executive Director, Mitra & Associates Mr. SK. All Noor, Head, Research Division, OPH, USAID/Bangladesh Mr. J.S. Kang, Population Specialist, World Bank Dr. Kanta Jamil, Demographer, OPH, USAID/Bangladesh Dr. Aye Aye Thwin, Research Adviser, GTZ xvii ACKNOWLEDGMENTS The authors of this report would like to thank Mr. Keith Purvis for writing the computer programs, setting up the data processing operation, and producing the tabulations, and Ms. Thanh L~ for her work in designing and selecting the sample. They would also like to acknowledge the following reviewers: Dr. Ann Blanc, Ms. Kaye Mitchell, Dr. Sidney Moore, Dr. Shea Rutstein, and Dr. Kate Stewart. It is also important to acknowledge the contribution of the following BDHS staff: Mr. A.B. Siddique Mozumder, Mr. N.C. Barman, Mr. Jahangir Hossain Sharif, Mr. Marful Alam, Ms. Sayera Banu, Mr. Shishir Paul, Mr. Haradhan Sen, and Mr. Suyeb Hussain. Chapter 11 was written by Dr. Kim Streatfield, Dr. S. Jahangeer Haider, and Mr. S.R. Chowdhury. xix SUMMARY OF FINDINGS The 1993-94 Bangladesh Demographic and Health Survey (BDHS) is a nationally-representative survey of 9,640 ever-married women age 10-49 and 3,284 of their husbands. The BDHS was designed to provide information on levels and trends of fertility, family planning knowledge and use, infant and child mortality, and maternal and child health. Fieldwork for the BDHS took place from mid-November 1993 to mid-March 1994. Survey data show that significant progress has been made toward achieving the goals of reducing fertility, increasing contraceptive use, and reducing childhood mortality; however, many challenges still await. FERTILITY Fertil ity Decline. BDHS data indicate that the previously documented rapid decline in fertility in Bangladesh is not only continuing, but probably accelerating. The total fertility rate has declined from 6.3 births per woman in the mid-70s to 3.4 births for the period 1991-93. Since 1989-91, fertility has declined from 4.3 to 3.4 births per woman, a drop of 21 percent in a two-year period. This is the most dramatic drop in fertility ever recorded in Bangladesh. BDHS data indicate that the decline in fertility has occurred among all age groups of women and in all five administrative divisions of the country at almost the same rate. Fertility Differentials. Although the rate of fertility decline has been generally uni form across groups, significant differences in fertility levels still exist. For example, fertility is considerably higher in Chittagong Division, with a total fertility rate of 4.0 births per woman, than in Rajsbahi and Khulna Divisions, with a rate of around 3.0 births per woman. Barishal and Dhaka Divisions have intermediate levels of fertility (3.5 births per woman). Moreover, fertility is about 30 percent higher in rural areas than in urban areas, a pattem that has persisted in various censuses and demographic surveys that have been carried out in the country. Fertility levels are closely related to women's education. Women with no formal education give birth to an average of 3.8 children in their lifetime, compared to 2.6 for women with at least some secondary education, a difference of 33 percent. Women with either incomplete primary or complete primary education have intermediate fertility rates. Age at First Birth. Although increased contraceptive use undoubtedly accounts for most of the decline in fertility, increasing age at first birth has also had an impact. The age at which Bangladeshi women have their first child has been increasing steadily, paralleling increases in age at marriage. For example, in 1975, the median age at first birth among women age 20-24 was 16.8; in 1989, it had risen to 18.0 and, by 1993-94, to 18.3. Increases of similar magnitude have occurred for other age cohorts. Despite the trend toward later age at first birth, childbearing still begins early in Bangladesh, with the large majority of women becoming mothers before they reach the age of 20. One in three teenage women (age 15-19) is already a mother or pregnant with her first child. Although data from 1991 indicate that there has been a slight decline over time, early childbearing in Bangladesh remains a challenge to policymakers. BDHS data shows that children bom to young mothers suffer higher rates of morbidity and mortality. Small Family Norm. BDHS data indicate that Bangladeshi couples have accepted the small family norm. Fifty-six percent of ever-married women prefer a two-child family, and another 24 percent consider a three-child family ideal, while only one percent of respondents said they would choose to have six or more children. Overall, the mean ideal family size among currently married women is 2.5 children, which is a xxi decline from 2.9 in 1989. BDHS data also indicate a high degree of agreement between husbands and wives as to fertility preferences. The proportion of women who want to stop childbearing has increased substantially in Bangladesh over the past decade. For example, the percentage of women with two children who want no more children has risen from only 39 percent in 1991 to 50 percent in 1993-94. Half of all currently married women age 10-49 in Bangladesh say they want no more children and 12 percent either have been sterilized or say that they cannot have any more children. An additional 22 percent say they would like to wait two or more years before having their next birth. Thus, the vast majority of women want either to space their next birth or to limit childbearing altogether. These women can be considered to be potentially in need of family planning services. Unplanned Fertility. Despite the relatively high and increasing level of contraceptive use, BDHS data indicate that unplanned pregnancies are still common. Overall, about one-third of births in the three years prior to the survey were reported to be unplanned; 20 percent were mistimed (wanted later) and 13 percent were unwanted. If unwanted births could be eliminated altogether, the total fertility rate in Bangladesh would reach the replacement level of 2.1 births per woman instead of the actual level of 3.4. FAMILY PLANNING Increasing Use of Contraception. A major cause of declining fertility in Bangladesh has been the steady increase in contraceptive use over the last two decades. The contraceptive prevalence rate has increased almost sixfold since 1975, from 8 to 45 percent of married women. Use of modem methods has grown even faster. Between 1991 and 1993-94, contraceptive use increased from 40 to 45 percent of married women and use of modem methods rose from 31 to 36 percent. Overall, there has been a steady growth in the contraceptive prevalence rate with an average increase of about two percentage points a year. Pill Dominated Method Mix. In terms of "method mix," the dominant change since the late 1980s has been the large increase in the number of couples using oral contraception. The proportion of married women relying on the pill almost doubled in the last four years, from 9 in 1989 to 17 percent in 1993-94 and the pill now accounts for40 percent of all contraceptive use. Conversely, use of female and male sterilization has stagnated or declined slightly since 1989 and now accounts for only 20 percent of all contraceptive use. This shift away from permanent methods to modem reversible methods has important implications for the family planning program in terms of cost, supply logistics, and method efficacy and is especially important given the increasing proportion of women who say they want no more children. Aside from the pill and sterilization, use of injection, condoms, the IUD, periodic abstinence (rhythm method) and withdrawal have increased slightly since 1991, but none is used by more than 5 percent of married women. Differentials in Family Planning Use. Differentials in current use of family planning by the five administrative divisions of the country are large and indicate that Chittagong Division is still lagging. More than half of the married women in Khulna (55 percent) and Rajshahi (55 percent) Divisions and slightly less than half in Barisal Division (48 percent) are current users. In contrast, less than one-third (29 percent) of the married women in Chittagong Division are using a method of contraception. Intermediate ~s Dhaka Division with a contraceptive prevalence rate of 44 percent. Over the past decade, surveys have consistently shown a significantly lower rate of contraceptwe use among women in Chittagong Division and a generally higher rate among women in Rajshahi Division. Knowledge of Contraception. Knowledge of contraceptive methods and supply sources has been xxii almost universal in Bangladesh for some time and the BDHS results confirm this fact. For example, results indicate that just slightly less than 100 percent of currently married women age 10-49 know at least one method of family planning. Knowledge of the pill, female sterilization, and injection is almost universal, while more than 4 out of 5 married women know the IUD, condom, and male sterilization. Considering traditional methods, periodic abstinence is more widely known than withdrawal (65 vs. 50 percent of currently married women). Knowledge about sources of supply for family planning methods is also widespread in Bangladesh. Almost all currently married women are aware of a source of a modem method. Moreover, B DHS data reveal that there are no significant differences in knowledge of methods and their sources of supply by background characteristics of currently married women. Knowledge of at least one method, particularly a modem method, is universal among both urban and rural women, among women in all five divisions, and across all categories of educational attainment. These results regarding family planning knowledge imply that little more can be done to improve general awareness of methods and sources and that further education and communication activities should focus on either increasing motivation to use and/or increasing the depth of knowledge of methods and dispelling rumors that may inhibit their wider use. Family Planning Messages. One reason for the high level of contraceptive awareness is that family planning messages are prevalent. Almost half o f the women interviewed reported that they had heard or secn a family planning message in the month prior to the survey. Radio is a more effective medium than television, billboards or posters, which is related to the limited electrical coverage and low female literacy in Bangladesh. Two in five women had heard a family planning message on the radio in the month before the interview, compared with less than one in five who had seen a message on television. Moreover, almost all women who had seen a family planning message on television had also heard a radio message. Less than one in ten women saw a family planning message on a billboard or poster in the month before the interview. Initiation of Contraceptive Use, There is evidence that the family planning program has been successful in encouraging women to initiate contraceptive use earlier in their reproductive lives. BDHS data indicate that over 40 percent of married teenage women have already used a family planning method at some time. Moreover, survey results show that younger women are much more likely than older women to have started using contraception before having any children. These two findings imply that young women are more likely to use contraception to space births, while older women use it to limit births. Unmet Need for Family Planning. Unmet need for family planning services has declined considerably since 1991. Data from 1991 show that 28 percent of currently married women were in need of services, compared with 19 percent in the 1993-94 BDHS. Just over half of the unmet need is comprised of women who want to space their next birth, while just under half is for women who want do not want any more children (limiters). I f all women who say they want to space or limit their children were to use methods, the contraceptive prevalence rate could be increased from 45 percent to 65 percent of married women. Currently, 70 percent of this "total demand" for family planning is being met. Correct Use of Pill. Pill users are generally complying with accepted standards for use. All but a small fraction were able to show interviewers a pill packet, almost all of which indicated that the pills were being taken in sequence. Moreover, almost all pill users said they had taken a pill in the last two days and two-thirds knew what to do if they forgot to take a pill for two days. Discontlnuation Rates. One challenge for the family planning program is to reduce the high levels of contraceptive discontinuation. BDHS data indicate that half of contraceptive users in Bangladesh stop using within 12 months of starting; one-fifth of those who stop do so as a result of side effects or health concems with the method. Discontinuation rates vary by method. Not surprisingly, the rates for the condom xxiii (72 percent) and withdrawal (55 percent) are considerably higher than for the IUD (37 percent) and the pill (45 percent). However, discontinuation rates for injection are relatively high, considering that one dose is usually effective for three months. Fifty-eight percent of injection users discontinue within one year of starting, a rate that is higher than for the pill. A sizeable proportion of women using injection, female sterilization, the IUD and the pill reported having health problems with their methods. Common complaints were feeling weak or tired and having headaches. Availability of Services. Health and family planning services are widely available in Bangladesh. BDHS data indicate that 97 percent of ever-married women live in areas covered by family planning field workers and the vast majority also have health workers and satellite clinics available. Social Marketing. After a decline between 1989 and 1991 in the proportion of both pill and condom users supplied through the Social Marketing Company, market share has been increasing slightly for pills and substantially for condoms. In 1993-94, 14 percent of pill users were using social marketing brands, up slightly from 1991. The proportion of condom users using social marketing brands dropped from 62 percent in 1989 to 41 percent in 1991 and then rebounded to 52 percent in 1993-94. Family Plamfing Field Workers. Field workers are providing a slightly larger share of family planning services now than in 199142 percent of modem method users in 1993-94 vs. 38 percent in the 1991 CPS. This no doubt reflects the fact that most of the increase in modem method use since 1991 is due to increased use of the pill, which is distributed primarily by field workers. The proportion of services provided through either pharmacies or shops has remained steady since 1991. Although still not a major source of family planning services, satellite clinics have gained slightly in importance, due ahnost entirely to an increase in the proportion of injection users who obtain services there. Field Worker Visitation. Despite the impressive coverage in placement of family planning field workers, survey data show only a slight increase in field worker visitation rates over time. In 1993-94, 38 percent of currently married women said they had been visited by a family planning field worker in the previous six months, up from 36 percent in 1991. Some women are more likely than others to have been visited by a field worker. Younger and older women are less likely to have been visited, presumably because they are either more likely to want to get pregnant or to be either infccund or sterilized. Women in Chittagong and Dhaka Divisions are less likely and those in Khulna Division more likely to have been visited by a field worker than women in Barisal or Rajshahi Divisions. MATERNALAND CHILD HEALTH Declining Childhood Mortality. Survey results indicate an improvement in child survival since the early 1980s. Under-five mortality has declined from 180 deaths per 1,000 births in the period 10-14 years before the survey (approximately 1979-82) to 133 for the period 0-4 years before the survey, a decline of 26 percent. The infant mortality rate declined by 25 percent over the same period (from 117 to 87 per 1,000 births). Further evidence of a decline in childhood mortality comes from a comparison of data from the 1993- 94 BDHS with previous data sources, which shows a general downward trend. Under-five mortality has declined from almost 190 deaths per 1,000 births in 1979-83 to 133 for the period 1989-93. Although encouraging, the BDHS rates show that almost one in seven children born in Bangladesh dies before reaching the fifth birthday, an indication that there is still much improvement to be made. Childhood Vaccinatlon Coverage. One possible reason for the declining mortality is improvement in childhood vaccination coverage. The BDHS results show that 59 percent of children 12-23 months are xxiv fully vaccinated, a vast improvement from less than 20 percent in a 1989 survey. Nonetheless, a large proportion of children obtain one or two vaccinations but fail to complete the full course. If dropout rates could be reduced, the level of full coverage could be improved still further. Childhood Health. The BDHS provides some data on childhood illness and treatment. Approximate- ly one in four children underage three had a respiratory illness in the two weeks before the survey. Of these, over one-fourth were taken to a health facility for treatment. Thirteen percent of children under three were reported to have had diarrhea in the two weeks preceeding the survey. The fact that almost three-quarters of children with diarrhea received some sort of oral rehydration treatment (fluid made from an ORS packet, recommended home fluid, or increased fluids) is encouraging. Also notable is the fact that half of children under age three received a Vitamin A capsule in the six months prior to the survey. Breastfeedlng Practices. The BDHS results document an exceptionally long duration of breastfeed- ing, with a median duration of over 35 months. Although breastfeeding has beneficial effects on both the child and the mother, BDHS data indicate that supplementation of breastfeeding with other liquids and foods occurs too early in Bangladesh. For example, among newborns less than two months of age, one-quarter we re already receiving supplemental foods or liquids. One in ten of these very young babies are given infant formula. Among children age 2-3 months, about half were exclusively breastfed and half were being given supplements. Maternal Health Care. BDHS data point to several areas regarding maternal health care in which improvements could be made. Results show that most Bangladeshi mothers do not receive antenatal care. Among births that occurred in the three years before the survey, almost three-quarters (73 percent) received no antenatal care during pregnancy. Moreover, 96 percent of births in Bangladesh are delivered at home and 60 percent are assisted by traditional birth attendants. Less than 10 percent of births are assisted by medically trained personnel. Proper medical attention during pregnancy and hygienic conditions during delivery can reduce the risk of complications and infections that can cause death or serious illness for either the mother or the newborn. Somewhat more encouraging is the fact that tetanus toxoid coverage is relatively widespread in Bangladesh. For two-thirds of births, the mothers received a tetanus toxoid injection during pregnancy. XXV @ INDIA RAJSHAHI DIVISION o @@ @@ @ @ @ ~ @ @ - @ @ KHDLNA" D IV IS ION BANGLADESH @ @ °° i @ @ @ ~l~jshahi ~-,~ oO o o : @ @ ~o @ DHAKADIVIS ION @ @ @ @ @ @ @ ° # @~@ W~U ~ ~@ODhaka S@ @ e@ ~ @ @ Bansal ® @@ DIVISION @ v INDIA BARISAL l '~ DIV IS ION ~t H BAY OF BENGAL SAMPLING POINTS @ Rural (232) Statistical Metropolitan Area (29) Municipality (40) MYANMAR (3 xxvi CHAPTER 1 INTRODUCTION 1.1 Geography and Economy Geography Bangladesh, a small country of 147,570 square kilometers, and 111.4 million people, emerged on March 26, 1941 as an independent country on the world's map following a war of liberation. It is almost entirely surrounded by India, except for a short southeastern frontier with Myanrnar and a south deltaic coastline on the Bay of Bengal. It stretches between 20 ° 34' and 26 ° 38' north latitude and 88 ° 01' and 92 ° 41' east longitude. The most significant feature of the landscape is the extensive network of large and small rivers that are of primary importance in the socioeconomic life of the nation. Chief among these, and lying like a fan on the face of the land are the Ganges-Padma, Brahmaputra-Jamuna, and the Megna. The climate of Bangladesh is dominated by seasonally reversing monsoons. It experiences a hot summer season with high humidity from March to June, a somewhat cooler but still hot and humid monsoon season from July through early October, and a cool, dry winter from November to the end of February. The fertile delta is frequented by natural calamities such as flood, cyclone, tidal-bore and drought. For administrative purposes, the country is divided into five divisions, ~ 64 districts, and 489 thanas (subdistricts) (BBS, 1993:3). Muslims constitute about 85 percent of the population of Bangladesh, Hindus about 14 percent, and Christians and others less than one percent. A small fraction of the population consists of several ethnic groups which are distinct in terms of language, race, religion, and customs. The national language of Bangladesh is Bangla, which is spoken and understood by all. Economy Agriculture is the most important sector of the nation's economy. It accounts for nearly 34 percent of the gross domestic product (GDP) and provides employment to about 66 percent of the workforce (BBS, 1993:224,104). Jute is the main non-food crop and the main cash crop of Bangladesh. About 15 percent of the cultivated land is used for crops other than jute and rice. Industry, though small, is increasing in importance as a result of foreign investments. Prospects for mineral resources, gas, coal, oil, appear to be bright in the near future. The per capita income is only US$210 (GB, 1994:2). Unemployment/underemploy- ment is a serious problem, and pressure on the land in rural areas has led to a constant influx of people from rural to urban areas. The fifth division, Barisal, was created in 1992 by subdividing the former Khulna Division. 1.2 Population Demographic Situation The population size and growth rate of the country have undergone significant changes over the past few decades. The population of the area which now constitutes Bangladesh was about 42 million in 1941. Since then, Bangladesh has experienced relatively high rates of population growth. The total population of Bangladesh grew from 76 million in 1974 to 90 million in 1981 and to 111 million in 1991 (BBS, 1993:92). The intereensal growth rate of population peaked in the mid- 1970s at around 2.5 percent per annum, followed by a continuing decline to 2.2 percent in 1991 (BBS, 1993:92). The 1991 census indicated that 45 percent of the population is below 15 years of age, 52 percent are between 15 and 64 years and 3 percent are age 65 or over (BBS, 1993:84). The relatively young age structure of the population indicates continued rapid population growth in the future. From 1975 to 1990, the elderly population (age 65 and above) increased from 2 to 3.1 million, and it is expected to increase to 4.3 million by the year 2005 (GB, 1994:17). There has been a substantial rise in the age at marriage. The mean age at first marriage for women has increased from 16.6 years in 1974 to 18.2 years in 1991; it increased from 23.9 to 25.3 years for men during the same period (BBS, 1993:86). The total fertility rate has decreased from about 6.3 in the mid- 1970s (MHPC, 1978:73) to 4.2 in 1990 (Mitra et al., 1993:35). There has been a substantial decline in the crude birth rate in Bangladesh. It was 34.4 births per 1,000 population in 1986, declined to 32.8 in 1990, and then to 30.8 in 1992 (BBS, 1993:87). Striking changes in the fertility preferences of married Bangladeshi women have been observed. In 1975, the mean desired family size was 4.1 children. In 1989, the desired family size, on average, dropped to 2.9 children, leaving the way open for further fertility decline (Huq and Cleland, 1990:53,54). Young women desired even smaller families, 2.5 children on average, a level close to replacement fertility. The crude death rate has fallen dramatically in Bangladesh from about 19 per 1,000 population in 1975 to 11.3 in 1990 (GB, 1994:4). Although infant and under-five mortality rates are declining, they are still high. The infant mortality rate was 150 deaths per 1,0(30 live births in 1975, and fell to about 110 in 1988 and 88 in 1992 (GB, 1994:5). Under-five child mortality, estimated at 24 per 1,000 births in 1982, declined to 19 in 1989 and to 14 in 1990 (GB, 1994:5). Maternal mortality has come down from 620 deaths per 100,000 births in 1982 to 470 in 1992. This small but important decline is mainly attributed to increased availability of family planning and immunization services, improved antenatal and delivery care, and a reduction in the number of births to high-risk mothers. There is evidence of modest improvement in life expectancy during the past decade. Life expectancy at birth was 46 years for males and 47 years for females in 1974 (U.N., 1981:60). It increased to 57.4 years for men and 56.8 years for women in 1992 (GB, 1994:5). Demographic Transition It can now be safely said that the demographic transition has started in Bangladesh. The country has passed through two phases of the classic demographic transition. It is now in the third phase when birth rates decline, but remain significantly higher than the death rates, resulting in continued but slower population growth. The decline in the population growth rate would have been even greater had it not been for the decline in mortality. 2 Fertility in Bangladesh is declining, yet the growth rate of the population is still high and its consequences have adverse effects on various development efforts. One significant consequence of high fertility and the declining mortality trend is a built-in "population momentum," which will continue to generate population increases well into the future, even in the face of rapid fertility decline. In 1992, Bangladesh had around 22 million married women in the reproductive ages; by the year 2001, this number is projected to rise to 31 million (GB, 1994:8). The government has set a goal of reaching replacement level fertility by the year 2005 (GB, 1994:6). Even if this occurs, the population will continue to grow for the next 40 to 60 years after 2005. One projection suggests that the population of Bangladesh may stabilize at 211 million by 2056. By the year 2010, Bangladesh is likely to have a population of about 150 million. The demographic goal is difficult but not impossible to achieve, in view of the trends already established in the success of family planning, maternal and child health, and other socioeconomic development programs. 1.3 Population, Family Planning and Maternal and Child Health Policies and Programs Family planning was introduced in the early 1950s through the voluntary efforts of social and medical workers. The govemment, recognizing the urgency of moderating population growth, adopted family planning as a govemment sector program in 1965. The present family planning infrastructure of Bangladesh has evolved in a process of development over the iast 35 years. The policy to reduce fertility rates has been repeatedly reaffirmed since liberation in 1971. The First Five-Year Plan (1973-78) of Bangladesh amplified "the necessity of immediate adoption of drastic steps to slow down the population growth" and reiterated that, "no civilized measure would be too drastic to keep the population of Bangladesh on the smaller side of fifteen crore (i.e., 150 million) for sheer ecological viability of the nation" (GB, 1994:7). Through three five-year plans, successive population programs contained new strategies to streamline administrative structures and reformulate program goals and objectives. From mid-1972, the family planning program received virtually unanimous, high-level political support. All subsequent governments that have come into power in Bangladesh have identified population control as the top priority for govermnent action. This political commitment is crucial in understanding the fertility decline in Bangladesh. The national policy went through several phases of evolution in response to emerging needs and circumstances. In 1976, accelerated growth of population was declared the country's number one problem; a population policy was outlined, operational strategies were worked out, specific field programs were developed, and organizational and management arrangements were made for implementing the programs. Population planning was seen as an integral part of the total development process, and was incorporated into successive five-year plans. The population policy is formulated by the National Population Council (NPC), chaired by the Prime Minister and including about 350 members comprising eminent personalities from different walks of life. Development of Program Approach Bangladesh population policy and programs have evolved through a series of development phases and have undergone changes in terms of strategies, structure, contents, and goals. The five distinct and broad phases may be identified as: (a) private and voluntary clinic-based programs (1953-60), (b) family planning services through limited government health care facilities (1960-65), (c) large-scale field-based government family planning programs (1965-75), (d) maternal and child health (MCH)-supported multi-sectoral family planning programs (1975-80), and (e) functionally integrated health and family planning programs with emphasis on MCH, primary health care, and family planning as a package, since 1980. The latest approach has been a shift towards launching a family planning social movement to raise and sustain awareness and interest in all segments of society about fertility reduction as a strategy for sustainable development. 3 The current policy and programs emphasize strategies that have an integrated approach to population planning and development. These are: • Tuming the family planning program into a social movement to increase social acceptance of family planning; Integrating the delivery of family planning and maternal and child health services; Promoting education (especially for girls); Improving the status of women; • Mobilizing community participation; Ensuring voluntarism and enhancing method choice through a cafeteria approach; • Enhancing a multi-/intersectoral approach to family planning education and service delivery; Involving nongovernmental organizations (NGOs) and the private sector to complement government efforts; • Expanding the number of service outlets; • Improving the quality of services; and • Promoting program sustainability by enhancing in-country production of contraceptives and maximizing human and organizational resources (GB, 1994:10). Program Achievement The national family planning/MCH program is being implemented with a contingent of about 30,000 female fieldworkers at the village level and a network of service outlets for easy availability of family planning/MCH services at the client's doorstep. These efforts have led to impressive achievements for the Bangladesh national family planning program, while operating in an unfavorable socioeconomic environment. General awareness about family planning is universal in Bangladesh; virtually all married women of reproductive age know at least one modem family planning method. Between 1975 and 1991, the use of contraceptives increased fivefold, from 8 to 40 percent of married women (Cleland et al., 1994:32). Between 1981 and 1991, the use of modem methods increased from 11 to 31 percent of married women, while use of traditional methods increased only slightly, from 8 to 9 percent of married women (Larson and Mitra, 1992:126; Mitra et al., 1993:53). Since 1981, the growth in use of reversible methods has outpaced gains by permanent methods, a reflection of the fact that family planning has become more widespread among younger women wishing to space births and the fact that reversible methods have been more strongly promoted by the supply system. Factors for Program Success Numerous factors have contributed to the increase in contraceptive use over the past 10 years. The elements identified as having contributed to the success of the program are: (1) strong political commitment to family planning programs by successive governments, (2) successful promotion of a small family norm through information and education activities and other multi-sectoral programs, (3) establishment of a widespread infrastructure for delivering family planning and health services down to the village level, (4) increased involvement of nongovernmental organizations to supplement and complement government's efforts, (5) flexibility to make policy and programmatic adjustments in response to emerging needs, and (6) strong support of the program by the international aid community (GB, 1994:36). The success achieved so far in the national family planning program is encouraging and has increased the confidence that it is possible to achieve further progress. But there remain several issues of concern, such as the tremendous growth potential built into the age structure as a consequence of past high fertility. Due to the increasing population entering childbearing age, the program will have to increase efforts substantially just to maintain the current level of contraceptive use. If demand for family planning also increases, that will put even more strain on the program. Other concerns are lack of a steady supply of contraceptives from extemal sources, which affects program performance; the need for further improvement in access to and quality of facilities and services; and the need for men to participate more actively in family planning acceptance. Despite these constraints, there exists a substantial demand for family planning services in Bangladesh and there is a need to assign priority to meeting that demand by improving the quality and supervision of outreach services. 1.4 Objectives of the 1993-94 Bangladesh Demographic and Health Survey The BDHS is intended to serve as a source of population and health data for policymakers and the research community. In general, the objectives of the BDHS are to: assess the overall demographic situation in Bangladesh, assist in the evaluation of the population and health programs in Bangladesh, and advance survey methodology. More specifically, the BDHS was designed to: provide data on the family planning and fertility behavior of the Bangladeshi population to evaluate the national family planning program, measure changes in fertility and contraceptive prevalence and, at the same time, study the factors which affect these changes, such as marriage patterns, urban/rural residence, availability of contraception, breastfeeding patterns, and other socioeconomic factors, and examine the basic indicators of maternal and child health in Bangladesh. 5 1.5 Survey Organization The 1993-94 BDHS was conducted under the authority of the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The survey was implemented by Mitra and Associates, a private research firm located in Dhaka. Macro International Inc. of Calverton, Maryland provided technical assistance to the project as part of the international Demographic and Health Surveys program. Financial assistance was provided by the U.S. Agency for International Development (USAID)/Dhaka. Sample Design Bangladesh is divided into five administrative divisions, 64 districts (zillas), and 489 thanas. In rural areas, thanas are divided into unions and then mauzas, an administrative land unit. Urban areas are divided into wards and then mahallas. The 1993-94 BDHS employed a nationally-representative, two-stage sample. It was selected from the Integrated Multi-Purpose Master Sample (IMPS), newly created by the Bangladesh Bureau of Statistics. The IMPS is based on 1991 census data. Each of the five divisions was stratified into three groups: 1) statistical metropolitan areas (SMAs) 2, 2) municipalities (other urban areas), and 3) rural areas. In rural areas, the primary sampling unit was the mauza, while in urban areas, it was the mahalla. Because the primary sampling units in the IMPS were selected with probability proportional to size from the 1991 census frame, the units for the BDHS were subselected from the IMPS with equal probabdity to make the BDHS selection equivalent to selection with probability proportional to size. A total of 304 primary sampling units were selected for the BDHS (30 in SMAs, 40 in municipalities, and 234 in rural areas), out of the 372 in the IMPS. Fieldwork in three sample points was not possible, so a total of 301 points were covered in the survey. Since one objective of the BDHS is to provide separate survey estimates for each division as well as for urban and rural areas separately, it was necessary to increase the sampling rate for Barisal Division und for municipalities relative to the other divisions, SMAs, and rural areas. Thus, the BDHS sample is not self- weighting and weighting factors have been applied to the data in this report. After the selection of the BDHS sample points, field staff were trained by Mitra and Associates and conducted a household listing operation in September and October 1993. A systematic sample of households was then selected from these lists, with an average "take" of 25 households in the urban clusters and 37 households in rural clusters. Every second household was identified as selected for the husband's survey, meaning that, in addition to interviewing all ever-married women age 10-49, interviewers also interviewed the husband of any woman who was successfully interviewed. It was expected that the sample would yield interviews with approximately 10,000 ever-married women age 10-49 and 4,200 of their husbands. ? Questionnaires Four types of questionnaires were used for the BDHS: a Household Questionnaire, a Women's Questionnaire, a Husbands' Questionnaire, and a Service Availability Questionnaire. The contents of these questionnaires were based on the DHS Model A Questionnaire, which is designed for use in countries with relatively high levels of contraceptive use. Additions and modifications to the model questionnaires were made during a series of meetings with representatives of various organizations, including the Asia 2 SMAs are extensions of the division headquarters and include rural areas. 3 Not all ever-married women were currently married, and some of the eligible husbands could not be mtcrviewed for various reasons. 6 Foundation, the Bangladesh Bureau of Statistics, the Cambridge Consulting Corporation, the Family Planning Association of Bangladesh, GTZ, the International Centre for Diarrhoeal Disease Research (ICDDR,B), Pathfinder International, Population Communications Services, the Population Council, the Social Marketing Company, UNFPA, UNICEF, University Research Corporation/Bangladesh, and the World Bank. The questionnaires were developed in English and then translated into and printed in Bangla. The Household Questionnaire was used to list all the usual members and visitors of selected households. Some basic information was collected on the characteristics of each person listed, including his/her age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for individual interview. In addition, information was collected about the dwelling itself, such as the source of water, type of toilet facilities, materials used to construct the house, and ownership of various consumer goods. The Women's Questionnaire was used to collect information from ever-married women age 10-49. These women were asked questions on the following topics: Background characteristics (age, education, religion, etc.), Reproductive history, Knowledge and use of family planning methods, Antenatal and delivery care, Breastfeeding and weaning practices, Vaccinations and health of children under age three, Marriage, Fertility preferences, and Husband's background and respondent's work. The Husbands' Questionnaire was used to interview the husbands of a subsample of women who were interviewed. The questionnaire included many of the same questions as the Women's Questionnaire, except that it omitted the detailed birth history, as well as the sections on maternal care, breastfeeding and child health. The Service Availability Questionnaire was used to collect information on the family planning and health services available in and near the sampled areas. It consisted of a set of three questionnaires: one to collect data on characteristics of the community, one for interviewing family welfare visitors and one for interviewing family planning field workers, whether govemment or nongovemment supported. One set of service availability questionnaires was to be completed in each cluster (sample point). Fieldwork The BDHS questionnaires were pretested in July 1993. Male and female interviewers were trained for 10 days at the office of Mitra and Associates. Many of the interviewers had participated in prior surveys. After training, the teams spent nine days in the field conducting interviews under the observation of staff from Mitra and Associates. Altogether, 209 women's and 57 husbands' questionnaires were completed. The field teams then spent three days in Dhaka in debriefing meetings, discussing the fieldwork and suggesting modifications to the questionnaires. On the basis of these suggestions, revisions in the wording and translations of the questionnaires were made. In October 1993, candidates for field staffpositions for the main survey were recruited. Recruitment criteria included educational attainment, maturity, ability to spend one month in training and at least four months in the field, and experience in other surveys. A total of 102 trainees were recruited. Training for the main survey was conducted at Mitra and Associates offices for four weeks (from 18 October to 15 November 1993). Initially, training consisted of lectures on how to fill in the questionnaires, with mock interviews between participants to gain practice in asking questions. Towards the end of the training, participants spent several days in field practice interviewing in various parts of Dhaka and Chittagong cities, as well as in some rural areas of the Tangail and Gazipur Districts. Trainees whose performance was considered superior were selected to be supervisors and field editors. Fieldwork for the BDHS was carried out by 12 interviewing teams. Each consisted of 1 male supervisor, 1 female field editor, 4 female interviewers, and 2 male interviewers, for a total of 96 field staff. In addition, each team included one person who was responsible for completing the Service Availability Questionnaire. Finally, Mitra and Associates fielded four quality control teams of two people each to check on the field teams. Fieldwork commenced on 17 November 1993 and was completed on 12 March 1994. The distribution of individual interviews with women was roughly: November (12 percent); December (25 percent); January (27 percent); February (26 percent); and March (10 percent). Data Processing All questionnaires for the BDHS were re- turned to Dhaka for data processing at Mitra and Associates. The processing operation consisted of office editing, coding of open-ended questions, data entry, and editing inconsistencies found by the computer programs. One senior staff member, 1 data processing supervisor, 1 questionnaire ad- ministrator, 2 office editors, and 5 data entry oper- ators were responsible for the data processing op- eration. The data were processed on five micro- computers. The DHS data entry and editing pro- grams were written in ISSA (Integrated System for Survey Analysis). Data processing commenced in early February and was completed by late April 1994. Response Rates Table 1.1 shows response rates for the sur- Table 1.1 Results of the household and individual interviews Number of households, number of interviews and response rates, Bangladesh 1993-94 Residence Result Urban Rural Total Household Interviews Households sampled 1495 8186 9681 Households found 1401 7854 9255 Households interviewed 1376 7798 9174 Household response rate 98.2 99.3 99.1 Individual interviews Number of eligible women 1510 8390 9900 Number of eligible women interviewed 1466 8174 9640 Eligible woman response rate 97.1 97.4 97.4 Number of eligible husbands 589 3285 3874 Number of eligible husbands interviewed 500 2784 3284 Eligible husband response rate 84.9 84.7 84,8 vey and reasons for nonresponse. A total of 9,681 households were selected for the sample, of which 9,174 were successfully interviewed. The shortfall is primarily due to dwellings that were vacant, or in which the inhabitants had left for an extended period at the time they were visited by the interviewing teams. Of the 9,255 households that were occupied, 99 percent were successfully interviewed. In these households, 9,900 women were identified as eligible for the individual interview and interviews were completed for 9,640 or 97 percent of these. In one-half of the households that were selected for inclusion in the husbands' survey, 3,874 eligible husbands were identified, of which 3,284 or 85 percent were interviewed. The principal reason for nonresponse among eligible women and men was failure to find them at home despite repeated visits to the household. The refusal rate was very low (less than one-tenth of one per- cent among women and husbands), Since the main reason for interviewing husbands was to match the infor- mation with that from their wives, survey procedures called for interviewers not to interview husbands of women who were not interviewed. Such cases account for about one-third of the non-response among hus- bands. Where husbands and wives were both interviewed, they were interviewed simultaneously but separately. CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS The purpose of this chapter is to provide a short descriptive summary of some socioeconomic characteristics of the household population and the individual survey respondents, such as: age, sex, residence and educational level. Also examined are environmental conditions such as housing facilities and household characteristics. This information on the characteristics of the households and the individual women interviewed is essential for the interpretation of survey findings and can provide an approximate indication of the representativeness of the survey. 2.1 Characteristics of the Household Population In the BDHS, information was collected about all usual residents and visitors who had spent the previous night in the selected household. This approach makes it possible to distinguish between the de jure population (those usually resident in the household) from the de facto population (those who spent the night before the interview in the household). A household was defined as a person or group of people who live together and share food. Age and Sex The distribution of the household population in the BDHS is shown in Table 2.1 by five-year age groups, according to sex and urban-rural residence. Because of relatively high levels of fertility in the past, Bangladesh has a larger proportion of its population in the younger age groups than in the older age groups, Table 2.1 Household population by age T residence and sex Percent distribution of the de facto household population and sex ratios by five-year age groups, according to urban-rural residence and sex, Bangladesh 1993-94 Urban Rural Total Age Sex Sex Sex group Male Female Total ratio Male Female Total ratio Male Female Total ratio 0-4 11.5 11.7 11.6 99.4 14,1 13.4 13.7 105.1 13.8 13,2 13.5 104.5 5-9 13.0 13.3 13.1 99.6 15.7 15.5 15.6 101.1 15.4 15.2 15.3 100.9 10-14 14.4 14.7 14.6 99.3 13.9 13.6 13.8 101.8 14.0 13.8 13.9 101.5 15-19 9.7 11.9 10.8 82.3 9.4 10.6 10.0 88.3 9,4 10.7 10.1 87.5 20-24 9.9 11.9 10.9 84.9 7.8 9.7 8.8 80.4 8.1 10.0 9.0 81.1 25-29 8.8 9.3 9.0 96.0 6.6 8.5 7.6 78.4 6.9 8.6 7.7 80.5 30-34 7.3 6.5 6.9 114.9 6.5 6.1 6.3 106.1 6.6 6.2 6.4 107.2 35-39 7.3 5.4 6.4 135.9 5.9 5.0 5.5 117.2 6.1 5.1 5.6 119.5 40-44 4.6 4.3 4.4 108.1 4.2 3.6 3.9 114.1 4.2 3.7 4.0 113.3 45-49 3.4 3.0 3,2 116.0 3.7 2.7 3.2 134.8 3.7 2.8 3.2 132.5 50-54 3.3 2.3 2,8 147.0 2.8 3.1 3.0 87.5 2.8 3.1 2.9 92.6 55-59 2.3 1.8 2.0 134.2 2.2 2.4 2.3 90.5 2.2 2.3 2.3 94.2 60-64 1,8 1.5 1.6 119,2 2.1 2.4 2.3 87.6 2.1 2.3 2.2 89.9 65-69 I,I 1.0 1.I I 11.1 1.8 1.2 1.5 151.8 1.7 1.2 1.4 147.7 70-74 0.8 0.6 0.7 135.9 1.7 0.9 1.3 193.5 1.6 0.8 1.2 188,7 75-79 0.4 0.3 0.3 105.5 0.7 0.4 0.6 174.0 0.7 0.4 0,5 167.4 80+ 0.6 0.4 0.5 t28.5 1.0 0.8 0.9 127.1 0.9 0.7 0.8 127.2 Total I00.0 I00,0 I00.0 101,7 I00.0 I00.0 100.0 99.8 100.0 I00.0 I00.0 IO0.0 Number 2830 2783 5612 5612 21608 21646 43254 43254 24438 24428 48866 48866 9 Figure 2.1 Population Pyramid, Bangladesh, 1993-94 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30.34 25-29 20-24 15-19 10-14 5-9 0-4 Male ~ Female i I p 10 5 0 5 tO Percent BDHS lg93-94 with one exception. There is a a smaller proportion of children under age five than age 5 to 9, which confirms recent declines in fertility (see Figure 2.1). Urban areas have relatively fewer people under age 15 than rural areas (39 vs. 43 percent). Also, the shift to lower proportions of total population begins at age group 5-9 in urban areas, instead of at age group 0-4 as in rural areas. These differences support the supposition that fertility declines in Bangladesh, as in many other countries, began with the urban population. The sex ratio, the number of males per 100 females, is 105 for the age group 0-4 years, while it is about 101 for ages 5-14 years. However, there is an excess of females over males at ages 15-29, followed by a reversal at ages 30-49 years; the pattem is repeated between the age ranges 50-64 years and 65 years and above. The 1991 BCPS documented a similar age-sex structure for the household population (Mitra et al., 1993). Migration of young men to other countries for work most likely contributes to the low sex ratios at ages 15-29. Overreporting of ages of men and/or underreporting of ages of women may also be an underlying cause of the observed irregular age-sex structure. The irregular bulge of women at ages 50-54 years suggests that, in addition to possible heaping on age 50, women may have been pushed from age 45-49 to 50-54, perhaps to reduce the workload of the interviewer. This pattern has been observed in other DHS surveys (Rutstein and Bicego, 1990). The pattern is more pronounced among women in rural than in urban areas. The impact of these irregularities on the quality of the data is probably small, since there are relatively few women at these ages. Figure 2.2 presents the distribution of the male and female household population by single year of age (see also Appendix Table C.I). The data show evidence of a preference for reporting ages that end in zero or five (age "heaping" or digit preference) that is common in countries where ages are not well known. 10 Figure 2.2 Distribution of De Facto Household Population by Single Year of Age and Sex Percent 4 I 2 I t II I / II II I * i I I 0 I P P i I1 i| t , I I I I It 1 .A, , , ,t. i~ fi t , i i , i i 10 15 20 25 30 ~5 40 45 50 55 60 65 70+ Single Year of Age BDHS 1993-94 Digit preference is considerably more pronounced for men than for women. This is most probably due to the fact that many of the women were individually interviewed and their ages probed in detail, while many of the men's ages were provided by proxy. Table 2.2 compares the broad age structure of the population from the 1989 Bangladesh Fertility Survey (BFS), the 1989 and 1991 Contraceptive Prevalence Surveys (CPSs), and the 1993-94 BDHS. There has been a slight decline in the proportion of population less than 15 years of age. Table 2.2 Population by age from selected sources Percent distribution of the de facto population by age group, selected sources, Bangladesh. 1989-I994 1989 1989 1991 1993-94 Age group BFS CPS CPS BDHS <15 43.2 43.2 42.7 42.6 15-59 50.9 50.9 51.2 51.2 60+ 5.9 5.9 6.0 6.2 Total 100.0 100.0 100.0 100.0 Median age U U U 18.4 U = Unknown (not available) Source: Huq and Cleland. 1990:28; Mitra et al. 1993:14 11 Household Composition Table 2.3 shows that a small minority of households in Bangladesh are headed by females (9 percent), with more than 90 percent headed by males. Female-headed households are equally uncommon in rural and urban areas. The average household size in Bangladesh is 5.4 persons, with almost no variation between rural and urban areas. Single person households are rare in both rural and urban areas. Fewer than five percent of Bangladeshi households consist of only one adult, either with or without children. About two-fifths of households contain two related adults of opposite sex (presumably most of which are married couples); one-half of households consist of three or more related adults. Households of three or more related adults are more common in rural (50 percent) than urban (46 percent) areas. Categorized as other, about 9 percent of households in urban areas are made up of unrelated persons. However, such households are much less common in the rural area (3 percent). Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, and kinship structure, according to urban-rural residence, Bangladesh 1993-94 Characteristic Residence Urban Rural Total Household headship Male 90.8 91.3 91.3 Female 9.2 8.7 8.7 Total 100.0 100.0 100.0 Number of usual members 1 0,8 1.2 1.2 2 6.6 6.5 6.5 3 12.4 13.5 13.4 4 18.4 18.8 18.8 5 19.8 17.8 18.0 6 15.2 15.6 15.6 7 10.5 10.0 10.1 8 5.2 6.4 6.3 9+ 11.1 10.1 10.2 Total 100.0 100.0 100.0 Mean size 5.5 5.4 5.4 Kinship structure One adult 3.2 4.8 4.6 Two related adults: Of opposite sex 40.6 41.1 41.0 Of same sex 1.2 1.8 1.7 Three or more related adults 46.3 49.7 49.3 Other 8.6 2.6 3.3 Total 100.0 100.0 100.0 Note: Table is based on de jure members; i.e., usual residents. 12 Education Education is a key determinant of the life style and status an individual enjoys in a society. It affects almost all aspects of human life, including demographic and health behavior. Studies have consistently shown that educational attainment has strong effects on reproductive behavior, contraceptive use, fertility, infant and child mortality, morbidity and issues related to family health and hygiene. Tables 2.4.1 and 2.4.2 provide data on educational attainment of the household population in the BDHS. Table 2.4.1 Educational level of the male household populat ion Percent distribution of the de facto male household population age six and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics, Bangladesh 1993-94 Median Background No edu- Primary primary Secondary/ years of characteristic cation incomplete complete lligher Missing Total Number schooling Age ! 6-9 23.5 76.1 0.3 0.0 0.0 100.0 2987 0.8 10-14 20.9 61.2 17.9 0.0 0.0 100.0 3410 2.8 15-19 26.4 30.3 37.4 5.9 0.0 100.0 2298 5.2 20-24 33.0 24.9 26.4 15.6 0.1 1~0.0 1974 5.0 25-29 40.8 23.6 21.1 14.5 0.0 100.0 1683 3.2 30-34 43.4 26.4 21.3 9.0 0.0 1000 1619 2.6 35-39 42.6 23.0 23.6 10.5 0.2 100.0 1484 3.0 40-44 42.1 23.0 22.0 12.6 0.3 100.0 1027 3.1 45-49 44.3 25.6 20.5 9.3 0.2 100.0 897 2.5 50-54 47.5 25.4 18.7 8.3 0.0 100.0 690 1.0 55-59 49.8 25.8 19.2 5.3 0.0 100.0 539 1.0 60-64 52.5 25.7 17.9 3.8 0.2 100.0 505 0.0 65+ 53.7 28 5 15.3 1.9 0.6 1043.0 1190 0.0 Residence Urban 20.0 31 5 28.0 20.5 0.0 100.0 2432 5.8 Rural 36.6 40.3 18.4 4.7 0.1 100.0 17873 1.7 Division Barisal 22.2 46.1 24.0 7.5 0.1 100.0 1311 3.4 Chittagong 34.6 41.0 19.2 5.1 0.1 100.0 5636 2.1 Dhaka 35.6 36.3 19.4 8.6 0.l 1000 6099 2.1 Khulna 32.2 40.3 21.3 6.2 0.0 100.0 2584 2.6 Rajsbabi 38.2 38.3 17.8 5.6 0.l 1000 4674 1.6 Total 34.6 39.2 19.5 6.6 0.1 100.0 20305 2.1 IExcludes 4 men for whom an age was not reported. Education has become more widespread over time in Bangladesh. This is apparent from the differences inlevels of educational attainment by age groups. A steadily decreasing percentage of both males and females have never attended school in each younger age group. For men, the proportion who have never aaended school decreases from 54 percent in the oldest age group (65 years or more) to 21 percent among those age 10-14; for women the decline is more striking: from 90 percent to 22 percent (see Figure 2.3). Despite considerable improvement in the spread of education, levels of educational attainment still remain discernibly low among people in Bangladesh, win a strong differential persisting between males and females, About one-third of men (35 percent) and about half of women (48 percent) age six years and above, have not received any formal education. The median number of years of schooling is 2.1 for men and less than one full year for women. In almost every age group there are smaller proportions of men than women 13 Table 2.4.2 Educational level of the female household populat ion Percent d isaibut ion of the de facto female household populat ion age six and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics, Bangladesh 1993-94 Median Background No edu- primary primary Secondary/ years of characteristic cation incomplete complete Higher Missing Total Number schcoling Age I 6-9 26.4 73.4 0.2 0.0 0.0 100.0 2924 0.8 10-14 22.2 59.8 18.0 0.1 0.0 100,0 3361 2.9 15-19 36.2 30.8 28.4 4.7 0.0 100.0 262.5 4.0 20-24 49.4 27.1 17.0 6.4 0.1 100.0 2435 1,0 25-29 54.6 26.1 15.7 3.5 0,0 100.0 2090 0.0 30-34 60.1 26.0 12.0 1.8 0.1 100.0 1511 0.0 35-39 63.0 25.5 9.7 1.9 0.0 100.0 1242 0.0 40-44 65.1 25.6 7.8 1.6 0.0 100.0 906 0.0 4549 73.7 20.4 4,6 1.3 0.0 100,0 677 0,0 50-54 81.2 15.5 2.8 0.5 0.0 lO0.O 745 0.0 55-59 81.2 15,7 2.8 0.3 0.0 100.0 572 0.0 60-64 86.4 10.8 2.9 0.0 0.0 100.0 561 0.0 65+ 89.7 9.3 0.6 0.0 0.3 100.0 762 0.0 Residence Urban 34.0 31.0 25.3 9.6 0.1 100.0 2389 3.3 Rural 50.0 38.0 10.8 1.1 0.0 100.0 18023 0.0 Division Barisal 30,7 50.4 16.5 2.4 0.0 100.0 1345 2.4 Chittagong 50.6 34.9 12.8 1.6 0.0 100.0 5971 0.0 Dhaka 49.7 343 13.0 3.0 0.1 100.0 6060 0.9 Khulna 41.9 42 5 13.3 2 3 0.0 100 0 2427 1.0 Rajshahi 51.4 37.1 10.1 1.5 0.0 I00,0 4608 0.0 To~al 48.2 37.2 12.5 2.1 0.0 100.0 20412 0.9 tExcludes 1 woman for whom an age was not reported. Figure 2.3 Percentage of Males and Females Who Have No Formal Education by Age Group Percent 100 . ,~ . .~e - - '~ 80 "~ - - 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Age Group BDHS1993-04 14 with no education and more men than women with secondary education. However, over time, the sex differential is narrowing; differences in educational attainment between school-age boys and girls have become almost insignificant (see Figure 2.3). Substantial urban-rural gaps in educational attainment persist. Over one-third of rural men (37 pereent)haveneverattendedschool---comparedtoonlyone-fifthofurbanmen(2Opercent). The differences are also striking for women---50 percent of rural women have never attended school, compared to only 34 percent of urban women. Urban-rural gaps are much larger at the secondary and higher level of education. Only about 5 percent of men and 1 percent of women in rural areas have received some secondary education; for urban areas the rates are 21 percent for men and 10 percent for women. As for differences by division, both men and women in Barisal and Khulna Divisions have higher education attainment than residents of other divisions. The proportion of population with no education is lower and the mean number of years of schooling is higher in both these divisions than in the other divisons. Table 2.5 presents enro//ment rates by age, sex and residence oftbe population age 6-24 years. Of every ten children age 6-15 years, almost seven (68 percent) are enrolled in school. But enrollment drops substantially after age 15; only about three out of ten older teenagers (29 percent) are still in school and only one out of eight in their early 20s (13 percent) are still in school. The substantial decline after age 15 may be partly due to the fact that many families need their grown children (age 16-24) for work or do not have the means to bear their educational expenses. It is encouraging that urban-rural gaps in enrollment of children have become virtually non-existent, with 68 percent of both urban and rural children age 6-15 currently enrolled in school. In fact, rural areas have a slightly higher proportion than urban areas of children 6-10 years enrolled in school. The increased rural enrollment of children may be a result of the recently launched 'Food For Education' program designed to encourage rural residents to send their children to school. However, rural enrollment rates still lag far behind urban rates among children older than 15. At ages 16-20 years, only 26 percent of adolescents are still in school in rural areas, compared to 45 percent in urban areas; at ages 21-24 years, only 10 percent of rural young adults are in school, compared to 26 percent in urban areas. The sex differential in school enrollment also seems to be disappearing, at least among younger children. At ages 6-15, only a slightly higher percentage of boys than girls are enrolled (69 vs. 66 percent). However, by ages 16-20 years, men are much more likely than women to be enrolled (38 vs. 21 percent), presumably due to early marriage or social seclusion, which cause young women to drop out of school. Table 2.5 School era'ollment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban- rural residence, Bangladesh 1993-94 Age group Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-10 72.1 75.1 74.8 71.0 72.7 72.5 71.5 73.9 73.7 11-15 67.1 62.1 62.7 62.7 57,9 58.5 64.9 59.9 60.6 6-15 69.6 69.4 69.4 66.9 65.9 66.0 68.2 67.7 67.8 16-20 51.4 36.0 37.9 40.2 17.7 20.7 45.3 26.4 28.8 21-24 34.2 19.6 21.7 19.6 3~7 5.8 26.2 10.4 12.6 15 Employment The BDHS Household Questionnaire included a question as to whether each person age eight and above was working for money. The resulting information is shown in Table 2.6 for males and females by age group according to urban-rural residence. As expected, men are much more likely than women to be employed, regardless of age group or residence. Overall, almost 60 percent of men are employed, compared to only about 10 percent of women. Not surprisingly, employment rates are higher among both men and women in their 20s and 30s and decline among men and women in their late 50s and 60s. Paid employment begins early in Bangladesh; at ages 10-14, 17 percent of boys and 6 percent of girls are working for money. By ages 15-19, almost half of boys and 10 percent of girls are engaged in paid employment. Table 2.6 Employment status Percentage of males and females who m'e working for money by age group and urban- rural residence, Bangladesh 1993-94 Males Females Age group Urban Rural Total Urban Rural Total 8-9 2.1 1.1 1.2 3.6 0.7 1.0 10-14 17.1 17.2 17.2 17.6 4.0 5.7 15-19 38.8 48.2 47.1 15.9 8.1 9.1 20-24 57.5 74.0 71.7 18.7 12.9 13.7 25-29 80.3 90.2 88.8 20.9 17.9 18.3 30-34 94.7 97.1 96.8 24.5 19.5 20.1 35-39 97.3 97.6 97.6 19.3 20.1 20.0 40-44 95.5 98.1 97.8 25.9 15.7 17.0 45-49 98.3 98.0 98.0 11.9 13.l 12.9 50-54 92.7 96.1 95.6 24.4 9.3 10.6 55-59 91.1 91.4 91.4 7.3 8.9 8.8 60-64 67.8 79.4 78.3 18.1 4.9 5.9 65+ 47.7 52.2 51.9 2.4 4.3 4.1 Total 56.6 57.7 57.5 16.5 9.8 10.6 Number 2,432 17,873 20,305 2,432 17,873 20,305 2.2 Hous ing Character ist ics Socioeconomic conditions were assessed by asking respondents questions about their household environment. This information is summarized in Table 2.7. As the table shows, only 18 percent of households in Bangladesh have electricity. Electricity is much more common in urban areas; three-quarters of urban households have electricity, compared to only 10 percent of rural households. Tubewells are the major source of drinking water in Bangladesh. Overall, about nine out of ten households (88 percent) obtain their drinking water from tubewells. Only 8 percent remain dependent on surface water such as surface wells (4 percent), ponds (3 percent) and rivers/streams (1 percent). Piped water is available mostly in urban areas. Among urban households, 27 percent have water piped into the residence, 10 percent obtain drinking water from taps (public or private) outside the residence, and 62 percent get their drinking water from tubewells. In rural areas, tubewells are the only major source of drinking water; more than9in 10 rural households obtain their drinking water from tubewells. Similarlevels of use oftubewells for drinking water in rural areas were also documented in the 1991 National Survey on Status of Rural Water Supply and Sanitation. 16 The majority (69 percent) of households in Bangladesh have sanitation facilities; however, only 41 percent have a hygienic toilet, while 30 pecent have no facility at all. Hygienic toilets include septic tank/mod- em toilets, water-sealed/slab latrines and pit toilets. As expected, sanitary facilities vary between rural and ur- ban areas. In rural areas, only 36 percent of households have hygienic toilets, compared to 81 percent of urban households. Moreover, one-third of rural households have no facility at all, compared to only 5 percent of urban households. There are also urban-rural differences in the types of hygienic toilets. Septic tank/modern toilets are the most common hygienic toilet in urban areas (49 percent), while in rural areas, pit latrines (17 percent) and water-sealed/slab toilets (15 percent) are the most common hygienic toilets. Tin is the most common roofing material in Bangladesh, accounting for over half of both rural and urban households. However, urban and rural households vary widely in the use of other types of roofs. In urban areas, 29 percent of households live in dwellings with cement, concrete or tiled roofs, while in rural areas, bamboo or thatch (40 percent) is the most common roof- ing material after tin. Almost three out of four households in Bangla- desh live in structures with walls made of natural mate- rials such as jute, bamboo or mud. About 10 percent live in houses with brick or cement walls and almost the same proportion live in houses with tin wails (9 per- cent). Urban households live in more solid dwellings than rural households. Half of urban households live in structures with brick or cement walls, compared to only 6 percent of rural households. Overall, nine out of ten households in Bangla- desh live in residences with floors made of earth (90 percent). However, more than half of urban households have cement or concrete flooring in their residences. Earth flooring is almost universal in rural areas (96 per- cent). As a way of estimating the extent of crowding, information was gathered in the BDHS on the numberof rooms households use for sleeping. Evidence of crowd- ing in Bangladeshi households is apparent in the esti- mates furnished in Table 2.7. Two-thirds of the house- Table 2.7 Housing characteristics Percent distribution of households by housing characteristics, according to urban-rural residence, Bangladesh 1993-94 Residence Characteristic Urban Rund Total Electricity Yes 75.2 10.4 17.8 No 24.8 89.6 82.2 Total 100.0 100.0 100.0 Source of drinking water Piped into residence 26.7 0.3 3.3 Piped outside residence 10.1 0.2 1.3 Tubeweil 62.0 91.0 87.7 Surface/other well 0.8 4.4 4.0 River/stream 0.1 0.8 0.7 Lake/pond 0.4 3.1 2.8 Other 0.0 0.l 0.1 Missing/Don't know 0.0 0.1 0.l Total ]00.0 100.0 ]00.0 Sanitation facility Septic tank/Modem toilet 49.4 4.2 9.3 Water/slab latrine 22.8 14.8 15.7 Pit latrine 8.4 16.6 15.7 Open latrine 9.1 20.7 19.3 Hanging latrine 4.9 10.0 9.4 No facility/bush 4.8 33.4 30.2 Other 0.6 0.4 0.4 Total 100.0 I00.0 100.0 Roof material Bamboo/thatch (Katcha) 10,7 40.2 36.8 Tin 55.7 52.3 52.7 Cement/concrete/tile 29.4 1.7 4.8 Other 4.1 5.8 5.6 Total 100.0 100.0 100.0 Wall material Jute/bamboo/mud (Katcha) 38.6 77.0 72.7 Wood 1.7 3.2 3.1 Brick/cement 50.5 5.6 10.7 Tin 7.7 9.7 9.4 Other 1.3 4.4 4.1 Total 10O.0 100.0 1{30.0 Floor material Earth (Katcha) 45.2 96,0 90.2 Wood 2.1 0.2 0.4 Cement/concrete 52.6 3.7 9.3 Missing/Don't know 0.0 0.l 0.l Total 100.0 100,0 100.0 Persons per sleeping room 1-2 39.5 34.2 34.8 3-4 38.2 42.2 41.8 5-6 17.1 17.8 17.8 7 + 5.2 5.6 5.6 Missing/Don't know 0.0 0.1 0.l Total 100.0 100.0 100.0 Mean persons per room 3.4 3.6 3.5 Number of households 1038 8136 9174 holds (65 percent) have three or more persons per sleeping morn, with a mean number of 3.5 persons. There are only slight differences between urban and rural households in the extent of crowding. 17 Household Possessions Respondents were asked about ownership of se- lected durable goods and agricultural land. The informa- tion was collected primarily as socioeconomic indicators of the population. Results are shown in Table 2.8. Possession of household durable goods is not very common in Bangladesh, since many of the families here cannot afford them. Nationally, 72 percent of households own a cot or bed, 49 percent a table, chair, or bench, 35 percent a watch or clock and only 22 per- cent an almirah (wardrobe). As for the more valuable items, 25 percent of households possess working radios, 16 percent own bicycles, and ortty 7 percent possess televisions in working condition. A higher proportion of urban than rural households possess every durable good asked about except bicycles, which reflects, among other things, the relatively better economic conditions in urban areas. Table 2.8 Household durable goods and agricultural land Percentage of households possessing various durable goods and agricultural land, by urban-rural residence, Bangladesh 1993-94 Ch~ac~nsfic Residence Urban Rural Total Almirah (wardrobe) 53.9 18.0 22.1 Table/chair/bench 68.2 46.1 48.6 Watch/clock 64.7 31.5 35.2 Cot/bed 89.4 70.0 72.2 Working radio 42.3 22.3 24.6 Working television 37.6 3.4 7.2 Bicycle 15.7 16.0 15.9 Agricultural land 33.9 59.4 56.6 Number of households 1038 8136 9174 Just over half of households in Bangladesh own agricultural land. This indicates that a large number ofB angladeshi families live in poverty, given that Bangladesh's economy is largely dependent on agriculture. Two-fifths of households in rural areas are without agricultural land (41 percent), while, as expected, households without agricultural land are more common in urban areas (66 percent). 2.3 Background Characteristics of Women Respondents General Characteristics Table 2.9 shows the distribution of female respondents by selected background characteristics. To assess their age, women were asked two questions in the individual interview: "In what month and year were you born?" and "How old were you at your last birthday?" Interviewers were trained to probe in situations in which respondents did not know their age or date of birth, and they were instructed as a last resort to record their best estimate of the respondent's age. The age distribution of ever-married women in the BDHS is very similar to that found in the 1991 CPS, with 42 percent in their 20s. The majority (57 percent) of ever-married women are age 15-29 years, compared to only 16 percent in the oldest age groups, 40-44 amd 45-49 years. The distribution of currently married women is similar to that of ever-married women. Among ever-married women, more than nine in ten are currently married (93 percent). Only 4 percent have been widowed, and 3 percent are divorced or separated. A similar distribution of ever-married women by current marital status was reported in the 1991 CPS. The majority (58 percent) of ever-married and currently married women have never attended school. Only one-quarter have completed primary school and only about 15 percent have secondary education. Nevertheless, the data show some improvement since 1991, when 61 percent of ever-married women had had no formal education (Mitra et al., 1993:18). 18 ~l'able 2.9 Background characteristics of respondents Percent distribution of ever-married women and currently married women by selected background characteristics, Bangladesh 1993-94 Ever-married women Currently married women Number of women Number of women Background Weighted Un- Weighted Un- characteristic percent Weighted weighted percent Weighted weighted Age <15 1.5 145 147 1.6 140 143 15-19 13.2 1271 1268 13.6 1224 1225 20-24 21.1 2033 2038 21.9 1964 1971 25-29 20.9 2012 1993 21.3 1911 1892 30-34 15.1 1456 1483 15.1 1353 1377 35-39 12.4 1197 1197 12.0 1079 1084 40-44 9.0 871 870 8.5 767 768 45-49 6.8 655 644 6.0 541 529 Marital status Married 93.2 8980 8989 100.0 8980 8989 Witiowed 4.0 389 384 NA NA NA Divorced/Deserted 2.8 271 267 NA NA NA Residence Urban 11.5 1108 1466 11.3 1013 1351 RurM 88.5 8532 8174 88.7 7967 7638 Division Barisal 6.3 606 1006 6.3 567 942 Chittagong 26.2 2527 2002 26.0 2334 1849 Dhaka 30.7 2963 2774 30.7 2756 2583 K.hulna 12.6 1217 1258 12.8 1145 1182 Rajshahi 24.1 2326 2600 24.3 2178 2433 Education No education 58.1 5598 5431 56.7 5093 4939 Primary incomplete 17.4 1681 1756 17.8 1601 1672 Primary complete 9.6 921 937 10.0 894 908 Secondary/Higher 14.9 1439 1516 15.5 1392 1470 Religion Islam 87.8 8468 8430 87.7 7880 7853 Hinduism 11.6 1121 1163 11,7 1051 1090 Christianity 0.4 36 32 0.4 35 31 Buddhism 0.1 13 13 0.1 13 13 Other 0.0 2 2 0.0 2 2 Total 100.0 9640 9640 100.0 8980 8989 NA = Not applicable In 1993-94, 12 percent of ever-married women live in urban areas. This is lower than the proportion urban reported in the 1991 CPS (15 percent) and is most probably due to definitional changes. In the 1991 CPS, thana headquarters were considered urban, as were the rural areas of the SMAs. A stricter definition of urban was employed in the IMPS sampling frame, from which the BDHS sample was drawn. Dhaka Division contains the largest proportion of ever-married women (31 percent), with roughly one-quarter living in each of Chittagong and Rajshahi Divisions. About 13 percent of women live in Khulna Division, and only 6 percent are in the new division, B arisal. The distribution of women by division is similar to that in the 1991 CPS, except that the proportion in Dhaka Division has increased slightly from 29 to 31 percent and the proportion in Rajshahi Division has decreased slightly from 26 to 24 percent (Mitra et al., 1993:14). 19 Almost nine out of ten ever-married women are Muslim; most of the remainder are Hindu. The composition by religion is similar to that reported in the 1991 CPS (Mitra et al., 1993:17). Differential Education Table 2.10 presents the distribution of female respondents by education, according to selected characteristics. Education is inversely related to age, that is, older women are less educated than younger women. For instance, 48 percent of women age 15-19 years have never attended school, compared to 75 percent of those age 45 -49. Table 2.10 Level of education Percent distribution of ever-married women by the highest level of education attended, according to selected background characteristics, Bangladesh 1993-94 Highest level of education Number Background No edu- Primary Primary Secondary/ of characteristic cation incomplete complete Higher Total women Age <15 ,18 1 23.1 18.9 10 0 100.0 145 15-19 48.7 21.2 11.8 18.3 100.0 1271 20-24 53.3 18.1 10.0 18.6 100.0 2033 25-29 55.4 16.8 9.3 18.5 100.0 2012 30-34 60.3 17.0 9.3 13.5 100.0 1456 35-39 64.2 14.7 I0.0 11.0 100.0 1197 40-44 65.8 18.6 6.6 9.0 100.0 871 45-49 75.2 13.2 6.3 5.3 100.0 655 Residence Urban 39.5 13.5 8.1 39.0 100.0 1108 Rural 60.5 17.9 9.8 11.8 t00.0 8532 Division Barisal 34.2 29.3 16.9 19.6 100.0 606 Chittagong 61.4 13A 10.3 14.9 100.0 2527 Dhaka 59.8 14,6 9.1 16 4 100.0 2963 Khulna 51.2 22,6 9.9 16.4 100.0 1217 Rajshahi 62,0 19.6 7.2 11.2 100.0 2326 Total 58.1 17,4 9.6 14.9 100.0 9640 Sixty percent of rural women have had no education at all, compared to 40 percent of urban women. In contrast, while about 4 in 10 urban women (39 percent) have attended secondary school, only 12 percent of rural women have done so. Both Barisal and Khulna Divisions appear to be educationally more advantageous for women. For example, only 34 percent of women in Barisal Division and 51 percent in Khulna Division have never attended formal school, compared to 60 percent or more in the other divisions. Women in Barisal are also more likely than women in the other divisions to complete primary school and to attend secondary school. 20 Access to Media Women were asked i f they usually read a newspaper, listen to the radio or watch television at least once a week. This information is of use in planning the dissemination of family planning messages. Table 2.11 shows that about two-fifths (39 percent) of women listen to the radio weekly. Only 18 percent watch television at least once a week, while not even one in ten reads a newspaper. Younger women are somewhat more likely than older women to listen to the radio. The higher the level of education a woman has, the more likely she is to have access to media; while only 10 percent of women with no education watch television once a week, half of those with secondary education do so. Women in rural areas am more disadvantaged in access to media. While 53 percent of women in urban areas listen to the radio weekly, only 37 percent of rural women do so. Similarly, 26 percent of women in urban areas read a newspaper once a week, compared to only 5 percent of women in rural areas. Women in Dhaka Division have greater access to media than women in the other divisions, especially with regard to television viewing. Table 2.11 Access to mass media Percentage of ever-married women who usually read a newspaper once a week, watch television once a week, or listen to radio once a week, by selected background characteristics, Bangladesh 1993-94 Read Watch Listen to Number Background newspaper television radio of characteristic weekly weekly weekly women Age <15 6.9 15.3 44.0 145 15-19 7.3 16.9 42.4 1271 20-24 7.7 18.5 42.2 2033 25-29 7.9 20.7 40.5 2012 30-34 7.3 17.1 35.9 1456 35-39 7.1 17.3 34.9 1197 40-44 5.2 15.3 34.1 871 45-49 4.2 14.3 32.6 655 Education No education 0.1 9.5 28.7 5598 Primary incomplete 2,8 15.8 43,8 1681 Primary complete 8.2 20.7 48.9 921 Secondary/Higher 38.7 50.5 65.0 1439 Residence Urban 25.9 61.2 52,6 1108 Rural 4.6 12.1 36.8 8532 Division Barisal 6.5 9.8 36.9 606 Chittagong 6.6 17.2 35.5 2527 Dhaka 9.4 24.6 41.7 2963 Khulna 5.5 14.4 36.1 1217 Rajshahi 5.6 13.6 40.0 2326 Total 7.1 17.8 38.7 9640 21 CHAPTER 3 FERTILITY 3.1 Introduction The measurement of fertility levels, differentials and determinants was a major objective of the 1993- 94 Bangladesh Demographic and Health Survey (BDHS). As one of the most densely populated countries in the world, Bangladesh takes enormous interest in measuring the rate of growth of its population. Previous surveys had indicated that the level of fertility was declining rapidly and there was considerable interest to see if the trend had continued. The fertility indicators presented in this chapter are based on reports provided by ever-married women age 15-49 years regarding their reproductive histories. Each woman was asked to provide informa- tion on the total number of sons and daughters to whom she had given birth who were living with her, the number living elsewhere, and the number who had died. The women were also asked for a history of all live births, including such information as: name, month and year of birth, sex and survival status. For children who had died, information on age at death was solicited. The above information is analyzed in the following sections to provide fertility levels and trends; fertility differentials by residence, division, and education; information on length of intervals between births; age at first birth; and the extent of childbearing among adolescents. A brief discussion of the quality of the BDHS fertility data appears in Appendix C.2. 3.2 Fertility Levels Table 3.1 gives the reported age-specific fertility rates for the three-year period preceding the survey per 1,000 women? The sum of the age-specific fertility rates (known as the total fertility rate) is a useful means of summarizing the level of fertility. It can be interpreted as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates. The general fertility rate represents the annual number of births in a population per 1,000 women age 15-44. The crude birth rate is the annual number of births in a population per 1,000 people. Both these measures are calculated using the birth history data for the three-year period before the survey and the age and sex distribution of the household population. The total fertility rate for the three years before the survey (approximately 1991 through 1993) is 3.4 children per woman. This represents a huge decline in fertility over the recent past (see section 3.4). The age pattern of fertility indicates that Bangladeshi women have children early in the childbearing period; by age 30, a woman will have given birth to over 70 percent of the children she will ever have. The crude birth rate l Numerators of the age-specific fertility rates are calculated by summing the number of live births that occurred in the period 1-36 months preceding the survey (determined by the date of interview and the date of birth of the child), and classifying them by the age (in five-year groups) of the mother at the time of birth (determined by the mother's date of birth). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. Since only women who had ever married were interviewed in the BDHS, the number of women in the denominators of the rates were inflated by factors calculated from information in the household questionnaire on proportions ever-married in order to produce a count of all women. Never-married women are presumed not to have given birth. 23 for the whole country is 29 births per 1,000 population. This is somewhat lower than the rate of 31 reported by the government's sample vital registration system for 1992 (BBS, 1993:87), but is slightly higher than the rate of 28 per 1,000 reported for a 1994 survey (BBS, 1994:5). Fertility is higher in rural areas than in urban areas (see Figure 3.1), a pattern that has persisted in various censuses and demographic surveys that have been carried out in Bangladesh (Huq and Cleland, 1990:106; Mitra et al., 1993:36). The difference is especially large at ages 15-19, which reflects longer education and later marriage of women in urban areas. The total fertility rate is estimated at 3.5 in rural areas, about 30 percent higher than that in the urban areas (2.7). Table 3.1 Current fertility Age-spocific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban-rural residence, Bangladesh 1993-94 Residence Age group Urban Rural Total 15-19 81 148 140 20-24 178 198 196 25-29 134 161 158 30-34 82 108 105 35-39 41 58 56 40-44 4 21 19 45-49 (17) 14 14 TFR 15-49 2.69 3.54 3.44 TFR 15-44 2.60 3.47 3.37 GFR 106 140 136 CBR 25.3 29.5 29.1 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Rates in parentheses are based on 125 to 249 woman-years of exposure. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CRR: Crude birth rate, expressed per 1,000 population 24 Figure 3.1 Age-Specific Fertility Rates By Urban-Rural Residence Births per 1,000 Women 25o 200 15o~ 100 50 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Group BDHS 1993-94 3.3 Fertility Differentials Table 3.2 and Figure 3.2 show differentials in fertility by division of residence and education. Fertility is highest in Chittagong Division, with a total fertility rate of 4.0 children per woman, and lowest in Rajshahi (3.0) and Khulna (3.1) Divisions. Barisal and Dhaka Divisions have intermediate levels of fertility, both having total fertility rates of 3.5 children per woman. Female education is strongly related to fertility levels. At current rates, women with no formal education would give birth to an average of 3.8 children in their lifetime, compared to 2.6 for women with at least some secondary education, a difference of 33 percent. Women with either incomplete primary or complete primary education have intermediate fertility rates between these two extremes. One way of examining trends in fertility over time is to compare the total fertility rates for the three years preceding the survey with the average number of children ever born to women who are now at the end of their childbearing period, age 40-49. The former is a measure of current fertility, while the latter is a measure of past or completed fertility. The data in Table 3.2 indicate that there has been a decline of about three children over the past 10 to 20 years in Bangladesh, from 6.6 to 3.4 births per woman. The decline has occurred across all divisions and all education levels. The decline has been greater for rural (3.2 children) than urban women (2.8 children). Among the divisions, women in Rajshahi Division have apparently experienced the greatest decline in fertility, with a current total fertility rate that is less than half the average number of children ever born to women now in their 40s. Fertility declines have also been large among women in all education groups. 25 Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey for women age 15-49 and mean number of children ever born to women age 40-49. by selected background characteristics. Bangladesh 1993-94 Mean number of children Total ever born Background fertility to women characteristic rate t age 40-49 Residence Urban (2.69) 5.45 Rural 3.54 6.73 Division Barisal (3.47) 6.46 Chittagong 3.95 6.76 Dhaka 3.45 6.51 Khuina (3.05) 6.20 Rajsbahi 3.03 6,66 Education No education 3,83 6.77 Primary incomplete (3.43) 6,55 Primary complete (3.26) 6,47 Secondary/Higher (2.58) 4.87 Total 3.44 6.57 Note: Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. ~Women age 15-49 years Figure 3.2 Total Fertility Rates by Selected Background Characteristics RESIDENCE Urban Rural DIVISION Barisal ~ - Chittagong ~; Dhaka L Khulna Ra jshah i EDUCATION No Education Prim. Incomp. Prim. Comp. Secondary+ . . . . . ~-~==~ 3 ,5 - - - - - - ~ 4 .0 - - - - 3 .5 --3.1 - - 3 .0 ] 3 .8 1 3,4 1 3.3 ] 2,6 2 3 Total Fertility Rate BDHS 1993-94 26 3.4 Fertility Trends Fertility rates reported in the BDHS reflect an extremely steep decline over the past 20 years when compared against previous estimates. Fertility has declined from 6.3 births per woman in the mid- 1970s to 3.4 births for the period 1991-93 (Table 3.3). Since the period 1989-91, fertility has declined from 4.3 to 3.4 births per woman, a drop of 21 percent in a two-year period. This is by far the most dramatic drop in fertility ever recorded in Bangladesh. As Figure 3.3 indicates, the decline since the mid-1980s has been generally uniform over all age groups of women except those 45-49, for whom there has been no change. Table 3.3 Trends in current fertility rates Age-specific rates and total fertility rates, selected sources, Bangladesh, 1975-1994 Survey and approximate time period 1975 1989 1989 1991 1993-94 BFS BFS CPS CPS BDHS Age group 1971-75 1984-88 1986-88 1989-91 1991-93 15-19 109 182 171 179 140 20-24 289 260 241 230 196 25-29 291 225 217 188 158 30-34 250 169 160 129 105 35-39 185 114 109 78 56 40-44 107 56 53 36 19 45-49 35 18 14 13 14 Total fertility rate 6.3 5.1 4.8 4.3 3.4 Note: For the 1975 and 1989 BFSs, the rates refer to the 5-year period preceding the survey; for the other surveys, the rates refer to the 3-year period preceding the survey. The two BFSs and the BDHS utilized full birth histories, while the 1989 and 1991 CPSs used 5-year and 8-year truncated birth histories, respectively. Source: 1975 BFS (MHPC, 1978:73); 1989 BFS (Huq and Cleland, 1990:103); 1989 CPS (Mitra et al., 1990:74); 1991 CPS (Mitra et al., 1993:34). Table 3.4 presents total fertility rates by single calendar year for 1980 to 1993 from various sources. The data, depicted in Figure 3.4, show the steep decline in fertility that has occurred in Bangladesh. The rates from the 1989 BFS and the 1989 and 1991 CPSs are generally consistent, while the data from the Bangladesh Bureau of Statistics' sample registration system are initially implausibly low and therefore show a more moderate decline over time. The steepest decline is shown by the data from the 1993-94 BDHS; the total fertility rates are higher than the other sources from 1984 to 1990, and then fall below those reported by the BBS. 27 Figure 3.3 Age-Specific Fertility Rates 1989, 1991, and 1993-94 Births per 1,000 Women 3oo 250 s ~ 5O i t i i i I " 15-19 20-24 25-29 35-39 40-44 45-49 3O-34 Age Group Note: 1989 rates are for a 5-year period before the survey and 1993-93 rates ere for a 3-year period before the survey. Source: Mitre et al,, 1993:34 Table 3.4 Trends in total fertility rates Annual total fertility rates, selected sources, Bangladesh, 1980-1993 Year Matlab 2 Bangladesh Bureau of 1989 1989 1991 1993-94 Treatment Comparison Statistics t BFS CPS CPS BDHS area area 80 5.0 6.8 81 5.0 6.7 82 5.2 6.4 6.6 5.0 6.3 83 5.1 6.1 6.2 4.5 6.1 84 4.8 5.9 6.6 4.0 5.1 85 4.7 5.5 5.1 6.3 4.5 6.0 86 4.7 5.1 5.2 5.0 6.1 4,3 5.5 87 4.4 4.8 5.0 4.9 5.6 4.1 5.2 88 4.4 4.9 4.6 5.2 3.8 5.4 89 4.3 4.3 4.9 3.4 4.9 90 4.3 4.2 4.4 3.4 5.0 91 4.2 3.8 3.0 4.3 92 4.2 3.4 2.9 3.8 93 3.7 3.3 2.9 3.9 Note: Rates from the surveys are 3-year moving averages except the most recent rate which is based on a two-year average. tRates are from the sample vital registration system except for 1993 which is from the BBS' Health and Demographic Survey. 2Rates are from a demographic surveillance system in one rural district (Matlab). Source: BBS (Cleland, et al., 1994:15 and BBS, 1994:5); 1989 BFS (Huq and Cleland, 1990:104); 1989 CPS and 1991 CPS (Mitra, et al., 1993:35); Matlab (ICDDR, B, 1994:3). 28 F igure 3 .4 T rends in the Total Ferti l ity Rate F rom Se lec ted Sources , Bang ladesh , 1980-1993 Births per Woman a 2 . . . . . . ; . ' . 80 81 82 83 84 85 87 8 89 91 92 g3 Year Note: All survey rates are based on 3-year moving averages, except most recent year (2-year average) Source: Table 3.4 Unlike survey data, the data from the Matlab district (Fable 3.4, last two columns) are collected in a surveillance system in which women are interviewed by field workers every two weeks. Thus, the data are less likely than survey data to suffer from recall error or problems in remembering or reporting dates. The demographic surveillance system covers a population of approximately 100,000 each in a "treatment" area, in which an intensive matemal and child health and family planning program has been in effect and a "comparison" area in which the residents receive the normal government and private health care (ICDDR,B, 1994:2). Although data from Matlab are not nationally representative and therefore not comparable to data from the other sources, they do provide evidence of the unprecedented decline in fertility that has taken place in Bangladesh. Figure 3.5 shows the total fertility rates for the Matlab study area and the 1993-94 BDHS fertility rates for the period 1982 to 1993. The data from the BDHS and the Matlab comparison area show roughly comparable rates of decline over time, although, once again, the decline depicted from the BDHS is steeper than that from the surveillance system. The fact that the low fertility rates reported in the BDHS for the years immediately preceding the survey are not accompanied by a proportionately large increase in contraceptive use, in age at marriage, or in another of the major fertility determinants, invites an investigation into data quality. A review of the data reveals no obvious systematic errors such as omission or displacement of births that are often found in survey data (see Appendix C.2). Moreover, a recent study in which data from a BDHS-type survey in the Matlab area were compared with those from the ICDDR, B surveillance system, showed almost identical fertility rates in the two sources, thus lending support to the BDHS fertilty data (see Appendix C.2). Some researchers hypothesize that Bangladeshi surveys routinely underestimate recent fertility because women tend to overreport the ages of their young children (Cleland et at., 1993:14; Cleland et al., 1994:17,18). To the extent that such age overreporting is random--that is, not selective of women with certain characteristics--it would not be readily detectable in the data. However, if age overreporting is a widespread cultural phenomenon, it would presumably have also affected the fertility rates reported in prior surveys. Thus, although the level of the total fertility rate reported in the BDHS for the years immediately preceding the survey may be underestimated, if rates from previous surveys were similarly affected, the data nonetheless indicate an extremely rapid decline in fertility in Bangladesh over the past two decades. 29 Figure 3.5 Trends in the Total Fertility Rate from Matlab (Treatment and Comparison Areas) and the BDHS, 1982-1993 Births per Woman 7, d 5 4 3 2 82 83 84 85 86 87 88 89 90 91 92 Year 93 Note: BDHS rates are based on 3-year moving averages, except 1993 (2-year average) Source: ICDDR.B, 1994:3 Table 3.5 shows that all divisions in Bangladesh experienced recent declines in fertility of almost identical magnitude. Although Chittagong Division had the highest fertility in the mid-1980s and still does today, the rate of de- cline in fertility is almost identical with that of the other di- visions. Table 3.6 shows the proportion of currently married women who reported that they were pregnant at the time of survey, according to age group. These data are useful be- cause, while fertility rates depend to some extent on accurate reporting of dates of events, the proportion pregnant is a "current status" indicator. Change over time in the percent pregnant is an independent indicator of fertility change. In Bangladesh, the proportion pregnant has generally declined over time, although not in a steady fashion. In the 1975 BFS, 13 percent of currently married women were reported to be pregnant at the time of the survey. By 1989, this pro- portion had declined to 9 percent; it then increased to 11 per- cent in 1991, and again declined to 9 percent in the 1993-94 BDHS. Although it is entirely possible that such fluctuations are real, misreporting may also be a factor. Table 3.5 Trends in fertility by division Total fertility rates by dwision and percent of change from the period 1984-88 to 1991-93, Bangladesh, 1989 BFS and 1993-94 BDHS 1989 1993-94 BFS BDHS Percent Division 1984-88 1991-93 change Chittagong 5.94 3.95 -34 Dhaka 5.18 3.45 -33 Khulna I 4.71 3.20 -32 Rajshahi 4.60 3.03 -34 Note: Rates for the 1989 BFS refer to the 5-year period preceding the survey, while those for the 1993-94 BDHS refer to the 3-year period preceding the survey. Rates are calculated for women age 15-49. IRefers to the former boundaries prior to the creation of Barisal Division. Source: Huq and Cleland, 1990:106 30 Table 3.6 Percent pregnant Percentage of currently married women who were pregnant at the time of interview, by age group, selected sources, Bangladesh, 1975-1994 1975 1989 1991 1993-94 Age group BFS BFS CPS BDHS 15-19 15.2 a 14.7 a 19.6 17.1 20-24 15.5 13.3 16.2 13.0 25-29 14.9 10.4 11.2 9.0 30-34 11.2 8.3 7.1 7.0 35-39 10.7 4.8 4.2 2.7 404.4 O U 1.5 0.8 454.9 U U 0.2 0.0 Total 12.5 9.3 10.7 8.7 U = Unknown (not available) aCurrently married women less than 20 years Source: 1975 BFS and 1989 BFS (Cleland et al., 1994:21); 1991 CPS (Mitra et al., 1993:39) Table 3.7 provides further insights into the fertility decline discussed above. The table gives the age- specific fertility rates for five-year periods preceding the survey, using data from respondents' birth histories. Figures in brackets represent partial fertility rates due to truncation; women 50 years of age and older were not included in the survey and the further back into time rates are calculated, the more severe is the truncation. For example, rates cannot be calculated for women age 45-49 for the period 5-9 years before the survey, because those women would have been over age 50 at the time of the survey and thus were not interviewed. The data show generally declining fertility experienced by women in most age groups during the last two decades. The decline from the period 5-9 to 0-4 years before the survey was much larger than the decline from 10-14 to 5-9 years before the survey, implying that the fertility decline has increased substantially in recent years. Alternatively, if, as discussed above, the ages of young children are routinely overstated in Bangladeshi surveys, the result could mimic a more rapid decline in fertility in the five years preceding the survey. Table 3.7 Age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of birth, Bangladesh 1993-94 Number of years preceding the survey Mother's age 0-4 5-9 10-14 15-19 15-19 159 207 234 225 20-24 216 290 296 309 25-29 172 242 294 275 30-34 122 191 237 [239] 35-39 70 141 [208] 404.4 30 [801 45-49 [16] Note: Age-speciflc fertility rates are per 1,000 women. Estimates in brackets are truncated. 31 Table 3.8 presents fertility rates for ever-married women by duration since first marriage for five-year periods preceding the survey. It is analogous to Table 3.7, but is confined to ever-married women and replaces age with duration since first marriage. The data confirm that the decline in fertility is apparent for all marriage durations in the past 10-14 years preceding the survey, with the exception of those married 0-4 years, as expected, since newly married couples are having their first children. Table 3.8 Fertility by marital duration Fertility rates for ever-married women by duration (years) since first marriage for five.year periods preceding the survey, Bangladesh 1993-94 Marriage duration at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 0-4 258 256 247 216 5-9 234 306 312 306 10-14 171 247 292 297 15-19 129 208 270 [241] 20-24 84 160 [215] 25-29 43 [105] Note: Duration-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 3.5 Children Ever Born The distribution of all women and currently married women by age and number of children ever born is presented in Table 3.9. The table also shows the mean number of children ever horn to women in each five-year age group, an indicator of the momentum of childbearing. The data indicate that more than one- quarter (27 percent) of all women age 15-19 years have given birth to a child. On average, women have given birth to three children by their late twenties, five children by their late thirties, and almost seven children by the end of their childbearing years. This same pattern is reflected by currently married women, with the exception that the percentage of currently married women age 15-19 who have had children is much higher than the percentage among all women age 15-19. The percentage of women age 45 -49 who have never had children provides an indicator of the level of primary infertility---the proportion of women who are unable to bear children at all. Since voluntary childlessness is rare in Bangladesh, it is likely that married women with no births are unable to bear children. The BDHS results suggest that primary infertility is low, less than one percent. It should be noted that this estimate of primary infertility does not include women who may have had one or more births but who are unable to have more (secondary infertility). 32 Table 3.9 Children ever born and living Percent distribution of all women and of currently married woman age 15-49 by number of children ever born (CEB) and mean number ever born and living, according to five-year age groups, Bangladesh 1993-94 Number of children ever born (CEB) Number Mean no. Mean no. Age of of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 72.6 21.0 5.9 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2566 0.34 0.30 20-24 22.3 25.8 28.7 16.4 5.5 0.8 0.4 0.1 0.0 0.0 0.0 100.0 2321 1.62 1.39 25-29 6.0 11.8 23.4 25.6 18.3 8.8 4.5 1.2 0.3 0.1 0.0 100.0 2057 2.91 2.47 30-34 3.8 5.4 11.6 19.0 20.4 16.2 12.2 6.5 3.5 1.4 0.2 100.0 1460 4.09 3.34 35-39 2.2 2,8 7.3 11.5 15.4 18,3 14,9 12.1 8.1 4.3 3,2 100,0 1200 5,16 4,15 40-44 1.8 1.6 4.3 5.9 9.2 14.5 15.5 15.2 12.4 7.5 12.1 100.0 878 6.36 4.94 45-49 0.7 1.4 3.5 4.8 8.1 11.3 13.7 16.1 13.6 11.4 15.6 100.0 656 6.86 5.22 Total 23.4 13.6 14,5 12.7 10.1 7.7 6.1 4.5 3.20 1.90 2.2 100.0 11138 2.95 2.40 CURRENTLY MARRIED WOMEN 15-19 44.5 42.2 12.3 L0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1224 0.70 0.62 20-24 10.5 28.8 33.4 19.3 6.4 1.0 0.5 0.1 0.0 0.0 0.0 100.0 1964 1.88 1.62 25-29 3.5 10.6 23.7 27.2 19.3 9.3 4.7 1.3 0.3 0.I 0.0 100.0 1911 3.04 2.59 30-34 2.7 3.7 11.5 19.3 20.9 16.9 12,8 6.9 3.7 1.5 0.2 100.0 1353 4.22 3.46 35-39 1.7 1.8 6.1 10.8 15.3 19.1 15,5 12.9 8.8 4.5 3.5 100.0 1079 5.34 4.32 40-44 0.7 1.2 3.9 4.9 8.5 14.2 15,4 16.2 13.1 8.3 13.6 100.0 767 6.62 5.17 45-49 0.4 0.9 2.2 4.8 7.1 10.2 137 16.1 14.3 12.8 17.3 100.0 541 7.11 5.47 Total 9.9 15.5 17.3 15.3 11.9 9.0 7.2 5.3 3.7 2.3 2.7 100.0 8840 3.48 2.85 A comparison of the mean number of children ever born reported in the 1993-94 BDHS and various other surveys is presented in Table 3.10. Despite the fluctuations between surveys, the data generally show only modest declines until the mid- 1980s. Between 1985 and 1989, the decline in mean number of children ever born was substantial in all but the youngest and oldest age groups. Although there was then little change belween 1989 and 1991, the rates again decline considerably between 1991 and 1993-94, especially among women age 25 and above. Table 3.10 Trends in children ever born Mean number of children ever bom by age group, selected sources, Bangladesh, 1975-1994 1975 1981 1983 1985 1989 1989 1991 1993-94 Age group BFS CPS CPS CPS BFS CPS CPS BDHS 15-19 0.6 0.5 0.6 0.4 0.4 0.4 0.4 0.3 20-24 2.3 2.0 2.2 2.0 1.7 1.8 1.7 1.6 25-29 4.2 3.7 3.8 3.6 3.1 3.3 3.2 2.9 30-34 5.7 5.4 5.5 5.1 4.7 4.7 4.5 4.1 35-39 6.7 6.4 6.5 6.5 5.9 5.9 5.7 5.2 40-44 7.1 7.3 7.4 7.4 6.6 7.0 6.7 6.4 45-49 6.7 7.6 7.5 7.2 7.3 7.5 7.4 6.9 Total U U U U U U 3.5 3.0 U = Unknown (not available) Source: 1983 and 1985 CPSs (Kanmer and Frankenberg, 1988:21); 1991 CPS (Mitra et al., t993:31); all others (Cleland et al., 1994:11) 33 3.6 Birth Intervals Information on birth intervals provides insight into birth-spacing patterns which have far-reaching impact on both fertility and child mortality levels. Research has shown that children born too soon after a previous birth are at increased risk of dying at an early age. Table 3.11 shows the percent distribution of births of order two or greater that occurred in the five years before the BDHS by the number of months since the previous birth. Table 3.11 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Bangladesh 1993-94 Number of months since previous birth Characteristic 7-17 18-23 24-35 36-47 48+ Median number of Number months since of Total previous birth births Age of mother 15-19 17.6 21.7 36,1 18.6 6.0 100.0 26,0 175 20-29 8.9 12.1 35.5 22.1 21.5 100.0 33.9 3311 30-39 6.2 11.5 30,1 22.9 29.3 100.0 36.6 1616 40 + 7,3 8.9 28.7 21.2 33.9 109.0 37.5 307 Birth order 2-3 8.2 11.8 31.9 21.9 26.1 100.0 35,4 2751 4-6 7.8 11.6 34.5 22.4 23.7 100.0 34.6 1884 7 + 9.7 13.6 36.8 22.8 17.1 100.0 31.5 774 Sex of prim" birth Male 8.4 10.9 33.2 22.2 25.4 100.0 35.2 2707 Female 8.1 13,2 33,8 22.2 22.6 100.0 34.3 2701 Survival of prior birth Living 5.5 11.3 33.8 23.5 25.9 100,0 35,8 4533 Dead 22.6 15.9 32.0 15.4 14.1 100.0 26.4 875 Res/dence Urban 7.2 12.2 25,6 21.8 33.2 100.0 37.4 497 Rural 8.4 12,0 34.3 22.2 23.1 100.0 34.4 4912 Division Barisal 8.6 11,7 28,7 25,1 25.9 100.0 36.3 350 Chittagon8 8,7 12.9 36.5 22.4 19.4 100,0 33,4 1751 Dhaka 8,7 12.0 33.4 21.1 24,8 100.0 34.4 1633 Khalna 7.1 10.1 28.2 22.2 32.5 100.0 37.7 531 Rajshahi 7,6 11,7 33.0 22.4 25.3 100.0 35,3 1144 Education No education 8.1 12.0 35.2 22.5 22.3 100.0 34.3 3432 Primary incomplete 7.7 12,9 32.6 22.6 24.3 100.0 34.9 915 Primary complete 11.1 10.7 29.7 23,0 25.5 100.0 35,0 498 Secondary/Higher 8.0 12.3 27,9 18.8 33.0 100.0 36.9 563 Total 8,3 12,0 33.5 22.2 24.0 100.0 34.7 5409 Note: The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 34 The data show that birth intervals are generally long in Bangladesh. Almost one-half (46 percent) of non-first births occur three or more years after the previous birth, while one-third take place 24-35 months after the previous birth. Only one in five births occurs after an interval of less than 24 months. The median birth interval is 35 months. This is considerably longer than the median birth interval of 30 months reported in the 1991 CPS (Mitra et al., 1993:37). Differences in the methods used to calculate the medians may account for some of the difference in the two medians. Younger women have shorter birth intervals than older women. The median birth interval for women age 15-19 is 26 months, compared to 38 months for women over age 40. A shorter median interval also prevails for children whose preceding sibling is dead, compared to those whose prior sibling is alive. This pattern presumably reflects early resumption of sexual intercourse, a shortened breastfeeding period, and minimal use of contraceptives. 3.7 Age at FirstBirth The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. In many countries, postponement of first births, reflecting an increase in the age at marriage, has contributed greatly to overall fertility decline. Early initiation into childbearing is generally a major determinant of large family size and rapid population growth, particularly in countries where family planning is not widely practiced. Moreover, bearing children at a young age involves substantial risks to the health of beth the mother and child. Early childbearing also tends to restrict educational and economic opportunities for women. Table 3.12 presents the percent distribution of women by age at first birth according to current age) For women age 20 and over, the median age at first birth is presented in the last column of the table. Childbearing begins early in Bangladesh, with the large majority of women becoming mothers before they reach the age of 20. The median age at first birth is around 18. Moreover, the data show that median age at first birth has increased slightly from around 17 for older women to around 18 for women in their 20s and early 30s. This slight change to later age at first birth is reflected in the smaller proportion of younger women whose first births occurred before age 15; about 16 percent of women in their 40s report having had their first birth before age 15, compared to only 5 percent of women age 15-19. Table 3.12 Age at first birth Percent distribution of women 15-49 by age at first birth, according to current age, Bangladesh 1993-94 Women Median with Age at first birth Number age at no of first Current age births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 72.6 5.4 18.8 3.2 NA NA NA 100.0 2566 a 20-24 22.3 10.5 36.3 19.2 9.1 2.7 NA 100.0 2321 18.3 25-29 6.0 12.3 39.6 19.4 12.9 7.7 2.1 100.0 2057 17.9 30-34 3.8 12.9 40.7 19.9 10.6 8.3 3.8 100.0 1460 17.7 35-39 2.2 14.9 44.2 18.8 10.7 6.3 2.9 100.0 1200 17.3 40-44 1.8 16.6 49.6 I8.5 8.2 2.7 2.5 100.0 878 16.9 45-49 0.7 16.3 44.3 18.7 9.3 7.3 3.5 100,0 656 17.3 NA = Not applicable JtLess than 50 percent of the women in the age group x to x+4 have had a birth by age x 2 The data are based on all women, including those who have never married (see Footnote 1 for a description of the inflation factors used to estimate the total number of women). 35 The age at which women in Bangladesh have their first child is steadily increasing, in line with increases in age at marriage. For example, in 1975, the median age at first birth among women age 20-24 was 16.8; in 1989, it had risen to 18.0 and by 1993-94, to 18.3 (Huq and Cleland, 1990:92). Increases of similar magnitude have occurred for women of other age groups. Differentials in median age at first birth as reported in the 1993-94 BDHS are shown in Table 3.13. Urban women start childbearing later than rural women; the median age at first birth is 18.5 for urban women and 17.6 for rural women age 20~19. Women in Chittagong Division generally have higher median ages at first birth than women in the other divisions, while women in Rajshahi generally have the lowest median ages at first birth. Women with secondary education start childbearing later than those with less or no education. Among women age 20-49, the median age at first birth is 17.3 for women with no education and 19.9 for women with at least some secondary education. Table 3.13 Median age at first birth Median age at first birth among women age 20-49 years, by current age and selected background characteristics, Bangladesh 1993-94 Background Current age Ages Ages characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Residence Urban a 18.3 18.0 17.6 17,7 17.9 18.5 18,0 Rural 18.1 17.8 17.6 17.3 16.8 17.2 17,6 17.4 Division Barisal 18.4 17.8 18.2 17.1 17,0 17.0 17.7 17.6 Chittagong 18.9 18.2 17.8 17.9 17.2 18.1 18,1 17.9 Dhaka 18.2 17.9 17,6 17.1 16.9 17.1 17.6 17,4 Khulna 18.5 17.7 18,3 16.8 16,7 16.9 17.7 17.3 Rajshahi 17.7 17.6 17,2 17.2 16.4 17.0 17.3 17.2 Education No education 17.5 17.5 17,7 17.2 16.7 17.2 17.3 17.3 Primary incomplete 17.5 17.4 17,4 16.7 16.9 17.2 17.3 17.2 Primary complete 18.4 18.3 17,0 17.3 16.7 (17.4) 17.7 17.5 Secondary/Higher a 19.5 18,4 18.7 18.5 (18.9) 19.9 18.9 Total 18.3 17.9 17,7 17.3 16.9 17.3 17.7 17.5 Note: The medians for cohort 15-19 could not be determined because half the women have not yet had a birth. aMedians were not calculated for these cohorts because less than 50 percent of women in the age group x to x+4 had had a birth by age x. Figures in parentheses are based on 25 to 49 women. 3.8 Teenage Fertility Early childbearing, particularly among teenagers (those under 20 years of age) has negative demographic, socioeconomic and sociocultural consequences. Teenage mothers suffer particularly from severe complications during delivery, which result in higher morbidity and mortality for both themselves and their children. In addition, the socioeconomic advancement of teenage mothers, in the areas of educational attainment and accessibility to job opportunities, may be curtailed. 36 Table 3.14 shows the percentage of teenagers age 15-19 who are mothers or pregnant with their first child, according to various background characteristics. Twenty-seven percent of teenage women in Bangladesh are mothers and another 6 percent are pregnant with their first child. Thus, one in three teenage women has begun childbearing. There has been a slight decline in this proportion over time; data from the 1991 CPS indicate that in that year 36 percent of teenage women had either given birth or were pregnant with their first child (Mitra et al., 1993:38). As expected, the proportion of women who have begun childbearing rises rapidly with age, from l 1 percent of those age 15 to 59 percent of those age 19 (see Table 3.14). Those residing in rural areas, those residing in Rajshahi Division, and those with no education are also more likely than others to have begun childbearing. These differentials parallel the differentials documented earlier about patterns in current and cumulative fertility. Table 3.14 Teenage pregnancy and motherhood Percentage of teenagers 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Bangladesh 1993-94 Percentage who are: Percentage who have Pregnant begun Number Background with first child- of characteristic Mothers child bearing teenagers Age 15 6.8 3.8 10.6 615 16 17.1 6.2 23.4 566 17 32.1 6,5 38,7 463 18 38.5 6.5 45.1 539 19 54.4 4.7 59.2 382 Residence Urban 16.0 4.2 20.3 321 Rural 29,0 5.7 34.8 2246 Division Barisal 27.4 6.2 33.6 159 Chittagong 18.0 7.1 25.1 797 Dhaka 30.2 3.4 33.7 727 Khulna 29.0 5.9 34.9 320 Rajshahi 35.4 5.6 41.0 575 Education No education 39.2 5.6 44.8 913 Primary incomplete 29.1 6.8 35.9 541 Primary complete 26.7 7.7 34.4 302 Secondary/Higher 12.6 3.7 16.3 849 Total 27.4 5.6 33.0 2566 Note: Numbers may not add to total due to slight differences in the factors used to inflate ever-married to all women by background characteristics. 37 Whereas most teenage women who have begun childbearing have given birth only once, a small proportion have had two births. As shown in Table 3.15, only 6 percent of women age 15-19 have had two or more births. The proportion is highest for women age 19 (24 percent). Table 3.15 Children born to teenagers Percent distribution of teenagers 15-19 by number of children ever born (CEB), Bangladesh 1993-94 Age 0 1 2+ Number of Mean children ever born number Number of of Total CEB teenagers 15 93.2 6.7 0.1 100.0 0.07 615 16 82.9 16.4 0.7 100.0 0.18 566 17 67.9 28.0 4.2 100.0 0.37 463 18 61.5 29.5 9.0 100.0 0.48 539 19 45.6 30.3 24.1 100.0 0.81 382 Total 72.6 21.0 6.4 100.0 0.34 2566 38 CHAPTER 4 FERTILITY REGULATION 4.1 Knowledge of Contraception and Sources Respondents' knowledge of contraceptive methods was assessed in the BDHS through a series of questions combining spontaneous recall and prompting procedures. The ability to name or recognize the name of a family planning method is a nominal test of a respondent's knowledge and not a measure of how much she may know about the method. However, knowledge of specific methods and of places where they can be obtained is a precondition for their use. Respondents were first asked to name the ways or methods by which a couple could delay or avoid pregnancy. Interviewers then asked about specific methods not men- tioned spontaneously by the respond- ent. Information was sought about six modem methods---the pill, IUD, injection, condom, female and male sterilization, as well as two tradi- tional methods---periodic abstinence (safe period or rhythm method) and withdrawal. Other methods men- tioned by the respondent, such as herbs or breastfeeding, were also re- corded. For each method recognized, the respondent was asked if she knew of a source or a person from whom she could obtain the method. Knowledge of contraceptive methods and supply sources has been almost universal in Bangladesh for many years and the BDHS results confirm this fact. For example, re- suits indicate that just slightly less than 100 percent of both ever-mar- fled and currently married women age 10-49 know at least one method of family planning (Table 4.1). Table 4.1 Knowledge of contraceptive methods and source for methods Percentage of ever-married women and currently married women age 10-49 who know specific contraceptive methods and who know a source (for information or services), by specific methods, Bangladesh 1993-94 Know method Know a source I Ever- Cun'ently Ever- Currently Contraceptive married married married married method women women women women Any method 99.7 99.8 98.0 98.2 Any modern method 99.7 99.8 97.8 98.0 Pill 99.5 99.5 95.6 96.0 IUD 89.4 90.0 78.7 79.4 Injection 96.3 96.6 88.8 89.3 Condom 86.6 87.4 78.5 79.4 Female sterilization 98.8 99.0 92.6 92.9 Male sterilization 82.9 83.1 75.1 75.4 Any traditional method 75.0 76.1 42.9 43.7 Periodic abstinence 64.0 65.0 42.9 43.7 Withdrawal 49.0 50.0 NA NA Other traditional methods 17.0 17.4 NA NA Numberofwomen 9640 8980 9640 8980 NA = Not applicable ~For modern methods, source refers to a place where the method or procedure can be obtained. For rhythm and natural family planning, source refers to a place or person from whom advice can be obtained on practicing these methods. A greater proportion of currently married women (100 percent) reported knowing a modem method than a traditional method (76 percent). This may be due in part to the fact that traditional methods are not included in the organized family planning efforts. In addition, learning of these methods through informal channels is not easy in a society such as Bangladesh where matters relating to sex are not freely discussed. Knowledge of the pill (100 percent), female sterilization (99 percent), and injection (97 percent) is almost universal, while more than 4 out of 5 married women know the IUD (90 percent), condom (87 percent) and 39 male sterilization (83 percent). Considering the traditional methods included in the questionnaire, periodic abstinence is more widely known than withdrawal (65 vs. 50 percent of currently married women). Knowledge about sources of supply for family planning methods is also widespread in Bangladesh. Almost all currently married women (98 percent) are aware of a source for a modem method of contraception. The great majority of women (96 percent) know a source where the pill is available; 93 percent know where to go for female sterilization; 89 percent know a source for injection; and 79 percent know about sources for IUDs and condoms. It is encouraging to note that 75 percent of women know a source for male sterilization. Trends in Knowledge of Family Planning Methods As mentioned above, the proportion of women of reproductive age who know of at least one family planning method has been extremely high for some time in Bangladesh. However, as shown in Table 4.2, knowledge of specific methods has become more widespread. For example, the proportion of ever-married women who have heard of the IUD doubled over the past decade, from 42 percent in 1983 to 89 percent in 1993-94. Knowledge of injection and especially the condom has also increased. The largest increases in knowledge levels occurred between 1975 and 1983 for most modem methods, however, knowledge of the IUD increased greatly between 1983 and 1989. Table 4.2 Trends in knowledge of family planning methods Percentage of ever-married women age 10-49 who know specific sources, Bangladesh, 1975-1994 family planning methods, selected 1975 1983 1985 1989 1989 1991 1993-94 Method BFS CPS CPS CPS BFS 1 CPS BDHS Any method 81.8 98.6 99.6 99,9 100.0 99.9 99.7 Any modern method 80.0 98.4 99.5 99.9 99.0 99.8 99.7 Pill 63.9 94.1 98,6 99.0 99.0 99.7 99.5 IUD 40.1 41.6 65,4 80.4 78.0 88,9 89.4 Injection U 61.8 74.1 87.5 81.0 95.2 96.3 Vaginal methods 10.0 19.4 26.3 25.8 24.0 U U Condom 21.1 59.0 75.5 76.9 83.0 85.6 86.6 Female sterilization 53.1 95.5 97,8 99.2 98.0 99.4 98.8 Male sterilization 51.4 72.9 84.3 84.0 87.0 87.4 82.9 Any traditional method 49.0 54.8 62.8 71.7 U 83.3 75.0 Periodic abstinence 28.0 26.4 41.2 40.1 46.0 68.0 64.0 Withdrawal 15.1 19.8 20.8 14.4 30.0 48.6 49.0 Number of women 6515 8523 8541 10293 11907 10573 9640 U = Unknown (no information) 1Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1975 BFS (MHPC, 1978:A245 and Vaessen, 1980:16); 1983 CPS (Mitra and Kamal, 1985:85, 89); 1985 CPS (Mitra, 1987:67, 70); 1989 CPS (Mitra et al., 1990:81, 84); 1989 BFS (Huq and Cleland, 1990:60); 1991 CPS (Mitra et al., 1993:42) Differentials in Knowledge of Methods and Sources BDHS data reveal that there are no significant differences in knowledge of methods and their sources of supply by background characteristics of currently married women (Table 4.3). Knowledge of at least one method, particularly a modem method, is universal among both urban and rural women, among women in all five divisions, and across all categories of educational attainment. 40 Table 4.3 Differentials in knowledge of contraceptive methods and source for methods Percentage of currently married women age 10-49 who know at least one contraceptive method and one modem contraceptive method and who know a source for a modem method and mean number of methods known (for information or services), by selected background characteristics, Bangladesh 1993-94 Mean Mean no. of Know a Know no. of Know modem source for Number Background any methods a modem methods modem of characteristic method known method I known method women Age 10-14 99.2 5.8 99.2 5.0 96.3 140 15-19 99.5 6.5 99.5 5.4 97.1 1224 20-24 99.7 6.9 99.7 5.6 98.2 1964 25-29 99.9 7.1 99.9 5.7 98.5 1911 30-34 99.9 7.1 99.9 5.6 98.6 1353 35-39 99.8 7.0 99.8 5.6 98.1 1079 40-44 99.4 6.9 99.4 5.5 97.9 767 45-49 100.0 6.5 100.0 5.3 97.0 541 Residence Urban 99.9 7.2 99.9 5.7 99.2 1013 Rural 99.7 6.9 99.7 5.6 97.9 7967 Division Barisal I00.0 7.2 100.0 5.8 99.4 567 Chittagong 99.3 6.4 99.3 5.3 94.8 2334 Dhaka 100.0 7.0 100.0 5.6 99.0 2756 Khuina 100,0 7.2 100.O 5,8 99.7 1145 Rajshahi 99.8 7.1 99.8 5.7 99.1 2178 Education No education 99.6 6.6 99.6 5.4 96.9 5093 Primary incomplete 99.9 7.1 99.9 5.7 99.1 1601 Primary complete 100.0 7.2 100.0 5.7 99.4 894 Second~y/Higher 100.0 7.6 100.0 5.8 99.9 1392 Total 99.8 6.9 99.8 5.6 98.0 8980 llncludes pill, IUD, injection, condom, female sterilization, and male sterilization Married women reported that they knew an average of seven family planning methods, six of which were modem methods. There are no significant differentials in the mean number of methods known by background characteristics, except that, on average, very young married women know fewer methods and women with more education know more methods. The high level of knowledge found in every sub-group indicates the success of efforts to disseminate contraceptive information to all eligible couples. However, there is still scope to increase the amount of information that is known about specific methods of contraception. 4.2 Ever Use of Family Planning All women interviewed in the B DHS who said that they had heard of a method of family planning were asked if they had ever used used it. Ever use of family planning methods thus refers to use of a method at any time without making a distinction between past and current use. Collection and analysis of ever-use data 41 has special significance for family planning programs. These data indicate the proportion of the population having exposure to contraceptive use at least once. Therefore, data on ever use reveal the success of programs in promoting use of family planning among eligible couples. In addition, data on ever use, together with data on current use are valuable for studying couples who discontinue using a method. While almost all currently married women reported knowing at least one method (particularly a modem method), only 66 percent of women report ever having used any method and 59 percent report having used a modem method (Table 4.4). This gap between knowledge and use may be due in part to the fact that only the most rudimentary aspects of knowledge were assessed in the BDHS; many women may lack the more detailed familiarity with methods that might lead to use. On the other hand, some women are either pregnant, or trying to get pregnant and thus have not yet had the need to use family planning. Table 4.4 Ever use of contraception Among ever-married women and currently married women age 10-49, the percentage who have ever used a contraceptive method, by specific method and age, Bangladesh 1993-94 Modern method Traditional method Any Female Male modem steri- steti- Any Periodic W~th- Number Any meth- In jet- Con- liza- ILl.a- trad. absti- draw- of Age method od PIlL IUD tion dora lion t£on method hence al Other wcnnen EVER-MARRIED WOMEN 10-14 32.8 22.5 17.9 0.0 1,1 6.0 0,0 0,0 16.2 10,5 9,9 0,0 145 15-19 42.0 35.3 28,0 2.8 4.6 11.0 0.1 0.4 14.6 9.8 7,0 0,5 1271 20-24 63.4 57.0 47.4 6.0 9.9 17.7 2.0 0.6 22,3 16.0 9.5 1,9 2033 25-29 72.6 67,2 53,9 10.9 15.8 16.7 6.5 1.2 27.4 18,3 12.5 3,6 2012 30-34 72 8 67,2 47.3 9.4 14.7 15.5 11.9 2.3 27.5 18.0 12,6 5 4 1456 35-39 72.6 66.0 43.0 9.4 13.1 13.4 17.6 2.0 27.9 18.3 10,8 5.7 1197 40-44 60.5 51,8 32.1 6.3 9.4 8.9 15.7 2.3 26.8 20.0 8.9 4.5 871 45-49 44.6 34,8 20.0 3,7 5.0 5.7 11.5 2.4 20 7 15 1 5 3 3 9 655 Total 63.1 56 4 42 0 7,3 11.0 13.9 7.9 1.4 24 0 16 5 10.1 3 4 9640 CURRENq'LY MARRIED WOMEN 10-14 33.9 23,3 18.5 0.0 1.1 6.2 0.0 0.0 16.8 10.9 10.2 0.0 140 15-19 43.3 36.3 28.7 2.9 4.8 11.3 0.1 0.4 15.1 10,1 7.2 0.5 1224 20-24 64.7 58.3 48.5 6.2 10.1 18.2 2,0 0,6 22.7 16.3 9,8 1.9 1964 25-29 74.5 69.1 55.6 11.4 16.4 17.2 6.6 1.3 28.3 18.8 13.0 37 1911 30-34 76.2 70.8 50.0 9.9 15.5 16.3 12.4 2.4 28.5 18 7 13 2 5 8 1353 35-39 76.5 69.6 45.7 I0.0 14.2 14.1 18,4 2.0 29.6 192 11.7 6.1 1079 40-44 65,7 56.8 35.9 6.8 10,4 10,1 16,6 2,4 29,3 21,7 9.7 5,2 767 45-49 49,3 38,4 22.9 4.1 5 4 6.3 12.0 2,6 23.3 16,6 6.0 4,7 541 Total 65.7 59,0 44.1 7.7 11,6 14,7 8.1 1,4 25.1 17.1 106 3.6 8980 One outstanding feature of the data on ever use is the large proportion of currently married women (44 percent) who have ever used the pill. Experience with this method far exceeds that with any other method. Periodic abstinence is the second most widely used method, having been used by 17 percent of currently married women. One possible future research priority is to find out exactly how this method is used by Bangladeshi women and the extent of its success in preventing pregnancies. Fifteen percent of married women have used condoms at some time, and 12 percent have used injection. The level of use of male sterilization is relatively low; only 1 percent of women reported that their husbands had had an operation to avoid having any more children. 42 Ever-use rates vary with the age of women. Everuse is lowest among the youngest women. However, the fact that one-third of currently married women age 10-14 have used a contraceptive method at least once and one-quarter have used a modem method indicates that women in Bangladesh are now willing to try methods early in their reproductive lives. The level of ever use rises to a high of 77 percent for those age 35- 39, then declines, reaching 49 percent among those who are age 45-49. Ever use of any modem method follows a similar pattern by age of women. There has been a steady increase in the level of ever use of family planning over the past 15-20 years in Bangladesh. In 1975, only 14 percent of ever-married women of reproductive age had ever used a family planning method, compared to 63 percent in 1993-94 (Table 4.5). For use of any modem method, the increase has been even steeper. Although ever use of all methods has increased over time, ever use of the pill has increased the most rapidly. Ever use of both female and male sterilization, as well as of periodic abstinence and withdrawal, appears to have either reached a plateau or declined in recent years. Table 4.5 Trends in ever use of family planning methods Percentage of ever-married women age 10-49 who have ever used specific family planning methods, selected sources, Bangladesh, 1975-1994 1975 1983 1985 1989 1989 1991 1993-94 Method BFS CPS CPS CP8 BFS 1 CPS BDHS Any method 13,6 33.4 32.5 44.2 45.0 59.0 63.1 Any modern method U 23.8 25.9 37.5 U 49.2 56.4 Pill 5.0 14.1 14.3 23.3 22.0 34.1 42.0 IUD 0.9 2.2 2.7 4.6 4.0 6.2 7.3 Injection U 1.2 1.3 2.8 2.0 6.6 I 1.0 Vaginal methods 0.5 2.2 1.6 2.4 1.0 2.9 U Condom 4.8 7.1 5.7 9.3 6.0 13.4 13.9 Female sterilization 0.3 5.8 7.4 8.7 9.0 8.0 7.9 Male sterilization 0.4 1.4 1.6 1.6 1.0 1.4 1.4 Any traditional method U 17.3 11.9 15.3 U 29.6 24.0 Periodic abstinence 4.5 11.0 7.8 9.7 13.0 21.5 •6.5 Withdrawal 2.6 5.3 2.9 3.6 7.0 l l . l 10.1 Number of women 6515 8523 8541 10293 11907 10573 9640 U = Unknown (no information) 1Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1975 BFS (MHPC, 1978:A275); 1983 CPS (Mitra and Kamal, 1985:117, 122); 1985 CPS (Mitra, 1987:108, 112); 1989 CPS (Mitra et al., 1990:88, 92); 1989 BFS (Huq and Cleland, 1990:61); 1991 CPS (Mitra et al., 1993:52) 4.3 Current Use of Contraception Current use of contraception is defined as the proportion of women who reported they were using a family planning method at the time of interview. In the BDHS, only women who were married at the time of the survey were asked questions about current use of family planning. Table 4.6 shows the percent distribution of currently married women by current contraceptive use status, according to age group. The findings show that 45 percent of married women age 10-49 are currently using contraception. Many more women are using modem methods (36 percent) than traditional methods (8 percent). Thus, modem methods account for 80 percent of overall use. 43 Table 4.6 Current use of family plarming Percent distribution of currently married women by contraceptive method currently used, according to age, Bangladesh 1993-94 Modern method Traditional method Any Female Male Not modern steri- stetl- Any Periodic With- cur- Number Any meth- Injee- Con- hza- liza- trad. absti- draw- rently of Age method od Pill IUD tion dora tion tion method ne~ee al Othcx using Total women 10-14 22.1 10.5 7.2 0.0 1.1 2.1 0.0 0.0 11.6 6.5 5.2 0.0 77.9 i00.0 140 15-19 24.7 19.6 12.4 1.8 2.3 2.9 0.l 0.2 5.1 3.3 1.7 0.1 75.3 100.0 1224 20-24 37.6 32.0 19.7 2.2 4.2 3.5 2.0 0.4 5.6 3.6 1.4 0.6 62.4 100.0 1964 25-29 50.6 43.5 23.5 3.0 6.0 3.6 6.6 0.9 7.1 3.8 2.6 0.7 49.4 100.0 1911 30-34 57.2 46.1 20.3 2.7 6.0 2.6 12.4 2.2 11.1 5.9 3.2 2.0 42.8 100.0 1353 35-39 58.5 46.7 15.7 2.2 5.7 3.3 18.4 1.4 11.8 6.2 3.7 1.9 41.5 100.0 1079 40-44 51.9 38.2 12.1 1.6 3.7 2.1 16.6 2.0 13.7 9.1 3.2 1.4 48.1 100.0 767 45-49 29.3 21.3 4.7 0.l 1.2 1.2 I2.0 2.1 8.0 4.5 1.2 2.3 70.7 100.0 541 Total 44.6 36.2 17,4 2.2 4.5 3.0 8.1 1.1 8.4 4.8 2.5 1.1 55.4 100.0 8980 The most popular method by far is the pill, which is used by 17 percent of married women. Use of the pill accounts for almost 40 percent of all contraceptive use in Bangladesh. Other commonly used methods are female sterilization (8 percent), periodic abstinence (5 percent), and injection (5 percent). Only 3 percent of married women reported that they rely on condoms as a contraceptive method, while another 3 percent said they use withdrawal as a method. The proportion of women who use the IUD or whose husbands are sterilized is 2 percent or less. The pattern of current use by age shows a peak at ages 30-39. The drop in contraceptive use among older women may reflect declining fecundity, while lower levels among women under 25 are to be expected since many may not yet have reached their desired family size. However, it is notable that one in five married women (22 percent) age 10-14 are deliberately controlling their fertility early in marriage. Similarly, women in age group 15-19 report a contraceptive use rate of 25 percent. The methods that women use vary by age. The pill and periodic abstinence are the most commonly used methods among women age 10-19. Among women in their early 20s, injection is the second most popular method after the pill. There is a gradual shift to longer-term methods among older women, so that by age 25-29, female sterilization is second to the pill; by age 35-39, it is the most widely used method. One in six married women (16 percent) in their late 30s and 40s has been sterilized. Trends in Cur rent Use of Family Planning The level of contraceptive use in Bangladesh has risen steadily over the last two decades. The contraceptive prevalence rate for any method has increased fivefold since 1975, from 8 to 45 percent of married women (see Table 4,7 and Figure 4.1). Use of modem methods has grown even faster. In the roughly two and one-half years since the 1991 CPS was conducted, contraceptive use has increased from 40 to 45 percent among married women and use of modem methods has risen from 31 to 36 percent. Overall, there has been a steady rise in the contraceptive prevalence rate since 1975, with an average increase of about two percentage points a year. 44 Table 4.7 Trends in current use of family planning methods Percentage of currently married women age 10-49 who are currendy using specific methods, selected sources, Bangladesh, 1975-1994 family planning 1975 1983 1985 1989 1989 1991 1993-94 Method BFS CPS CPS CPS BFS CPS BDHS Any method 7.7 19.1 25.3 31.4 30.8 39.9 44.6 Any modern method 5.0 13.8 18.4 24.4 23.2 31.2 36.2 Pill 2.7 3.3 5.1 9.1 9.6 13.9 17.4 IUD 0.5 1.0 1.4 1.7 1.4 1.8 2.2 Injection U 0.2 0.5 I. I 0.6 2.6 4.5 Vaginal methods 0.0 0.3 0.2 0.2 0.1 U U Condom 0.7 1.5 1.8 1.9 1.8 2.5 3.0 Female sterilization 0.6 6.2 7.9 9.0 8.5 9.1 8.1 Male sterilization 0.5 1.2 1.5 1.5 1.2 1.2 1.1 2.7 5.4 6.9 7.0 7.6 8.7 8.4 0.9 2.4 3.8 3.8 4.0 4.7 4.8 0.5 1.3 0.9 1.2 1.8 2.0 2.5 1.3 1.8 2.2 2.0 1.8 2.0 1.1 Number of women U 7662 7822 9318 10907 9745 8980 U = Unknown (no information) Source: 1975 BFS (Islam and Islam, 1993:43); 1983 CPS (Mitra and Kamal, 1985:159); 1985 CPS (Mitra, 1987:147); 1989 CPS (Mitra et al., 1990:96); 1989 BFS (Huq and Cleland, 1990:64); 199i CPS (Mitra et al., 1993:53) Any traditional method Periodic abstinence Withdrawal Other traditional methods Figure 4.1 Trends in Contraceptive Use among Currently Married Women 10-49, from Selected Sources, Bangladesh, 1975 to 1993-94 Percent Currently Using 50 40 30 20 10 1975 1983 1986 1969 1991 Year [ "Modern Methods BB Traditional Methods i 1993-94 45 In terms of specific family planning methods, the dominant change in Bangladesh since the late 1980s has been a large increase in the number of couples using the pill. The proportion of married women relying on the pill almost doubled in the last four years, from 9 percent in 1989 to 17 percent in 1993-94 (see Figure 4.2). Use of injection, condoms, and the IUD have also increased slightly since 1989, while use of female and male sterilization has declined slightly. Use of periodic abstinence and of withdrawal have increased slightly since 1991. Figure 4.2 Trends in Modern Contraceptive Use among Currently Married Women 10-49, from Selected Sources, Bangladesh, 1975 to 1993-94 Percent Using Method 2O 10 • :g • 1975 1983 1 g85 1989 1991 1993-94 Year The 1993-94 BDHS data indicate that a majority of modem method users are using reversible methods as opposed to permanent methods. The shift towards modem reversible methods is largely due to a significant increase in use of the pill from 1985 to 1993, as well as to the decline in popularity of female and male sterilization. Differentials in Current Use of Family Planning BDHS data indicate that some women are much more likely to be using contraception than others (see Table 4.8 and Figure 4.3). The level of current contraceptive use is higher in urban areas (54 percent) than in rural areas (43 percent). The pill is the most popular method among both urban and rural women. The condom is the next most widely used method among urban couples, while female sterilization is the second most popular method for rural women. There is a sharp difference in condom use between urban (8 percent) and rural (2 percent) couples. This may be due to the fact that female field workers, who provide a substantial part of family planning services in rural areas, are shy about discussing condoms with men. Appropriate motivational strategies need to be developed to involve men in taking an active part in the adoption of family planning methods. 46 Table 4.8 Current use of fJ~,nily planning by background characteristics Percent dista'ibution of currently married women age 1@49 by contraceptive method currently used. according to selected background characteristics, Bangladesh 1993-94 Modern method Traditional method Fca'n ale Male Any sterl- steri- Any Periodic Net Number Bwckgrouod Any modem lnjec- Con- llza- liza- trad. absu- With- currently of characteristic meahod method Pill IUD tion dora tion tion method hence drawal Other using Total worsen Residence Urban 54.4 44.6 20,9 3.7 4.4 8.3 6.4 0.7 9.8 5.5 3.8 0.5 45.6 100,0 1013 Rural 43.3 35,1 16,9 2,0 4.5 2.3 8.3 1.1 8.2 4,8 2.3 1.1 56.7 100,0 7967 Division Bafisal 47.7 37.8 18.2 2,4 4.7 2.8 8,2 1.4 10.0 5.1 3.0 1.8 52.3 100,0 567 Chittagong 29.3 23.4 9.1 2.0 4.4 2.1 5.5 0,3 5.9 3.3 1.6 1,0 70.7 100.0 2334 Dhaka 44.3 36.3 18,2 1.9 4.4 3.0 8,2 0.7 S.0 4.6 2.4 1.0 55.7 100.0 2756 Khulna 55.3 42.8 20.1 3.1 5.4 4.4 8.5 1.3 12,5 7.1 4.3 1.0 44.7 100.0 1146 Rajshahi 54.8 45.9 23,5 2.1 4,2 3.3 10.4 2.3 8.9 5.5 2.3 1.1 45.2 100.0 2178 Education No education 41.0 34.3 14.7 1.5 5.0 1.2 10,4 1.5 6.7 3.9 1.4 1.3 59.0 1(30.0 5094 Primary incomplete 45.5 36.8 19,0 2.6 4,9 2.4 6,9 0.9 8.7 5.6 2.3 0.8 54,5 100.0 1601 Primary complete 45.6 34.1 19.8 2.5 3.6 4.0 4.0 0.3 11.4 6,7 4.0 0.7 54.4 100.0 894 Seeondary/lligher 56.1 43.9 23.8 3.9 2,7 9.7 3,5 0.4 12.1 6.2 5.4 0.6 43.9 100.0 1392 Number of living children 0 14.3 9.0 4.7 0.1 0,2 2.8 0.6 0.7 5.3 3.7 1.6 0.0 85.7 100.0 1149 1 34.5 29.1 17.4 2.4 3.3 3.3 1.8 1.0 5.4 3.2 2.0 0.1 65.5 100.0 1604 2 50.I 42.3 22.7 2.8 4.4 3.5 7.2 1.6 7.8 4.5 2.7 0.6 49.9 1000 1821 3 57,6 48.2 20.6 3.6 6.4 3.2 13,4 1.1 9.3 5.0 3.2 1.1 42.4 100,0 1502 4+ 51.9 40.8 17.4 1.8 6.0 2.4 12.2 1.0 11.1 6.3 2.5 2.2 48 1 100.0 2904 Total 44.6 36.2 17.4 2,2 4.5 3.0 8.1 1,1 8.4 4.8 2 5 1.1 55.4 100,0 8980 Differentials in current use of family planning by the five administrative divisions of the country are large. More than half of the married women in Khulna (55 percent) and Rajshahi (55 percent) Divisions and slightly less than half in Barisal Division (48 percent) are current users. In contrast, less than one-third (29 percent) of the married women in Chittagong Division are using a method of contraception. Dhaka Division is intermediate with a contraceptive prevalence rate of 44 percent. In all divisions, the use of modern methods accounts for about 80 percent of all use. Large differentials in current use are found for different educational groups. Forty-one percent of married women with no formal education are currently using a method, compared to 46 percent of women with either incomplete or complete primary school, and 56 percent of those with at least some secondary education. Looking only at modern method use, however, it is of interest that there are no significant differences by education until the secondary school level. The pill is the most commonly used method among women in all education categories. The second most popular method among women who have no education or who did not complete primary school is female sterilization; among those who completed primary school it is periodic abstinence; and among those with secondary school the condom is the second most widely used method. It is interesting that more educated women are more likely to use traditional methods. These patterns are no doubt influenced by the fact that uneducated women tend to be older and of higher parity than more educated women. 47 Figure 4.3 Current Use of Contraception among Currently Married Women 10-49 by Selected Background Characteristics RESIDENCE Urban Rural DIVISION Barisal Chittagong ~ - Dhaka_ L-- Khulna-- -- Ra shahi EDUCATION No Education Prim. Incomp. [~ Prim. Comp. L~ Secondary+ 0 . . . . . . . [ 43 ~ 2 9 ~------------~-~ -- ~ ~ - - - 55 ~ ~ = ~ ~ ~ 55 10 20 ao 40 50 Percent 60 BDHS 1993-94 The number of living children, or parity, is an indicator of actual reproductive behavior. The relationship between parity and contraceptive use provides an indication of the effect of actual reproductive behavior on use and/or the opposite--the effect of contraceptive use on the number of children. As shown in Table 4.8, current use demonstrates a curvilinear relationship with the number of living children. The proportion using any contraceptive method rises from a low of 14 percent of currently married women with no children to 58 percent for those with three children and then declines to 52 percent of women with four or more children. This decline may be due in part to women's actual or perceived infecundity at higher parities. Two issues emerge from this analysis of family planning use. First, contraceptive use among married women under age 25 and among those with less than two children is no longer negligible. Although the rates for these groups are still low relative to other groups, they are high enough to indicate that young couples are willing to use family planning methods early in marriage. The second issue is the continuing low level of contraceptive use in Chittagong Division. This is examined in more detail in Table 4.9 which shows trends in the use of contraception since 1983 by division. It is clear that even ill 1983, Chittagong Division lagged well behind the other three divisions in levels of use. Thus, although prevalence rates in Chittagong Division increased between 1983 and 1993-94 at roughly the same rate as in the other divisions (more than doubling), the initial discrepancy remains. This disparity requires further study to assist in designing program interventions to bring Chittagong Division in line with the rest of the country. 48 Table 4.9 Trends in current use of family planning methods by division Percentage of currently married women age 10-49 who are currently using any method, any modem method or any traditonal method of family planning, by division, selected sources. Bangladesh, 1983-1994 Type of melhod/ 1983 1985 1989 1989 1991 1993-94 Division CPS CPS CPS BFS l CPS BDHS Any method Chittagong 12.6 16.1 19.8 21.0 27.1 29.3 Dhaka 20.5 26.0 34.5 32.0 41.7 44.3 Khulna 20.7 28.2 36.6 35.0 45.7 52.8 Rajshahi 22.6 30.3 34.7 38.0 46.1 54.8 Any modern method Chittagong 8.7 11.5 15.3 U 20.5 23.4 Dhaka 15.5 19.9 27.6 U 32.9 36.3 Khuina 14.2 20.0 2%9 U 34.6 41.1 Rajshahi 16.1 21.5 26.7 U 37.2 45.9 Any traditional method Chittagong 3.9 4.7 4.5 U 6.6 5.9 Dhaka 5.0 6.1 6.9 U 8.9 8.0 Khulna 6.5 8.2 8.7 U 11.1 11.7 Rajshahi 6.5 8.8 8.0 U 8.8 8.9 Note: Data from the 1993-94 BDHS were recategorized to represent the previous four divisions. U = Unknown (no information) 1Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1983 CPS (Mitra and Kamal, 1985:188); 1985 CPS (Miua, 1987:166); 1989 CPS (Mitra et al., 1990:113); 1989 BFS (Huq and Cleland, 1990:68); 1991 CPS (Mitra et al., 1993:56) 4.4 Number of Children at First Use of Family Planning In order to investigate when during the family building process couples become motivated to initiate family planning use, the BDHS includcd a question for all women who had ever used a method as to how many living children they had when they first used a method. Table 4.10 shows the distribution of ever- Table 4.10 Number of children at first use of contraception Percent distribution of ever-married women age 10-49 by number of living children at the time of first use of contraception. according to current age, Bangladesh 1993-94 Number of living children at time Never of first use of contraception Number used of Current age contraception 0 1 2 3 4+ Missing Total women 10-14 67.2 31.4 1.4 0.0 0.0 0.0 0.0 100.0 145 15-19 58.0 22.9 17.3 1.7 0.0 0.0 0.2 100.0 1271 20-24 36.6 18.0 27.7 12.3 4.2 1.0 0.2 100.0 2033 25-29 27.4 11.3 22.0 19.0 12.1 7.8 0.3 100.0 2012 30-34 27.2 5.5 12,8 15.0 16.6 22.7 0.2 100.0 1456 35-39 27.4 2.7 8.4 12.6 13.7 34.9 0.3 100.0 1197 40-44 39.5 1.7 4.7 4.7 9.4 39.9 0.1 100.0 871 45-49 55.4 1.5 2.8 3.4 7.3 29.3 0.3 100.0 655 Total 36.9 11.1 16.3 11.3 9.0 15.2 0.2 100.0 9640 49 married women by the number of living children they had when they first used a method. Overall, two-fifths (39 percent) of women initiated contraceptive use when they had fewer than three living children and 11 percent initiated use when they had no children. There is a tendency for younger women to have initiated family planning use at lower parities than older women. For example, 28 percent of women age 20-24 started using contraception after their first child, compared to only 3 percent of women 45 -49. This probably reflects the fact that young women are more likely to use contraception to space births, while older women use it to limit births. 4.5 Family Planning Decisionmaking Discussion between spouses and the process of making decisions that affect the family are important issues in determining the extent of acceptance of use of family planning. In the BDHS, ever-married women who had ever used family planning were asked whether they or their husbands had more influence in making the decision to use family planning for the first time) Table 4.11 presents the results from this question. Table 4.11 Family plarming decisionmakin g Percent dis¢ibution of ever-married women who have ever used modern family planning by whether respondent or her husband had more influence in the decision to first use family planning, according to selected background characteristics, Bangladesh 1993-94 Husband Other Respondent Husband and wife relative Not Number Background had more had more had equal had more stated/ of characteristic influence influence influence influence Other Missing Total women Age 10-14 9.8 59.3 16.3 8.2 0.0 6.4 100.0 33 15-19 19.4 34.2 39.9 3.2 1.1 2.3 100.0 448 20-24 25.7 25.8 42.5 2.4 0.6 3.1 100.0 1159 25-29 29.7 19.9 43.4 1.9 1.0 4.1 100.0 1353 30-34 32.5 20.5 38.6 1.3 0.4 6.6 100.0 979 35-39 35.2 16.6 39.7 1.9 0.9 5.6 100.0 790 40-44 32.3 17.8 39.0 2.1 1.2 7.6 100.0 452 45-49 35.9 17.2 36.3 4.5 1.5 4.5 100.0 228 Residence Urban 29.2 18.6 43.6 1.4 0.7 6.5 100.0 787 Rural 29.7 22.5 40.2 2.3 0.9 4.4 100.0 4654 Division Barisal 30.7 22.2 40.1 1.9 0.4 4.7 100.0 374 Chittagong 35.3 21.8 35.5 2.0 1.4 4.0 100.0 1028 Dhaka 30.7 21.5 38.8 3.2 1.2 4.7 100.0 1755 Khulna 29.3 23.3 37.6 1.5 0.7 7.7 100.0 811 Rajshahi 24.5 21.7 48.5 1.4 0.2 3.7 100.0 1473 Education No education 33.9 21.0 37.6 2.7 1.1 3.7 100.0 2803 Primary incomplete 29.7 23.0 40.4 1.9 0.9 4.2 100.0 1018 Primary complete 26.8 23.2 42.4 1.2 1.0 5.4 100.0 564 Secondary/Higher 19.9 22.7 48.2 1.4 0.1 7.7 100.0 1057 Total 29.7 21.9 40.7 2.2 0.8 4.7 100.0 5442 Due to an error in the questionnaire, current users of periodic abstinence and withdrawal were not asked this question. 50 Overall, 41 percent of respondents said that they and their husbands had equal influence in the decision to use family planning for the first time, while 30 percent said that they had more influence, and 22 percent said their husbands did. Younger women are more likely than older women to say that their husbands had more influence in the decision. Differences by urban-rural residence and by division are small, except that couples in Rajshahi Division appear to be more egalitarian than most, with a larger proportion of women reporting equal influence. Interestingly, a larger proportion of uneducated than educated women say that they had more influence in the decision to use family planning, while those with more education are likely to report equal influence of husband and wife in family planning decisionmaking. 4.6 Problems with Current Method of Family Planning An understanding of the problems that users experience is important in efforts to improve family planning service delivery in Bangladesh. Table 4.12 presents information from the BDHS on the main problems reported by women who were currently using family planning methods. A sizeable proportion of women using injection, female sterilization, the IUD, and the pill reported having health problems with their methods, Commoncomplaints were feelingweakortired andhavingheadaches. The mostcommonproblem reported by injection users is amenorrhea (no menstruation), while IUD users complain of excessive bleeding. Health problems were rare or nonexistent among users of condoms, male sterilization, periodic abstinence, and withdrawal, presumably because all of these methods are either used by men or, in the case of periodic abstinence, by mutual consent of the couple. Non-health problems were rarely reported for any method. Table 4.12 Problems with current method of family planning Percentage of current users of family planning who are having problems with their method, by specific method and type of problem, Bangladesh 1993-94 Contraceptive method Female Male stefili- sterili- Periodic With- Pioblem Pill IUD Injection Condom zation zation abstinence drawa/ Other Total Any health problem 32.7 35.9 47.7 4.3 47.2 14.5 0.0 1.2 13.0 29. i Weight gain 1.4 0.6 0.6 0.0 1.0 0.0 0.0 0.0 0.0 0.8 Weight loss 2.7 5.3 3.5 0.0 12.8 2.0 0.0 0.3 3.6 4.2 Excessive bleeding 2.0 13.1 4.2 0.0 6.6 0.0 0.0 0.0 4.4 3.2 Hypertension 0.3 2.2 1.3 0.0 1.4 0.0 0.0 0.0 1.0 0.7 Headache 21.6 8.8 15.4 0.0 15.7 1.9 0.0 0.4 2.9 13.4 Nausea 6.3 1.0 1.5 0.0 1.8 0.0 0.0 0.0 0.0 3.0 No menstruation 1.0 1.I 23.6 0.4 2.9 0.0 0.0 0.0 0.0 3.4 Weak/tired 15.7 15.7 18.9 0.4 29.3 9,9 0.0 0.4 5.5 14.7 Dizziness 4.5 1.2 5.9 0.8 10.4 0.0 0.0 0.0 2.4 4.5 Otl~r 7.3 15.8 10.6 3.1 20,5 9.0 0.0 0.9 5.4 9.1 Non-health problem 1.2 2.1 1.2 1.7 2.4 6.1 0.6 0.0 1.3 1.5 Number of users 1560 196 404 269 766 98 434 220 96 4045 4.7 Reasons for Selecting Fami ly P lanning Methods It is useful to understand why couples choose to use a particular method as opposed to another. Is it because they have little knowledge about methods or limited access to them? This question is of particular importance in Bangladesh, where women have at least heard about most of the methods (see Table 4.3) and thus are more able to make informed choices. It is also useful to understand why the pill has become the predominant method in recent years. Table 4.13 shows the distribution of current users of specific methods by the main reason they decided to use that method. 51 Table 4.13 Reason for using current method of family planning Percent distribution of current users of family planning by main reason they decided to use the method, according to specific methods, Bangladesh 1993-94 Contraceptive method Female Male sterili- sterili- Periodic With- Re ,on Pill IUD Injection Condom zation zation abstinence drawal Other Total Family planning worker recommended 3.0 8.3 5.6 1.8 3.1 1.1 1.5 0.9 0.0 3.1 Friend, relative recommended 3.8 6.2 1.6 3.1 2.9 10.8 3.9 2.9 9.7 3.7 Side effects of other methods 26.5 40.2 41.4 55.5 4.8 0.0 53.0 51.7 43.1 30.4 Method easy to use 39.7 28.9 36.4 15.6 1.3 0.0 21.8 l 1.0 7.3 24.7 Access/Availability 13.2 1.5 2.9 3.1 0.8 1.0 1.1 0.9 6.2 6.2 Cost 0.2 0.5 0.0 0.0 0.1 0.0 0.0 0.0 2.1 0.2 Wanted permanent method 0.4 3.0 2.3 0.0 74.2 45.1 0.1 0.0 15.1 16.0 Husband preferred 10.4 6.0 5.5 18.6 8,5 36.6 13.5 27.0 8.9 11.7 Wanted more effective method I. l 3.3 2.6 0.5 1.2 0.0 0.2 1.0 3.2 1.3 Other 1.4 2.2 1.7 1.S 2.6 ,1.5 4.8 4.1 3.5 2.4 Don't know/Missing 0.3 0.0 0.0 0.2 0.4 1.0 0.1 0.5 1.0 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100,0 Number of users 1560 196 404 269 766 98 434 220 96 4045 Reasons for selecting methods vary by method. As expected, pill users are most likely to say that they chose the pill because it was easy to use (40 percent), although one-quarter say that side effects of other methods led them to choose the pill. Other reasons cited by pill users are availability of the method (13 percent) and husband's preference for the method (10 percent). The main masons that users of the IUD, injection, and periodic abstinence selected their methods are side effects of other methods and the ease of using their methods. Not surprisingly, women who have been sterilized and those whose husbands have been sterilized are most likely to say they chose the method because it was pcrmanent. Over one-third of women whose husbands were sterilized said that their husband's preference for the operation was the main mason for choosing it. Although the majority of condom and withdrawal users said that the possible side effects of other methods influenced them to use their current method, husband's preference was also an important reason. It is interesting to note that substantial proportions of contraceptive users choose their method not so much because of the advantages of that method, but because of the perceived problems with using other methods. For these women, selection of a method becomes a process of eliminating the less desirable options. Ease of use, is of course, another major criterion in method selection. The fact that husband's preference is also commonly cited indicates that husbands are often involved in making decisions about use of family planning. 4.8 Pill Use Use of the pill has incmasod tremendously over the past decade. It now accounts for 40 percent of all use and half of all modem method use. Because of the importance of the pill, the BDHS included a number of special questions about pill use including the brand ofpiU used, the quality of pill use, and the cost of pills. 52 Use of Social Marketing Brands Bangladesh has an active contraceptive social marketing program that distributes pills, condoms, and oral rehydration salts through a network of some 140,000 retail outlets (pharma- cies, small shops, and kiosks) throughout the country. The Social Marketing Company carries several brands of oral contraceptives, namely Maya, Norquest, and Ovacon. To obtain infor- mation on the number of users purchasing the social marketing brands, BDHS interviewers asked all respondents who were current pill users to show them their pill packet. If the user had the packet available, the interviewer recorded the brand on the questionnaire. If not, the interview- er showed the woman a chart depicting all the major pill brands and asked the user to identify which brand she was currently using. Overall, 14 percent of pill users were us- ing social marketing brands (Table 4.14). Over three-quarters of pill users were using the gov- ernment-supplied brand, Combination-5, which is provided free of charge through government Table 4.14 Use of pill brands Percent distribution of curre~at pill users by brand of pill used, according to urban-rural residence, Bangladesh 1993-94 Residence Pill brand Urban Rural Total GovernmenffNGO Combination-5 57.1 79.2 76.2 Noriday 0.1 0.1 0.1 Ovral 1.5 1.1 1.2 Social marketing Maya 4.5 2.0 2.3 Norquest 6.1 3.4 3.7 Ovacon 10.6 7.8 8.2 Private Marvelon 2.4 1.0 1.2 Ovostat 12.3 3.0 4.3 Other Lyndiol 0.2 0.l 0.2 Nordette 2.2 0.5 0.8 Other brand 0.5 0.2 0.3 Don't know/Missing 2.4 1.5 1.6 Total 100.0 100.0 100.0 Number of pill users 212 1348 1560 field workers and clinics. Urban pill users are somewhat less likely to use the government brand and somewhat more likely to use one of the social marketing brands than rural users. As shown in Table 4.15, social marketing brands account for a greater market share of pill use in Barisal and Khulna Divisions than in the other three divisions. Table 4.15 Use of social marketing brand pills Percentage of pill users who are using a social marketing brand, by urban-rural residence and division, Bangladesh 1993 -94 Residence Division Urban Rural Total Barisal * 16.8 18.1 Chittagong (14.3) 11.9 12.3 Dhaka 23.l 10.1 13.2 Khulna * 16.9 17.5 Rajshahi (16.2) 13.7 13.8 Total 21.2 13.1 14.2 Note: Maya, Norquest and Ovacon are considered social marketing brands. Figures in parentheses are based on 25 to 49 women. * Fewer than 25 unweight~d women 53 The percentage of pill users using a brand provided by government or non-governmental organizations (NGOs) has increased substantially over time, from only 40 percent in 1983 to 78 percent in 1993-94 (Figure 4.4). The social marketing program's market share increased in the late 1980s, decreased between 1989 and 1991 and has held steady in recent years. The private sector has accounted for a steadily diminishing share of pill use over time. Figure 4.4 Trends in Market Share of Specific Pill Brands among Current Pill Users, Selected Sources, 1975 to 1993-94 Percent Currently Using 100 80 60 40 20 0 77 78 1983 1986 1989 1991 Year 1993-94 Source: Mitra et al., 1993:72 Quality of Pill Use The BDHS collected information on a number of indicators that measure the "quality of use" of the pill. Among these are the proportion of women who said they were currently using the pill but were unable to show a packet of pills to the interviewer, the proportion of users whose packet of pills showed evidence of pills being taken out of sequence or not at all, the proportion of users who said they had not taken a pill in the last two days, and responses to a question on what users do when they forget to take a pill. Tables 4.16 and 4.17 present the results. The fact that 95 percent of current pill users were able to show a packet of pills to the interviewer indicates a high level of compliance. When asked the masons for not having the packet available, half of the women said that they had "run out" of pills (data not shown). Since all of the major brands of pills in Bangladesh contain 28 pills in a packet and are meant to be taken without any break, many of the women who "ran out" of pills may in fact not be protected against pregnancy. However, they account for a small proportion of total pill users. 54 Table 4.16 Quality of pill use Percentage of ctm'ent pill users who were unable to show a pill packet, who had taken pills out of sequence or who last took a pill three or more days before the survey, by selected background characteristics, Bangladesh 1993-94 Pills Last Unable taken pill Number Background to show out of taken of pill characteristic packet sequence 3+ days users Age 10-14 * * * I0 15-19 6.1 3.8 10.5 151 20-24 4.3 5.5 9.8 388 25-29 4.1 5.3 9.1 450 30-34 7.9 7.2 II.9 275 35-39 3.1 4.7 I0.I 169 40-44 7.4 8.8 12.8 93 45-49 10.8 8.1 28.1 25 Residence Urban 5.7 4.2 9.4 212 Rural 5.l 5.9 10.6 1348 Division Barisal 6.2 6.2 8.3 103 Chittagong 4.7 4.7 12,6 213 Dhaka 6.7 6.1 12.3 501 Khulna 4.7 8.4 12.3 230 Rajshahi 3.9 4.4 7.4 513 Education No education 4.9 7.7 11.0 748 Primary incomplete 4.9 4.4 10.9 304 Primary complete 5.0 4.6 8.5 177 Secondary/Higher 6.1 2.9 9.9 331 Total 5.2 5.7 10.5 100 Number of pill users 81 89 163 1560 * Fewer than 25 unweighted women Table 4.17 Action taken if forgot to take the pill Percent distribution of current pill users by action that they would take if they forgot to take two or more pills, Bangladesh 1993-94 Action taken Total Start again as usual 8.5 Take extra pills 63.5 Use another method 1.7 Extra pills plus another method 0.8 Other 0.6 Never forgot 24.9 Total 100.0 Number of pill users 1560 55 Among pill users who were able to show a packet, it appeared that most users took the pills systematically. Only 6 percent of pill users showed the interviewers packets in which pills had apparently been taken out of sequence. Of these women, many reported that either health reasons or ignorance had led them to take pills out of order (data not shown). Eleven percent of pill users said that the last time they had taken a pill was more than two days before the interview. Although it is possible that most of these women were in the period between packets, it is likely that many were unprotected, since most pills used in Bangladesh are meant to be taken continuously. Of those who had not taken a pill in the past two days, four-fifths said that the reason was that they were menstruating, that they had run out of pills, or that their husbands were away (data not shown). All these indicators of the quality of pill use show only minor variations by background characteristics of the women. All current pill users were also asked the following question: "Just about everyone forgets to take a pill sometime. What do you do when you forget to take a pill for two days in a row?" As shown in Table 4.17, two-thirds ofpiU users gave correct responses, i.e., that they would take extra pills, use another method, or both. Most of the remainder declined to answer the question in that they said they never forgot to take a pill. Almost one in ten said they would continue taking the pill as usual, taking only one pill on the day they forgot, and thus possibly leaving themselves exposed to risk of pregnancy.

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