Bangladesh - Demographic and Health Survey - 1997

Publication date: 1997

Bangladesh Demographic and Health Survey 1996-1997 A NIPORT National Institute of Population Research and Training (NIPORT) Ministry of Health and Family Welfare Ira Mitra and Associates -~DHS Demographic and Health Surveys Macro International Inc. Bangladesh Demographic and Health Survey 1996-1997 A NIPORT National Institute of Population Research and Training (NIPORT) Ministry of Health and Family Welfare Ira Mitra and Associates -~DHS Demographic and Health Surveys Macro International Inc. World Summit for Children Indicators: Banaladesh 1996-97 Value BASIC INDICATORS Infant mortality Childhood undernutrition Clean water supply Sanitary excreta disposal Basic education Children in especially difficult situations Infant mortality rate Under-five mortality rate Percent stunted Percent wasted Percent underweight Percent of households with a safe water supply I Percent of households with flush toilets or VIP latrines Percent of women 15-49 with completed primary education Percent of men 15-49 with completed primary education Percent of girls 6-12 attending school Percent of boys 6-12 attending school Percent of women 15-49 who are literate Percent of children who live in single-adult households 82 per 1,000 116 per 1,000 54.6 17.7 56.3 97.4 30.5 35.2 47.8 76.3 74.8 36.4 3.3 SUPPORTING INDICATORS Women's Health Birth spacing Safe motherhood Family planning Nutrition Maternal nutrition Breastfeeding Child Health Vaccinations Percent of births within 24 months of a previous birth Percent of births with medical prenatal care Percent of births with prenatal care in first trimester Percent of births with medical assistance at delivery Percent of births in a medical facility Percent of births at high risk Contraceptive prevalence rate (any method, married women) Percent of currently married women with an unmet demand for family planning Percent of currently married women with an unmet need for family planning to avoid a high-risk birth Percent of mothers with low BM1 Percent of children under 4 months who are exclusively breastfed 17.7 26.4 12.1 8.1 4.1 58.0 49.2 15.8 12.4 52.0 50.9 Percent of children whose mothers received tetanus toxoid vaccination during pregnancy 74.7 Percent of children 12-23 months with measles vaccination 69.9 Percent of children 12-23 months fully vaccinated 54.1 Diarrhea control Percent of children with diarrhea in preceding 2 weeks who received oral rehydration therapy (sugar-salt-water solution) 61.0 Acute respiratory infection Percent of children with acute respiratory infection in preceding 2 weeks who were seen by medical personnel 32.9 1 Piped, well, and bottled water Bangladesh Demographic and Health Survey 1996-1997 S. N. Mitra Ahmed A1-Sabir Anne R. Cross Kanta Jamil National Institute of Population Research and Training (NIPORT) Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh Macro International Inc. Calverton, Maryland USA December 1997 The Bangladesh Demographic and Health Survey (BDHS) is part of the worldwide Demographic and Health Surveys program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information about the BDHS may be obtained from the Mitra and Associates at 2/17 lqbal Road, Block A, Mohammadpur, Dhaka, Bangladesh (Telephone: 818-065; Fax: c/o 832-915) or from NIPORT, Azimpur, Dhaka, Bangladesh (Telephone: 507-866 and Fax: 863-362). Additional information about the DHS project may be obtained by writing to : DHS, Macro International Inc., 11785 Beltsville Drive, Calverton, MD 20705 (Telephone: 301-572-0200 and Fax: 301-572-0999). Reconur~nded citation: Mitra, S.N., Ahmed A1-Sabir, Anne R. Cross, and Kanta Jamil. 1997. Bangladesh Demographic and Health Survey, 1996-1997. Dhaka and 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 Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Map of Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxii CHAPTER1 1.1 1.2 1,3 1.4 INTRODUC~ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Geography and Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Population, Family Planning and Maternal and Child Health Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Organization of the 1996-97 Bangladesh Demographic and Health Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 CHAPTER 2 2.1 2.2 2.3 CHARACTERIST ICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . . . 7 Characteristics of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Background Characteristics of Women and Men Respondents . . . . . . . . . . . . . . . . . . 16 CHAPTER3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 FERT IL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Fertility Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Fertility Differentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Children Ever Born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Teenage Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 CHAPTER4 4.1 4.2 4.3 4,4 4,5 4.6 4.7 FERT IL ITY REGULAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Knowledge of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Knowledge and Ever Use of Menstrual Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Number of Children at First Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Problems with Current Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Reasons for Selecting Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 iii Page 4.8 Use of Social Marketing Brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.9 Age at Sterilization and Sterilization Regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.10 Cost of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 4.11 Source of Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 4.12 Contraceptive Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 4.13 Nonuse of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 4.14 Family Planning Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 4.15 Family Planning Outreach Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 4.16 Couples' Communication and Attitudes Toward Use of Family Planning . . . . . . . . . . 77 CHAPTER5 5.1 5.2 5.3 OTHER PROXIMATE DETERMINANTS OF FERT IL ITY . . . . . . . . . . . . . . . . 81 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 CHAPTER6 6.1 6.2 6.3 6.4 FERT IL ITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAPTER7 7.1 7.2 7.3 7.4 7.5 INFANT AND CHILD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Levels and Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Socioeconomic Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . 102 Demographic Differentials in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . 103 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 CHAPTER8 8.1 8.2 8.3 8.4 MATERNAL AND CHILD HEALTH . 109 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Childhood Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Childhood Illness and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 CHAPTER 9 9.1 9.2 9.3 INFANT FEEDING, CHILDHOOD AND MATERNAL NUTRIT ION . . . . . . 129 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Children' s Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Nutritional Status of Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 iv CHAPTER 10 CHAPTER 11 REFERENCES APPENDIX A APPENDIX B APPENDIX C APPENDIX D APPENDIX E Page KNOWLEDGE OF A IDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 AVAILABIL ITY OF HEALTH AND FAMILY PLANNING SERVICES . . . 145 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149 SURVEY IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 EST IMATES OF SAMPL ING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 DATA QUAL ITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 PERSONS INVOLVED IN THE 1996-97 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 QUEST IONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 V Table 1.1 Tal:le 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 2.11.1 Table 2.11.2 Table 2.12 Table 2.13 Table 2.14 Table 2.15.1 Table 2.15.2 Table 2.16 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 4.1 Table 4.2 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 TABLES Fage Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Population by age from selected sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Educational level of the female and male household population . . . . . . . . . . . . . . . . 11 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Household possessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Health-care-seeking behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Differentials in age and education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Level of education by background characteristics: women . . . . . . . . . . . . . . . . . . . . 19 Level of education by background characteristics: men . . . . . . . . . . . . . . . . . . . . . . . 19 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Employer and form of earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Occupation: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Occupation: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Decisions on use of earuings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Current fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Trends in current fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Trends in fertility by division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Percent pregnant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Trends in fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Trends in children ever born . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Age ;t first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Adolescent pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Trends in knowledge of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Knowledge of contraceptive methods among couples . . . . . . . . . . . . . . . . . . . . . . . . 45 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Trends in ever use of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Menstrual regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Current use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Trends in current use of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Current use of contraception by background characteristics . . . . . . . . . . . . . . . . . . . 53 Trends in current use of family planning methods by division . . . . . . . . . . . . . . . . . . 55 Comparison of reported contraceptive use by spouses . . . . . . . . . . . . . . . . . . . . . . . . 57 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 vii 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 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 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 7.4 Table 7.5 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Table 8.7 Page Problems with current method of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Reason for using current method of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Use of pill brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Use of condom brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Timing of sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Sterilization regret . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Cost of methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Source of supply for modem contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . 65 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Reasons for discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Exposure to family planning messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Contact with family planning fieldworkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Satellite clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Discussion of family planning with husband . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Attitudes of couples toward family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Perception of spouse's attitude toward family planning . . . . . . . . . . . . . . . . . . . . . . . 79 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Trends in proportion never married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Postpartum amenorrhea, abstinence, and insusceptibility . . . . . . . . . . . . . . . . . . . . . 85 Median duration of postpartum insusceptibility by background characteristics . . . . 86 Fertility preferences by number of living children . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Ideal and actual number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Mean ideal number of children by background characteristics . . . . . . . . . . . . . . . . . 96 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Trends in infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . . . . . 102 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . . . . 104 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Opinion on medical checkups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . . . . . 112 Tetanus toxoid vaccinations and medical testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 viii Table 8.8 Table 8.9 Table 8.10 Table 8.11 Table 8.12 Table 8.13 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 10.1 Table 10.2 Table 10.3 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table A.I.1 Table A. 1.2 Table B. 1 Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table B.7 Table B.8 Table B.9 Table B.10 Table B. 11 Table C. 1 Table C.2 Table C.3 Table C.4 Table C.5 Table C.6 Page Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . . . . . 122 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Men who report signs and symptoms of disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Treatment with vitamin A capsules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Nutritional status of children by demographic characteristics . . . . . . . . . . . . . . . . . 135 Nutritional status of children by background characteristics . . . . . . . . . . . . . . . . . . 137 Nutritional status of mothers by background characteristics . . . . . . . . . . . . . . . . . . 139 Knowledge of AIDS and sources of AIDS information: women . . . . . . . . . . . . . . . 142 Knowledge of ways to avoid HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Awareness of AIDS-related health issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Distance to public services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Presence of income-generating organizations in cluster . . . . . . . . . . . . . . . . . . . . . . 147 Presence of health and family planning workers and services in the communi ty . . . 147 Presence of government and non-governmental family planning fieldworkers . . . . 148 Sample implementation: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sample implementation: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 List of selected variables for sampling errors, Bangladesh 1996-97 . . . . . . . . . . . . 162 Sampling errors - National sample, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . 163 Sampling errors - Urban sample, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . 164 Sampling errors - Rural sample, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . 165 Sampling errors - Barisal, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Sampling errors - Chittagong, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . 167 Sampling errors - Dhaka, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Sampling errors - Khulna, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Sampling errors - Rajshahi, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Sampling errors - Sylhet, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Sampling errors of differences between contraceptive prevalence rates from the 1993-94 and 1996-97 BDHSs (for the 301 clusters common to both surveys), Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . 176 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Births by calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 ix Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 3.6 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 5.1 Figure 6.1 Figure 6.2 Figure 6.3 Figure 6.4 Figure 6.5 Figure 6.6 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 8.1 Figure 8.2 Figure 8.3 Figure 8.4 FIGURES Page Population Pyramid, Bangladesh 1996-97 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Distribution of De Facto Household Population by Single Year of Age and Sex . . . . 9 Percentage of Males and Females with No Education by Age Group . . . . . . . . . . . . 12 Trends in Household Ownership of Durable Goods . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Age-Specific Fertility Rates by Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Total Fertility Rates by Selected Background Characteristics . . . . . . . . . . . . . . . . . . 29 Trends in Total Fertility Rates, 1971-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Trends in Total Fertility Rates by Calendar Year from Selected Sources, 1985-1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Age-Specific Fertility Rates 1989, 1991, 1993-94 and 1996-97 . . . . . . . . . . . . . . . . . 32 Trends in Fertility by Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Trends in Contraceptive Use Among Currently Married Women 10-49 . . . . . . . . . . 51 Trends in Use of Specific Contraceptive Methods Among Currently Married Women Age 10-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Trends in Contraceptive Method Mix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Percentage of Currently Married Women Using a Contraceptive Method by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Trends in Contraceptive Use by Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Trends in Use of Types of Pill Brands, 1991-1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Distribution of Current Users of Contraception by Source of Supply . . . . . . . . . . . . 66 Trends in Proportion Never Married Among Women 15-19 and 20-24 . . . . . . . . . . . 83 Fertility Preferences Among Currently Married Women 10-49 . . . . . . . . . . . . . . . . . 89 Percentage of Currently Married Women and Men Who Want No More Children by Number of Living Children . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Fertility Preferences Among Married Couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Percentage of Married Women with Two Children Who Want No More Children by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Trends in Unmet Need for Family Planning by Division . . . . . . . . . . . . . . . . . . . . . . 94 Percentage of Births by Planning Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Trends in Infant and Child Mortality 1989-93 to 1992-1996 . . . . . . . . . . . . . . . . . . 100 Infant Mortality Rates from Selected Sources, 1985-1995 . . . . . . . . . . . . . . . . . . . . 101 Under-Five Mortality by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . 103 Under-Five Mortality by Selected Demographic Characteristics . . . . . . . . . . . . . . . 105 Percent Distribution of Births by Antenatal and Delivery Care . . . . . . . . . . . . . . . . 111 Percentage of Children 12-23 Months Who Have Received Specific Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Percentage of Children Age 12-23 Months Who Have Received All Vaccinations by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Trends in Vaccination Coverage Among Children Age 12-23 Months . . . . . . . . . . 120 xi Figu~9.1 ~gu~9.2 ~gu~9.3 ~gu~9.4 Figure 10.1 Page Median Duration of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Percentage of Children under Five Who Are Stunted, According to Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Percentage of Children under Five Who Are Stunted, According to Socioeconomic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Percentage of Mothers Shorter than 145 cm or with Low Body Mass Index (BMI), Selected Countries . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Percentage of Women and Men Who Have Ever Heard of AIDS, According to Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 xii Secretary Ministry of Health and Family Welfare Government of the People's Republic of Bangladesh FOREWORD The 1996-97 Bangladesh Demographic and Health Survey (BDHS) is a nationally representative sample survey designed to provide information on basic national indicators of social progress including fertility, childhood mortality, contraceptive knowledge and use, maternal and child health, nutritional status of mothers and children and awareness of AIDS. BDHS data indicate decline in fertility and infant and child mortality and steady increase in contraceptive use. Despite the relatively high and increasing level of contraceptive use, BDHS data indicate that unplanned pregnancies are still common. If unplanned births could be eliminated altogether, the total fertility rate in Bangladesh would reach the replacement level of 2.1 births per woman instead of actual level of 3.3. The findings of this report together with other national surveys are very Important in assessing the achievements of Family Planning and Health Programmes. Information obtained from the 1996-97 BDHS can be used to review the progress of Health and Family Planning Programmes, and to improve future policies and programmes. The need, however, for further detailed analysis of BDHS data remains. It Is hoped that such analysis will be carried out by the academiclans, researchers and programme personnel to provide more in-depth knowledge for future direction and effective implementation of a national Health and Family Planning Programme. In conclusion, I would like to thank NIPORT, Mitra and Associates and Macro International Inc. for their efforts in conducting the 1996-97 BDHS. USAID/Dhaka also deserve thanks for their Nnancial assistance that helped ensure the ultimate success of this important undertaking. ( M u ~ xiii A NIIDiDRT Director General National Institute of Population Research and Training (NIPORT) PREFACE The 1996-97 Bangladesh Demographic and Health Survey (BDHS) is the second of this kind of survey conducted in Bangladesh. The BDHS was implemented through a collaborative effort of NIPORT, Mitra and Associates, and Macro International Inc. The financial support for the survey was made by the United States Agency for International Development (USAID)IDhaka. The main objective of the 1996-97 BDHS is to provide policy-makers and programme managers in population and health with detailed information on fertility and family planning, childhood mortality, and maternal and child health. The content of the 1996-97 BDHS has been significantly expanded from the previous survey to include two new modules on nutritional status of mothers and children and awareness of AIDS. The Technical Review Committee (TRC) consisted of experts from government, non- government and international organization as well as researchers and professionals working in health and population sector put forth their valuable opinion in major phases of the survey. In addition, a Technical Task Force (TTF) was formed with the representatives from NIPORT, Mitra and Associates, USAID/Dhaka, ICDDR, B, Population Council/Dhaka and Macro International Inc. for designing and implementing the survey. I would like to extend my gratitude and appreciation to the members of the TRC and TTF for their contributions at different phases of the survey. The preliminary results of the 1996-97 BDHS, with its major findings, were officially announced through a press conference and a dissemination seminar was held in June 1997. The final report supplements the preliminary report released earlier. I hope that the survey results would be useful for monitoring as well as development of national health and family planning programmes. I express my heartfelt thanks to the professionals of Macro International Inc., professionals and staff of Mitra and Associates and professionals of research unit of NIPORT for their sincere efforts in successful completion of the survey. (Anil ~ h a ) XV SUMMARY OF FINDINGS The 1996-97 Bangladesh Demographic and Health Survey (BDHS) is a nationally-representative survey of 9,127 ever-married women age 10-49 and 3,312 currently married men age 15-59. 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 and nutrition. Fieldwork for the BDHS took place from early November 1996 to mid-March 1997. Survey data generally confirm patterns observed in the 1993-94 BDHS, showing increasing contraceptive use and declining childhood mortality; however, many challenges still await. FERTILITY Fertility Decline. The BDHS data indicate that there has been an imperceptibly small decline in fertility since the 1993-94 survey. The total fertility rate has declined from 3.4 births per woman in the period 1991-93 to 3.3 births for the period 1994-96. Although such an apparently abrupt halt in the previously rapid fertility decline is difficult to explain, the results from the 1996-97 survey confirm that fertility is now at a low level. Fertility Differentials. Although the rate of fertility decline has been generally uniform across groups, significant differences in fertility levels still exist. For example, fertility is considerably higher in Sylhet and Chittagong Divisions (with total fertility rates of more than 4 births per woman), than in Rajshahi and Khulna Divisions (with rates of 2.8 and 2.5 births per woman, respectively). Barisal and Dhaka Divisions have intermediate levels of fertility (3.3 and 3.2 births per woman, respectively). Moreover, fertility is about 60 percent higher in rural areas than in urban areas, a pattern 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 3.9 children in their lifetime, compared with 2.1 for women with at least some secondary education, a difference of 86 percent. Women with either incomplete primary or complete primary education have intermediate fertility rates. Small Family Norm. The 1996-97 BDHS data confirm that Bangladeshi couples have accepted the small family norm. Sixty percent of ever-married women prefer a two-child family, and another 21 percent consider a three-child family ideal, while less than 1 percent of respondents say they would choose to have six or more children. Overall, the mean ideal family size among married women is 2.5 children, identical to the mean found in 1993-94. BDHS data also indicate a high degree of agreement between women and men 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 1996-97. Almost half of all currently married women age 10-49 in Bangladesh say they want no more children and 9 percent have been sterilized. 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 11 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 3.3. xvii 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 sixfold since 1975, from 8 to 49 percent of married women. Use of modem methods has grown even faster. Between 1993-94 and 1996-97, contraceptive use increased from 45 to 49 percent of married women and use of modem methods rose from 36 to 42 percent. Overall, there has been a steady growth in the contraceptive prevalence rate with an average increase of almost 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 quadrupled in the last 11 years, from 5 percent in 1985 to 21 percent in 1996-97 and the pill now accounts for 42 percent of all contraceptive use. Conversely, use of female and male sterilization has stagnated or declined slightly since 1989 and now accounts for only 18 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 costs, 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 injectables, condoms, and periodic abstinence (rhythm method) have increased since 1993-94, while use of IUDs and withdrawal have declined slightly. Differentials in Family Planning Use. Differentials in current use of family planning in the six administrative divisions of the country are large and indicate that Sylhet Division is lagging behind the rest of the country. Sixty-two percent of married women in Khulna Division and 59 percent of those in Rajshahi Division are current users. In contrast, only 20 percent of the married women in Sylhet Division and 37 percent of those in Chittagong Division are using a method of contraception. Intermediate are Dhaka and Barisal Divisions with contraceptive prevalence rates of around 50 percent. Urban-rural gaps in contraceptive use are large (62 vs. 48 percent, respectively) and increasing. Knowledge of Contraception. Knowledge of contraceptive methods and supply sources has been almost universal in Bangladesh for some time and the BDHS results indicate that 100 percent of currently married women age 10-49 know at least one method of family planning. More than 9 in 10 married women know the pill, IUD, injectables, condom, and female sterilization, while about 8 in 10 know male sterilization and menstrual regulation. Considering traditional methods, periodic abstinence is more widely known than withdrawal (68 vs. 50 percent of currently married women). Unmet Need for Family Planning. Unmet need for family planning services has declined since 1993-94. Data from the 1993-94 BDHS show that 19 percent of currently married women were in need of services, compared with 16 percent in the 1996-97 BDHS. Half of the unmet need is comprised of women who want to space their next birth, while just under half is for women who do not want any more children (limiters). If all women who say they want to space or limit their children were to use methods, the contraceptive prevalence rate could be increased from 49 percent to 67 percent of married women. Currently, 76 percent of this "total demand" for family planning is being met. Discontinuation Rates. One challenge for the family planning program is to reduce the high levels of contraceptive discontinuation. BDHS data indicate that almost 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 concerns with the method. Discontinuation rates vary by method. Not surprisingly, the rates for the condom (65 percent) and withdrawal (60 percent) are considerably higher than for the IUD and periodic abstinence (both 41 percent) and the pill (44 percent). However, discontinuation rates for injectables are relatively high, considering that one dose is usually effective for three months. Fifiy-one percent of injection users discontinue within one year of starting, a rate that is higher than for the pill. xviii 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 fleldworkers 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 1996-97, 19 percent of pill users were using social marketing brands, up from 1993-94. The proportion of condom users using social marketing brands dropped from 62 percent in 1989 to 41 percent in 1991, rebounded to 52 percent in 1993-94, and increased further to 58 percent in 1996- 97. Family Planning Fieldworkers. Fieldworkers are providing a slightly smaller share of family planning services now than in 1993-94 39 percent of modem method users in 1996-97 vs. 42 percent in 1993-94. This has occurred in spite of the fact that much of the increase in modem method use since 1993- 94 is due to increased use of the pill, which is distributed predominantly by fieldworkers, as well as the fact that fieldworkers have been increasingly used to distribute other methods such as injectables and IUDs. The proportion of supply provided through the private sector--most notably pharmacies--has increased from 10 to 15 percent since 1993-94. Fieldworker Visitation. Despite the impressive coverage in placement of family planning fleldworkers, survey data show a slight decrease in fieldworker visitation rates since 1993-94. In 1996-97, 35 percent of currently married women said they had been visited by a family planning fieldworker in the previous six months, down from 38 percent in 1993-94. Some women are more likely than others to have been visited by a fleldworker. 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 infecund or sterilized. Women in Chittagong and Sylhet Divisions are less likely and those in Rajshahi and Khuina Divisions more likely to have been visited by a fieldworker than women in Barisal or Dhaka Divisions. MATERNAL AND CHILD HEALTH Declining Childhood Mortality. Survey results confirm the improvement in child survival since the early 1980s. Under-five mortality declined from 133 deaths per 1,000 births in 1989-93 to 116 for the period 1992-96. The infant mortality rate declined over the same period (from 87 to 82 per 1,000 births). Although encouraging, the BDHS rates show that almost 1 in 9 children born in Bangladesh dies before reaching the fifth birthday, an indication that there is still much improvement to be made. The data also show that early childbearing (under age 18) increases the risk of childhood mortality. Childhood Vaccination Coverage. The 1996-97 BDHS results show that 54 percent of children 12-23 months are fully vaccinated, a decline from 59 percent in 1993-94. However, closer examination of the data by vaccine reveals that this trend is entirely due to a decline in the proportion receiving the third dose of polio vaccine (from 67 to 62 percent). Coverage of all other vaccines has increased slightly since 1993-94. Childhood Health. The BDHS provides some data on childhood illness and treatment. Approxi- mately 1 in 3 children under age five had a fever and 13 percent had respiratory illness in the two weeks before the survey. Of these, one-third were taken to a health facility for treatment. Eight percent of children under five were reported to have had diarrhea in the two weeks preceeding the survey. The fact that three- quarters of children with diarrhea received some type of oral rehydration therapy (fluid made from an ORS packet, recommended homemade fluid, or increased fluids) is encouraging. Also notable is the fact that two- thirds of children under five received a vitamin A capsule in the six months prior to the survey. xix Breasffeeding Practices. The BDHS results document an exceptionally long duration ofbreastfeed- ing, with a median duration of 33 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, 30 percent were already receiving supplemental foods or liquids. 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 five years before the survey, almost three-quarters received no antenatal care during pregnancy. Moreover, 95 percent of births in Bangladesh are delivered at home and 57 percent are assisted by untrained traditional birth attendants. Only 8 percent of births are assisted by medically trained personnel, with another 8 percent assisted by trained traditional birth attendants. 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 three- quarters of births, the mothers received a tetanus toxoid injection during pregnancy. Nutritional Status of Children and Mothers, Unlike the 1993-94 BDHS, the 1996-97 survey included an anthropometric component in which all children under five and their mothers were weighed and measured. Results show that malnutrition is a serious problem in Bangladesh. Over half of children under five (55 percent) show evidence of chronic malnutrition or stunting, while 18 percent are acutely malnourished (wasted). The situation is also serious among women--17 percent of mothers of children under five are less than 145 cm in height, an indication of malnutrition. Over half have a body mass index (BMI) below 18.5, indicating that they are acutely malnourished. Awareness of AIDS. The BDHS results indicate that awareness of AIDS is low in Bangladesh. Only 19 percent of ever-married women and 33 percent of currently married men had ever heard of the disease. Of those who had heard of it, only small percentages could name a means of avoiding getting AIDS. XX RAJSHAHI DIVISION BANGLADESH • OA • e • .~ • ~o • "5 ~•o o• INDIA KHULNA DIVISION I • 0 O0 ••0 • O~ ~ " ( • • •A ' ~ O0 - - Q A ~ • • OSylhet•(" :. •" • . . • " ' " . - ' " . c. ,oo,o o• " •"qro0~ t(' %~,/olvIs,oN • ummm I • . . ~ "& • • ~! m• O, " J -e- -• '1 g (~•0• nu 00 • . , , ( ,o • . o _-"l~-~,,,-1o) ~ '%• SYLHET DIVISION INDIA 1 Chittagong BARISAL DIVISION BAY OF BENGAL SAMPLING POINTS • Rural (242) i Statistical Metropolitan Area (29) & Municipality (42) MYANMAR xxii CHAPTER 1 INTRODUCTION 1.1 Geography and Economy Bangladesh, a small country of 147,570 square kilometers and over 120 million people, gained independence on March 26, 1971 following a war of liberation. It is almost entirely surrounded by India, except for a short southeastern frontier with Myanmar and a southern coastline on the Bay of Bengal. 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 seasonal 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 six divisions, t 64 districts, and 490 thanas (subdistricts) (BBS, 1997a:3). Muslims constitute almost 90 percent of the population of Bangladesh, Hindus about 10 percent, and others less than one percent. The national language of Bangladesh is Bangla, which is spoken and understood by all. Agriculture is the most important sector of the nation's economy. It accounts for 30 percent of the gross domestic product (GDP) and provides employment to 64 percent of the workforce (BBS, 1997a:270,159). Jute is the main non-food crop and the main cash crop of Bangladesh. Less than 20 percent of the cropped land area is used for crops other than jute and rice (BBS, 1997a: 187,188). Industry, though small, is increasing in importance as a result of foreign investments. Prospects for mineral resources, gas, coal, and oil, appear to be bright. However, the per capita income is only US$210 and half of Bangladesh's population entered the 1990s with incomes below the poverty line (GOB, 1994:2; World Bank, 1995:xvii). Unemployment/underemployment is a serious problem, and pressure on the land in rural areas has led to influx of people from rural to urban areas. 1.2 Population The population of the area which now constitutes Bangladesh has grown from about 42 million in 1941 to about 120 million in 1995 (BBS, 1997a: 149,140), making it the ninth most populous country in the world and one of the most densely populated. The intercensal population growth rate peaked in the early 1970s at around 2.5 percent per annum, followed by a decline to 2.2 percent during the 1981-91 period (BBS, 1997a:149). The relatively young age structure of the population indicates continued rapid population growth in the future; according to the 1991 census, 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, 1997a: 139). This young age structure constitutes a built-in "population momentum," which will continue to generate population increases well into the future, even in the face of rapid fertility decline. For example, in 1992 Bangladesh had around The sixth division, Sylhet, was created in 1994 by subdividing the former Chittagong Division. 22 million married women in the reproductive ages; by the year 2001, this number is projected to rise to 31 million (GOB, 1994:8). Even if replacement level fertility is achieved by the year 2005--as targeted by government policy--the population will continue to grow for 40 to 60 years later. One projection suggests that the population of Bangladesh may stabilize at 211 million by the year 2056. Bangladesh has undergone a remarkable demographic transition over the last two decades. The total fertility rate has declined from about 6.3 in the early 1970s (MOHPC, 1978:73) to 3.4 in the early 1990s (Mitra et al., 1994:27). The crude death rate has also fallen dramatically, from about 19 per 1,000 population in 1975 to 8 in 1995 (GOB, 1994:4; BBS, 1997a:144). Although infant and under-five mortality rates are declining, they are still high. The infant mortality rate was 150 deaths per 1,000 live births in 1975 and fell to 87 in 1989-93 (GOB, 1994:5; Mitra et al., 1994:92). Maternal mortality has come down from 6.2 deaths per 1,000 births in 1982 to 4.4 in 1995. 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 (GOB, 1994:5; BBS, 1997a: 144). Because of the mortality decline, 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 (UN, 1981:60). It increased to 59 years for men and 58 years for women in 1995 (BBS, 1997a:145). Striking changes have also been observed in the fertility preferences of ma~ied Bangladeshi women. In 1975, when married women were asked how many children they would ideally like to have, the response was an average of 4.1 children (Huq and Cleland, 1990:53,54). By 1993-94, the mean ideal family size had dropped to 2.5 (Mitra et al., 1994:88). 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 government, recognizing the urgency of moderating population growth, adopted family planning as a government sector program in 1965. 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" (GOB, 1994:7). 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 government action. This political commitment is crucial in understanding the fertility decline in Bangladesh. In 1976, the government declared the rapid growth of population as the country's number one problem and adopted a broad-based, multisectoral family planning program along with an official population policy (GOB, 1994:9). Population planning was seen as an integral part of the total development process, and was incorporated into successive five-year plans. Policy guidelines and strategies for the population program are formulated by the National Population Council (NPC), which is chaired by the Prime Minister. 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. In the mid-1970s, the government instituted the deployment of full-time, local Family Welfare Assistants (FWAs)----community- based family planning motivators and distributors who currently number almost 24,000. A social marketing program to promote the sale of pills and condoms was also initiated in the mid-1970s. Another characteristic of the population program is the involvement of more than 200 non-governmental organizations. 2 Since 1980, the program has stressed functionally integrated health and family planning programs. The goal is to provide an essential package of high quality, client-centered, reproductive and child health care, family planning, communicable disease control and limited curative services at a one-stop service point. Currently, the government's most important objectives in the area of health and population are the reduction of infant mortality and morbidity, reduction of maternal mortality and morbidity, improvement of nutrition, and reduction of fertility to replacement level by 2005. The government's policy of providing health care is based on the principles of universal coverage and accessibility, optimum utilization and development of human resources for health, appropriate use of technology, gender equity, improvement of the quality of life, priority service for the most vulnerable groups including women, children and the poor, and promoting health as an integral part of overall socioeconomic development. Although no comprehensive health policy has ever been formulated since independence, development of such a policy is a high priority of the current administration. Private sector involvement in both health and population services is being encouraged. Numerous factors have contributed to the increase in contraceptive use over the past 20 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 multisectoral 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 (GOB, 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 expand 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 external 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. 1.4 Organization of the 1996-97 Bangladesh Demographic and Health Survey Survey Objectives and Implementing Organizations 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 objective of the BDHS is to provide up-to-date information on fertility and childhood mortality levels; nuptiality; fertility preferences; awareness, approval, and use of family planning methods; breastfeeding practices; nutrition levels; and maternal and child health. This information is intended to assist policymakers and administrators in evaluating and designing programs and strategies for improving health and family planning services in the country. 3 The 1996-97 BDHS was conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The survey was implemented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. Macro International Inc. of Calverton, Maryland provided technical assistance to the project as part of its international Demographic and Health Surveys program, while financial assistance was provided by the U.S. Agency for International Development (USAID)/Bangladesh. Sample Design Bangladesh is divided into six administrative divisions, 64 districts (zillas), and 490 thanas. In rural areas, thanas are divided into unions and then mauzas, a land administrative unit. Urban areas are divided into wards and then mahallas. The 1996-97 BDHS employed a nationally-representative, two-stage sample that was selected from the Integrated Multi-Purpose Master Sample (IMPS) maintained by the Bangladesh Bureau of Statistics. Each division was stratified into three groups: 1 ) statistical metropolitan areas (SMAs) 2, 2) municipalities (other urban areas), and 3) rural areas. 3 In the 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 probability so as to retain the overall probability proportional to size. A total of 316 primary sampling units were utilized for the BDHS (30 in SMAs, 42 in municipalities, and 244 in rural areas). In order to highlight changes in survey indicators over time, the 1996-97 BDHS utilized the same sample points (though not necessarily the same households) that were selected for the 1993-94 BDHS, except for 12 additional sample points in the new division of Sylhet. Fieldwork in three sample points was not possible (one in Dhaka Cantonment and two in the Chittagong Hill Tracts), so a total of 313 points were covered. Since one objective of the BDHS is to provide separate estimates for each division as well as for urban and rural areas separately, it was necessary to increase the sampling rate for Barisal and Sylhet Divisions and 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. Mitra and Associates conducted a household listing operation in all the sample points from 15 September to 15 December 1996. A systematic sample of 9,099 households was then selected from these lists. Every second household was selected for the men's survey, meaning that, in addition to interviewing all ever-married women age 10-49, interviewers also interviewed all currently married men age 15-59. It was expected that the sample would yield interviews with approximately 10,000 ever-married women age 10-49 and 3,000 currently married men age 15-59. Questionnaires Four types of questionnaires were used for the BDHS: a Household Questionnaire, a Women's Questionnaire, a Men' s Questionnaire and a Community 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. These model questionnaires were adapted for use in Bangladesh during a series of meetings with a small Technical Task Force that consisted of representatives from NIPORT, Mitra and Associates, USAID/Bangladesh, the International Centre for Diarrhoeal Disease Research, Bangladesh 2 SMAs are extensions of the four original division headquarters (Dhaka, Chittagong, Khulna, and Rajshahi cities) and include rural areas. 3 In the original IMPS (and therefore in the BDHS subsample), urban areas were confined to the urban parts of SMAs and other municipalities as defined in 1991. Subsequent definitions of urban have included all 490 thana headquarters, new growth centers, and peripheral areas of SMAs and yield estimates of about 20 percent urban (Hossain, 1997). (ICDDR,B), Population Council/Dhaka, and Macro International Inc (see Appendix D for a list of members). Draft questionnaires were then circulated to other interested groups and were reviewed by the BDHS Technical Review Committee (see Appendix D for list of members). The questionnaires were developed in English and then translated into and printed in Bangla (see Appendix E for final version in English). The Household Questionnaire was used to list all the usual members and visitors in the 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 the 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 five, Marriage, Fertility preferences, Husband's background and respondent's work, Knowledge of AIDS, Height and weight of children under age five and their mothers. The Men's Questionnaire was used to interview currently married men age 15-59. It was similar to that for women except that it omitted the sections on reproductive history, antenatal and delivery care, breastfeeding, vaccinations, and height and weight. The Community Questionnaire was completed for each sample point and included questions about the existence in the community of income-generating activities and other development organizations and the availability of health and family planning services. Training and Fieldwork The BDHS questionnaires were pretested in July 1996. Male and female interviewers were trained at the office of Mitra and Associates. After training, the teams conducted interviews in various locations in the field under the observation of staff from Mitra and Associates and members of the Task Force. Altogether, 300 Women's and 90 Men's Questionnaires were completed. Based on observations in the field and suggestions made by the pretest field teams, the Task Force made revisions in the wording and translations of the questionnaires. In October 1996, candidates for field staff positions for the main survey were recmited. 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. Training for the main survey was conducted at the office of Mitra and Associates for four weeks (5-31 October 1996). Initially, training consisted of lectures on how to complete the questionnaires, with mock interviews between participants to gain practice in asking questions. Towards the end of the training course, the participants spent several days in practice interviewing in various places close to Dhaka. Trainees whose performance was considered superior were selected as 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, 5 female interviewers, 2 male interviewers, I porter for the anthropometric equipment, and 1 cook, for a total of 132 field staff. In addition, Mitra and Associates fielded four quality control teams of two persons each to check on the field teams. In order to monitor the quality of the data collection, officials from the Ministry of Health and Family Welfare, NIPORT, USAID/Bangladesh, Population Council/Bangladesh, and Macro visited selected sample points. Fieldwork commenced on 2 November 1996 and was completed on 11 March 1997. The distribution of interviews with individual women was roughly: November (24 percent); December (26 percent); January (26 percent); February (19 percent); and March (6 percent). Data Processing All questionnaires for the BDHS were returned 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. The data were processed on 5 microcomputers working in double shifts. The DHS data entry and editing programs were written in ISSA (Integrated System for Survey Analysis). Data processing com- menced in mid-November 1996 and was completed by mid-April 1997. Response Rates Table 1.1 shows response rates for the survey and reasons for nonresponse. A total of 9,099 households was selected for the sample, of which 8,682 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 8,762 households occupied, 99 percent were success- fully interviewed. In these households, 9,335 women were identified as eligible for the individual interview (i.e., ever-married and age 10-49) and interviews were completed for 9,127 or 98 percent of them. In the half of the households that were selected for inclusion in the men's survey, 3,611 eligible ever-married men age 15-59 were identified, of whom 3,346 or 93 percent were interviewed. 4 The principal reason for nonresponse among eligible women and men was the failure to find them at home despite repeated visits to the household. The refusal rate was low. T~ble 1.1 Results of the household an 0 individual interviews Number of households, number of interviews, and response rates, Bangladesh 1996-97 Residence Result Urban Rural Total Household interviews Households sampled 1,462 7,637 9.099 Households occupied 1,369 7,393 8,762 Households interviewed 1,355 7.327 8,682 Household response rate 99.0 99.1 99. l Individual interviews Number of eligible women 1,494 7,841 9,335 Number of eligible women interviewed 1,449 7.678 9,127 Eligible woman response rate 97.0 97.9 97.8 Household interviews Households sampled 737 3,837 4,574 Households occupied 688 3,714 4,402 Households interviewed 679 3,681 4,360 Household response rate 98.7 99.1 99.0 Individual interviews Number of eligible men 589 3,022 3,611 Number of eligible men interviewed 535 2,811 3,346 Eligible man response rate 90.8 93,0 92.7 4 The intent of the survey was to collect data on currently married men. However, the Household Questionnaire followed the same format as for women and required all ever-married men be identified for interview. One of the first questions in the Men's Questionnaire concerned current marital status, at which point, interviewers stopped interviewing all formerly married men. Thus, although 3,346 ever-married men were interviewed, completed questionnaires are available only for the 3,312 currently married men. 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 and men 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) and the de facto population (those who spent the night before the interview in the household). A household is 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, Table 2.1 Household nooulation by abe. residence and sex Percent distribution of the de facto household population by five*year age groups, according to urban-rural residence and sex, Bangladesh 1996-97 Urban Rural Total Age group Male Female Total Male Female Total Male Female Total 0-4 10.2 10.2 10.2 13.3 13.2 13.2 12.9 12.8 12.9 5-9 11.7 11.8 11.8 15.0 14.6 14.8 14.6 14.3 14.5 10-14 13.1 13.9 13.5 13.9 13.5 13.7 13.8 13.5 13.7 15-19 10.9 12.6 11.8 10.2 11.5 10.9 10.3 11.6 11.0 20-24 8.4 11.9 10.2 7.1 9.4 8.3 7.3 9.7 8.5 25-29 9.7 11.0 10.4 7.0 8.6 7.8 7.3 8.9 8.1 30-34 8.0 7.6 7.8 6.3 6.3 6.3 6.5 6.5 6.5 35-39 8.4 5.1 6.8 6.3 5.2 5.7 6.5 5.2 5.8 40-44 5.9 4.5 5.2 4.6 3.9 4.2 4.8 4.0 4.4 45-49 4.0 2,2 3.1 4.0 3. I 3.6 4.0 3.0 3.5 50-54 3.1 2,5 2.8 2.8 2.7 2.8 2.8 2.7 2.8 55-59 1.7 2,2 2.0 2.3 2.8 2.6 2.3 2.8 2.5 60-64 1.6 1.9 1.7 2.0 2.1 2.1 2.0 2.1 2.0 65-69 1.4 0,8 1.1 2.0 1.2 1.6 1.9 1.2 1.5 70-74 1.0 0,6 0.8 1.5 0.8 1.2 1.4 0.8 1.1 75-79 0.5 0,4 0.5 0.8 0.3 0.5 0.7 0.3 0.5 80+ 0.2 0,6 0.4 0.9 0.6 0.7 0.8 0.6 0.7 Missing/ Don't know 0.0 0.1 0.1 0,0 0.0 0.0 0.0 0.0 0.0 Total 100,0 100.0 100.0 100,0 100.0 100.0 100.0 100.0 100.0 Number 2,554 2,614 5,168 19,519 19,912 39,431 22,073 22,526 44,599 7 Bangladesh has a larger proportion of its population in the younger age groups than in the older age groups. Evidence of recent declines in fertility is reflected in the fact that there is a smaller proportion of children under age five than age 5 to 9, which confirms recent declines in fertility (see Figure 2.1). Figure 2.1 Population Pyramid, Bangladesh 1996-97 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 Age 10 5 O 5 10 Percent BDHS 1996-97 Urban areas have relatively fewer people under age 15 than rural areas (36 vs. 42 percent). Another indication of the 'older' age of the urban population is the fact that the largest age group is 10-14, as opposed to 5-9 in rural areas. Overall, the number of women slightly exceeds the number of men. This pattern is especially pronounced at ages 15-29, which may be due in part to international migration of young men for work. However, some combination of overreporting of ages of men and/or underreporting of ages of women may account for the excess of men over women at ages 65 and above. Figure 2.2 presents the distribution of the male and female household population by single year of age (see also Appendix Table C. 1). 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. Digit preference is considerably more pronounced for men than for women. This is 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. Women also provided a detailed history of all their births, which is likely to have resulted in more accurate reporting of their own ages due to probing the dates of birth of their children. Figure 2.2 Distribution of De Facto Household Population by Single Year of Age and Sex Percent 0 1 O 20 30 40 60 60 70 Single Year of Age [--Female --Male] BDHS 1996-97 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 (CPS), and the 1993-94 and 1996-97 Bangladesh Demographic and Health Surveys (BDHS). There has been a decline in the proportion of population less than 15 years of age and an increase in the proportion ages 15-59. Although this pattern is consistent with a decline in fertility, the slight decline since 1993-94 in the proportion age 60 and above is less explicable. Table 2.2 Povulation by aze from selected source~ Percent distribution of the de facto population by age group, selected sources, Bangladesh, 1989-97 1989 1989 1991 1993-94 1996-97 Age group BFS CPS CPS BDHS BDHS <15 43.2 43.2 42.7 42.6 41.0 15-59 50.9 50.9 51.2 51.2 53.1 60+ 5.9 5.9 6.0 6.2 5.9 Total 100.0 100.0 100.0 100.0 100,0 Median age U U U 18.4 18.8 U = Unknown (not available) Source: Huq and Cleland, 1990:28; Mitra et al., 1993:14; Mitra et al., 1994:11 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 5.3 persons, with no variation be- tween rural and urban areas. Single-person house- holds are rare in both rural and urban areas. 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, contracep- tive use, fertility, infant and child mortality, morbid- ity and issues related to family health and hygiene. Table 2.4 provides data on educational attainment of the household population listed in the 1996-97 BDHS. Table 2.3 Household comoosition Percent distribution of households by sex of head of household and household size, according to urban-rural residence, Bangladesh 1996-97 Characteristic Residence Urban Rural Total Household headship Male 90.6 90.8 90.7 Female 9.4 9.2 9.3 Number of usual members 1 0.9 1.5 1.5 2 6.2 6.3 6.3 3 13.0 14.8 14.6 4 20.6 19.5 19.6 5 20.2 18.8 19.0 6 15.2 14.7 I4.7 7 9.5 9.6 9.6 8 6.2 6.1 6.1 9+ 8.2 8.7 8.6 Total 100.0 100.0 100.0 Mean size 5.3 5.3 5.3 Note: Table is based on de jure members, i.e., usual residents. Education has become more widespread over time in Bangladesh. This is apparent from the differences in levels 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 attended school decreases from 52 percent in the oldest age group (65 years or more) to 17 percent among those age 10-14; for women the decline is more striking: from 87 percent to 17 percent (see Figure 2.3). Despite this improvement in the spread of education, levels of educational attainment still remain low in Bangladesh, with a strong differential persisting between males and females. One-third of men (33 percent) and 44 percent of women age six years and above, have not received any formal education. The median number of years of schooling is 1.7 for men and less than one full year for women) In almost every age group there are smaller proportions of men than women with no education and more men than women with secondary education. However, over time, the sex differential is narrowing. For example, at age group 10-14. differences in educational attainment between boys and girls are insignificant (see Figure 2.3). Substantial urban-rural gaps in educational attainment persist. Over one-third of rural men (35 percent) have never attended school, compared with less than one-fifth of urban men (17 percent). The differences are also striking for women 46 percent of rural women have never attended school, compared with only 30 percent of urban women. Conversely, the proportions of men and women with some secondary education are twice as high in urban as in rural areas t Comparison with data from the 1993-94 BDHS is made difficult due to an error in the earlier survey in which the levels of schooling were mislabeled and the median years of schooling were overestimated. This accounts for the apparent decline in median years of schooling between the two surveys. 10 Table 2.4 Ed¢cational lev¢l 9f the female and male household oooulation Percent distribution of the de facto female and 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 1996-97 Don't Median Background No Primary Primary know/ years of characteristic education incomplete complete Secondary+ Missing Total Number schooling FEMALE Age ~ 6-9 22.6 77.1 0.1 0.2 0.0 100.0 2,670 0.0 10-14 17.1 54.4 8.0 20.5 0.0 100.0 3,045 2.4 15-19 29.6 18.8 11.9 39.7 0.0 100.0 2,623 4.1 20-24 43.7 15.4 10.8 30.1 0.0 100.0 2,185 2.1 25-29 52.5 16.9 9.2 21.4 0.0 100.0 1,996 0.0 30-34 56.2 17.5 9.0 17.3 0.0 100.0 1,458 0.0 35-39 56.7 18.6 8.3 16.3 0.1 100.0 1,163 0.0 40-44 66.9 13.8 8.9 10.3 0,0 100.0 894 0.0 45-49 70.2 15.5 7.1 7.2 0.0 100.0 683 0.0 50-54 77.9 12.1 4.4 5.5 0.1 100.0 610 0.0 55-59 79.5 11.8 5.0 3,6 0.1 100.0 622 0.0 60-64 82.7 9.8 4.5 2.7 0.3 100.0 464 0.0 65+ 86.5 7.9 3.0 2.2 0.3 100.0 657 0.0 Residence Urban 30.3 24,2 6.9 38.6 0.0 100.0 2,289 3.2 Rural 45.8 31.4 7.6 15.1 0.0 100.0 16,790 0.0 Division Barisal 26.8 38.8 12.8 21.6 0.1 100.0 1,271 2.2 Chittagong 41.8 28.5 8.5 21.3 0.0 100.0 4,251 0.5 Dhaka 45.9 29.1 6.2 18.8 0.0 100.0 5,897 0.0 Khulna 39.6 34.5 6.8 19.1 0, l 100.0 2,236 0.7 Rajshahi 48.5 30.7 7.1 13.6 0. l 100.0 4,284 0.0 Sylhet 52.7 28.1 7.9 11.4 0.0 100.0 1,141 0.0 Total 44.0 30.6 7.5 17.9 0.0 100.0 19,080 0,0 MALE Age L 6-9 23.5 75.7 0.6 0.2 0.1 100.0 2,683 0.0 10-14 17.0 55.9 7.7 19.2 0.1 100.0 3,052 2.4 15-19 21.8 20.9 8.5 48.6 0.1 100.0 2,269 4.7 20-24 30.3 14.7 9.7 45.1 0.1 100.0 1,602 4.5 25-29 37.1 14.8 8.2 39.7 0.2 100.0 1,622 3.5 30-34 42.9 15.6 7.1 34.3 0.1 100.0 1,442 2.1 35-39 41.8 17.4 8.5 32.0 0.2 100.0 1,442 1.9 40-44 43.3 15.4 8.1 32.7 0.5 100.0 1,050 1.5 45-49 42.8 16.7 9.2 30.6 0.8 100.0 877 1.8 50-54 44.5 14.5 11.2 29.6 0.2 100.0 624 1.8 55-59 48.2 17.7 11.3 22.5 0.2 100.0 500 0.0 60-64 52.2 16.6 8.9 21.5 0.8 100.0 436 0.0 65+ 52.2 17.0 9.5 20.0 1.2 100.0 1,078 0.0 Residence Urban 16.8 22.9 5.8 54.1 0.3 100.0 2,243 5.6 Rural 34.8 32.8 7.7 24.5 0.3 100.0 16,440 1.3 Division Barisal 20.6 37.9 9.0 32.4 0.1 100.0 1,152 2.8 Chittagong 27.7 32.9 8.4 30.9 0.2 100.0 3,967 2.3 Dhaka 34.7 29.4 6.7 28.9 0.3 100.0 5,821 1.4 Khulna 30.0 33.3 6.5 29.7 0.4 100.0 2,308 2.1 Rajshahi 37.0 30.6 6.8 25.2 0.3 100.0 4,304 1.1 Sylhet 40.2 32.3 10.5 16.7 0.2 100.0 1,132 0.5 Total 32.6 31.6 7.4 28.0 0.3 100.0 18,684 1.7 i Excludes 10 women and 8 men for whom an age was not reported 11 100 80 60 40 20 Percent Figure 2.3 Percentage of Males and Females With No Education by Age Group 0 6-9 10 14 15 19 20-24 25-29 30 34 35 39 4044 45-49 50 54 55 59 60-64 65+ Age Group [-.-Male +Femai~ I BDHS 1996-97 As for differences by division, both men and women in Barisal Division have higher educational attainment than residents of other divisions. The proportion of the population with no education is lower and the proportion with some secondary education is higher in this division than in the other divisions. Men and women in Sylhet Division are the most educationally disadvantaged. Table 2.5 presents enrollment rates by age, sex and residence of the population age 6-24 years. Of every ten children age 6-15 years, seven (71 percent) are enrolled in school. But enrollment drops substantially after age 15; only about one-third of older teenagers (32 percent) are still in school and only 1 out of 7 in their early 20s (14 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. Table 2.5 School enrollment Percentage of the de facto household population age 6-24 years enrolled in school, by age group, sex, and urban-rural residence, Bangladesh 1996-97 Male Female Total Age group Urban Rural Total Urban Rural Total Urban Rural Total 6-10 80.4 74.8 75.3 77.9 76.1 76.3 79.1 75.5 75.8 11-15 65.9 65.8 65.8 62.3 65.8 65.4 64.0 65.8 65.6 6-15 73.1 70.7 71.0 69.9 71.4 71.2 71.4 71.1 71.1 16-20 52.0 37.9 39.7 38.3 22.5 24.5 44.6 29.6 31.5 21-24 36.0 19.0 21.3 26.6 6.9 9.8 30.2 11.8 14.4 12 Table 2.6 Housin~ characteristics Percent distribution of households by housing characteristics, according to urban-rural residence. Bangladesh 1996-97 Characteristic Residence Urban Rural Total Electricity Yes 79.5 15.1 22.4 No 20.0 83.9 76.7 Don't know/Missing 0.5 1.0 0.9 Total 100.0 100.0 100.0 Source of drinking water Piped into residence 32.1 0.4 4.0 Piped outside residence 7.1 0.3 1.1 Tube well 60.0 94.0 90.2 Surface well 0.2 2.2 2.0 Pond/lake 0.4 2.3 2.1 River/stream 0.1 0.5 0.5 Other 0.1 0.2 0.2 Total 100.0 100.0 100.0 Sanitation facility Septic tank, modem 50.8 4.3 9.6 Water sealed/slab latrine 26.6 20.2 20.9 Traditional pit toilet 5.6 13.6 12.7 Open latrine 11.4 26.6 24.9 Hanging latrine 1.4 6.1 5.5 No facility/bush 4.2 29.1 26.3 Other 0.1 0.2 0.2 Total 1(30.0 100.0 100.0 Roof material Katcha (bamboo/thatch) 9.2 31.8 29.2 Tin 53.7 59.3 58.7 Cement/concrete 34,5 2.0 5.7 Other 2.6 6.9 6.4 Total 100.0 100.0 1(30.0 Wall material Jute/bamboo/mud 33.9 75.2 70.6 Wood 0.8 2.6 2.4 Brick/cement 56.3 6.6 12.3 Tin 7.3 12.2 11.7 Other 1.7 3.3 3.1 Total 100.0 100.0 100.0 Floor material Earth/bamboo 39.9 94.9 88.7 Wood 1.5 0.2 0.3 Cement/concrete 58.5 4,7 10.8 Other 0.0 0.2 0.2 Total 100.0 1130.0 100.0 It is encouraging that urban-rural gaps in enrollment of children have become virtually nonex- istent, with 71 percent of both urban and rural chil- dren age 6-15 currently enrolled in school. In fact, a slightly higher proportion of rural than urban children age 11-15 years are enrolled in school. However, rural enrollment rates still lag far behind urban rates among children older than 15. At ages 16-20 years, only 30 percent of rural adolescents are still in school, compared with 45 percent of urban youth; at ages 21-24 years, only 12 percent of rural young adults are in school, compared with 30 percent in urban areas. The sex differential in school enrollment also seems to be disappearing, at least among younger children. At ages 6-15, the proportions of boys and girls enrolled are indistinguishable. However, by ages 16-20 years, men are much more likely than women to be enrolled (40 vs. 25 percent), presumably due to early marriage or social seclusion, which cause young women to drop out of school. 2.2 Housing Characteristics Socioeconomic conditions were assessed by asking respondents questions about their household environment, This information is summarized in Table 2.6. As the table shows, only 22 percent of households in Bangladesh have electricity. Electric- ity is much more common in urban areas; 4 in 5 urban households have electricity, compared with 15 percent of rural households. The proportion of households with electricity has increased from 18 percent in 1993-94 to 22 percent in 1996-97. Tubewells are the major source of drinking water in Bangladesh. Overall, 9 in 10 households obtain their drinking water from tubewells. Only 5 percent depend on surface water such as surface wells, ponds and rivers/streams. Piped water is available mostly in urban areas. Among urban households, 32 percent have water piped into the residence, 7 percent obtain drinking water from taps (public or private) outside the residence, and 60 percent get their drinking water from tubewells. In rural areas, tubewells are the only major source of drinking water; 94 percent of rural households obtain their drinking water from tubewells. There has been little change in sources of drinking water since 1993- 94. 13 The majority (74 percent) of households in Bangladesh have sanitation facilities; however, only 43 percent have hygienic toilets (septic tank/modern toilets, water-sealed/slab latrines and pit toilets), while 26 percent have no facility at all. As expected, sanitation facilities vary between rural and urban areas. In rural areas, only 38 percent of households have hygienic toilets, compared with 83 percent of urban households. Moreover, 29 percent of rural households have no facility at all, compared with only 4 percent of urban households. Tin is the most common roofing material in Bangladesh, accounting for over half of both urban and rural households. However, urban and rural households vary widely in the use of other types of roofs. In urban areas, 34 percent of households live in dwellings with cement or concrete roofs, while in rural areas, bamboo or thatch (32 percent) is the most common roofing material after tin. Seven in ten households in Bangladesh live in structures with walls made of natural materials such as jute, bamboo or mud. Twelve percent live in houses with brick or cement walls and the same proportion live in houses with tin wails. Urban households live in more solid dwellings than rural households. Over half of urban households live in structures with brick or cement walls, compared with only 7 percent of rural households. Overall, 9 out of 10 households in Bangladesh live in residences with floors made of earth (89 per- cent). However, almost 6 in 10 urban households have cement or concrete flooring in their residences. Earth flooring is almost universal in rural areas (95 percent). Household Possessions Respondents were asked about ownership of selected durable goods and agricultural land. The information was collected primarily as socioeco- nomic indicators of the population. Results are shown in Table 2.7. Possession of household durable goods is not very common in Bangladesh, since many fami- lies cannot afford them. Nationally, 78 percent of households own a cot or bed, 55 percent a table, chair, or bench, 46 percent a watch or clock, and only 27 percent an almirah (wardrobe). As for more valuable items, 32 percent of households possess radios, 19 percent own bicycles, and only I 1 percent possess televisions. One in six households owns none of the items asked about. More 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. There is also evidence that the socio- Table 2.7 Household DOSSeSsions Percentage of households possessing various consumer durable goods, according to urban-rural residence, Bangladesh 1996-97 Durable good Residence Urban Rural Total Almirah 60.0 22,6 26.8 Table/chair/bench 74.5 52.2 54.7 Watch/clock 76.7 41.6 45.6 Cot/bed 93.0 75.9 77.9 Radio 51.5 29,1 31.6 Television 48.6 5,8 10.6 Bicycle 18.4 19,4 19.3 None of the above 4.2 17,4 15.9 Agricultural land 39.2 58.7 56.5 Number of households 984 7,698 8,682 economic status of Bangladeshi households has improved over time, since there has been an increase since 1993-94 in the proportion of households owning all the durable goods asked about (Mitra et al., 1994:18)(Figure 2.4). Just over half of households in Bangladesh own agricultural land. This indicates that a large number of Bangladeshi 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); as expected, households without agricultural land are more common in urban areas (61 percent). 14 Figure 2.4 Trends In Household Ownership of Durable Goods 100 80 60 40 20 0 Percent of households 78 AImlrah Table, Watch, Cot, Radio Tele- Bicycle Land chair clock bed vision 1[£]1993-94 m1996-97 I BDHS 1996-97 Health Care The 1996-97 BDHS included a question as to whether anyone in the interviewed household had been to a health facility, a doctor, or a nurse in the two weeks prior to the survey and, if so, where he or she went and the purpose of the visit. Answers to these questions can provide a picture of the health-care-seeking behavior of the population. As shown in Table 2.8, almost one in four households reported that a member of the household had recently sought medical care. Differences in health-care-seeking behavior by urban-rural residence and division are not large, although households in Chittagong appear to have higher levels than those in other divisions. Private doctors and clinics and traditional doctors provide almost half of the health care visits reported by households, with another 19 percent provided by pharmacies. Only 20 percent of health care visits are provided by government facilities, with roughly equal proportions visiting a hospital or medical college, a thana health complex, and a family welfare center. Urban households are more likely to report visits to private doctors and clinics, while rural households are more likely to report visits to traditional doctors. Although urban and rural households in which a member recently sought health care are almost equally likely to report visits to government facilities (20 percent), urban households are more likely than rural households to have visited a hospital or medical college, presumably because they are more common in urban areas, while rural households are more likely than urban households to report visits to thana health complexes or family welfare centers. Differences in sources of health care by division are not great. It is interesting that households in Barisal Division are more likely to report visits to satellite or immunization clinics and less likely than households in other divisions to have visited traditional doctors. Households in Rajshahi Division are most likely to report visits to traditional doctors. By far the most common reason for seeking health care is illness. 15 Table 2.8 Health-care-seeking behavior Percentage of households in which someone visited a health facility or a doctor or nurse in the 2 weeks preceding the survey and, of these households, the percent distribution by type of place visited and reason for visit, Bangladesh 1996-97 Residence Division Place visited/ reason Urban Rural Barisal Chittagong Dhaka Khulna Rajshahi Sylhet Total Percentage of households seeking health care 29.2 23.0 19.0 32.6 23.7 23.1 19.2 19.9 23.7 Place visited Hospital/medical college 15.5 5.8 8.6 6.7 9.5 9.5 2.4 6.5 7.2 Family welfare center 2.3 5.6 4.5 6.3 4.3 4.2 4.9 7.6 5.1 Thana health complex 2.0 6.7 8.9 6.1 5.2 2.8 7.1 12.4 6.0 Satellite/EPl clinic 0.2 1.5 8.3 1.3 0.6 1.3 0.5 1.9 1.3 Privateclinic/doctor 43.5 21.1 26.8 22.2 26.3 34.0 18.1 19.6 24.2 Traditional doctor 4.1 28.5 12.9 27.4 18.9 23.3 35.9 27.0 25.1 Pharmacy 20.6 18.5 17.2 18.5 22.8 12.5 17.7 15.1 18.8 Shop 1.2 3.3 3.8 1.1 3.4 3.9 4.6 0.6 3.0 Friends/relatives 0,4 0.3 0.6 0.5 0.4 0.4 0.0 0.0 0.3 Fieldworker. FWA 0.9 0.8 0.0 1.1 1.3 0.0 0.7 0.0 0.8 Other 7.9 6.6 7.8 7.8 5,2 6.8 7.3 8.8 6.8 Does not know 0.2 0.4 0.0 0.3 0.4 0.4 0,5 0.0 0.4 Missing 1.3 0.9 0.6 0.8 1.6 0.9 0.2 0.6 1.0 Total 100.0 100.0 100.0 100.0 100.0 I00.0 100.0 100.0 100.0 Reason for the visit Immunization 2.2 2.7 11.7 2.4 1.7 1,5 2.0 5.2 2.6 Family planning 0.6 1.3 1.9 0.5 1.3 2.0 1.2 1.9 1.2 Antenatal checkup 2.6 0.8 1.3 1.1 0.9 1.0 0.9 2.5 1.1 Illness 85.5 88.8 78.2 88.8 87.9 88.0 92.7 81.6 88.3 Accident 3.2 1.6 3.2 1.0 2.6 1.3 1.3 1.9 1.8 Other 6.0 4.4 3.1 5.9 4.8 6,2 1.6 6.3 4.6 Missing 0.0 0.5 0.6 0.3 0.7 0.0 0.2 0.6 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households with a visit 287 1,771 107 540 661 243 413 94 2,058 EPI = Expanded Programme on Immunization FWA = Family Welfare Assistant 2.3 Background Characteristics of Women and Men Respondents General Characterist ics Table 2.9 shows the distribution of female and male respondents by selected background characteristics. To assess their age, respondents 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 is very similar to that found in the 1993-94 BDHS, with the majority (54 percent) of ever-married women age 15-29 years. The currently married men interviewed are older than the ever-married women, in large part because men marry at older ages than women. 16 Table 2.9 Background characteristics of resoondents Percent distribution of ever-married women and currently married women and men by selected background characteristics, Bangladesh 1996-97 Background characteristic Ever-married women Currently married women Currently married men Number of women Number of women Number of men Weighted Un- Weighted Un- Weighted Un- percent Weighted weighted percent Weighted weighted percent Weighted weighted Age 10-i4 1.6 145 146 1.7 143 144 NA NA NA 15-19 14.3 1,301 1,272 14.8 1,252 1,223 0.7 23 23 20-24 18.9 1,727 1,716 19.6 1,655 1,644 5.9 194 190 25-29 20.9 1,905 1,921 21.4 1,812 1,828 14.7 487 469 30-34 15.4 1,402 1,412 15.3 1,297 1,307 18.7 620 619 35-39 12.4 1,128 1,144 12.2 1,031 1,046 18.8 621 627 40-44 9.4 861 867 8.8 740 745 14.8 492 491 45-49 7.2 658 649 6.2 520 513 11.2 371 383 50-54 NA NA NA NA NA NA 8.2 272 281 55-59 NA NA NA NA NA NA 7.0 231 229 Marital status Currently marred 92.6 8,450 8,450 100.0 8,450 8,450 100.0 3,312 3,312 Widowed 4.3 391 389 NA NA NA NA NA NA Divorced 3.1 286 288 NA NA NA NA NA NA Residence Urban 11.7 1,063 1,449 11.5 968 1,328 12.1 400 532 Rural 88.3 8,064 7,678 88.5 7,482 7,122 87.9 2,912 2,780 Division Barisal 6.5 598 937 6.6 560 879 6.0 199 315 Chittagong 20.1 1,836 1,359 20.1 1,701 1,259 17.6 584 411 Dhaka 31.6 2,882 2,529 31.4 2,656 2,334 31.9 1,056 950 Khulna 12.1 1,107 1,084 12.1 1,024 1,003 12.9 428 406 Rajshahi 24.1 2,198 2,314 24.2 2,049 2,154 26.5 877 934 Sylhet 5.5 506 904 5.4 460 821 5.1 168 296 Education No education 54.6 4,983 4,899 53.3 4,502 4,422 42.0 1,390 1,376 Primary incomplete 17.2 1,572 1,602 17.4 1,470 1,497 22.6 750 734 Primary complete 10.0 913 928 10.2 862 881 6,2 204 210 Secondary+ 18.2 1,659 1,698 19.1 1,615 1,650 29.2 968 992 Religion Islam 89.5 8,168 8,I09 89.3 7,549 7,493 87.5 2,897 2,871 Hinduism 9.9 906 975 10.1 851 916 12.1 401 428 Buddhism 0.4 36 28 0.4 36 27 0.1 4 4 Christianity 0.1 14 13 0.1 13 12 0.2 6 6 Other 0.0 2 2 0.0 2 2 0.l 3 3 Total 100.0 9,127 9,127 100.0 8,450 8,450 100.0 3,312 3,312 NA=Not applicable Twelve percent of respondents live in urban areas, with 88 percent in rural areas. This is a lower proportion urban than the 20-22 percent currently quoted. The major reason for the discrepancy is the definition of urban (see Footnote 3). Almost one-third of female and male respondents live in Dhaka Division, while roughly one-quarter live in Rajshahi Division and one-fifth in Chittagong Division. About 12 percent of respondents live in Khulna Division, 6-7 percent in Barisal Division, and 5-6 percent in Sylhet Division. The distribution of ever-married women by division is very similar to that in the 1993-94 BDHS (Mitra et al., 1994:19). 17 The majority (55 percent) of ever-married women have never attended school. Only 28 percent have completed primary school and only 18 percent have secondary education. Nevertheless, the data show some improvement in female education since 1993-94, with the proportion of ever-married women with no formal education declining from 58 to 55 percent and the proportion with secondary education increasing from 15 to 18 percent (Mitra et al., 1994:19). In general, married men are better educated than women, with the majority having some education and 29 percent having some secondary school, compared with only 18 percent of ever-married women. About 9 in 10 respondents are Muslim, with most of the remainder being Hindu. The composition by religion is similar to that reported in the 1993-94 BDHS (Mitra et al., 1994:19). Because the married men interviewed in the BDHS were selected from a subsample of households in which ever-married women were interviewed, it is possible to match male respondents with their wives to obtain a dataset of matched couples. Table 2.10 shows husband-wife differentials in age and educa- tion for 3,028 couples. For almost all married cou- ples, the husband is older than the wife--generally 5 to 14 years older. The mean age difference is 9 years. Regarding educational differences, in about one-third of married couples, neither the husband nor the wife has any education, while in another third, both have some education. For the remaining one- third of couples, the proportion in which the husband has some education and the wife has none is twice that in which the wife is educated and the husband is not (22 vs. 10 percent). Table 2.10 Differentials in age and education Percent distribution of couples by differences between spouses in age and level of education, Bangladesh 1996- 97 Number of Characteristic Percent couples Age (husband's age minus wife's age) Wife older 1.3 40 0-4 years 12.9 392 5-9 years 42.1 1,273 10-14 years 31.3 947 15 years + 12.4 376 Mean age difference (years) 9.4 3,028 Education Both husband and wife not educated 32.4 98 l Wife educated, husband not 9.9 301 Husband educated, wife not 21.5 651 Both husband and wife educated 36.2 1,095 Total 100.0 3,028 Differential Education Tables 2.11.1 and 2.11.2 present the distribution of women and men by education, according to selected characteristics. Among ever-married women, education is inversely related to age, that is, older women are less educated than younger women. For instance, 41 percent of ever-married women age 15-19 years have never attended school, compared with 71 percent of those age 45-49. Among currently married men, the distribution by education level is more uniform across age groups. Among both women and men, urban residents have more education than rural residents. For example, 57 percent of rural women have had no education at all, compared with 36 percent of urban women. In contrast, while about 4 in 10 urban women (42 percent) have attended secondary school, only 15 percent of rural women have done so. Women and men in Barisal, Chittagong, and Khulna Divisions appear to be more educated than those in the other divisions. For example, less than half the ever-married women in Barisal and Khulna have no education, compared with about 60 percent or more in Rajshahi and Sylhet. Women in Barisal and Chittagong Divisions are also more likely than women in the other divisions to complete primary school and to attend secondary school. 18 Table 2.11.1 Level of education by backfrround characteristics: women Percent distribution of ever-roamed women by highest level of education attended, according to age, residence, and division, Bangladesh 1996-97 Level of education Number Background No Primary Primary Secon- of characteristic educ. incomplete complete dary+ Total women Age 10-14 42.0 27.2 16.1 14.7 100.0 145 15-19 40.8 20.6 13.8 24.8 100.0 1,301 20-24 49.8 16.2 10.7 23.3 100.0 1,727 25-29 54.9 16.9 9.6 18.6 100.0 1,905 30-34 56.7 17.8 8.8 16.6 100.0 1,402 35-39 57.4 18.1 8.4 16.1 100.0 1,128 40-44 66.6 13.7 8.5 11.1 100.0 861 45-49 71.0 14.1 7.7 7.1 100.0 658 Residence Urban 35.5 13.1 9.2 42.2 100.0 1,063 Rural 57.1 17.8 10.1 15.0 100.0 8,064 Division Barisal 30.0 29.2 18.5 22.2 100.0 598 Chittagong 51.0 14.1 11.8 23.2 100.0 1,836 Dhaka 57.6 14.8 8.8 18.8 100.0 2,882 Khulna 47.9 23.7 9.2 19,3 100.0 1,107 Rajshahi 61.0 17.2 8.6 13.1 100.0 2,198 Sylhet 66.5 14.3 8.0 11.2 100.0 506 Total 54.6 17.2 10.0 18.2 100.0 9,127 Table 2.11.2 Level of education bv backaround characteristics: men Percent distribution of currently married men by highest level of education attended, according to age, residence, and division, Bangladesh 1996-97 Level of education Number Background No Primary Primary Secon- of characteristic educ. incomplete complete dary+ Total men Age 15-19 49.1 22.1 6.1 22.7 100.0 23 20-24 46.3 26.3 6.1 21.2 100.0 194 25-29 43.8 18.2 7.9 30.1 100.0 487 30-34 38.9 24.8 4.4 31.8 100.0 620 35-39 42.8 22.5 6.0 28.7 100.0 621 40.44 37.9 22.0 5.1 35.0 100.0 492 45-49 41.6 21.2 8.7 28.5 100.0 371 50-54 43.7 24.2 5.2 26.9 100.0 272 55-59 46.6 25.3 7.0 21.1 100.0 231 Residence Urban 20.8 13.2 4.1 61.9 100.0 400 Rural 44.9 23.9 6.4 24.8 100.0 2,912 Division Barisal 30.5 23.7 6.7 39.2 100.0 199 Chittagong 34.9 27.9 5.7 31.5 100.0 584 Dhaka 43.0 19.4 6.1 31.5 100.0 1,056 Khulna 38.9 25.3 5.3 30.5 100.0 428 Rajshahi 48.0 21.6 6.1 24.3 100,0 877 $ylhet 49.7 22.2 9.9 18.3 100,0 168 Total 42.0 22.6 6.2 29.2 100,0 3,312 19 Access to Media Female and male respondents were asked in the BDHS if 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 and health messages. The data indicate that of the three media, radio is by far the most widespread and that men are more likely than women to access all three media. For example, Table 2.12 shows that two-fifths (40 percent) of ever-married women listen to the radio weekly, compared with two- thirds of men. Only 27 percent of women watch television at least once a week, compared with more than half of the men. And while less than 1 in 10 women reads a newspaper, one-quarter of men report doing so. Consequently, half of women report having weekly exposure to none of the three media, compared with only one-quarter of men. Tabl¢ 2.12 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 daily, by selected background characteristics and percentage of men who carry out these activities, Bangladesh 1996-97 Mass media Read Watch Listen Number No news- tele- to All of Background mass paper vision radio three women/ characteristic media weekly weekly daily media men Age 10-14 48.2 6.7 19.9 45.8 1.7 145 15-19 45.2 9.4 28.2 44.9 4.7 1,301 20-24 47.2 9.4 28.9 43.3 6.1 1,727 25-29 48.2 9.7 30.6 41.9 6.8 1,905 30-34 53.1 7.4 27.7 36.4 4.1 1,402 35-39 54.4 9.0 25.5 36.9 6.5 1,128 40-44 57.8 7.5 21.7 33.4 4.4 861 45-49 62.2 5.8 18.7 30.4 4.1 658 Residence Urban 16.9 29.4 76.1 52.5 21.5 1,063 Rural 55.5 5,9 20.5 37.9 3.3 8,064 Division Barisal 54.4 10.5 21.6 41.0 7.0 598 Chittagong 48.5 I0.5 29.7 41.0 6.5 1,836 Dhaka 49.8 10.4 32.1 37.8 6.8 2,882 Khulna 50.1 7.2 28.6 40.3 4.4 1,107 Rajshahi 50.9 5.8 21.5 42.3 3.3 2,198 Sylhet 66.2 5.2 14.3 29.1 2.6 506 Education No education 66.5 0.0 14.8 27.4 0.0 4,983 Primary incomplete 48.5 2.0 25.2 42.9 1.1 1,572 Primary complete 35.6 9.5 34.8 52.4 5,2 913 Secondary+ 15.6 40.2 61.0 66.0 25.7 1,659 All women 51.0 8.6 27.0 39.6 5,4 9,127 All men 26.1 25.1 52.7 63.8 18,3 3,312 20 Differentials in exposure to media are shown only for ever-married women. They indicate that younger women are somewhat more likely than older women to listen to the radio. Exposure to all three media is higher among urban and more educated women. For example, the proportion of women who watch television at least once a week ranges from 15 percent of those with no education to 61 percent of those with some secondary school. Differentials by division are not large, except that women in Sylhet Division have less exposure to all three media than women in other divisions. It is interesting to note that, while women's access to radio and newspapers has hardly changed since 1993-94, television-viewing has increased considerably. For example, the proportion of ever-married women who read newspapers weekly has increased from 7 percent in 1993-94 to 9 percent in 1996-97, while the proportion who listen to the radio has increased from 39 to 40 percent. The proportion who watch television weekly, however, has increased from 18 to 27 percent (Mitra et al., 1994:21). Employment and Occupation In the 1996-97 BDHS, information was collected about current employment. Although data were collected from ever-married female and currently married male respondents, the analysis in this section concentrates on women. Data in Table 2.13 indicate that 63 percent of ever-married women report being unemployed and 37 percent employed at the time of the survey. Most employed women work all year, with a minority working seasonally. The proportion unemployed is higher among younger women, urban women, and better educated women. Women in Rajshahi Division are more likely to be employed than women in the other divisions. Rural women are more likely to be employed seasonally than urban women, presumably as agricultural laborers. Women who reported themselves as employed at the time of the survey were asked if they worked for a member of their family, for someone else, or if they were self-employed. They were also asked if they earned cash for their work (Table 2.14). Roughly one-quarter of working women are self-employed, while 20 percent work for others and 54 percent work in a family business. Sixty-two percent of employed women earn cash for their work. Rural working women are more likely than urban women to work in a family business, while urban women are more likely to work for others. Urban women who work are also much more likely than rural women to receive cash earnings (88 vs. 60 percent). Divisional differences show that women in Barisal Division are more likely to be self-employed, less likely to work for relatives, and more likely to earn cash than women in other divisions, while working women in Sylhet are less likely to be self-employed and less likely to be paid in cash. Differences by education level in type of employment and form of payment are not large. Table 2.15.1 indicates the types of occupations in which working women are engaged. Almost half of employed women are manual laborers, with 41 percent engaged in skilled labor and 8 percent in unskilled labor. Another 46 percent are employed in agricultural jobs, with the vast majority working on other people's land. Only 4 percent of working women are employed in professional, technical, or managerial jobs. As expected, agricultural jobs are more common among rural women, while urban women are more likely to be employed in manual labor. Women in Khulna Division are more likely and those in Dhaka Division less likely to be employed in agriculture; conversely, women in Dhaka Division are more likely to be employed in manual jobs. As expected, women with no education are more likely to be employed in the agriculture sector, while those with some secondary school are more likely to have skilled manual labor. 21 Percent distribution of ever-married women by employment status and continuity of employment, according to background characteristics, Bangladesh 1996-97 Currently employed Work Work Work Number Background Not all season- occasion- of characteristic employed year ally ally Missing Total women Age 10-14 80.8 12.4 6.8 0.0 0.0 100.0 145 15-19 75.8 14.1 9.5 0.4 0.1 100.0 1,301 20-24 66.7 20.3 11.9 0.8 0.3 100.0 1,727 25-29 59.8 27.0 12.5 0.7 0.1 100.0 1,905 30-34 57.0 30.7 12.0 0.3 0.0 100.0 1,402 35-39 56.2 31.2 11.4 1.2 0.0 100.0 1,128 40-44 56.6 27.8 14.4 0.9 0.3 100.0 861 45-49 64.0 20.6 14.3 1.1 0.0 100.0 658 Residence Urban 72.1 23.9 3.4 0.4 0.3 100.0 1,063 Rural 61.6 24.4 13.1 0.7 0.1 100.0 8,064 Division Barisal 72.7 19.6 6.1 1.3 0.3 100.0 598 Chittagong 69.1 18.9 11.5 0.4 0.1 100.0 1,836 Dhaka 64.7 24.7 9.7 0.7 0.1 100.0 2,882 Khulna 61.1 23.8 14.3 0.6 0.2 100.0 1,107 Rajshahi 51.4 32.4 15.3 1.0 0.1 100.0 2,198 Sylhet 71.7 14.0 14.2 0.1 0.0 100.0 506 Education No education 58.9 27.0 13.3 0.7 0.l 100.0 4,983 Primary incomplete 63.1 23.5 13.0 0.3 0.I 100.0 1,572 Primary complete 68.1 20.2 10.2 1.4 0.1 100.0 913 Secondary+ 71.6 19.5 8.0 0.6 0.3 100.0 1,659 Total 62.9 24.4 12.0 0.7 0.1 100.0 9,127 Table 2.15.2 presents similar data for currently married men. It shows that only a fraction of men are not currently working. Almost half of men work in agriculture, mostly on their own land. One-quarter of men have professional, technical or managerial jobs, while another quarter work as manual laborers. Women who said they were paid in cash for their work were asked whether they themselves or someone else usually decides how the money they earn is used. As shown in Table 2.16, more than 2 in 5 employed women decide for themselves how to spend their cash earnings, while almost half say they decide with someone else how to spend their money. Nine percent of working women say that someone else decides how to spend their earnings. Older women, urban women, women in Barisal Division, and those who are not currently married are more likely than other women to decide for themselves how to spend their earnings. In the survey, all employed women who had a child under age six l iving at home were asked who cared for the child while the mother was working. Less than half of working women (45 percent) have a child under age six (data not shown). The vast majority of these women (69 percent) say they look after their own children while at work, while 14 percent leave the child in the care of older children and 12 percent use other relatives as caretakers. Very few employed mothers leave their young children with their husbands, with neighbors or friends, with servants, or with child care institutions. Urban working women are less likely than rural women to have a child under six and when they do, they are also less likely to care for their children themselves while at work. 22 Table 2.14 Emvlover and form of earnings Percent distribution of currently employed women by employer and form of earnings, according to background characteristics, Bangladesh 1996-97 Employed by Employed by Self-employed a noarelative a relative Does Does Does Number Background Earns not earn Earns not earn Earns not earn of characteristic cash cash cash cash cash cash Missing Total women Age 10-14 (21.8) (0.0) (8.3) (0.0) (13.9) (56.0) (0.0) 100.0 28 15-19 18.3 7.7 11.6 4.0 21.3 36.4 0.7 100.0 314 20-24 17.3 5.1 14.3 4.3 27.9 30.2 0.9 100.0 573 25-29 20,4 5.6 17.6 4.7 27.8 23.7 0.2 100.0 766 30-34 23.4 6,6 17.0 3.5 27.7 21.5 0.4 100.0 603 35-39 25.3 3.9 15.2 3,4 29.6 22.4 0.1 100.0 494 40-44 15.4 5.1 17.4 6.9 25.7 28.9 0.6 100.0 374 45-49 15.5 5.4 11.0 8.8 22.6 36.8 0.0 100.0 236 Residence Urban 25.8 1.8 39.6 2.4 22.4 7.1 0.8 100.0 297 Rural 19.5 5.9 13.2 4,9 27.2 29.1 0.4 100.0 3,090 Divtslon Barisal 33.7 3.7 15.1 5,5 23.9 18.0 0.0 100.0 161 Chittagong 17.8 6.5 7.6 6,2 29.8 31.5 0.6 100.0 567 Dhaka 24.2 4.5 16.7 3.5 26.6 24.1 0.4 100.0 1,016 Khulna 15.5 6.3 20.9 6.1 23.3 27.4 0.5 100.0 430 Rajshahi 18.1 5.9 15.3 4.0 28.9 27.3 0.4 100.0 1,069 Sylhet 12.5 5.8 23.3 5.8 12.6 40.0 0.0 100.0 143 Education No education 19.1 5.7 16.4 5.7 27.8 25.0 0.3 100.0 2,046 Primary incomplete 21.7 6.3 10.3 4.7 25.9 30.5 0.5 100.0 580 Primary complete 22.0 4.1 10.2 2.2 27.2 34.0 0.4 100.0 291 Secondary+ 21.3 4.8 20.8 1.6 22.7 27.8 0.9 100.0 471 Total 20.1 5.5 15.5 4.6 26.7 27.1 0.4 100.0 3,387 Note: Figures in parentheses are based on 25 to 49 unweighted cases. 23 Table 2,15.10ccuoation: women Percent distribution of currently employed women by occupation and type of agricultural land worked or type of nonagricultural employment, according to background characteristics, Bangladesh 1996-97 Agricultural Nonagricultural ProL/ Number Background Own Rented Other's tech./ Skilled Unskilled of characteristic land land land manag, manual manual Other Missing Total women Age 10-14 (12.1) (0.0) (27.1) (0.0) (60.2) (0.7) (0.0) (0,0) I00.0 28 15-19 10.8 2.1 33.2 1.0 47,3 4.7 0.1 0.7 100.0 314 20-24 9.7 1.2 34.6 2.6 42,1 7.9 0.7 1.1 100.0 573 25-29 9~2 0.8 36.3 3.2 40,8 8.5 0.7 0.4 100.0 766 30-34 7.4 2.0 35.6 5.5 38.4 9.7 1.1 0.4 100.0 603 35-39 7.0 2.1 37.9 4.6 37.2 8.7 2.3 0.2 100.0 494 40-44 8,1 3.4 32.7 3.3 40.3 9.9 0.9 1.5 100.0 374 45-49 10.5 4.4 28,9 2.6 44.2 7.2 2.1 0.2 100.0 236 Residence Urban 0.7 0,2 11.0 6.3 57.7 19.8 3.0 1.3 100.0 297 Rural 9.6 2.I 37.1 3.2 39.4 7.2 0.9 0.6 100.0 3,090 Division Barisal 2.0 0.0 39.0 4.4 41.4 9,6 0.6 3.0 100,0 161 Chittagong 15.3 3.5 36.1 3.9 33.1 5.2 2.3 0.6 100.0 567 Dhaka 3.9 0.5 31.5 3.0 48.2 11.7 0.7 0.5 100.0 1,016 Khulna 21.8 2.5 40.6 3.6 22.1 7.3 1.2 1.0 100.0 430 Rajshahi 2.6 1.2 37.5 3.8 47.3 6.4 0.7 0.4 100.0 1,069 Sylhet 32.5 l 1.2 I 1.2 1.2 30.9 I 1.3 1.5 0.0 100.0 143 Education No education 6.5 2.3 36.9 4.1 36.6 12.2 0.9 0.4 100.0 2,046 Primary incomplete 12.8 1.6 38.8 2.1 38.7 3.9 1.1 1.1 I00.0 580 Primary complete 11.9 1.3 37.0 3.9 41.9 2.7 0.7 0.6 100.0 291 Seconda~+ 11.9 0.8 19.6 1.9 62.6 0.2 1.8 I.I 100.0 471 Total 8.8 [.9 34.8 3.5 41.0 8.3 1.1 0.6 I00.0 3,387 Note: The "professional, technical, managerial" category includes professional, technical, clerical and managerial occupations, Figures in parentheses are based on 25-49 unweighted cases. 24 Table 2.15.2 Occupation: men Percent distribution of cutter, fly marred men by occupation and type of agricultural land worked or type of nonagi'icuRural employment, accordin to background characteristics, Bangladesh 1996-97 Agricultural Nonagricultural Not Prof./ Number Background currently Own Rented Other teeh./ Skilled Unskilled of characteristic employed land land land manag, manual manual Other Missing Total men Age 15-19 (3.4) (27.9) (0.0) (35.6) (1.8) (8.6) (22.7) (0.0) (0.0) 100.0 23 20-24 3.7 26.0 10.0 15.4 14.2 12.3 14.9 1.4 2.1 100.0 194 25-29 1.0 18.9 8.1 14.7 25.6 12.7 18.2 0.6 0.I I00.0 487 30-34 0.5 22.2 6.9 13.2 27.3 13.7 14.9 0.7 0.6 I00.0 620 35-39 0.2 23.5 8.5 13.8 25.9 13.9 13.6 0.4 0.2 I00.0 621 40-44 0.1 23.6 7.7 13.6 32.9 10.7 10.8 0.2 0.4 100.0 492 45-49 2.9 25.6 8.7 16.1 24.5 10.5 11.7 0.0 0.0 I00.0 371 50-54 1.7 25.8 12.8 14.5 22.6 12.8 7.8 1.0 1.0 100.0 272 55-59 7.3 39.0 9.3 13.7 22.3 4.0 4.2 0.0 0.3 I00.0 231 Residence Urban 1.7 2.3 0.2 0.8 48.4 29.5 15.6 1.5 0.0 I00.0 400 Rural 1.5 27.3 9.6 16.2 22.5 9.5 12.5 0.3 0.5 I00.0 2,912 Division Bafisal 0.1 16.9 7.5 10.6 37.6 11.3 11.9 0.7 3.4 100.0 199 Chittagong 3.4 13.6 11.6 8.6 32.1 13.9 15,7 0.9 0,0 100.0 584 Dhaka 1.4 25.1 7.3 13.3 24.7 14.2 13.1 0.5 0.4 100.0 1,056 Khulna 1.4 31.1 6.7 13.5 25.7 9.7 11.5 0.4 0.0 100.0 428 Rajshahi 0.5 28.6 8.9 19.6 20.5 9.8 11.6 0.2 0.3 100.0 877 Sylhet 2.5 25.0 8.7 19.9 21.1 8.2 13.8 0.4 0.4 100.0 168 Education No education Primary incomplete Primary complete Secondary+ 0.9 20.6 11.5 25.6 13.0 8.2 19.7 0.4 0.2 100.0 1,390 1.0 29.3 10.7 11.7 22.2 10.2 13.8 0.2 0.8 100.0 750 1.1 33.9 8.6 8.4 26.8 12.8 7.3 0.6 0.6 100.0 204 2.9 23.6 2.4 1.6 46.0 18.5 3.7 0.7 0.5 100.0 968 Total 1.5 24.3 8.5 14.4 25.6 11.9 12.9 0.5 0.5 100.0 3,312 Note: The "professional, technical, managerial" category includes professional, technical, clerical and managerial occupations, Figures in parentheses are based on 25-49 unweighted cases 25 Table 2,16 Decisions on use of earnings Percent distribution of women receiving cash earnings by person who decides how earnings will be used, according to background characteristics, Bangladesh 1996-97 Person who decides how earnings will be used Jointly with Number Background Self someone Someone of characteristic only else else Missing Total women Age 10-19 32.2 53.9 13.8 0.0 100.0 174 20-24 35.2 55.7 9.0 0.0 100.0 341 25-29 43.0 50.3 6.7 0.0 100.0 504 30-34 43.9 47.9 8.1 0.0 100.0 412 35-39 42.5 48.3 8.8 0.4 100.0 347 40-44 47.2 41.7 11.1 0.0 100.0 220 45-49 49.8 39.1 11.1 0.0 100.0 116 Residence Urban 60.5 36.3 3.2 0.0 100.0 263 Rural 39.1 51.0 9.8 0.1 100.0 1,851 Division Barisal 56.6 34.7 8.7 0.0 100.0 117 Chittagong 46.1 43.4 10.5 0.0 100.0 313 Dhaka 42.9 50.0 6.9 0.2 100.0 688 Khulna 44.2 43.6 12.1 0.0 100.0 257 Rajshahi 34.3 55.9 9.8 0.0 100,0 669 Sylhet 48.1 47,6 4.3 0.0 100.0 69 Education No education 41.1 50.0 9.0 0.0 100.0 1.298 Primary incomplete 38.5 49.8 11.7 0.0 100.0 337 Primary complete 43.3 49.6 7.1 0.0 100.0 173 Secondary+ 47.3 45.0 7.3 0.4 100.0 306 Marital status Currently married 35.l 55.3 9.5 0.1 100.0 1,819 Not married 82.8 l 1.3 5.8 0.0 100.0 295 Total 41.8 49,2 9.0 0.1 100.0 2,114 26 CHAPTER 3 FERTILITY 3.1 Introduction The measurement of fertility levels, differentials and determinants was a major objective of the 1996- 97 BDHS. Interest in the fertility data was particularly keen, given the fact that the 1993-94 BDHS estimated a very low fertility rate that engendered some skepticism. 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 information on the 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 then asked for a history of all their 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 educa- tion; information on length of interval 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 Fert i l i ty Leve ls Table 3.1 gives the reported age-specific fertility rates for the three-year period preceding the survey per 1,000 women) The sumof 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 Table 3.1 Current fertility rates Age-specific and cumulative fertility rates and the cmde birth rate for the three years preceding the survey, by urhan-mral residence, Bangladesh 1996- 97 Residence Age group Urban Rural Total 15-19 88 155 147 20-24 140 200 192 25-29 99 158 150 30-34 53 102 96 35-39 28 46 44 40-44 12 19 18 45-49 (0) 7 6 TFR 15-49 2.10 3.43 3.27 TFR 15-44 2.10 3.40 3.24 GFR 86 135 129 CBR 22.6 30.2 29.4 Note: Ratesarefor theperiod 1-36monthspreceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Rates in paren- theses are based less than 250 woman-years of exposure. TFR: Total fertility rate, expressed per woman GFR: Ganeral fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate. expressed per 1,000 pop- ulation 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 t 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 numbers 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-rnarried women are presumed not to have given birth. 27 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 1994 through 1996) is 3.3 children per woman. This represents a statistically insignificant decline in fertility over the 3-year period since the 1993-94 BDHS (see section 3.4). The age-specific rates indicate a pattern of early childbearing, with a peak at age group 20-24. Three-quarters of childbearing occurs before age 30. The crude birth rate for the whole country is 29 births per 1,000 population. This is unchanged from the level measured in the 1993-94 B DHS, but is somewhat higher than the rate of 27 reported both by the government's sample vital registration system for 1995 (BBS, 1997:144) and by the Health and Demographic Survey for 1995 (BBS, 1995:2). 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., 1994:24). The difference is especially large at younger ages, which probably reflects longer education and later marriage of women in urban areas. The total fertility rate is estimated at 3.4 in rural areas and has more or less reached replacement level in urban areas (2.1). Figure 3.1 Age-Specific Fertility Rates by Residence Births per 1,000 Women 250 200 150 100 i 5O 0 200 99 102 i i i [ p 15o19 20-24 25-29 30-34 35-39 40-44 45-49 Age I'P, Urban q-Rural] BDHS 1996-97 3.3 Fertility Differentials Table 3.2 and Figure 3.2 show differentials in fertility by administrative division of residence and education. Fertility is highest in Sylhet and Chittagong Divisions, with total fertility rates of 4.2 and 4.1 children per woman, respectively. Fertility is lowest in Khulna (2.5) and Rajshahi (2.8) Divisions. Barisal 28 and Dhaka Divisions have intermediate levels of fertility, with total fertility rates of 3.3 and 3.2 children per woman, respectively. This pattern is similar to that found in the 1993-94 BDHS. Female education is strongly related to fertility levels. At current rates, women with no formal educa- tion would give birth to an average of 3.9 children in their lifetime, compared with 2.1 for women with at least some secondary education, a difference of 46 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 6.0 to 3.3 births per woman. The decline has occurred across all divisions and all education levels, although it has been greater for women in Khulna and Rajshahi Divisions where the current total fertility rates Table 3.2 Fertility by back~ound characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 40-49, by selected background char- acteristics, Bangladesh 1996-97 Mean number of children Total ever bum Background fertility to women characteristic rat~ age 40-49 Residence Urban 2.10 4.61 Rural 3.43 6.13 Division Barisal 3.31 5.81 Chittagong 4.06 6.58 Dhaka 3.18 5.77 Khulna 2.52 5.68 Rajshahi 2.78 5,73 Sylhet 4.20 6.40 Education No education 3.93 6.14 Primary incomplete 3.27 5.86 Primary complete 3.01 6.27 Secondary+ 2,12 4,56 Total 3.27 5.97 Women age 15-49 years are 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. Figure 3.2 Total Fertility Rates by Selected Background Characteristics RESIDENCE L Urban Rural ~ DIVISION Barisal Chittagong Dhaka Khulna Rajshahi Sylhet EDUCATION No education Prim. incomplete Prim. complete Secondary+ 0 ~ 2 . 1 " - - 3,4 3.3 3,2 2.5 2.8 ;, 3.9 3,3 3,0 ~;~ ~ ~:~ ; ~;~ ~# ~s ~:~ ~1 2.1 1 2 3 4 Births per Woman 4.1 4.2 BDHS 1996-97 29 3.4 Fertility Trends Fertility in Bangladesh has declined extremely rapidly over the past 20 years, from 6.3 births per woman in the mid-1970s to 3.3 births for the period 1994-96 (Table 3.3 and Figure 3.3). This is truly an exceptionally steep decline. However, although few would deny that fertility has fallen rapidly, the various data sources show rather different pictures of fertility trends, especially when examined by calendar year (see Figure 3.4). The rates from the 1989 BFS and the 1991 CPS 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 rate of 3.4 from the 1993-94 BDHS (which is placed in 1992, the midpoint of the 3-year reference period) is considerably lower than rates from the other sources, while the rate from the 1996-97 BDHS (plotted at 1995) is more in line. Moreover, the total fertility rate for the period 1991-93 constructed from the retrospective birth histories in the 1996-97 BDHS data (3.8) is higher than the rate of 3.4 derived from the 1993-94 survey itself for the same period. This is a curious finding, given that a 1994 study appeared to validate the 1993-94 estimates of fertility. 2 Investigation of the age pattern of fertility shows no anomalies; 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 (Figure 3.5). 3 However, data Table 3.3 Trends in current fertility rates Age-specific and total fertility rates, selected sources, Bangladesh, 1975 to 1996-97 Survey and approximate time period 1975 1989 1991 1993-94 1996-97 BFS BFS CPS BDHS BDHS Age group 1971-75 1984-88 1989-91 1991-93 1994-96 15-19 109 182 179 140 147 20-24 289 260 230 196 192 25-29 291 225 188 158 150 30-34 250 169 129 105 96 35-39 185 114 78 56 44 40-44 107 56 36 19 18 45-49 35 18 13 14 6 Total fertility rate 6.3 5.1 4.3 3.4 3.3 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 BDHSs utilized full birth histories, while the 1991 CPS used an 8-year truncated birth history. Source: 1975 BFS (MHPC, 1978:73); 1989 BFS (Huq and Cleland, 1990:103); 1991 CPS (Mitra et al., 1993:34); 1993-94 BDHS (Mitra et al., 1994:24) 2 The study was implemented in Matlab thana by the International Centre for Diarrhoeal Disease Research, Bangladesh (Bairagi, et al., 1995). The study involved conducting a BDHS-type survey in a sample of about 3,000 households. The data were then compared with those from the ICDDR, B continuous surveillance system. The fact that the fertility rates from the two sources were almost identical lent support to the BDHS fertility data. 3 Because the surveys were based on ever-married women only and weights were used to inflate results to reflect fertility rates for all women, data for the youngest age group (15-19) are particularly unstable due to fluctuations of the weighting factors. This may account for the inconsistent trend in fertility rates for this age group. 30 from the 1996 Health and Demographic Survey conducted by the Bangladesh Bureau of Statistics show a very different age pattern of fertility, having much lower rates for younger women and much higher rates for older women (BBS, 1997b:20). Figure 3.3 Trends In Total Fertility Rates, 1971-1996 Births per Woman 1971-75 1984-88 1986-88 1989-91 1991-93 1994-96 BDHS 1996-97 Another source of fertility data comes from ICDDR,B' s surveillance system in Matlab thana. Unlike survey data, the data 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 maternal 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. Estimates for 1995 put the total fertility rate at 3.0 for the treatment area and 3.6 for the comparison area, down from 3.4 and 5.0 prevailing in 1990 (Mostafa, et al., 1996:40). Results show that the recent declines in fertility have occurred throughout the country. Because of changes in division boundaries, it is necessary to recalculate fertility rates for the former four divisions of the country. Table 3.4 and Figure 3.6 show that all divisions in Bangladesh experienced recent declines in fertility of similar magnitude. Although Chittagong/Sylhet Division had the highest fertility in the mid- 1980s and still does today, the rate of decline in fertility is almost identical with that of the other divisions. 31 Figure 3.4 Trends In Total Fertlllty Rates by Calendar Year from Selected Sources, 1985-1995 Births per Woman -}- 1989 BFS E-1991 CPS ~-BBS ÷BDHSs i I I i I 1985 1987 1989 1991 1993 1995 Note: Ratu are ba~=d on 3-yur moving averages, except BDHS rates whi~ refer to a 3-ysar mfomnce pedod and BBS data for 1994.96 whloh =re from the Health and Demographic Surveys. BDHS 1996-97 Figure 3.5 Age-Specific Fertility Rates 1989, 1991, 1993-94 and 1996-97 Births per 1,000 Women 3O0 250 200 150 100 50 0 I I I / I 15-19 20-24 25-29 30-34 35-39 40-44 Age 1"~-1989 BFS "K-1991 CPS - - 1993-94 BE)HS --1996-97 BDHS J 45-49 Note: 1989 rates refer to the 5-ysar pedod preceding the survey; aN Others are 3-year rates, BDHS 1996-97 32 Table 3.4 Trends in fertility by division Total fertility rates by division and percent change from the period 1984-88 to 1994-96, Bangladesh, 1989 BFS. 1993-94 BDHS, and 1996-97 BDHS 1989 1993-94 1996-97 Percent BFS BDHS BDHS change Division 1984-88 1991-93 1994-96 1984-96 Chittagong 1 5.94 3.95 4.10 -31 Dhaka 5.18 3.45 3.18 -39 Khulna I 4.71 3.20 2.80 -4l Rajshahi 4.60 3.03 2.78 -40 Note: Rates for the 1989 BFS refer to the 5-year period preceding the survey, while those for the BDHSs refer to the 3-year period preceding the surveys. Rates are calculated for women age I5-49. l Refers to the former boundaries prior to the creation of Bafisal and Sylhet Divisions. Source: Huq and Cleland, 1990:106; Mitra et al, 1994:30 Figure 3.6 Trends in Fertility by Division Births per Woman 7.0 6,0 5.0 4.0 3.0 2.0 1.0 0.0 Chittagong/ Sylhet Dhaka Khulna/ Barisal Im1989 BFS m1993-94 BDHS D1996-97 BDHS I Rajshahi BDHS 1996-97 33 Table 3.5 Percent nre~ant Percentage of currently married women who were pregnant at the time of interview, by age group, selected sources, Bangladesh, 1975-1997 1975 1989 1991 1993-94 1996-97 Age group BFS BFS CPS BDHS BDHS 15-19 15.2 a 14.7 a 19,6 17.1 14.7 20-24 15.5 13.3 16.2 13.0 10.3 25-29 14.9 10.4 11.2 9.0 8.9 30-34 11.2 8.3 7.1 7.0 5.1 35-39 10.7 4.8 4.2 2.7 3.4 40-44 U U 1.5 0.8 1.3 45-49 U U 0.2 0.0 0.0 Total 12.5 9.3 10.7 8.7 7.7 2c= Unknown (not available) urrently 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 3.5 shows trends in the proportion of currently married women who reported that they were pregnant at the time of the survey, according to age group. Reports on current pregnancy are almost surely underestimates, since many women may be pregnant but not yet aware of their status. However, the data are useful because, 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 percentage 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 reported themselves as pregnant at the time of the survey. By 1989, this proportion had declined to 9 percent; it then increased to 11 percent in 1991, again declined to 9 percent in the 1993-94 BDHS and then to 8 percent in 1996-97. Although it is entirely possible that such fluctuations are real, misreporting may also be a factor. Table 3.6 provides further insights into the fertility decline discussed above. The table gives the age- specific fertility rates for f ive-year periods preceding the survey, using data from respondents' birth histories. Table 3.6 Trends in age-sDecific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by women's age at the time of birth, Bangladesh 1996-97 Number of years preceding the survey Woma/l's age at birth 0-4 5-9 10-14 15-19 15-19 157 211 243 246 20-24 198 255 287 291 25-29 153 218 251 272 30-34 101 151 193 [246] 35-39 53 100 [167] 40-44 20 [70] 45-49 [7] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 34 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. However, trends in fertility rates calculated from retrospective birth histories must be viewed with caution, since they may suffer from errors due to age and date misreporting. Table 3.7 presents fertility rates for ever-married women by duration (years) since first marriage for five-year periods preceding the survey. It is analogous to Table 3.6, but is confined to ever-married women and replaces age with duration since first marriage. The data show that the decline in fertility is apparent for all marriage durations in the two decades preceding the survey, with the exception of those married 0-4 years. This pattern implies that fertility control tends to be practiced later in marriage and that newly married couples continue to have children at more or less the same rate as before. Table 3.7 Trends in fertility by marital duration Fertility rates for ever-married women by duration (years) since first marriage for five-year periods preceding the survey, Bangladesh 1996-97 Number of years preceding the survey Marriage duration 0-4 5-9 10-14 15-19 0-4 255 262 260 234 5-9 226 278 300 306 10-14 158 220 257 279 15-19 I l l 175 213 [253] 20-24 66 119 [185] 25-29 31 [85] Note: Duration-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. 3.5 Chi ldren Ever Born The distribution of all women and currently married women by age and number of children ever born is presented in Table 3.8, The table also shows the mean number of children ever born to women in each five-year age group, an indicator of the momentum of childbearing. The data indicate that almost one-third (31 percent) of all women age 15-19 years have given birth. On average, women have given birth to three children by their late 20s and over six children by the end of their childbearing years. Figures for currently married women do not differ greatly from those for all women at older ages; however, at younger ages the percentage of currently married women who have had children is much higher than the percentage among all women. 35 Table ~-8 Children ~ver born and livin~ Percent distribution of all women and of currently married women age 15-49 by number of children ever born (CEB) and mean number ever born and living, according to five-year age groups, Bangladesh 1996-97 Number of children ever born (CEB) Number Mean Mean no. Age of no. of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL WOMEN 15-19 69.0 24.1 6.3 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,592 0.39 0.35 20-24 27.6 24.1 28.4 14.3 4.6 0.9 0.1 0.0 0.0 0.0 0.0 1(30.0 2,087 1.47 1.29 25-29 8.0 12.2 25.0 24.8 16.8 7.7 3.5 1.5 0.4 0.1 0.0 100.0 1,973 2.78 2.40 30-34 2.4 5.5 15.6 19.4 22.6 14.6 11.2 5.5 2.1 0.8 0.3 100.0 1,409 3.91 3.28 35.39 1.9 3.5 9.7 15.4 15.5 17.5 13.3 10.1 7.9 2.8 2.3 100.0 1,129 4.82 3.95 40-44 1.9 3.1 5.4 10.3 15.1 13.0 14.8 13.9 9.0 7.1 6.5 100.0 861 5.60 4.48 45-49 1.3 1.6 3.7 6.3 8.7 14.3 16.3 14.3 11.7 10.3 11.5 100.0 658 6.44 5.07 Total 24.3 14.2 15.4 12.9 10.4 7.3 5.7 4.1 2.6 1.6 1.5 100.0 10,707 2.76 2.30 CURRENTLY MARRIED WOMEN 15-19 37.5 48.3 12.9 1.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,252 0.78 0.70 20-24 11.9 28.5 34.8 17.8 5.7 1.1 0.1 0.0 0.1 0.0 0.0 100.0 1,655 1.81 1.59 25-29 3.9 11.5 26.0 26.2 18.1 8.4 3.7 1.6 0.4 0.1 0.0 1100.0 1,812 2.94 2.55 30-34 1.3 4.3 14.5 19.6 23.8 15.6 11.6 5.7 2.2 0.9 0.3 100.0 1,297 4.05 3.40 35-39 1.3 2.6 8.8 15.4 15.9 18.5 12.9 10.7 8.5 3.0 2.4 100.0 1,031 4.96 4.07 40-44 1.7 2.3 4.4 8.5 15.6 13.0 14.8 14.6 10.1 7.6 7.4 100.0 740 5.82 4.68 45-49 0.9 1.4 3.1 5.8 7.7 14.5 15.8 15.0 12.6 10.2 12.9 lO0.O 520 6.63 5.22 Total 9.5 16.8 18.5 15.5 12.7 8.8 6.6 4.8 3.2 1.8 1.8 100.0 8,307 3.30 2.76 The percentage of women in their 40s 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 2 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). A comparison of the mean number of children ever born reported in the 1996-97 BDHS and various other surveys is presented in Table 3.9. The comparison does not highlight recent changes in fertility, but Table 3.9 Trends in children ever born Mean number of children ever born by age group, selected sources, Bangladesh, 1975-1996 1975 1981 1983 1985 1989 1989 1991 1993-94 1996-97 Age group BFS CPS CPS CPS BFS CPS CPS BDHS BDHS 15-19 0.6 0.5 0.6 0.4 0.4 0.4 0.4 0.3 0.4 20-24 2.3 2.0 2.2 2.0 1.7 1.8 1.7 1.6 1.5 25-29 4,2 3.7 3.8 3.6 3.1 3.3 3.2 2.9 2.8 30-34 5.7 5.4 5.5 5.1 4.7 4.7 4.5 4.1 3.9 35-39 6.7 6.4 6.5 6.5 5.9 5.9 5.7 5.2 4.8 40-~ 7.1 7.3 7.4 7.4 6.6 7.0 6.7 6.4 5.6 45-49 6.7 7.6 7.5 7.2 7.3 7.5 7.4 6.9 6.4 Total U U U U U U 3.5 3.0 2.8 U = Unknown (not available) Source: 1983 and 1985 CPSs (Kanmer and Frankenberg, 1988:21); 1991 CPS (Mitra et al., 1993:31); 1993-94 BDHS (Mitra et al. 1994:33); all others (Cleland et al., 1994:11) 36 rather is an indication of the cumulative changes in fertility over the decades prior to the surveys. 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 between 1989 and 1991, the rates again decline considerably between 1991 and 1993-94, especially among women age 25 and above and show further decline between 1993-94 and 1996-97 at all ages except 15-19. 3.6 B i r th 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 3.10 shows the percent distribution of non- first births that occurred in the five years before the BDHS by the number of months since the previous birth. The data show that birth intervals are generally long in Bangladesh. Over half (52 percent) of non- first births occur three or more years after the previous birth, while almost one-third take place 24-35 months after the previous birth. Fewer than 1 in 5 births occurs after an interval of less than 24 months. The median birth interval is 37 months. This is slightly longer than the median birth interval of 35 months reported in the 1993-94 BDHS (Mitra et al., 1994:34). As expected, younger women have shorter birth intervals than older women, presumably because they are more fecund and want to build their families. The median birth interval for women age 15-19 is 25 months, compared with 44 months fur women over age 40. A shorter median interval also prevails for children whose preceding sibling has died, compared with those whose prior sibling is alive. This pattern presumably reflects a shortened breastfeeding period due to the death of the prior sibling, as well as minimal use of contraceptives. 3.7 Age at First Birth 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 both the mother and child. Early childbearing also tends to restrict educational and economic opportunities for women. Table 3.11 presents the percent distribution of women by age at first birth according to current age. 4 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 between 17 and 18. The data show that the median age at first birth has increased slightly from around 17 for older women to around 18 for women in their early 20s. 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 20 percent of women in their 40s report having had their first birth before age 15, compared with only 9 percent of women age 15-19. 4 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). 37 Table 3.10 Birth intervals Percent distribution of non-first births in the live years preceding the survey by number of months since previous birth, according to demographic and socioeconomic characteristics, Bangladesh 1996-97 Number of months since previous birth Characteristic 7-17 18.23 24-35 36-47 48+ Total Median number of Number months since of previous birth births Age of mother 15-19 23.3 19.9 36.7 13.3 6.8 100.0 25.3 194 20-29 6.8 11.3 31.6 24.2 26.0 I00.0 36.1 2,857 30-39 5.9 8.1 26.9 22.8 36.3 1190.0 40.0 1,287 40 + 4.1 6.4 27.5 I8.7 43.3 100.0 44.4 212 Birth order 2-3 6.6 10.4 28.1 23.5 31.4 100.0 37.8 2,456 4-6 7.3 10.3 31.9 22.6 27.9 100.0 36.1 1,541 7 + 9.3 11.6 35.7 22.9 20.4 100.0 33.4 553 Sex of prior birth Male 6.8 10.6 29.2 23.7 29.6 100.0 37.1 2,231 Female 7.5 10.5 31.4 22.5 28.2 100.0 36.2 2,319 Survival of prior birth Living 4.8 9.3 30.2 24.5 31.2 100.0 37.9 3,876 Dead 20.3 17.5 31.2 15.4 15.5 I00.0 26.8 675 Residence Urban 8.6 8.2 20.2 19.4 43.6 I00.0 43.2 356 Rural 7.0 10.8 31.2 23.4 27.6 100.0 36.3 4,194 Division Barisal 5.8 10.2 30.5 22.6 30.9 100.0 36.7 298 Chittagong 7.5 10.6 36.8 22.4 22.6 100.0 34.4 1,174 Dhaka 6.8 9.8 28.3 23.4 31.7 100.0 37.7 1,387 Khulna 6.9 11.7 25.7 20.6 35.1 100.0 38.8 406 Rajshahi 6.7 10.2 27.3 23.4 32.4 100.0 38.1 943 Sylhet 9.8 13.3 29.7 27.1 20.0 100.0 35.1 341 Education No education 7.5 10.3 32.2 23.4 26.6 100.0 36.0 2,874 Primary incomplete 6.7 11.9 28.3 23.5 29.6 100.0 37.1 752 Primary complete 6.4 11.3 28.9 21.9 31.4 I00.0 37.3 402 Secondary+ 6.6 9.6 23.8 21.8 38.2 100.0 41.3 522 Total 7.1 10.6 30.3 23.1 28.9 100.0 36.6 4,550 Note: First births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Comparisons with data from other sources confirm that the age at which women in Bangladesh have their first child has increased steadily over time, in line with increases in age at marriage, with the exception of the past few years. 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 1996-97, to 18.4 (Huq and Cleland, 1990:92). However, comparison of data from the 1993-94 and 1996-97 BDHSs shows a slight decline in the overall median age at first birth among women age 20-49, from 17.7 to 17.4. This may signal a plateau in the trend towards later age at first birth. 38 Table 3.11 A~e at first birth Pement distribution of women 15-49 by age at first birth, according to current age, Bangladesh 1996-97 Women with Age at first birth no Current age births <15 15-17 18-19 20-21 22-24 25+ Median Number age at of first Total women birth 15-19 69.0 9.2 18.9 3.0 NA NA NA 100.0 2,592 a 20-24 27.6 14.7 31.8 16.8 6.5 2.6 NA 100.0 2,087 18.4 25-29 8.0 16.0 41.0 17.8 8.9 6.3 2.0 100,0 1,973 17.4 30-34 2.4 15.9 45.7 17.1 8.5 6.5 3.9 100.0 1,409 17.2 35-39 1.9 19.3 39.9 18.3 8.4 7.3 4.8 100.0 1,129 17.3 40-44 1.9 20.9 48.5 14.7 6.0 5.2 2.8 100,0 861 16.6 45-49 1.3 18.7 45.6 18.4 8.6 4.3 3.0 1130,0 658 16.9 [qA = Not applicable Omitted because less than 50 percent of the women in the age group x to x+4 have had a birth by age x Differentials in median age at first birth as reported in the 1996-97 BDHS are shown in Table 3.12. Urban women start childbearing later than rural women; the median age at first birth is 18.9 for urban women and 17.2 for rural women age 20-49. Women in Sylhet Division consistently have higher median ages at first birth than women in the other divisions, while women in Raj shahi Division generally have the lowest median ages at first birth. Women with secondary education start child-bearing later than those with less or no education. Among women age 25-49, the median age at first birth is 16.8 for women with no education and 19.3 for women with at least some secondary education. Table 3.12 Median ate at first birth Median age at first birth among women age 20-49 years, by current age and selected background characteristics, Bangladesh 1996-97 Current age Background Ages Ages characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Residence Urban 23.6 18.6 17,9 18.3 17.5 19.0 18.9 18.2 Rural 18.1 17.3 17.1 17.2 16.5 16.8 17.2 17.0 Division Batisal 18.4 17.3 17.3 17.7 16.7 17.9 17.5 17.3 Chittagoog 19.4 17.9 17.6 17.3 17.3 17.4 17.9 17.6 Dhaka 18.5 17.3 17,2 16.9 16.8 16.9 17.4 17.1 Khulna 18.4 17.4 17.0 17.2 16.1 16.2 17,2 16.9 Rajshahi 17,0 16.8 16.7 17.4 15.8 16.2 16.7 16.7 8ylhet a 19.6 18.3 17.9 17.4 18.2 18.9 18.4 Education No education 17.0 16.8 16.9 16.9 16.6 16.7 16.8 16.8 Primary incomplete 17.0 16.8 16.9 17.0 16,0 17.1 16.9 16.8 Primary complete 18.2 17.7 17.4 17.4 16.2 17.6 17.5 17,3 Secondary+ a 20.3 19.0 19.0 18.2 18.6 a 19.3 Total 18.4 17.4 17,2 17.3 16.6 16.9 17.4 17.2 ~qote: The medians for cohort 15-19 could not be determined because half the women have not yet had a birth. Medians were not calculated for these cohorts because less than 50 percent of women in the ago group x to x+4 had a birth by age x. 39 3.8 Teenage Fert i l i ty Early childbearing, particularly among teenagers (those under 20 years of age) has negative demographic, socioeconomic and sociocultural consequences. Teenage mothers are more likely to suffer 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. Table 3.13 Adolescent ore~nancv and motherhood Percentage of women 15-19 who are mothers or pregnant with their first child, by selected background characteristics, Bangladesh 1996-97 Percentage who are; Percentage who have Pregnant begun Number Background with first child- of characteristic Mothers child bearing women Age 15 8.5 5.5 14.1 540 16 23.5 5.2 28.7 635 17 32.6 3.7 36.4 478 18 43.2 4.7 48.0 525 19 54.6 3.1 57.7 414 Residence Urban 20.3 4.5 24.8 329 Rural 32.2 4.5 36.7 2,291 Division Barisat 28.4 5.1 33.5 185 Chittagong 27.4 3.8 31.1 599 Dhaka 31.7 3.6 35.3 769 Khulna 30.9 5.2 36.1 296 Rajshahi 37.9 5.9 43.8 598 Sylhet 18.6 5.5 24.1 140 Education No education 48.2 5.8 54.0 767 Primary incomplete 33.7 5.2 38.8 494 Primary complete 35.8 3.7 39.5 317 Secondary+ 15.1 3.6 18.7 1,024 Total 31.0 4.6 35.6 2,592 Table 3.13 shows the percentage of teenagers age 15-19 who are mothers or pregnant with their first child, according to various background characteristics. Thirty-one percent of teenage women in Bangladesh are mothers and another 5 percent are pregnant with their first child. Thus, 36 percent of teenage women have begun childbearing. There has been a slight increase in this proportion since the 1993-94 BDHS, which indicated that 33 percent of women age 15-19 had begun childbearing (27 percent had delivered a child and 6 percent were pregnant with their first child) (Mitra et al., 1994:37). While this trend may signal an increase in early childbearing, the differences are not large and they are highly dependent on the sensitive inflation factors used to estimate the total number of women (see Footnote 1). 40 AS expected, the proportion of women who have begun childbearing rises rapidly with age, from 14 percent of those age 15 to 58 percent of those age 19 (see Table 3.13). Those residing in rural areas and especially those residing in Rajshahi Division are also more likely than others to have begun childbearing, while girls in Sylhet Division are the least likely to have started childbearing. Education is strongly related to early childbearing. Girls with no education are far more likely to have begun childbearing than those with primary and especially those with some secondary education. 41 CHAPTER 4 FERTILITY REGULATION 4.1 Knowledge of Contracept ion In the BDHS, knowledge of contraceptive methods was assessed through a series of questions combining spontaneous recall and prompting procedures. Female and male 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 mentioned spontaneously by the respondent. The ability to name or recognize the name of a family planning method is a nominal test of respondents' knowledge and not a measure of how much they might know about the method. However, knowledge of specific methods is a precondition for their use. In the 1996-97 BDHS, information was sought about seven modem methods--the pill, IUD, injection, Norplant, condom, and female and male sterilization--as well as two traditional methods, periodic abstinence (safe period or rhythm method) and withdrawal. Other methods mentioned by the respondent, such as herbs or breastfeeding, were also recorded. It should be noted that information about Norplant was not sought in the 1993-94 BDHS. Table 4.1 shows the percentage of ever-married women, currently married women and currently married men who have heard about specific methods of family planning. Although the data are given separately for ever-married and currently married women, ever-married women are not included in the discussion of knowledge of family planning methods because there is virtually no difference in the proportion knowing a method between ever-married and currently married women. Table 4.1 Knowledge of contracentive methods Percentage of ever-married and currently married women and of currently married men who know any contraceptive methods, by specific methods, Bangladesh 1996-97 Ever- Currently Currently Contraceptive roamed married married method women women men Any method 1(30.0 100.0 99.9 Any modern method 100.0 100.0 99.8 Pill 99.9 99.9 99.7 IUD 91.4 91.8 68.1 Injectables 98.0 98.2 92.7 Condom 9t.0 91.6 97.1 Female sterilization 98.9 98.9 98.5 Male sterilization 83.4 83.8 90.0 Norplant 26.5 27.0 13.7 Any traditional method 76.6 77.4 79.8 Periodic abstinence 68.2 68.9 70.4 Withdrawal 49.8 50.9 49.2 Other 9.9 10.2 9.2 Number of women/men 9,127 8,450 3,312 Mean number of methods 8.0 8.0 7.4 43 Knowledge of at least one family planning method is universal among married Bangladeshi women and men. More importantly, virtually all respondents who know at least one method know a modem method. Traditional methods are considerably less widely known than modem methods, probably because traditional methods are not included in the organized family planning program efforts. In addition, learning of these methods through informal channels is not easy in a society like that in Bangladesh where matters relating to sex are not freely discussed. With regard to knowledge of specific methods, virtually all currently married women have heard about the pill, injectables, and female sterilization and 92 percent know about the IUD and condom. Other methods recognized by at least half of all currently married women are male sterilization (84 percent), periodic abstinence (safe period or calendar rhythm--69 percent), and withdrawal (51 percent). Only about 1 in 4 currently married women has heard of Norplant. Ten percent of women mentioned methods that were not on the list, mostly traditional methods like ayurvedic methods, plants and herbs. As among currently married women, the pill and female sterilization are universally known among currently married men. There is also virtually no difference between currently married women and men in knowledge of periodic abstinence and withdrawal. However, for the remaining methods, men are less likely to know about female methods, such as the IUD, injectables, and Norplant, while they are more likely to have heard about male methods, namely, condoms and male sterilization. For example, only 68 percent of currently married men have heard about the IUD, compared with 92 percent of currently married women and the proportion knowing condoms was higher for men (97 percent) than for women (92 percent). Trends in Knowledge of Family Planning Methods Trends in knowledge of family planning methods are shown in Table 4.2 in terms of the proportion of ever-married women who have heard of specific methods. The proportion of women of reproductive age who know of at least one family planning method has been extremely high in Bangladesh (99 percent) since the early 1980s. However, knowledge of specific methods has become more widespread since then. For example, the proportion of ever-married women who have heard of the IUD has more than doubled since 1983, from 42 to 91 percent in 1996-97. Knowledge of injectables and condoms also increased significantly over the same period. Although the largest increases in knowledge levels occurred between 1975 and 1983 for most modem methods, it is notable that awareness of all modem methods increased between 1993-94 and 1996-97. Knowledge of periodic abstinence and condoms increased the most between these two recent surveys. The 1996-97 BDHS data confirm the findings of the 1993-94 BDHS, indicating that contraceptive knowledge is widespread among subgroups in the country. Knowledge of at least one method, particularly a modem method, is universal among both women and men in all age groups, in both urban and rural areas, in all the divisions and across all categories of educational attainment (data not shown). The high level of knowledge found in every subgroup indicates the success of program 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. Table 4.3 shows the correspondence in knowledge of family planning methods between husbands and wives interviewed in the 1996-97 BDHS. Generally, there is a high degree of correspondence between spouses; if one partner knows a method, the other is likely to know it as well, or, if one partner does not know a method, the other is also likely not to know it. However, there is less consistency for female methods such as the IUD, Norplant, and periodic abstinence, and for male methods such as condoms and male sterilization; wives are generally more likely to know the female methods than their husbands, while husbands are more likely to know the male methods than their wives. 44 Table 4.2 Trends in knowledge of family nlannina methods Percentage of ever-married women age 10-49 who know specific family planning methods, selected sources, Bangladesh, 1975-1996 1975 1983 1985 1989 1989 1991 1993-94 1996-97 Method BFS CPS CPS CPS BFS t CPS BDHS BDHS Any method 81.8 98.6 99.6 99.9 100.0 99.9 99.7 100.0 Any modern method 80.0 98.4 99.5 99.9 99.0 99.8 99.7 100.0 Pill 63.9 94. I 98.6 99.0 99.0 99.7 99.5 99.9 IUD 40.1 41.6 65.4 80.4 78.0 88.9 89.4 91.4 lnjectables U 61.8 74.1 87.5 81.0 95.2 96.3 98.0 Vaginal methods 10.0 19.4 26.3 25.8 24.0 U U U Condom 21.1 59.0 75.5 76.9 83.0 85.6 86.6 91.0 Female sterilization 53.1 95.5 97.8 99.2 98.0 99.4 98.8 98.9 Male sterilization 51.4 72.9 84.3 84.0 87.0 87.4 82.9 83.4 Any traditional method 49.0 54.8 62.8 71.7 U 83.3 75.0 76.6 Periodic abstinence 28.0 26.4 41.2 40.1 46.0 68.0 64.0 68.2 Withdrawal 15.1 19.8 20.8 14.4 30.0 48.6 49.0 49.8 Number of women 6,515 8,523 8,541 10,293 11,907 10,573 9,640 9,127 iU --- Unknown (no information) Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1975 BFS (MHPC, 1978:A245 and Vaessan, 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); 1993-94 BDHS (Mitra et al., 1994:40) Table 4.3 Knowledge of contracentive methods amon~ counles Percent distribution of couples by contraceptive knowledge, according to specific methods, Bangladesh 1996-97 Only Only Both husband wife Neither Contraceptive know knows knows knows method method method method method Total Any method 99.9 0.0 0.1 0.0 100.0 Any modern method 99.8 0.0 0.2 0.0 10O.0 Pill 99.6 0.1 0.3 0.0 100.0 IUD 65.4 3.4 27.1 4.2 100.0 Injectables 91.5 1.2 6.9 0.4 100.0 Condom 89.8 7.2 2.2 0.8 100.0 Female sterilization 97.6 0.9 1.5 0.0 100.0 Male sterilization 78.3 12.2 6.9 2.6 100.0 Norplant 6.3 7.5 21.6 64.7 100.0 Any traditional method 65.4 14.6 14.6 5.4 100.0 Periodic abstinence 52.0 18.4 19.7 9.9 100.0 Withdrawal 29.7 19.7 22.3 28.3 100.0 Other 2.4 6.9 8.1 82.6 100.0 Note: Figures are based on 3,028 couples. 45 4.2 Ever Use of Contracept ion Both women and men interviewed in the 1996-97 BDHS who said that they had heard of a method of family planning were asked if they had ever used the method, that is, if they had used it at least once. 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 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 indicate the success of programs in promoting use of family planning methods among eligible couples. In addition, data on ever use--together with data on current use--are valuable for studying couples who discontinue use. Table 4.4 shows the percentage of ever-married women, currently married women and currently married men who have ever used specific family planning methods. The data for women are given by age group. Among ever-married women, almost 7 in l0 (69 percent) have ever used a method and nearly 6 in l0 (63 percent) have used a modem method, while only a quarter (23 percent) reported having ever used a traditional method. The pill has, as expected, by far the highest ever use rate, having been used by half (49 percent) of ever-married women. The next most common ever used methods are periodic abstinence (17 percent), injectables (16 percent) and condoms (15 percent), followed by withdrawal (10 percent), female Table 4.4 Ever use of contraceofon Percentage of ever-mamed and currently married women and currently mamod men who have ever used any contraceptive method, by specific method and age, Bangladesh 1996-97 Modem method Traditional method Number Any Any modem Age method method Pill IUD Female Male Menstrual Any Periodic of Inject- sterili- sterili- Nor- regu- trad. abstin- With- Other respon- ables Condom zation zation plant lation method ence drawal method dents EVER-MARRED WOMEN 10-14 24.5 18.7 12.7 0.4 0.7 7.5 0.0 0.0 0.0 0.0 9,6 7.3 6.3 0.8 145 15-19 52.9 46.9 38.7 1.6 6.9 14.0 0.1 0.1 0.2 1.5 14.8 9.7 7.6 0.6 1,301 20-24 68.6 62.3 53.2 4.9 15.3 16.1 1.6 0.4 0.2 2.1 19.9 13.4 9.5 1.0 1,727 25-29 78.0 73.0 60.3 9.0 21.0 18.5 4.5 1.0 0.2 4,9 24,2 17.2 11.4 2.4 1,905 30-34 81.9 76.9 61.7 11.2 22.2 19.2 10.7 0.9 0.5 5.3 28.6 20,8 I L4 3.2 1,402 35-39 76.4 70,0 49.4 9.8 19.1 14.2 15.4 1.9 0.0 4.5 29,8 23.0 9.4 4.8 1,128 40-44 67.3 60.5 37.8 5.7 13.1 9.2 18.0 3.3 0.0 2.9 25.1 19.0 8.7 4.2 861 45-49 50.3 39.4 19.9 4.7 5.8 5.3 14.9 2.6 0.0 1.6 21.3 17.3 5.7 1.9 658 Total 69.2 63.0 48.9 6.9 15.7 15,0 7.6 1.2 0.2 3.4 23.0 16.7 9.5 2.4 9,127 CURRENTLY MARRIED WOMEN 10-14 24.7 18.9 12.8 0.4 0.7 7.5 0.0 0.0 0.0 0.0 9.7 7.4 6.3 0.8 143 15-19 54,4 48.2 39.8 1.7 7.2 14.4 0.0 0.1 0.2 1.6 15.3 10.1 7.8 0.7 1.252 20-24 70,2 63.9 54.5 5.1 15.7 16.8 1.7 0.4 0.2 2.2 20.4 13.7 9.8 1.0 1,655 25-29 79,9 74.7 62.0 9.4 22,0 18.9 4.5 1.0 0.2 5. I 24.8 17.6 11.6 2.5 1.812 30-34 85.5 80.7 65.1 11.9 23,8 20.4 11.1 0.8 0.5 5.7 29.9 21.7 12.1 3.5 1,297 35-39 80.4 74.0 52,4 10.3 20.0 15.2 15.9 2.0 0.0 4.8 31.1 23.9 9.7 5.2 1,031 40-44 73.8 66.8 42.2 6.5 15.1 10.4 19.0 3.6 0.0 3.2 27.7 20.9 9,3 4.6 740 45-49 55.9 44.6 22.7 5.9 6.7 5.9 16.2 3.3 0.0 2.0 23.4 18.8 6,3 2.4 520 Total 72.2 66.0 51.5 7.3 16,7 15.9 7.6 1.2 0.2 3.6 24.0 17.3 9.9 2.6 8,450 CURRENTLY MARRIED MEN Total 81.3 73.5 59.9 7.5 15.8 30.1 8.1 1.6 0,1 4.8 39.5 33.6 11.0 2.8 3.312 46 sterilization (8 percent) and the 1UD (7 percent). A negligible 1 percent report use of male sterilization and very few women report ever use of the newest method, Norplant. As expected, currently married women are more likely than ever-married women to say they have ever used a family planning method. Ever use rates are higher among men than among women for every contraceptive method inquired about. Eighty-one percent of currently married men, compared with 72 percent of currently married women, report having ever used a method. Differences are strikingly large in the case of condom use; 30 percent of currently married men have ever used condoms, compared with only 16 percent for currently married women. Ever use rates vary with age of women, being lowest among the youngest women. However, the fact that more than half (54 percent) of currently married women age 15-19 have used a contraceptive method at some time and nearly half (48 percent) have used a modem method indicates that women in Bangladesh have begun to understand the advantages of practicing family methods early in their reproductive careers. The level of ever use rises to a high of 86 percent for currently married women age 30-34, then declines to 56 percent among those age 45-49. Ever use of modem methods by age of women follows a similar pattern. There has been a steady increase in the level of ever use of family planning over the past two decades in Bangladesh. In 1975, only 14 percent of ever-married women of reproductive age had ever used a family planning method, compared with 69 percent in 1996-97, a fivefold increase (Table 4.5). For modem methods, the increases have been even steeper, with ever use of the pill increasing 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 plannin~ methods Percentage of ever-married women age 10-49 who have ever used specific family Bangladesh, 1975-1996 planning methods, selected sources, 1975 1983 1985 1989 1989. 1991 1993-94 1996-97 Method BFS CPS CPS CPS BFS " CPS BDHS BDHS Any method 13.6 33.4 32.5 44.2 45.0 59.0 63.1 69.2 Any modern method U 23.8 25.9 37.5 U 49.2 56.4 63.0 Pill 5.0 14.1 14.3 23.3 22.0 34.1 42.0 48.9 IUD 0.9 2.2 2.7 4.6 4.0 6.2 7.3 6.9 Injectables U 1.2 1.3 2.8 2.0 6.6 11.0 15.7 Vaginal methods 0.5 2.2 1.6 2.4 1.0 2.9 U U Condom 4.8 7.1 5.7 9~3 6.0 13.4 13.9 15.0 Female sterilization 0.3 5.8 7.4 8.7 9.0 8.0 7.9 7.6 Male sterilization 0.4 1.4 1.6 1.6 1.0 1.4 1.4 1.2 Any traditional method U 17.3 11.9 15.3 U 29.6 24.0 23.0 Periodic abstinence 4.5 11.0 7.8 9.7 13.0 21.5 16.5 16.7 Withdrawal 2.6 5.3 2.9 3.6 7.0 11.1 10.1 9.5 Number of women 6,515 8,523 8,541 10,293 11,907 10,573 9,640 9,127 = Unknown (no information) Published 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) 47 4.3 Knowledge and Ever Use of Menstrual Regulation Respondents in the 1996-97 BDHS were also asked if they knew about or had ever used menstrual regulation (MR). Results shown in Table 4.6 indicate that almost 4 in 5 ever-married and currently married women know about MR, in contrast to only half of currently married men. Ever use of the method is negligible, however, with only 3-4 percent of women and about 5 percent of men saying they had ever used MR. Levels of ever use are highest among respondents who are currently in their late 20s and 30s. Table 4.6 Menstrual re~,ulation Percentage of ever-married and currently married women and of currently married men who know of menstrual regulation and the percentage who have ever used menstrual regulation by age group. Bangladesh 1996-97 Ever- Currently Currently married married married Age group women women men 78.2 78.9 52.1 Know of menstrual regulation Ever used menstrual regulation 10-14 0.0 0.0 15-19 1.5 1.6 20-24 2.1 2.2 25-29 4.9 5.1 30-34 5.3 5.7 35-39 4.5 4.8 40-44 2.9 3.2 45-49 1.6 2.0 Total 3.4 3.6 4.8 Note: Data are not shown for men by age group due to small sample size. 4.4 Cur rent Use o f Cont racept ion Current use of contraception is defined as the proportion of women and men who reported they were using a family planning method at the time of interview. Although ever-married women age 10-49 were interviewed in the BDHS, only women who were currently married at the time of the survey were asked the questions on current use of family planning. Table 4.7 shows the percent distribution of currently married women and men by current contraceptive use status according to age group. Overall, 49 percent of currently married women are using a contraceptive method, with 42 percent using a modem method. Although modem methods account for 85 percent of overall use, there is still a substantial 8 percent of currently married women who rely on traditional methods. These figures are very similar to the contraceptive prevalence rate of 49 reported in the 1995 Health and Demographic Survey, which also recorded that 42 percent of married women were using modem methods (BBS, 1997b:23). The most popular method by far is the pill, which is used by 21 percent of currently married women. Use of the pill accounts for 42 percent of all contraceptive use in Bangladesh. Other commonly used methods are female sterilization (8 percent), injectables (6 percent), periodic abstinence (5 percent), and condoms (4 percent). The IUD, male sterilization, and withdrawal are each used by less than 2 percent of currently married women. 48 Table 4.7 Current use of contraception Percent distribution of currently married women and men by contraceptive method currently used, according to age, Bangladesh 1996-97 Modem method Traditional method Any Any modern Age method method Pill IUD CURRENTLY MARRIED WOMEN Number Female Male Menstrual Any Periodic Not of [nject- sterili- sterili- Nor- regu- trad. abstin- With- Other currently respon- ables Condom zation zation plant lation method ence drawal method using Total denis 10-14 15.6 9.1 4.8 0.0 0.3 3.9 0.0 0.0 0.0 0.0 6.5 3.5 2.3 0.8 84.4 100.0 143 15-19 32.9 27.8 17.9 1.0 4.4 4.3 0.0 0.1 0.2 0.0 5.0 3.2 1.7 0.1 67.1 100.0 1,252 20-24 43.1 37.6 24.2 1.5 6.4 3.2 1.7 0.4 0.2 0.0 5.5 3.0 2.0 0.4 56.9 100.0 1,655 25-29 52.5 46.0 25.2 2.4 8.5 4.3 4.5 1.0 0.2 0,0 6.5 3.9 1.8 0.7 47.5 100.0 1,812 30-34 63.1 54.0 26.9 2.4 7.8 5.2 I1.1 0.5 0.1 0.0 9.0 6.0 2.2 0.8 36.9 100.0 1,297 35-39 63.9 51.9 20.8 1.9 7.1 4.1 15.9 1.9 0.0 0.1 11.9 9.2 1.6 1.1 36.1 100.0 1,031 40-44 54.7 42.7 12.1 1.4 3.9 2.8 19.0 3.5 0.0 0.0 12.0 S.0 1.9 2.2 45.3 100.0 740 45-49 35.1 27.6 3.8 1.2 1.7 1.6 16.2 3.0 0.0 0.0 7.5 4.9 1.6 1.0 64.9 100.0 520 Total 49.2 41.6 20.8 1.8 6.2 3.9 7.6 1.1 0.1 0.0 7.7 5.0 1.9 0.8 50.8 100.0 8,450 CURRENTLY MARRIED MEN 15-19 * * * * * * * * * * * * * * 100.0 23 20-24 42.6 33.5 20.1 1.6 4.3 6.9 0.0 0.0 0.6 0.0 9.1 7.5 1.1 0.5 57.4 100.0 194 25-29 48.5 38.3 24.7 1.8 6.8 4.8 0.0 0.2 0.0 0.0 10.2 8.3 1.6 0.3 51.5 100.0 487 30-34 59.3 50.4 31.0 1.8 6.3 7.0 3.5 0.7 0.0 0.0 8.9 7.4 0.9 0.6 40.7 100.0 620 35-39 63.1 54.0 30.0 1.1 8.9 6.1 7.1 0.7 0.0 0.0 9.1 6.7 1.6 0.9 36.9 100.0 621 40-44 70.2 56.7 26.4 2.6 9.0 6.5 10.9 1.3 0.0 0.0 13.5 10.5 1.3 1.6 29.8 100.0 492 45-49 69.1 56.6 25.2 1.5 7.9 6.7 13.3 1.8 0.0 0.0 12.5 8.8 1.9 1.9 30.9 100.0 371 50-54 65.4 47.8 11.5 2.0 4.3 3.1 19.5 7.4 0.0 0.0 17.7 12.1 3.1 2.5 34.6 100.0 272 55-59 46.2 35.2 6.4 1.2 5.2 1.5 17.4 3.4 0.0 0.0 11.0 9.0 0.6 1.4 53.8 100.0 231 Total 59.6 48.5 24.5 1.7 7.1 5.7 7.9 1.6 0.0 0.0 11.1 8.5 1.5 I.I 40.4 100.0 3,312 Note: An asterisk indicates fewer than 25 unweighted cases. Men are more likely than women to report that they are currently using a family planning method--60 versus 49 percent among currently married men and women, respectively. Such a large discrepancy may be due to overreporting by men, either to appease the interviewer or because they were embarrassed to admit that they were not practicing family planning. It could also be due to underreporting by women who were using a family planning method but were too shy to report that they were. Although there is no clear basis to discard the information given by either women or men as unreliable, it seems that women are more likely to be the reliable reporters of contraceptive use as they are the actual users in most cases. Although men report higher use than women for all methods except withdrawal and the IUD, the largest differences are for the pill and periodic abstinence. The latter has been found in other DHS surveys and may be due to men's misunderstanding of the difference between periodic abstinence and abstinence for other reasons. Contraceptive use varies considerably by age. Women are most likely to use contraception when they are in their 30s. Almost two-thirds of currently married women age 30-39 report they are currently using a family planning method. The drop in current use among older women may reflect their declining fecundity--whether real or perceived--while lower levels of use among younger women probably are due to an unwillingness to use a method until they have a certain number of children or a desired sex composition. However, it is impressive that 1 in 3 married women age 15-19 is using a method, providing clear evidence that younger women have begun to appreciate the advantages of deliberately controlling childbirth early in marriage. Since 1993-94, contraceptive use has increased much more rapidly among women 15-19 than others, by 33 percent, from 25 to 33 percent in the 1996-97 BDHS. 49 There are also variations by age in the methods that women use. The pill is by far the most popular method among married women under age 20 and among women in their 20s and 30s as well. Among women in their 20s, injectables are the second most popular method after the pill. But with a gradual shift to long-term methods among older women, the popularity of female sterilization increases, becoming second to the pill by age 30-34 and the most widely used method among women in their 40s. Trends in Current Use of Family Planning The contraceptive prevalence rate has increased sixfold since 1975, from 8 to 49 percent of married women (Table 4.8 and Figure 4.1). In the three years since the 1993-94 BDHS, contraceptive use has increased by an impressive 10 percent, from 45 to 49 percent of married women, with the use of modem methods rising from 36 to 42 percent. Overall, there has been a steady growth in the contraceptive prevalence rate since 1975 with an average increase of about two percentage points a year. 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 oral contraception. The proportion of married women relying on the pill increased considerably in the last five years, from 14 percent in 1991 to 21 percent in 1996-97 (Figure 4.2). Use of short-term methods like injectables and condoms has also increased, while use of long-term methods such as sterilization and the IUD has declined. Among traditional methods, use of periodic abstinence has hardly changed since 1993-94, while use of withdrawal has declined slightly during the same period. Thus, the proportional share that each method contributes to the overall use of contraception-----~own as the "method mix"- -has changed over time. For example, the pill now accounts for 42 percent of all contraceptive use, compared with 39 percent in 1993-94 and 35 percent in 1991 (Figure 4.3). On the other hand, the share contributed by female sterilization has dropped from 23 percent in 1991 to 18 percent in 1993-94 and 15 percent in 1996-97. Table 4.8 Trends in current use of contracentive methods Percentage of currently married women age 10-49 who are currently using specific contraceptive methods, selected sources, Bangladesh, 1975-1996 1975 1983 1985 1989 1991 1993-94 1996-97 Method BFS CPS CPS BFS CPS BDHS BDHS Any method 7.7 19.1 25.3 30.8 39.9 44.6 49.2 Any modern method 5.0 13.8 18.4 23.2 31.2 36.2 41.6 Pill 2.7 3.3 5.1 9.6 13.9 17.4 20.8 IUD 0.5 1.0 1.4 1.4 1.8 2.2 1.8 Injectables U 0.2 0.5 0.6 2.6 4.5 6.2 Vaginal methods 0.0 0.3 0.2 0.1 U U U Condom 0.7 1.5 1.8 1.8 2.5 3.0 3.9 Female sterilization 0.6 6.2 7.9 8.5 9.1 8.1 7.6 Male sterilization 0.5 1.2 1.5 1.2 1.2 1.1 1.1 Any traditional method 2.7 5.4 6.9 7.6 8.7 8.4 7.7 Periodic abstinence 0.9 2.4 3.8 4.0 4.7 4.8 5.0 Withdrawal 0.5 1.3 0.9 1.8 2.0 2.5 1.9 Other traditional methods 1.3 1.8 2.2 1.8 2.0 1.1 0.8 Number of women U 7,662 7,822 10,907 9,745 8,980 8,450 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 BFS (Huq and Cleland, 1990:64); 1991 CPS (Mitra et al., 1993:53); 1993-94 BDHS (Mitra et al., 1994:45) 50 Figure 4.1 Trends In Contraceptive Usa Among Currently Married Women 10-49 60 50 40 30 20 10 1975 49,2 1983 1985 1989 1991 1993-94 1996-97 mModern Methods BlTraditionsl Methods I BDHS 1996-97 F igure 4.2 T rends in Use o f Spec i f i c Cont racept ive Methods Among Currently Married Women Age 10-49 21 Injectables Pill Female SteriLization 6 0 5 10 15 20 Percent 25 BDHS 1996-97 5] 100 80 60 40 20 0 Percent Figure 4.3 Trends In ContraceptlveMethodMIx 1991 1993-94 1996-97 IS]Traditional IBSterilizatiorl r'~Condom EBlnjectables I IUD IBPJll Note: Perc~ us~g specific methods among currently marded women 10-49 who ,ate uslrlg 8 molhOd. BDHS 1996-97 Differentials in Current Use of Family Planning Differentials in current use of family planning by selected background characteristics are shown in Table 4.9 and Figure 4.4. They are useful to identify, among other things, the subgroups of the population that may be in need of more care and attention in the delivery of family planning services. The level of current contraceptive use is higher in urban than in rural areas (62 vs. 48 percent among women). The urban-rural gap has widened since 1993-94, with contraceptive use having increased more in urban than rural areas. 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 (I 3 percent) and rural (3 percent) couples, probably reflecting wider availability and easier access to the method in the urban than rural areas. Differentials in current use of family planning by the six administrative divisions of the country are large. Sixty-two percent of married women in Khulna Division and 59 percent in Rajshahi Division are using a family planning method, compared with only 20 percent of women in Sylhet Division. Intermediate levels of use are reported for women in Dhaka (50 percent), Barisal (49 percent), and Chittagang (37 percent). There are no marked variations in the relative popularity of methods by division, except that injectables are more widely used in Khnlna and Barisal Divisions than elsewhere. In all divisions, use of modern methods accounts for at least 80 percent of all use. 52 Table 4.9 Current use of conttaceoBon by back£ro~nd chatacleristics Percent distribution of currently married women and men by contta~epfve method currently used, according to selected background characteristics, Bangladesh 1996-97 Modem method Traditional method Number Any Female Male Any Periodic Not of Background Any modern lnjecl- sterili- sterili- N~- trod. abstin- With- Other currently respon- characteristic method method Pill IUD ables Condom zation zafion plant method ence drawal method using Total dents CURRENTLY MARRIED WOMEN Residence Urban Rural Division Barisal Chthagong Dhaka Khulna Rajshahi Sylhet Education No education Primary incomp. Primary complete Secondary+ Number of living children None 1 2 3 4+ Total 62,1 52.6 22.2 2.8 5.7 13.2 7,9 0.7 0,0 9.5 5.0 3,5 1,0 37.9 I00.0 968 47.6 40.1 20.6 1.7 6.3 2.7 7.6 1.2 0.1 7.4 5.0 1,7 0.7 52.4 100.0 7.482 49.4 41.0 20.8 2.1 7.0 3.8 6.1 1.2 0.0 8.3 4,6 2.6 1.2 50.6 100.0 560 37.2 30,8 13.1 2.6 5.5 3.2 5.8 0.5 0.0 6.4 4.2 I.I 1.2 62.8 100.0 1,701 49.8 42.1 21.9 1.2 5.2 5.0 8.0 0.6 0,1 7.8 4.9 2.1 0.7 50.2 I00.0 2,656 61.9 51.0 26.6 2,4 9,1 3,8 7,7 1.2 0.2 10.9 7.0 3.3 0.5 38.1 100.0 1,024 58.6 51.0 26.3 1.5 6.8 3.6 10,1 2.4 0,2 7.6 5,3 1.6 0.7 41.4 100.0 2,049 20.1 16.0 5.4 1.5 5,1 1,4 2.6 0.0 0,0 4.1 3.7 0.4 0.0 79.9 I00.0 460 45.8 39.5 18.3 1.3 7.0 1.6 9,7 1.4 0.1 6.4 4.3 1,0 1,0 54.2 I00.0 4,502 51,2 43.9 22.5 1.2 8.3 2.7 7.9 1.3 0.0 7.3 4,4 2.3 0.6 48,8 100.0 1,470 51.1 41.9 23,7 2.6 4,8 4.9 4.8 L0 0.0 9.1 6.8 1.7 0.8 48.9 100.0 862 56,0 45.1 24.7 3,1 3.0 10.7 3.1 0.2 0.2 10.8 6.6 3.9 0.4 44.0 100.O 1.615 16.4 11.3 5.8 0,0 0.0 4.2 0.2 1.0 0.0 5.2 3.3 1.7 0.2 83.6 I00.0 1,006 42.3 35.6 22.5 1,9 5.0 4.5 1.5 0.I 0.1 6.7 4.2 2.1 0.3 57,7 100.0 1.631 88.1 50.9 27.4 2,2 7.1 5.4 7.6 I.I 0.2 7.2 4.2 2.5 0.5 41.9 100.0 1.803 59.5 51.0 24.0 2,2 8.0 3.7 12.0 1.0 0,1 8.4 5.7 2,0 0.8 40.5 100.0 1,423 54.6 45.4 19.3 1,9 7.9 2.5 11,9 1.8 0.1 9.2 6.4 1.3 1.4 45,4 1(30.0 2,588 49,2 41.6 20.8 1,8 6.2 3,9 7.6 1.1 0.1 7,7 5.0 1.9 0.8 50,8 I00.0 8,450 CURRENTLY MARRIED MEN Residence Urban 703 57.2 26.7 2.2 Rural 58.1 47.3 24.2 1.6 Division Barisal 59.0 47.1 26.3 1.0 Chiuagong 84.7 40.6 17.3 2.7 Dhaka 60.5 49,7 27.6 0.9 Khulna 68.1 54.8 28,9 2.8 Rajshahi 64.2 55.3 26.4 1.5 Sylhet 26.3 19.2 6.7 2.5 Education No education 53,3 44.4 20.8 0.8 Primary thcomp. 59,7 48.2 24.6 1.8 Primary complete 56.9 47.3 26.8 2,0 Secondary+ 69.2 55.0 29.3 3.0 Number of living children None 27.4 17.7 10,3 0.3 I 53.7 43.5 26.2 2.1 2 66.2 54.4 30.1 1.4 3 69.6 589 27,3 2.3 4+ 63.4 51.7 23.0 1.8 Total 59,6 48.5 24.5 1.7 4.7 14.8 8.3 0.4 0.0 13,5 10.0 2.6 0.9 29.3 100.0 400 7.4 4.5 7.9 1.7 0.0 10.8 8,3 1.3 1.1 41.9 100,0 2,912 7.8 5.1 4.7 2.1 0.0 11.9 8.9 1.6 1.4 41.0 I00.0 199 7,8 4,6 7.4 0.7 0.0 14.1 11.7 0.4 2.0 45,3 100.0 584 6.1 6,7 7.6 0.6 0A 10.8 8.8 1.2 0.9 39,5 100.0 1,056 8.7 5.5 7.3 1,7 0.0 13.3 8.6 4,1 0.5 31.9 I00.0 428 7.5 6.1 10.6 3,2 0.0 8.9 6.3 1,5 I.I 35.8 I00.0 877 3.0 3.2 3.0 0.7 0.0 7.1 6.4 0.4 0.4 73.7 100.0 168 &2 2.8 9.8 2.1 0.0 8.9 7.2 0.9 8.5 4.7 7. I 1.4 0.2 11.5 8.5 1.0 6.5 2.2 8.0 1.8 0.0 9,6 6.9 1,9 4.4 11.5 5.9 0.9 0.0 14.2 10.8 2.5 0.8 46.7 100.0 1,390 2.0 40.3 100.0 750 0.8 43.1 1000 204 0.9 30.8 100.0 968 0.2 6.6 0,0 0,3 0.0 9.7 8.1 1.3 0.3 72.6 I00.0 333 6.1 7.7 1.3 0.0 0.2 10.2 8.7 L3 0.2 46.3 100.0 618 7.1 6.7 7,6 1.4 0.0 11.8 8.9 2,5 0.5 33.8 I00.0 679 9.2 6.3 11.3 2.4 0.0 10.7 8.1 1.3 1.4 30,4 I00.0 574 8,5 3.5 12.4 2,4 0.0 11.7 8,5 1.1 2.1 36.6 100.0 1,108 7.1 5.7 7.9 1.6 0.0 11,I 8.5 1.5 I.l 40,4 I00.0 3.312 53 Figure 4.4 Percentage of Currently Married Women Using a Contraceptive Method by Background Characteristics RESIDENCE Urban Rural DIVISION Barisal Chittagon 9 Dhaka Khulna Rajshahl Sylhet 1 2 EDUCATION No Education Primary Incom. Primary Comp. Secondary+ 0 - - - ~'; 48 49 37 50 92 59 J ' l 46 : , 51 , 51 ~0 10 20 30 40 50 60 Percent 70 BDHS 1996-97 Current use differs by educational level of women, although the differentials are not as pronounced as in many countries. Forty-six percent of women with no formal education are currently using a method, compared with 51 percent of women with either incomplete or complete primary school and 56 percent of those with least some secondary education. Educational differentials in contraceptive use have narrowed since 1993-94, with no increase among women with secondary education and almost equal percentage point increases for women in all other educational categories. Method mix also varies by educational level. Among women in all educational categories, the pill is the most widely used method. The second most popular method among women with no education is female sterilization; among those with some primary education it is injectables; among those with completed primary education it is periodic abstinence; and among those with secondary education, the condom is the second most widely used method. It is interesting to note that more educated women are more likely to use traditional methods. These patterns are no doubt influenced by the fact that the more educated women tend to be younger and of lower parity than less educated women and therefore presumably less motivated to control their family size. Contraceptive use rates are also related to family size. As expected, fewer women use contraception before having a child. After the first child, contraceptive use increases sharply, reaching 60 percent among women with 3 children. Thereafter, use declines slightly to 55 percent of women with four or more children, possibly because of women's actual or perceived in fecundity at higher parities. Differentials in contraceptive use as reported by currently married men mirror those reported by married women, except that the levels of use are generally higher. As mentioned above, men are more likely than women to report use of the pill and periodic abstinence. A more precise way to compare discrepancies in contraceptive use reporting between men and women is to compare husbands and wives (see discussion of Table 4.11 below). 54 Table 4.10 indicates that differentials in contraceptive use by division are beginning to narrow somewhat, at least according to the old divisional boundaries. ~ Contraceptive use has increased steadily in all divisions since 1983; however, since 1993-94, it has increased relatively more rapidly in the combined divisions of Chittagong and Sylhet (formerly Chittagong Division) and in Dhaka Division than in Khulna/Barisal and Rajshahi Divisions (Figure 4.5). In Chittagong/Sylhet, contraceptive use increased by 15 percent, while the increase was 12 percent for Dhaka Division, 9 percent for Khulna/Barisal Division and only 7 percent for Rajshahi Division. Of course, the creation of Sylhet Division, which isolates the sections of the former Chittagong Division that have the lowest contraceptive use levels, results in wider divisional differences than existed previously. Table 4. l0 Trends in current use of family olannin~ methods bv division Percentage of currently married women age 10-49 who are currently using any method, any modem method, or any traditional method of family planning, by division, selected sources, Bangladesh, 1983-1996 Type of method/ 1983 1985 1989 1989 1991 1993-94 1996-97 Division CPS CPS CPS BFS I CPS BDHS BDHS Any method Chittagong/Sylhet 12.6 16.1 19.8 21.0 27.1 29.3 33.6 Dhaka 20.5 26.0 34.5 32.0 41.7 44.3 49.8 Khulna/Barisal 20.7 28.2 36.6 35.0 45.7 52.8 57.5 Rajshahi 22.6 30.3 34.7 38.0 46.1 54.8 58.6 Any modern method Chittagong/Sylhet 8.7 11.5 15.3 U 20.5 23.4 27.6 Dhaka 15.5 19.9 27.6 U 32.9 36.3 42.1 Khulan/Barisal 14.2 20.0 27.9 U 34.6 41.1 47.5 Rajshahi 16.1 21.5 26.7 U 37.2 45.9 51.0 Any traditional method Chittagong/Sylhet 3.9 4.7 4.5 U 6.6 5.9 5.9 Dhaka 5.0 6.1 6.9 U 8.9 8.0 7.8 Khulna/Barisal 6.5 8.2 8.7 U 11.1 11.7 10.0 Rajshahi 6.5 8.8 8.0 U 8.8 8.9 7.6 Note: Data from the 1993-94 and 1996-97 BDHS were recategorized to represent the previous four divisions. tU = Unknown (no information) Published data were presented in whole numbers; the decimal was added to balance the table. Source: 1983 CPS (Mitra and Kamal, 1985:188); 1985 CPS (Mitra, 1987:166); 1989 CPS (Mitra et al., 1990:113); 1989 BFS (Huq and Cleland, 1990:68); 1991 CPS (Mitra et al., 1993:56) In fact, the most important issue emerging from this analysis of family planning use is the extremely low level of contraceptive use in Sylhet Division. Further studies need be undertaken to investigate the reasons for low use of family planning in Sylhet in order to assist in designing program interventions to bring the division in line with the rest of the country. Because Sylhet and Barisal are relatively new divisions, the table is structured according to the original four divisions. 55 Figure 4.5 Trends in Contraceptive Use by Division 70 60 50 40 30 20 10 0 Percent of Married Women Using a Method Chittagong/ Sylhet Dhaka Khutna/ Barisal [[]1989 BF~; 1111993-94 BDHS D1996-97 BDHS I Rajshahi BDHS 1996-97 Contraceptive Use Reporting Among Married Couples It was pointed out above that the contraceptive prevalence rate among currently married men (60 percent) is considerably higher than that for currently married women (49 percent). Part of the discrepancy could be due to contraceptive use with non-marital partners, which is presumably higher among men than women. Another explanation could be marriages in which the spouses are not currently co-habiting, thus reducing the need for contraceptive use. Such a situation is likely to be more common among women than men, for example when men work overseas on a labor contract. However, misreporting and lack of communication between spouses is also a possible explanation. Fortunately, it is possible to link wives and husbands who were both interviewed and compare their individual responses about contraceptive use. Table 4.11 shows the extent of agreement (shown in italics on the diagonal) in reporting of contraceptive use between husbands and wives. Among the matched couples, 60 percent of husbands report that they are using a family planning method, compared with only 55 percent of their wives. The discrepancy is mostly observed in reporting of the use of the pill, condoms and periodic abstinence. Most of the discrepancy for these methods is due to couples in which the husbands say they are using these methods while their wives say they are not using any method at all. While at least some of the discrepancies between husbands and wives in reporting of contraceptive use could be due to extra-marital use, some may be due to misunderstanding of the method. For example, higher reporting of periodic abstinence use among men than women has been observed in many countries and may be due to confusion between periodic and long-term abstinence. Finally, underreporting of contraceptive use among women because of embarrassment or ignorance (e.g., condom use by husband without her knowledge) is also a possible explanation for the discrepancy. 56 Table 4.11 Comoarison of reverted contracentive use by svouses Percent distribution of couples according to wife's and husband's reported current contraceptive use status, Bangladesh 1996-97 Wife: current contraceptive method Female Male Periodic Husband: current Inject- sterili- sterili- abstin- With- Other Not contraceptive method Pill IUD ables Condom zation zation ence drawal method using Total Pill 21.7 0.1 0.3 0.1 0.0 0.0 0.4 0.3 0.0 2.3 25.2 IUD 0.0 1.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 1.7 lnjectables 0.2 0.1 6.2 0.0 0.1 0.0 0.0 0.0 0.1 0.8 7.5 Condom 0.2 0.0 0.0 3.5 0.0 0.0 0.6 0.2 0.0 1.0 5.6 Female sterilization 0.0 0.0 0.1 0.0 7.7 0.0 0.0 0.0 0.0 0.3 8.0 Male sterilization 0.0 0.0 0.0 0.0 0.2 1.3 0.0 0.0 0.0 O. 1 1.6 Periodic abstinence 0.6 0.1 0.1 0.1 0.0 0.0 3.2 0.5 0.0 3.8 8.3 Withdrawal 0.0 0.0 0.0 0.1 0.0 0.0 0.2 0.8 0.0 0.2 1.4 Other 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.6 0.4 1.1 Not using 0.7 0.1 0.3 0.3 0.2 0.0 1.2 0.4 0.2 36.1 39.5 Total 23.5 1.9 7.1 4.1 8.1 1.4 5.7 2.2 1.0 45.1 100.0 4.5 Number of Children at First Use The BDHS included a question for all women who had ever used a method as to how many l iving children they had when they first used a method. Table 4.12 shows the distribution of ever-married women by the number of l iving children they had when they first used a method, according to five-year age group. These data enable the examination of both periodic and cohort changes in the timing of the initiation of contraceptive use during the family building process. Table 4.12 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at the time of first use of contraception, and median number of children at first use, according to current age, Bangladesh 1996-97 Median Never Number of living children at time number of used of first use of contraception Number children contra- of at first Current age ception 0 1 2 3 4+ Missing Total women use 10-14 75.5 21.5 3.0 0.0 0.0 0.0 0.0 100.0 145 0.0 15-19 47.1 27.8 21.8 3.2 0.0 0

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