Bangladesh - Demographic and Health Survey - 2005

Publication date: 2005

Bangladesh Demographic and Health Survey 2004 National Institute of Population Research and Training (NIPORT) Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh ORC Macro Calverton, Maryland USA May 2005 CONTRIBUTORS TO THE REPORT Ahmed Al-Sabir S.N. Mitra Shahidul Islam Subrata K. Bhadra Anne Cross Sushil Kumar Special acknowledgement: Dr. Kanta Jamil, Program Coordinator for Research, PHN Team, USAID, Dhaka for technical assistance at all steps of survey implementation, analysis, and report generation. This report summarizes the findings of 2004 Bangladesh Demographic and Health Surveys (2004 BDHS) conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare and implemented by Mitra and Associates of Dhaka. ORC Macro provided financial and technical assistance for the survey through the financial aid provided by USAID/Bangladesh. 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. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID. Additional information about the 2004 BDHS may be obtained from: NIPORT Azimpur Dhaka, Bangladesh Telephone: 862-5251 Fax: 861-3362 Mitra and Associates 2/17 Iqbal Road, Block A Mohammadpur, Dhaka, Bangladesh Telephone: 911-5053 Fax: 912-6806 Additional information about the MEASURE DHS project may be obtained from: ORC Macro 11785 Beltsville Drive Suite 300 Calverton, MD 20705 USA Telephone: 301-572-0200 Fax: 301-572-0999 Internet: http://www.measuredhs.com Suggested citation: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ORC Macro. 2005. Bangladesh Demographic and Health Survey 2004. Dhaka, Bangladesh and Calverton, Maryland [USA]: National Institute of Population Research and Training, Mitra and Associates, and ORC Macro. Contents | iii CONTENTS Page Tables and Figures . ix Preface. xv Foreword . xvii Summary of Findings . xix Map of Bangladesh.xxvi CHAPTER 1 INTRODUCTION 1.1 GEOGRAPHY AND ECONOMY .1 1.2 POPULATION.2 1.3 POPULATION, FAMILY PLANNING AND MATERNAL AND CHILD HEALTH POLICIES AND PROGRAMS .2 1.4 ORGANIZATION OF THE 2004 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY .5 1.4.1 Survey Objectives and Implementing Organizations .5 1.4.2 Sample Design.5 1.4.3 Questionnaires .6 1.4.4 Training and Fieldwork .7 1.4.5 Data Processing .8 1.4.6 Coverage of the Sample.8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age, Sex, and Residence .11 2.2 Household Composition .14 2.3 Educational Attainment of Household Members .14 2.3.1 School Attendance .17 2.4 Employment .18 2.5 Housing Characteristics.20 2.6 Household Possessions .22 2.7 Wealth Index.23 2.8 Arsenic in Household Drinking Water.24 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics of Respondents .29 3.2 Educational Attainment.32 3.3 Exposure To Mass Media .35 iv | Contents 3.4 Employment .37 3.4.1 Employment Status .37 3.4.2 Control Over Women’s Earnings.40 3.5 Women’s Empowerment .42 3.5.1 Women’s Participation in Decisionmaking: Women’s Perspective .42 3.5.2 Wife’s Participation in Decisionmaking: Husbands’ Perspective.45 3.5.3 Freedom of Movement.45 3.6 Men’s Attitudes Towards Wife-Beating .46 CHAPTER 4 FERTILITY 4.1 Introduction .49 4.2 Current Fertility Levels .50 4.3 Fertility Differentials.51 4.4 Fertility Trends.53 4.5 Children Ever Born and Living .55 4.6 Birth Intervals .57 4.7 Age at First Birth .59 4.8 Adolescent Fertility .60 CHAPTER 5 FERTILITY REGULATION 5.1 Knowledge of Family Planning Methods.63 5.2 Ever Use of Contraception .64 5.3 Knowledge and Ever Use of Menstrual Regulation .65 5.4 Current Use of Contraception.66 5.4.1 Trends in Current Use of Family Planning .67 5.4.2 Differentials in Current Use of Family Planning .69 5.5 Number of Children at First Use of Contraception .72 5.6 Problems with Current Method.72 5.7 Use of Social Marketing Brands.74 5.8 Age at Sterilization and Sterilization Regret .75 5.9 Source of Family Planning Services .78 5.10 Contraceptive Discontinuation.79 5.11 Future Intentions to Use Family Planning .82 5.11.1 Future Use of Contraception .82 5.11.2 Reasons for Not Intending to Use Contraception .82 5.11.3 Preferred Method for Future Use.83 5.12 Family Planning Outreach Services .84 5.13 Discussion about Family Planning between Spouses .87 5.14 Exposure To Family Planning Messages .87 Contents | v CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Introduction .91 6.2 Marital Status.91 6.3 Age at First Marriage .93 6.4 Postpartum Amenorrhea, Abstinence, and Insusceptibility .96 6.5 Termination of Exposure to Pregnancy.99 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children. 101 7.2 Desire to Limit Childbearing . 103 7.3 Need for Family Planning Services . 105 7.4 Ideal Family Size. 107 7.5 Wanted and Unwanted Fertility. 111 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Introduction . 115 8.2 Assessment of Data Quality. 115 8.3 Levels and Trends in Infant and Child Mortality . 117 8.4 Socioeconomic Differentials in Infant and Child Mortality. 118 8.5 Demographic Differentials in Infant and Child Mortality . 120 8.6 Perinatal Mortality . 121 8.7 High-Risk Fertility Behavior. 122 CHAPTER 9 CAUSES OF DEATH IN CHILDREN UNDER FIVE YEARS OF AGE 9.1 Introduction . 125 9.2 Description of the Data Collection Instrument . 126 9.3 Assigning Cause of Death. 126 9.4 Causes Of Death Among Children Under Five . 129 9.5 Differentials in Causes of Deaths among Children Under Five. 130 CHAPTER 10 MATERNAL AND CHILD HEALTH 10.1 Antenatal Care. 135 10.1.1 Antenatal Care Coverage . 135 10.1.2 Number and Timing of Antenatal Visits. 137 10.1.3 Health Services Received during Pregnancy. 138 10.1.4 Tetanus Toxoid Vaccinations . 140 10.2 Delivery Care . 141 10.2.1 Place of Delivery . 141 10.2.2 Assistance during Delivery . 143 10.3 Caesarean Section . 144 10.4 Postnatal Care . 145 vi | Contents 10.5 Complications during Pregnancy, during delivery or after delivery. 147 10.5.1 Knowledge of Life-Threatening Maternal Conditions. 147 10.5.2 Experience of Specific Maternal Complications around Delivery. 147 10.5.3 Treatment for Maternal Complications. 148 10.6 Childhood Vaccination . 150 10.6.1 Vaccination Coverage. 150 10.6.2 Differentials in Vaccination Coverage . 151 10.6.3 Trends in Vaccination Coverage. 151 10.7 Childhood Illness and Treatment . 154 10.7.1 Acute Respiratory Infection. 154 10.7.2 Childhood Diarrhea. 160 10.7.3 Treatment of Diarrhea . 161 CHAPTER 11 INFANT FEEDING AND NUTRITIONAL STATUS OF CHILDREN AND WOMEN 11.1 Breastfeeding and Supplementation. 165 11.1.1 Initiation of Breastfeeding . 165 11.1.2 Age Pattern of Breastfeeding. 167 11.1.3 Duration of Breastfeeding . 169 11.1.4 Complementary Feeding . 171 11.2 Micronutrient Intake. 173 11.2.1 Micronutrient Intake among Children . 173 11.2.2 Micronutrient Intake and Deficiencies among Women . 173 11.3 Nutritional Status of Children under Five . 176 11.3.1 Stunting . 177 11.3.2 Wasting . 181 11.3.3 Underweight . 182 11.3.4 Nutritional Status of Women . 182 CHAPTER 12 KNOWLEDGE, ATTITUDES AND BEHAVIOR RELATED TO HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS 12.1 Knowledge of HIV/AIDS . 185 12.2 Knowledge of Ways to Avoid HIV/AIDS . 188 12.3 Knowledge of HIV/AIDS-Related Issues and Communication with Spouses . 193 12.4 Awareness, Prevalence, and Treatment of Sexually Transmitted Infections (STIs) . 196 Contents | vii CHAPTER 13 COMMUNITY CHARACTERISTICS. 203 CHAPTER 14 POLICY IMPLICATIONS OF THE 2004 BDHS 14.1 National Policy Environment. 209 14.2 Fertility . 210 14.3 Family Planning . 213 14.4 Childhood Health and Mortality . 215 14.5 Maternal Care. 218 14.5.1 Use of Antenatal Care. 218 14.5.2 Place of Delivery and Delivery Attendant. 218 14.5.3 Postnatal Care . 220 14.6 Knowledge of HIV/AIDS and Ways to Avoid AIDS . 220 14.7 Arsenic in Household Drinking Water. 221 14.8 Disparities . 222 REFERENCES . 223 APPENDIX A SAMPLE IMPLEMENTATION . 229 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 233 APPENDIX C DATA QUALITY TABLES. 247 APPENDIX D BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY PERSONNEL . 253 APPENDIX E QUESTIONNAIRES . 259 APPENDIX F SUMMARY INDICATORS.341 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Population by age from selected sources. 13 Table 2.3 Household composition. 14 Table 2.4.1 Level of education of household population: women . 15 Table 2.4.2 Level of education of household population: men . 16 Table 2.5 School attendance . 17 Table 2.6 Employment status. 18 Table 2.7 Form of earnings. 19 Table 2.8 Household characteristics . 21 Table 2.9 Household durable goods and land ownership . 22 Table 2.10 Level of arsenic in household drinking water. 26 Table 2.11 Arsenic levels and knowledge of arsenic and markings on tubewells . 27 Figure 2.1 Population Pyramid, Bangladesh 2004. 12 Figure 2.2 Distribution of De Facto Household Population by Single Year of Age and Sex . 13 Figure 2.3 Trends in Percentage of Men and Women Age Six and Above With No Education by Sex and Residence. 17 Figure 2.4 Percentage of Household Respondents Who Know About Arsenic in Water, According to Background Characteristics . 25 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1.1 Background characteristics of respondents: women . 30 Table 3.1.2 Background characteristics of respondents: men. 31 Table 3.2.1 Level of education by background characteristics: women. 33 Table 3.2.2 Level of education by background characteristics: men. 34 Table 3.3.1 Exposure to mass media: women. 35 Table 3.3.2 Exposure to mass media: men . 36 Table 3.4.1 Employment status: women. 38 Table 3.4.2 Employment status: men . 39 Table 3.5 Decision on use of earnings . 40 Table 3.6 Decision on use of wife’s earnings . 41 Table 3.7 Women’s participation in household decisionmaking . 42 Table 3.8 Women’s participation in decisionmaking by background characteristics . 44 Table 3.9 Wife’s participation in decisionmaking. 45 Table 3.10 Freedom of movement . 46 Table 3.11 Men’s attitude towards spousal violence . 47 x | Tables and figures Figure 3.1 Differences in husband’s and wife’s ages (husband’s age minus wife’s age) . 32 Figure 3.2 Education of couples . 34 Figure 3.3 Percentage of ever-married women and all men exposed to various media at least once a week. 37 CHAPTER 4 FERTILITY Table 4.1 Current fertility rates . 50 Table 4.2 Fertility by background characteristics. 51 Table 4.3 Trends in current fertility rates . 53 Table 4.4 Percent pregnant . 54 Table 4.5 Trends in fertility by marital duration . 55 Table 4.6 Children ever born and living. 56 Table 4.7 Trends in children ever born. 57 Table 4.8 Birth intervals. 58 Table 4.9 Age at first birth . 59 Table 4.10 Median age at first birth . 60 Table 4.11 Teenage pregnancy and motherhood . 61 Figure 4.1 Age-Specific Fertility Rates by Residence. 52 Figure 4.2 Total Fertility Rates by Background Characteristics . 52 Figure 4.3 Trends in Total Fertility Rates . 54 CHAPTER 5 FERTILITY REGULATION Table 5.1 Knowledge of contraceptive methods . 63 Table 5.2 Ever use of contraception . 64 Table 5.3 Trends in ever use of family planning methods. 65 Table 5.4 Menstrual regulation. 66 Table 5.5 Current use of contraception . 66 Table 5.6 Trends in current use of contraceptive methods. 67 Table 5.7 Current use of contraception by background characteristics . 70 Table 5.8 Number of children at first use of contraception . 72 Table 5.9 Problems with current method of contraception . 73 Table 5.10 Use of pill brands. 74 Table 5.11 Use of condom brands . 75 Table 5.12 Timing of sterilization . 76 Table 5.13 Sterilization regret. 77 Table 5.14 Source of supply of modern contraceptive methods. 78 Table 5.15 Contraceptive discontinuation rates . 80 Table 5.16 Reasons for discontinuation . 81 Table 5.17 Future use of contraception . 82 Table 5.18 Reason for not intending to use contraception . 83 Table 5.19 Preferred method of contraception for future use . 84 Table 5.20 Contact with family planning fieldworkers and health fieldworkers . 85 Table 5.21 Satellite clinics . 86 Table 5.22 Discussion of family planning with husband. 87 Table 5.23 Exposure to family planning messages. 88 Figure 5.1 Trends in Contraceptive Use (%) Among Currently Married Women 10-49, Selected Surveys, 1975-2004 . 68 Figure 5.2 Trends in Contraceptive Method Mix Currently Married Women 10-49 Using a Method, Selected Surveys ,1991-2004. 69 Tables and Figures | xi Figure 5.3 Contraceptive Use and Women’s Status Indicators . 71 Figure 5.4 Distribution of Current Users of Modern Contraceptive Methods By Source of Supply. 79 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status. 92 Table 6.2 Trends in proportion never married . 93 Table 6.3.1 Age at first marriage: women . 93 Table 6.3.2 Age at first marriage: men. 94 Table 6.4.1 Median age at first marriage: women. 95 Table 6.4.2 Median age at first marriage: men. 96 Table 6.5 Postpartum amenorrhea, abstinence and insusceptibility . 97 Table 6.6 Median duration of postpartum insusceptibility by background characteristics . 98 Table 6.7 Menopause . 99 Figure 6.1 Trend in First Marriage of Women 20-24 by Age 18 . 94 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children. 101 Table 7.2 Fertility preferences by age . 103 Table 7.3 Desire to limit childbearing. 104 Table 7.4 Need for family planning services . 106 Table 7.5.1 Ideal and actual number of children: women . 108 Table 7.5.2 Ideal and actual number of children: men . 109 Table 7.6 Mean ideal number of children by background characteristics . 110 Table 7.7 Fertility planning status . 111 Table 7.8 Wanted fertility rates . 113 Figure 7.1 Fertility Preferences Among Currently Married Women Age 10-49 .102 Figure 7.2 Percent of Currently Married Women Who Want No More Children by Number of Living Children.102 Figure 7.3 Percentage of Married Women Who Want No More Children by Number of Living Children and Background .105 Figure 7.4 Trend in Unmet Need for Family Planning by Division.107 Figure 7.5 Trend in Unplanned Births by Percent .112 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Trend in early childhood mortality rates. 117 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 118 Table 8.3 Early childhood mortality rates by demographic characteristics . 120 Table 8.4 Perinatal mortality . 123 Table 8.5 High-risk fertility behavior. 124 Figure 8.1 Trends in Infant and Child Mortality . 117 Figure 8.2 Under-Five Mortality Rate by Socioeconomic Characteristics . 119 Figure 8.3 Under-Five Mortality Rate by Demographic Characteristics. 121 xii | Tables and figures CHAPTER 9 CAUSES OF DEATH IN CHILDREN UNDER FIVE YEARS OF AGE Table 9.1 Causes of death among children under five by age group . 130 Table 9.2 Causes of death among children under five by sex of child and residence . 131 Table 9.3 Causes of death among children under five by mother’s education. 132 Table 9.4 Causes of death among children under five by division . 133 Figure 9.1 Flow Chart Showing the Different Tiers Used in Assigning Cause of Death Based on Algorithms (ref) . 127 CHAPTER 10 MATERNAL AND CHILD HEALTH Table 10.1 Antenatal care . 136 Table 10.2 Number of antenatal care visits and timing of first visit . 138 Table 10.3 Health care during pregnancy. 139 Table 10.4 Tetanus toxoid injections . 140 Table 10.5 Place of delivery . 142 Table 10.6 Assistance during delivery . 143 Table 10.7 Delivery characteristics . 144 Table 10.8 Postnatal care for mother and children . 145 Table 10.9 Postnatal care by background characteristics. 146 Table 10.10 Knowledge of life threatening maternal conditions. 147 Table 10.11 Experience of complications around delivery . 148 Table 10.12 Treatment seeking for maternal complications . 149 Table 10.13 Vaccinations by source of information . 150 Table 10.14 Vaccinations by background characteristics. 152 Table 10.15 Prevalence and treatment of acute respiratory infection (ARI) . 155 Table 10.16 Prevalence of fever . 157 Table 10.17 Prevalence of diarrhea . 158 Table 10.18 Treatment of diarrhea . 159 Table 10.19 Feeding practices during diarrhea . 161 Table 10.20 Treatment of diarrhea . 162 Table 10.21 Feeding practices during diarrhea . 163 Figure 10.1 Reasons for Not Seeing Anyone for Antenatal Care . 137 Figure 10.2 Vaccinations by Background Characteristics . 153 Figure 10.3 Trends in Vaccination Coverage among Children Age 12-23 Months . 153 CHAPTER 11 INFANT FEEDING AND NUTRITIONAL STATUS OF CHILDREN AND WOMEN Table 11.1 Initial breastfeeding . 166 Table 11.2 Breastfeeding status by child’s age . 167 Table 11.3 Median duration of breastfeeding . 170 Table 11.4 Foods consumed by children in the day preceding the interview . 172 Table 11.5 Micronutrient intake among children . 174 Table 11.6 Micronutrient intake and deficiency among mothers. 175 Table 11.7 Nutritional status of children by demographic characteristics . 179 Table 11.8 Nutritional status of children by background characteristics. 180 Table 11.9 Nutritional status of women by background characteristics. 184 Tables and Figures | xiii Figure 11.1 Infant Feeding Practices by age . 168 Figure 11.2 Trends in Exclusive Breastfeeding for Children Under Six Months . 169 Figure 11.3 Trends in Complementary Feeding for Children 6-9 Months. 169 Figure 11.4 Median Duration (Months) of Breastfeeding. 171 Figure 11.5 Percentage of Children Under Five Who Are Stunted, According to Demographic Characteristics . 178 Figure 11.6 Percentage of Children Under Five Who Are Stunted According to Socioeconomic Characteristics. 178 Figure 11.7 Trends in Nutritional Status of Children Under Five . 181 Figure 11.8 Trends in the Nutritional Status of Women with Children under Five Years of Age. 183 CHAPTER 12 KNOWLEDGE, ATTITUDES, AND BEHAVIOR RELATED TO HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Table 12.1.1 Knowledge of HIV/AIDS and sources of AIDS information: women. 186 Table 12.1.2 Knowledge of HIV/AIDS and sources of AIDS information: men . 187 Table 12.2.1 Knowledge of ways to avoid HIV/AIDS: women. 189 Table 12.2.2 Knowledge of ways to avoid HIV/AIDS: men . 190 Table 12.3.1 Knowledge of HIV/AIDS and its prevention: women. 191 Table 12.3.2 Knowledge of HIV/AIDS and its prevention: men. 192 Table 12.4 Perceptions of HIV/AIDS-related issues . 194 Table 12.5 Discussion of HIV/AIDS with spouse . 195 Table 12.6.1 Knowledge of signs and symptoms of STIs : women. 196 Table 12.6.2 Knowledge of signs and symptoms of STIs : men. 197 Table 12.7 Gynecological health problems . 198 Table 12.8 Women seeking treatment for gynecological health problems . 199 Table 12.9 Self-reportiing of sexually-transmitted infections (STIs) and STI symptoms . 200 Table 12.10 Men seeking treatment for STIs. 201 Figure 12.1 Trends in Knowledge of HIV/AIDS Among Ever-Married Women and Currently Married Men. 188 Figure 12.2 Percentage of Ever-married Women and All Men Who have Heard of HIV/AIDS, by Background Characteristics . 188 Figure 12.3 Trends in Knowledge of Two or More Correct Ways to Avoid HIV/AIDS Among Ever-Married Women and Currently Married Men. 193 CHAPTER 13 COMMUNITY CHARACTERISTICS Table 13.1 Distance to nearest general services . 204 Table 13.2 Distance to nearest education facilities . 205 Table 13.3 Availability of income-generating organizations. 205 Table 13.4 Availability of family planning and health services . 206 Table 13.5 Distance to nearest health and family planning services . 207 CHAPTER 14 POLICY IMPLICATIONS OF THE 2004 BDHS Table 14.1 Percent reduction in mortality per year, among children under five .215 Figure 14.1 Percentage of Women Age 15-19 Ever Married .211 Figure 14.2 Percentage of Females Age 15-19 with No Education and Percentage with at Least Some Secondary Education .212 xiv | Tables and figures Figure 14.3 Median Age at Marriage and Median Age at First Birth among women age 20-24 .213 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Sample implementation: women . 229 Table A.2 Sample implementation: men. 230 Figure A.1 Urban Sampling Points . 231 Figure A.2 Rural Sampling Points . 232 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 236 Table B.2 Sampling errors: Total sample . 237 Table B.3 Sampling errors: Urban sample. 238 Table B.4 Sampling errors: Rural sample. 239 Table B.5 Sampling errors: Barisal sample. 240 Table B.6 Sampling errors: Chittagong sample . 241 Table B.7 Sampling errors: Dhaka sample. 242 Table B.8 Sampling errors: Khulna sample. 243 Table B.9 Sampling errors: Rajshahi sample. 244 Table B.10 Sampling errors: Sylhet sample . 245 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution. 247 Table C.2.1 Age distribution of eligible and interviewed: women. 248 Table C.2.2 Age distribution of eligible and interviewed: men . 248 Table C.3 Completeness of reporting . 249 Table C.4 Births by calendar years . 249 Table C.5 Reporting of age at death in days . 250 Table C.6 Reporting of age at death in months . 251 Preface | xv Director General National Institute of Population Research and Training (NIPORT) PREFACE The Bangladesh Demographic and Health Survey 2004 is the fourth survey of this type conducted in Bangladesh. The main objective of this survey is to provide policy-makers and program managers in health and family planning with detailed information on fertility and family planning, childhood mortal- ity, maternal and child health, nutritional status of children and mothers, and awareness of HIV/AIDS. The survey consisted of two parts: a household-level survey of women and men and a community survey around the sample points from which the households were selected. Preparations for the survey started in mid-2003 and the fieldwork was carried out between January and May 2004. Financial support for the BDHS survey was provided by the United States Agency for International Development (USAID)/Dhaka. It was implemented through a collaborative effort of NIPORT, Mitra and Associates, and ORC Macro. The findings of this report will be instrumental in assessing the achievements of family planning, nutrition, and health programs. The report provides estimates of key indicators by socioeconomic and demographic differentials. The preliminary results of the 2004 BDHS, with its major findings, were offi- cially announced through a national seminar in September 2004. The final report supplements the pre- liminary report, which was released earlier. I believe that the information obtained from this survey will help the policymakers and program managers in the formulation of new programs and monitoring the on- going programs. The Technical Review Committee (TRC) consisted of experts from government, non- government, and international organizations, as well as researchers and professionals working in the health and population areas. The TRC contributed their valuable opinions in major phases of the survey. In addition, the Technical Task Force (TTF) was formed with representatives from NIPORT, Mitra and Associates, USAID/Dhaka, ICDDR,B, the NGO Service Delivery Program, and ORC Macro to design and implement the survey. I would like to extend my thanks and appreciation to the members of the TRC and TTF for their contributions at different phases of the survey. I express my sincere thanks to the professionals of the Research Unit of NIPORT, ORC Macro, and Mitra and Associates for their sincere efforts in timely completion of the survey. USAID/Dhaka deserves special thanks for providing financial support for the survey. (Lokman Hakim) Preface | xvii Secretary Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh FOREWORD The Bangladesh Demographic and Health Survey (BDHS) is a nationally representative survey designed to obtain and provide information on the basic indicators of social progress including fertility, childhood mortality, reproductive and child health, nutritional status of mothers and children and aware- ness of HIV/AIDS. Previously, BDHS surveys were carried out in 1993-1994, 1996-1997, and 1999- 2000. The findings of the 2004 BDHS presented in this report provide up-to-date, and reliable informa- tion on a number of key health and demographic topics of interest to planners, policymakers, program managers, and researchers that will guide the planning, implementation, monitoring and evaluation of the Health, Nutrition and Population Sector Program (HNPSP) in Bangladesh. The data indicate there has been a decline in the total fertility rate and a steady increase in contraceptive use. After an almost decade- long stagnation, fertility declined to 3.0 children per woman in 2004. The 2004 BDHS findings also show a trend toward increasing utilization of health services for mothers and children. While the survey results are encouraging, there is still a long way to go to achieve the national health and demographic goals. The findings of this report together with other national surveys will enhance the understanding of important issues related to the HNPSP in Bangladesh. Information obtained from the 2004 BDHS can be used to review the progress of programs and to improve future policies and strategies. Further analysis of the BDHS data is necessary. It is hoped that academicians, researchers and program personnel will carry out such analysis and provide in-depth knowledge to guide the future direc- tion and effective implementation of the HNPSP. The successful completion of the 2004 BDHS was made possible by the contributions of a num- ber of organizations and individuals. I deeply appreciate the United States Agency for International De- velopment (USAID), Dhaka for providing financial support. I would like to thank NIPORT, Mitra and Associates, and ORC Macro for the effort they put into implementing the 2004 BDHS. (A. F. M. Sarwar Kamal) Summary of Findings | xix SUMMARY OF FINDINGS The 2004 Bangladesh Demographic and Health Survey (2004 BDHS) is a nationally repre- sentative survey of 11,440 women age 10-49 and 4,297 men age 15-54 from 10,500 households covering 361 sample points (clusters) throughout Bangladesh, 122 in urban areas and 239 in the rural areas. This survey is the fourth in a series of national-level population and health surveys con- ducted as part of the global Demographic and Health Surveys (DHS) program. It is designed to provide data to monitor the population and health situation in Bangladesh as a followup to the 1993- 1994, 1996-1997 and 1999-2000 BDHS surveys. The survey utilized a multistage cluster sample based on the 2001 Bangladesh Census and was designed to produce separate estimates for key indicators for each of the six divisions of the country—Barisal, Chittagong, Dhaka, Khulna, Rajshahi and Sylhet. Data collection took place over a five-month period from 1 January to 25 May 2004. Previous surveys included only ever- married women and currently married men; this is first DHS survey in Bangladesh to also include never-married and formerly married men, i.e., the sample for the survey was ever-married women age 10-49 and all men age 15-54. The survey obtained detailed information on fertility levels, marriage, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality and causes of death of children under five, mater- nal and child health, awareness and behavior re- garding HIV/AIDS, and other sexually transmitted infections (STIs). In the previous surveys, anthro- pometric measurements (height and weight) were restricted to mothers who had a child under five years, and their young children. In the 2004 BDHS, all children under five in the household and all interviewed women had their height and weight measured. In addition, the 2004 BDHS collected information on the level of arsenic in drinking water. The 2004 BDHS was conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. It was implemented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. Technical assistance was provided by ORC Macro through the MEASURE DHS pro- gram. Financial support for the survey was provided by the U.S. Agency for International Development (USAID)/Bangladesh. FERTILITY Fertility Levels and Trends. In 1971-1975, women in Bangladesh were having on average 6.3 children. The total fertility rate (TFR) declined to 5.1 fifteen years later, and to 4.3 in 1989-1991. The TFR plateaued at around 3.3 for most of the 1990s, when the three earlier BDHS surveys took place. Data from the 2004 BDHS indicate that after almost a decade- long stagnation, the Bangladesh fertility rate has de- clined slightly to 3.0 children per woman. Comparison of the Bangladesh TFR with fertility rates in other Asian countries that have implemented a DHS survey indicates that, with a TFR of 3.0, Bangladesh is in the mid-range among the countries—below Nepal (4.1 in 2001), Cambodia (3.8 in 2000), and the Philippines (3.5 in 2003), but above India (2.8 in 1998-1999), In- donesia (2.6 in 2002-2003), and Vietnam (1.9 in 2002). Fertility Differentials. Differentials in fertility by background characteristics are substantial. Women in rural areas have more children than their urban counterparts (3.2 and 2.5 children per woman, respec- tively). The TFR is highest in Sylhet division (4.2) and lowest in Rajshahi (2.6). As expected, women’s education is strongly associated with lower levels of fertility; the TFR decreases from 3.6 among women with no education to 2.2 among those who have at least completed their secondary education. Similar differentials are observed by wealth quintile, with the TFR decreasing from 4.0 among women in the lowest wealth quintile to 2.5 among those in the highest wealth quintile. Unplanned Fertility. Despite a steady rise in the level of contraceptive use over the past thirty years, the 2004 BDHS data indicate that unplanned pregnan- cies are common in Bangladesh. Overall, 3 out of 10 births in Bangladesh are either unwanted (14 percent) xx | Summary of Findings or mistimed and wanted later (16 percent). How- ever, the proportion of unplanned births declined from 33 percent in 1999-2000 to 30 percent in 2004. The proportion of unwanted births did not change. Fertility Preferences. There is considerable desire among currently married Bangladeshi women to stop having children. A total of 54 per- cent of women age 10-49 reported not wanting another child, and 6 percent are already sterilized. Twenty-one percent of women want to have a child but would prefer to wait two or more years. Thus, over 80 percent of women want either to space their next birth or to limit childbearing alto- gether. Only 13 percent of women would like to have a child soon (within two years). A compari- son of the 1999-200 and 2004 data shows that the proportion of women who want to limit childbear- ing has not changed. As in the 1999-2000 BDHS, a majority of ever-married women and currently married men embrace the two-child family as an ideal (2.4 and 2.3 children, respectively). FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is universal in Bangladesh. Among ever-married women, the most widely known methods of family planning are the pill (100 percent), injectables (99 percent), female sterilization (96 percent), and condom (92 per- cent); these are followed by the IUD (85 percent), Norplant (76 percent), male sterilization (73 per- cent), periodic abstinence (70 percent), and with- drawal (58 percent). Since overall knowledge of contraceptive methods was already high in 1999-2000, little change has taken place. However, knowledge of Norplant has increased from 56 to 77 percent among currently married women. Use of Contraception. The contraceptive prevalence rate (any method) among currently married women is 58 percent. The most com- monly used modern method is the pill (26 per- cent), followed by injectables (10 percent). Fe- male sterilization and male condoms are used by 5 percent and 4 percent of married women, respectively, while Norplant, the IUD, and male sterilization are each used by only 1 percent. Periodic abstinence, used by 7 percent of married women, is the most com- monly used traditional method. Trends in Contraceptive Use. Over the past three decades, use of any method of contraception by married women has increased sevenfold, from 8 to 58 percent, while use of modern methods has increased almost tenfold, from 5 to 47 percent. The same trend was observed between the 1999-2000 BDHS and the 2004 BDHS, when use of any method increased from 54 to 58 percent and use of modern methods increased from 43 to 47 percent. Trends in the contraceptive method mix show that short-term methods, especially the pill, are gaining in popularity against long-term methods, such as the IUD, Norplant, and sterilization. The pill now accounts for 45 percent of all contracep- tive use, compared with 35 percent in 1991. On the other hand, long-term methods now account for only 12 percent of all contraceptive use, compared with 30 percent in 1991. Differentials in Contraceptive Use. Women in urban areas are slightly more likely to use contracep- tive methods (63 percent) than their rural counterparts (57 percent); however, the condom is the only method that shows differentials in use by urban-rural resi- dence: 8 percent in urban areas compared with only 3 percent in rural areas. Differentials are more marked by division: use of any method varies from 32 percent in Sylhet and 47 percent in Chittagong to 64 percent in Khulna and 68 percent in Rajshahi. Contraceptive prevalence is 54 percent in Barisal and 59 percent in Dhaka. There is little variation in contraceptive use by level of education. However, women in economically better-off households tend to use family planning more than those in households in the lowest wealth quintile (63 and 54 percent, respectively). The propor- tion of women using contraception increases with in- creasing number of children. Twenty-three percent of women with no children are currently using a contra- ceptive method, compared with 62 to 70 percent of women with two or more children. Source of Modern Methods. In Bangladesh, both the public and private sectors are important sources of supply for users of modern methods (57 and 36 percent, respectively). The most common pub- lic sector source remains government fieldworkers (23 Summary of Findings | xxi percent), although their share has declined sub- stantially since 1993-1994 (42 percent). Upazila health complexes are the second most important public source (10 percent). Pharmacies (29 per- cent) provide most of the methods in the private sector (an increase from 21 percent in 1999-2000). Femicon, the most commonly used social market- ing brand of pills, is distributed through a network of retail outlets including pharmacies. Of every ten pills used in Bangladesh, three carry the Femi- con brand. Contraceptive Discontinuation. One in two contraceptive users in Bangladesh stops using their method within 12 months of starting. The most common reason for discontinuation is side effects or health problems. Discontinuation rates are highest for condoms (72 percent) and with- drawal (60 percent), and lowest for periodic absti- nence (41 percent). Unmet Need for Family Planning. Eleven percent of married women have an unmet need for family planning. Unmet need is about equally di- vided between spacing and limiting births. Unmet need declined from 15 percent in 1999-2000 to 11 percent in 2004. It has remained high in Sylhet division (21 percent), while dropping substantially in Rajshahi (7 percent) and Khulna (8 percent). Overall, 84 percent of the demand for family planning is currently being met. MATERNAL HEALTH Antenatal Care. Antenatal care coverage in- creased sharply between the 1999-2000 BDHS and the 2004 BDHS. One-third of women re- ceived an antenatal checkup from a medically trained provider in 1999-2000 compared with one- half (49 percent) in 2004. Thirty-one percent of women received antenatal care from a doctor and 17 percent received care from a nurse, midwife, or paramedic. A relatively high proportion of women received no antenatal care (44 percent), especially in Sylhet (52 percent) and Barisal (53 percent). Two in three women received at least two doses of tetanus toxoid for their most recent birth in the five years preceding the survey, 21 percent received only one tetanus toxoid injection, and 15 percent received none, which was an improve- ment since the 1999-2000 BDHS (19 percent). Delivery Care. Nationally, nine in ten births in the last five years were delivered at home; only 9 per- cent were delivered in a health facility. Delivery in a health facility is substantially higher among women who have at least completed their secondary education (44 percent), and among those in the highest wealth quintile (30 percent). The data also show that only 13 percent of babies were delivered by medically trained providers, compared with 63 percent who were deliv- ered by untrained birth assistants. Postnatal Care. Only 15 percent of women who had a non-institutional live birth in the five years pre- ceding the survey received postnatal care within two days of delivery; more than 80 percent received no postnatal care at all. Maternal Complications around Delivery. One in four births in the five years preceding the survey had at least one of the following maternal complica- tions around delivery—prolonged labor, excessive bleeding, baby’s hands or feet came first, fever with foul-smelling discharge, convulsions/eclampsia. The most common complication was prolonged labor of over 12 hours, associated with one in six live births. For 11 percent of the births, the mothers experienced excessive bleeding, and 3 percent had convulsions. Two other problems, high fever with foul discharge and baby’s hands or feet coming first, were reported for 5 and 1 percent of births, respectively. Treatment was sought from a medically trained provider for only 29 percent of the cases that had maternal complications around delivery. Nearly four in ten women with complications did not seek any care. The 2004 BDHS data confirm the findings of the 2001 BMMS, that there are two main problems regarding the treatment of maternal complications: first, a large proportion of women with potentially life-threatening maternal complications seek no health care; and second, among those who do seek health care, about half seek assistance from providers that are not medically trained. CHILD HEALTH Childhood Mortality. Data from the 2004 BDHS show that under-five mortality (88 deaths per 1,000 live births) has continued to decline thanks pri- marily to the substantial decline (20 percent) in child mortality (age 1-4 years) over the past five years. However, this still means that for the most recent five- xxii | Summary of Findings year period, one in every eleven Bangladeshi chil- dren dies before reaching age five, while one in fifteen children dies before reaching the first birthday (65 deaths per 1,000 live births). A ma- jority of infant deaths occur during the first month of life (neonatal mortality). The 2004 BDHS also collected information on causes of death. Overall, for all children under five, the two most important causes of death were: possible serious infections (31 percent) including possible ARI and diarrhea and ARI (21 percent), which particularly affect children age 1-11 months. Birth asphyxia (12 per- cent), which occurs in the first 28 days, diarrhea (7 percent), and prematurity/low birth weight (7 percent) were responsible for most of the other deaths. Childhood Vaccination Coverage. Seventy-three percent of Bangladeshi children age 12-23 months are fully immunised—most of them by 12 months of age as recommended—while 3 percent have received no vaccinations. More than nine in ten children have received BCG and the first dose of DPT and polio vaccines. While coverage for the first dose of DPT and polio is high, there is a de- cline with subsequent doses, with only about 81 percent of children receiving the recommended three doses of these vaccines. Seventy-six percent of children have received measles vaccine. Full vaccination coverage is highest in Khulna division (83 percent) and lowest in Sylhet division (62 per- cent). Mother’s education is strongly associated with children’s vaccination coverage: only 60 per- cent of children of mothers with no education are fully vaccinated compared with 92 percent of chil- dren of highly educated mothers. Child Illness and Treatment. Among chil- dren under five years of age, 21 percent were re- ported to have had symptoms of acute respiratory illness in the two weeks preceding the survey. Of these, only one-fifth were taken to a health facility or provider for treatment, and one-third received no treatment at all. Eight percent of children under five years had diarrhea in the two weeks preced- ing the survey. Of these, 16 percent were taken to a health provider. Use of oral rehydration therapy (ORT) for children with diarrhea has remained unchanged since 1999-2000, but there has been a shift toward greater use of the commercially available packets of oral rehydration salts (ORS), from 61 to 67 percent. Overall, 83 percent of the children with diarrhea received ORS, recommended home fluids (RHF), or increased fluids. Forty percent of children under five years had a fever in the two weeks preceding the survey. Of these, nearly two-thirds were taken to a provider for treat- ment, but only 19 percent were taken to a medically trained provider/facility. NUTRITION Breastfeeding Practices. Almost all (98 percent) Bangladeshi children are breastfed for some period of time. Twenty-four percent of infants were put to the breast within one hour of birth, and 83 percent started breastfeeding within the first day. This is a substantial increase when compared to the 1999-2000 BDHS data. The median duration of any breastfeeding in Bangladesh is 32 months, but it varies among divi- sions from 36 months in Khulna and Rajshahi to around 26 months in Chittagong and Sylhet. Exclusive breastfeeding of children under six months (based on 24-hour period before the survey) has not improved in the past 10 years; it remained un- changed at around 45 percent between 1993-94 and 1999-2000, and has declined to 42 percent most re- cently. Supplementary feeding of children who are also breastfed has greatly improved over the past decade. In 1993-1994, only 29 percent of children age 6-9 months received complementary foods while being breastfed, compared with 62 percent in 2004. The most commonly used complementary foods are rice, wheat, and porridge (over 60 percent); 20 to 25 per- cent of the children in this age group received other complementary foods (fruits, meat/fish/eggs, and green leafy vegetables), and a smaller proportion re- ceived dal. Feeding children with a bottle with a nipple starts very young, and three in ten infants age 2-3 months receive some food this way. Also, commercially pro- duced baby formula is more popular than it was at the time of the 1999-2000 BDHS. Intake of Vitamin A. Ensuring that children 6- 59 months receive enough vitamin A may be the sin- gle most effective child survival intervention because deficiencies in this micronutrient can cause blindness and increase the severity of infections such as measles Summary of Findings | xxiii and diarrhea. Between the 1999-2000 BDHS and the 2004 BDHS, vitamin A supplementation among children 12-59 months increased from 80 to 84 percent, but it actually dropped by half for children age 9-11 months (from 73 to 38 percent). Consumption of fruits and vegetables rich in vi- tamin A is another way to ensure that children are protected from blindness or infection. Overall, 7 in 10 children under three consumed such foods. Only 15 percent of mothers with a birth in the past five years reported receiving a vitamin A dose postpartum. Three percent of interviewed women reported night blindness during preg- nancy. Nutritional Status of Children. According to the 2004 BDHS which measured all children under five in the household, 43 percent of children are stunted and 17 percent severely stunted. Thir- teen percent of children under five are wasted and 1 percent severely wasted. Weight-for-age results show that 48 percent of children under five are underweight, with 13 percent severely under- weight. Comparison of children whose mothers were interviewed shows that in spite of the fact that child nutritional levels showed a substantial improvement from 1996-1997 to 1999-2000, since then no noticeable improvement has occurred ex- cept that the severe stunting has slightly decreased and overall wasting has increased from 10 to 13 percent. Nutritional Status of Women. The mean height of Bangladeshi women is 151 centimetres, which is above the critical height of 145 centime- tres. A high proportion of women (16 percent) are below 145 centimetres. Thirty-four percent of women were found to be chronically malnour- ished, their body mass index (BMI) being less than 18.5. One in ten women was found to be overweight or obese (BMI 25 or higher). A woman’s place of residence, level of education, and household wealth quintile are strongly associ- ated with her nutritional status. For example, 37 percent of rural women are considered thin (<18.5), compared with 25 percent of their urban counterparts. Among divisions, Sylhet has the highest proportion of women who are thin (48 percent) and Khulna the least (29 percent). Al- though Bangladeshi women with children under five years are not getting taller, there is a substan- tial improvement in mother’s nutritional status as measured by BMI. Since 1996-97, the proportion of mothers below the cutoff point of BMI of 18.5 contin- ued to drop, from 52 percent in 1996-97 to 38 percent in 2004—a decline of 27 percent in less than ten years. Arsenic in Drinking Water. Arsenic in drinking water is a hazard to human health. Its main source is arsenic-rich rocks through which the water has fil- tered. It may also occur because of mining or indus- trial activity. In Bangladesh, arsenic-contaminated water is found particularly in tubewells. Overall, in the 2004 BDHS, one in twelve households were found to have elevated levels of arsenic (equal to or greater than 50 parts per billion) in their drinking water. The problem is especially severe in Chittagong, where 22 percent of the households tested had arsenic- contaminated water; arsenic contamination is almost nonexistent in Barisal and Rajshahi (1 and 2 percent). HIV/AIDS AND STIS Awareness of HIV/AIDS. Knowledge of HIV/ AIDS among ever-married women increased from 19 percent in 1996-1997 to 31 percent in 1999-2000, and then it almost doubled to 60 percent in 2004. For currently married men, the corresponding proportions are 34, 51, and 78 percent. A respondent’s place of residence, level of edu- cation, and household wealth quintile are strongly as- sociated with HIV/AIDS awareness. Whereas 82 per- cent of women and 93 percent of men in urban areas have heard of AIDS, only 54 percent of women and 78 percent of men in rural areas have heard of the dis- ease. Education is positively associated with knowl- edge of HIV/AIDS. It ranges from 37 percent among women with no education, to 71 percent among those who have completed primary school (only), to virtu- ally all women (98 percent) who have completed sec- ondary education. A similar pattern can be found when analyzing the data by wealth quintile. Thirty-seven percent of ever-married women, 57 percent of never-married men, and 45 percent of cur- rently married men know that condom use is a way to avoid contracting HIV/AIDS, a clear improvement over the results of the 1999-2000 BDHS. About one in three married women and one in eight among all men or currently married men know that limiting the num- ber of sexual partners can prevent HIV/AIDS. Overall, six in ten women and 42 percent of men do not know any way to avoid the disease. xxiv | Summary of Findings Among respondents who know of HIV/ AIDS, seven in ten women and 84 percent of men correctly reported that a healthy looking person can have the AIDS virus. In 2004, 29 percent of ever-married women were able to cite two or more correct ways to avoid contracting HIV/AIDS. Since 1999-2000, the unprompted knowledge of at least two correct ways to avoid HIV/AIDS has increased substan- tially among ever-married women (from 7 to 29 percent) and moderately among currently married men (from 19 to 26 percent). Awareness of Sexually Transmitted Infections (STIs). Knowledge of STIs is generally lower than that of HIV/AIDS. Ninety-four percent of women and 78 percent of married men still do not have any knowledge of STIs. Knowledge of STIs is highest among women and men who have completed secon- dary education, 19 and 38 percent, respectively. Map of Bangladesh | xxv Introduction │ 1 INTRODUCTION 1 1.1 GEOGRAPHY AND ECONOMY Bangladesh is located in the northeastern part of South Asia and covers an area of 147,570 square kilometers. It is almost entirely surrounded by India, except for a short southeastern frontier with Myanmar and a southern coastline on the Bay of Bengal. It lies between latitudes 20° 34′ and 26° 38′ north and longitudes 88° 01′ and 92° 41′ east, and has a tropical climate. The Moguls ruled the country from the 13th century till the 18th century, when the British took over and administered the subcontinent until 1947. During British rule, Bangladesh was a part of India. In 1947, the independent states of Pakistan and India were created with the present Bangladesh territory as a part of Pakistan. Bangladesh emerged on the world map as a sovereign state on March 26, 1971 after fighting a 9-month war of liberation. Most of Bangladesh consists of low, flat and alluvial soil. The most significant feature of the landscape is the extensive network of large and small rivers that are of primary importance to the socioeconomic life of the nation. Chief among these, lying like a fan on the face of the land, are the Ganges-Padma, Brahmaputra-Jamuna, and Megna rivers. The climate of Bangladesh is dominated by seasonal monsoons. The country 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 floods, cyclones, tidal bores, and drought. For administrative purposes, the country is divided into 6 divisions, 64 districts, and 496 upazilas (subdistricts) (BBS, 2001:19). Muslims constitute almost 90 percent of the population of Bangladesh, Hindus constitute about 9 percent, and others constitute about 1 percent. The national language of Bangladesh is Bangla, which is spoken and understood by all. Agriculture is the overwhelmingly dominant sector of the economy, occupying 80 percent of the total population and contributing 25 percent of gross domestic product (GDP). The average per capita income is as low as $444 and more than one-third of the population live below the absolute poverty line (UNDP, 2003). Rice, wheat, jute, sugarcane, tobacco, oilseeds, and potatoes are the principal crops. The country produces about 51 million kilograms of tea per year, a sizeable quantity of which is exported to foreign markets after meeting the internal demand. Bangladesh produces about 1,057,000 metric tons of superior quality jute annually and 16 percent of export earnings come from raw-jute manufactures (BBS, 2001). Industry, although small, is increasing in importance as a result of foreign investments. Unemployment/underemployment is a serious problem, and pressure on the land in rural areas has led to movement of people from rural to urban areas. Bangladesh ranks 138th in the Human Development Index (HDI) as presented in the Human Development Report of 2004 with a HDI value of 0.519. With this HDI value, the country belongs to the category of medium human development countries. However, Bangladesh ranks among the three last countries in this category, followed by Sudan and Cameroon. Within the region, the position of Bangladesh is better only than Pakistan, which ranks 144 in the HDI. 2 │ Introduction Bangladesh is still struggling to emerge from the realm of poverty. Bangladesh ranks 72nd among 94 developing countries in terms of the Human Poverty Index (HPI). The HPI is a multidimensional measure of poverty for developing countries; it takes into account social exclusion, lack of economic opportunities, and deprivations in survival, livelihood and knowledge. 1.2 POPULATION Bangladesh is the most densely populated country in the world, excluding city-states such as Hong Kong and Singapore. The country has a population of about 140 million, with a corresponding population density of more than 900 per square kilometer. During the first half of the last century the population increased by only 45 percent. This slow increase was due to a combination of high birth rates and high death rates. In the second half of the century, population growth was rapid, tripling during the period. The relatively young age structure of the population indicates continued rapid population growth in the future. According to the 2001 census, 39 percent of the population is under 15 years of age, 57 percent are between 15 and 64 years, and 4 percent are age 65 or over (BBS, 2003:51). This young age structure constitutes built-in “population momentum,” which will continue to generate population increases well into the future, even in the face of rapid fertility decline. The population projections indicate that the population will increase rapidly even after attaining replacement-level fertility because of the echo effect of the high fertility experienced in the past. The Bangladesh Population Policy indicates that the population should stabilize at 210 million by 2060, if replacement-level fertility is reached by 2010. This estimate of future population size is reasonably consistent with the World Bank projections from 1994 (Bos et al., 1994), and the United Nations projections 1996 revision (United Nations, 1996), both of which estimated a mid-21st century population of 218 million. However, there is wide disparity between the estimates of the Bangladesh Government and others on the time when the population would stabilize. The World Bank boldly forecast a final stationary population of 263 million by mid-22nd century (2150), whereas others have not projected beyond the mid-21st century. Recently however, the United Nations has revised their estimate for 2050 by 25 million (or 11 percent) to 243 million, apparently on the basis of the decade long fertility plateau (United Nations, 2004). This recent and very substantial upward revision of the mid-century population by the United Nations seems unduly pessimistic because a five-year delay in attaining replacement-level fertility adds only 3 percent to the population at any point in time. Nevertheless, Bangladesh still faces many decades of continued population growth, and efforts to slow that growth need to continue, through the family planning program, and increasingly, through social and health interventions that will facilitate further fertility decline, so that progress towards economic development is not hindered. 1.3 POPULATION, FAMILY PLANNING AND MATERNAL AND CHILD HEALTH POLICIES AND PROGRAMS Family planning was introduced in Bangladesh (then East Pakistan) 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 by the Government of Bangladesh since liberation in 1971. The First Five-Year Plan (1973-1978) of Bangladesh emphasized “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 15 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 Introduction │ 3 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 the 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’s population policy and programs have evolved through a series of developmental phases and have undergone changes in strategies, structure, content, 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 numbered almost 24,000 at the height of the program a few years ago. A social marketing program to promote the sale of birth control pills and condoms was also initiated in the mid-1970s. Another characteristic of the population program is the involvement of more than 200 nongovernmental organizations (NGOs). 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. The Fifth Five-Year Plan, the Health and Population Sector Program (HPSP) 1998- 2003 was formulated keeping in view the principles of the Health and Population Sector Strategy (HPSS) with a single sector for both health and population. The main objective of the HPSP was to ensure universal access to essential health care services of acceptable quality and to further slow population growth. Moreover, to overcome the multidimensional problems and to meet the challenge according to the spirit of the International Conference on Population and Development (ICPD), the Government of Bangladesh launched the Health, Nutrition and Population Sector Program (HNPSP) in 2003. This aimed to reform the health and population sector. The program entails provision of a package of essential and quality health care services responsive to the needs of the people, especially those of children, women, elderly and the poor. Recently, the government adopted the Bangladesh Population Policy with the objectives to improve the status of family planning, and maternal and child health, including reproductive health services and to improve the living standard of the people of Bangladesh through striking a desired balance between population and development in the context of the Millennium Development Goals (MDGs) and a Poverty Reduction Strategy Paper (PRSP). The objectives of the population policy include the following: • Reduce the total fertility rate (TFR) and increase the use of family planning methods among eligible couples through raising awareness of family planning; • Attain a net reproduction rate equal to one by the year 2010 so as to stabilize population around 2060; • Ensure adequate availability and access of reproductive health services, especially family planning services to all including information, counseling and services for adolescents; • Improve maternal health with emphasis on reduction of maternal mortality; • Reduce reproductive tract and sexually transmitted infections (RTI/STIs) and prevent the spread of HIV/AIDS; • Reduce infant and under-five mortality rates; • Reduce maternal and child malnutrition; 4 │ Introduction • Promote and actively support programs for elimination of gender disparity in education, health and nutrition; • Ensure early childhood development programs; • Ensure and support gender equity and empower women; • Develop the human resource capacity of planners, managers and service providers, including improved data collection, research and dissemination; • Actively support measures to provide food and social security and shelter for the disadvantaged including the elderly, destitute, physically and mentally retarded persons; • Actively support measures to regulate and reduce rural to urban migration; • Support measures for environmental sustainability with emphasis on access to safe drinking water; • Support poverty alleviating strategies and a conducive environment for improved quality of life; • Ensure coordination among relevant Ministries in strengthening population and development linkages and making their respective mandates and implementation strategies more population- focused. 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 promotion of health as an integral part of overall socioeconomic development. Private-sector involvement in both health and population services is being encouraged. There has been considerable variation across the health and population sector in effectiveness of services. Some projects have very effectively targeted certain diseases or conditions, while others have been less effective. Under the HPSP, since 1998, the adoption of a sector-wide program approach has brought its own set of issues. However, throughout these strategy changes, the family planning program has continued to function reasonably effectively, and contraceptive use has steadily become more widespread. 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 educational 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 the 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. Because of 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. Introduction │ 5 1.4 ORGANIZATION OF THE 2004 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 1.4.1 Survey Objectives and Implementing Organizations The Bangladesh Demographic and Health Survey (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 • Advance survey methodology. More specifically, the objective of the BDHS survey 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. The 2004 BDHS survey 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. ORC Macro of Calverton, Maryland, provided technical assistance to the project as part of its international Demographic and Health Surveys program, and financial assistance was provided by the U.S. Agency for International Development (USAID)/Bangladesh. 1.4.2 Sample Design The sample for the 2004 BDHS covered the entire population residing in private dwellings units in the country. Administratively, Bangladesh is divided into six divisions. In turn, each division is divided into zilas, and in turn each zila into upazilas. Each urban area in the upazila is divided into wards, and into mahallas within the ward; each rural area in the upazila is divided into union parishads (UP) and into mouzas within the UPs. The urban areas were stratified into three groups, i) Standard metropolitan areas, ii) Municipality areas, and iii) Other urban areas. These divisions allow the country as a whole to be easily separated into rural and urban areas. For the 2001 census, subdivisions called enumeration areas (EAs) were created based on a convenient number of dwellings units. Because sketch maps of EAs were accessible, EAs were considered suitable to use as primary sampling units (PSUs) for the 2004 BDHS. In each division, the list of EAs constituted the sample frame for the 2004 BDHS survey. A target number of completed interviews with eligible women for the 2004 BDHS was set at 10,000, based on information from the 1999-2000 BDHS. The 2004 BDHS sample is a stratified, a multistage cluster sample consisting of 361 PSUs, 122 in the urban area and 239 in the rural area. After the target sample was allocated to each group area according to urban and rural areas, the number of PSUs was calculated in terms of an average of 28 completed interviews of eligible women per PSU (or an average of 30 selected households per PSU). Mitra and Associates conducted a household listing operation in all the sample points from 3 October 2003 to 15 December 2003. A systematic sample of 10,811 households was then selected from these lists. All ever-married women age 10-49 in the selected households were eligible respondents for 6 │ Introduction the women’s questionnaire. For the men‘s survey, 50 percent of the selected households were chosen through systematic sampling. Interviewers interviewed one randomly selected man, regardless of marital status, in the age group 15-54, from each of the selected households. It was expected that the sample would yield interviews with approximately 10,000 ever-married women age 10-49 and 4,400 men age 15- 54. 1.4.3 Questionnaires The BDHS used a Household Questionnaire, a Women’s Questionnaire, a Men’s Questionnaire, and a Community Questionnaire. The contents of these questionnaires was based on MEASURE DHS+ model questionnaire. These model questionnaires were adapted for use in Bangladesh during a series of meetings with the Technical Task Force, which consisted of representatives from NIPORT, Mitra and Associates, USAID/Dhaka, ICDDR,B’s Center for Health and Population Research, Bangladesh, Pathfinder/Dhaka, and ORC Macro (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). The questionnaires were developed in English and then translated into and printed in Bangla. In addition, two versions of a Verbal Autopsy Questionnaire were used. One version was for neonatal deaths (0-28 days old at death) and the other was for deaths among older children (age 29 days to 5 years at death). The verbal autopsy instruments were developed using the previous two BDHS verbal autopsy surveys, the WHO verbal autopsy questionnaire, and the instrument used since 2003 in the Matlab Health and Demographic Surveillance System. 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 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 arsenic level of the water used by households for drinking was also tested. The Household Questionnaire was also used to record the heights and weights of all children under six years of age. 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 • Awareness of AIDS and other sexually transmitted diseases • Causes of deaths of children under five years of age The Men’s Questionnaire was used to collect information from men age 15-54 whether ever married or not. The men were asked questions on the following topics: • Background characteristics (including respondent’s work) • Health and life style (illness, use of tobacco) Introduction │ 7 • Marriage and sexual activity • Participation in reproductive health care • Awareness of AIDS and other sexually transmitted diseases • Attitudes on women’s decision making roles • Domestic violence The Community Questionnaire was completed for each sample cluster and included questions about the existence of development organizations in the community and the availability and accessibility of health and family planning services. The Verbal Autopsy Questionnaire was used for collection of open-ended information including narrative stories on the following topics: • Identification including detailed address of respondent • Informed consent • Detailed age description of deceased child • Information about caretaker or respondent of deceased child • Detailed birth and delivery information • Open-ended section allowing the respondent to provide a narrative history • Maternal history including questions on prenatal care, labor and delivery, and obstetrical complications • Information about accidental deaths • Detailed signs and symptoms preceding death • Treatment module and information on direct, underlying • Contributing causes of death from the death certificate, if available. The survey questionnaires, with the exception of the Verbal Autopsy Questionnaires, are included in Appendix E. 1.4.4 Training and Fieldwork The BDHS Women’s Questionnaire was pretested in September 2003 and the Men’s Questionnaire was pretested in December 2003. For the pretest, 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 Technical Task Force (TTF). Altogether, 108 Women‘s and 45 Men’s Questionnaires were completed. Based on observations in the field and suggestions made by the pretest field teams, the TTF made revisions in the wording and translations of the questionnaires. In November 2003, candidates for field staff positions for the main survey were recruited. Recruitment criteria included educational attainment, maturity, ability to spend one month in training and at least four months in the field, and experience in other surveys. Training for the main survey was conducted for four weeks (1 December to 30 December 2003). 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 one male supervisor, one female field editor, five female interviewers, two male interviewers, and one logistics 8 │ Introduction staff person, for a total of 120 field staff for the survey. Mitra and Associates also fielded four quality control teams of two persons each to check on the field teams. In addition to these field control teams, NIPORT monitored fieldwork by using their quality control teams. Additionally, USAID, ORC Macro, and NIPORT monitored the fieldwork by visiting teams in the field. Fieldwork commenced on 1 January 2004 and was completed on 25 May 2004. Fieldwork was implemented in five phases. 1.4.5 Data Processing All questionnaires for the BDHS were periodically returned to Dhaka for data processing at Mitra and Associates. The processing of the data collected began shortly after the fieldwork commenced. 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 six microcomputers working in double shifts and carried out by 10 data entry operators and two data entry supervisors. The concurrent processing of the data was an advantage since the quality control teams were able to advise field teams of problems detected during the data entry. In particular, tables were generated to check various data quality parameters. Data processing commenced on 12 January 2004 and was completed by 24 June 2004. 1.4.6 Coverage of the Sample Table 1.1 shows response rates for the survey and reasons for nonresponse. A total of 10,811 households were selected for the sample; 10,523 were occupied, of which 10,500 were successfully interviewed. The shortfall is primarily due to dwellings that were vacant or destroyed or in which the inhabitants had left for an extended period at the time the interviewing teams visited them. Of the households occupied, 99.8 percent were successfully interviewed. In these households, 11,601 women Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence, Bangladesh 2004 Residence Urban Rural Total Result Number Percent Number Percent Number Percent Household sample Households occupied 3,522 96.6 7,001 97.7 10,523 97.3 Households absent for extended period of time 46 1.3 76 1.1 122 1.1 Dwelling vacant or destroyed 68 1.9 74 1.0 142 1.3 Other 10 0.3 14 0.2 24 0.2 Total households selected 3,646 100.0 7,165 100.0 10,811 100.0 Household interviews Households interviewed 3,513 99.7 6,987 99.8 10,500 99.8 Household not interviewed 9 0.3 14 0.2 23 0.2 Total households occupied 3,522 100.0 7,001 100.0 10,523 100.0 Household response rate 99.7 99.8 99.8 Individual interviews: women Eligible women interviewed 3,904 98.3 7,536 98.8 11,440 98.6 Eligible women not interviewed 69 1.7 92 1.2 161 1.4 Total eligible women 3,973 100.0 7,628 100.0 11,601 100.0 Eligible woman response rate 98.3 98.8 98.6 Individual interviews: men Eligible men interviewed 1,514 95.6 2,783 95.7 4,297 95.7 Eligible men not interviewed 69 4.4 124 4.3 193 4.3 Total eligible men 1,583 100.0 2,907 100.0 4,490 100.0 Eligible man response rate 95.6 95.7 95.7 Introduction │ 9 were identified as eligible for the individual interview (i.e., ever-married and age 10-49) and interviews were completed for 11,440 or 98.6 percent of them. In households that were selected for inclusion in the man’s survey, 4,490 eligible men age 15-54 were identified, of which 4,297 or 95.7 percent were interviewed. 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 nonresponse rates for the current survey were lower than those for the 1999-2000 survey. Household Population and Housing Characteristics │ 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter provides information on the social, economic, and demographic characteristics of the households included in the 2004 BDHS. It presents information on household population characteristics, such as age, sex, educational attainment, and employment status. It also provides information on household characteristics, such as source of drinking water, electricity, sanitation facilities, housing construction materials, possession of durable goods, and ownership of a homestead and land. This information is intended to assist in the assessment of the representativeness of the survey. In the 2004 BDHS, information was also collected on the prevalence of arsenic in household drinking water, through testing of arsenic in drinking water at the time of the survey. For the purpose of the 2004 BDHS, a household is defined as a person or a group of related and/or unrelated persons who usually live in the same dwelling unit(s), who have common cooking and eating arrangements, and who acknowledge one adult member as a head of the household. A member of the household is any person who usually lives in the household; a visitor is someone who is not a member of the household, but stayed in the household the night before the interview. This survey collected information for all usual residents of the selected household (de jure population) and persons who stayed in the selected household the night before the date of interview (de facto population). This method of data collection allows the analysis of either de jure or de facto population. 2.1 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE Age and sex are important demographic variables and are the primary basis of demographic classification in vital statistics, censuses, and surveys. They are also important variables in the study of mortality, fertility, and nuptiality. The distribution of the de facto household population in the 2004 BDHS is shown in Table 2.1 by five-year age groups, according to sex and urban-rural residence. The household population includes 51,255 persons, and the sample is 78 percent rural and 22 percent urban. Females constitute 51 percent of the population. Overall, the proportions of persons in the younger age groups are substantially larger than the proportions in the older age groups for each sex and in both urban and rural areas. The age-sex structure of the population is shown by a population pyramid in Figure 2.1. The pyramid is wide based and slightly narrower at the lowest base, a pattern that typically describes a high- fertility regime that has recently declined slightly. Figure 2.2 shows the distribution of the male and female household population by single year of age. The figure shows that noticeable heaping is observed at ages ending with 0 and 5. Ages ending with 1 and 9 are underreported. 12 │ Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Bangladesh 2004 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 11.3 11.5 11.4 13.8 12.7 13.2 13.2 12.4 12.8 5-9 12.5 10.8 11.7 13.6 12.8 13.2 13.3 12.4 12.8 10-14 11.7 12.6 12.2 13.0 12.3 12.7 12.7 12.4 12.6 15-19 10.5 13.5 12.0 9.5 12.5 11.0 9.8 12.7 11.3 20-24 8.6 11.1 9.9 7.1 9.7 8.4 7.4 10.0 8.7 25-29 7.4 9.1 8.3 6.6 7.9 7.2 6.8 8.1 7.5 30-34 7.7 7.3 7.5 6.6 6.7 6.7 6.8 6.9 6.8 35-39 6.6 6.2 6.4 6.0 5.5 5.7 6.1 5.7 5.9 40-44 6.7 4.8 5.7 5.5 4.3 4.9 5.8 4.4 5.1 45-49 5.0 4.1 4.5 4.4 4.2 4.3 4.5 4.2 4.4 50-54 3.5 2.5 3.0 3.5 2.6 3.1 3.5 2.6 3.0 55-59 2.3 1.9 2.1 2.2 2.8 2.5 2.2 2.6 2.4 60-64 2.4 1.7 2.1 2.7 2.2 2.4 2.6 2.1 2.3 65-69 1.4 0.9 1.1 1.7 1.3 1.5 1.7 1.2 1.4 70-74 1.2 0.7 1.0 1.8 1.1 1.4 1.7 1.0 1.3 75-79 0.5 0.4 0.4 0.7 0.5 0.6 0.7 0.5 0.6 80+ 0.7 0.8 0.7 1.3 0.9 1.1 1.2 0.8 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,530 5,721 11,251 19,570 20,435 40,004 25,099 26,156 51,255 Household Population and Housing Characteristics │ 13 Table 2.2 compares the broad age structure of the population from the 1989 Bangladesh Fertility Survey; the 1989 and 1991 Contraceptive Prevalence Surveys; and the 1993-1994, 1996-1997, 1999- 2000, and 2004 Bangladesh Demographic and Health Surveys. There has been a decline in the proportion of population less than 15 years of age and an increase in the proportion age 15-59; also, the median age of the population has been increasing. This pattern is consistent with a decline in fertility. Table 2.2 Population by age from selected sources Percent distribution of the de facto population by age group, selected sources, Bangladesh 1989-2004 Age group 1989 BFS 1989 CPS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS <15 43.2 43.2 42.7 42.6 41.0 39.2 38.2 15-59 50.9 50.9 51.2 51.2 53.1 54.4 55.1 60+ 5.9 5.9 6.0 6.2 5.9 6.4 6.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Median age u u u 18.4 18.8 19.5 20.2 u = Unknown (not available) Source: Huq and Cleland, 1990:38; Mitra et al., 1993:14; Mitra et al., 1997:9; NIPORT et al., 2001:11 14 │ Household Population and Housing Characteristics 2.2 HOUSEHOLD COMPOSITION Table 2.3 shows the distribution of households by sex of the head of household and by household size, according to urban-rural residence. At the national level and in rural areas, women head 10 percent of Bangladeshi households. The proportion of female-headed households is slightly lower in urban areas (9 percent). Fifty-eight percent of households in Bangladesh are composed of three to five members; the corresponding figure for urban areas is 60 percent. Average household size in Bangladesh is 5.0 members; urban household size is marginally smaller than rural household size. Table 2.3 Household composition Percent distribution of households by sex of head of household and household size, according to residence, Bangladesh 2004 Residence Characteristic Urban Rural Total Sex of head of household Male 90.6 89.7 89.9 Female 9.4 10.3 10.1 Total 100.0 100.0 100.0 Number of usual members 1 1.4 1.8 1.7 2 6.8 7.2 7.1 3 16.0 15.3 15.5 4 23.3 22.5 22.7 5 20.7 19.4 19.7 6 14.8 14.2 14.4 7 7.0 8.5 8.2 8 4.3 4.6 4.5 9+ 5.6 6.4 6.2 Total 100.0 100.0 100.0 Number of households 2,306 8,194 10,500 Mean size 4.9 5.0 5.0 Note: Table is based on de jure members, i.e., usual residents. 2.3 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Education is a key determinant of the lifestyle and status an individual enjoys in a society. It affects many aspects of life, including demographic and health behavior. Studies have shown that educational attainment has strong effects on reproductive behavior, contraceptive use, fertility, mortality, morbidity, and attitudes and awareness related to family health and hygiene. In the 2004 BDHS, information on educational attainment was collected for each member of the household age six years and above. Tables 2.4.1 and 2.4.2 present the distribution of the de facto female and male household populations, respectively, by educational level, according to age, urban-rural residence, and administrative division. Generally, education has become more widespread over the years among both men and women, as is clear from a comparison of older and younger cohorts. Household Population and Housing Characteristics │ 15 Table 2.4.1 Level of education of household population: women Percent distribution of the de facto female household population age six and over by highest level of education attended or completed, according to background characteristics, Bangladesh 2004 Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number of women Median number of years Age 6-9 12.4 87.0 0.1 0.4 0.0 100.0 2,573 0.2 10-14 7.3 49.5 5.6 37.5 0.1 100.0 3,245 3.6 15-19 12.0 17.5 9.8 52.9 7.7 100.0 3,321 5.7 20-24 23.9 17.7 9.4 32.6 16.4 100.0 2,625 4.6 25-29 40.1 20.0 9.1 19.1 11.8 100.0 2,129 1.9 30-34 48.4 22.1 7.9 14.8 6.8 100.0 1,795 0.0 35-39 56.0 20.8 6.7 11.6 4.8 100.0 1,479 0.0 40-44 56.4 18.4 8.0 12.5 4.7 100.0 1,159 0.0 45-49 61.8 18.9 8.3 7.6 3.5 100.0 1,095 0.0 50-54 69.6 13.3 7.0 7.5 2.5 100.0 684 0.0 55-59 74.2 17.1 5.3 2.8 0.6 100.0 676 0.0 60-64 80.1 10.2 4.5 4.3 0.5 100.0 547 0.0 65+ 85.0 8.9 2.9 2.7 0.2 100.0 915 0.0 Residence Urban 28.2 27.1 6.8 25.5 12.3 100.0 4,932 3.2 Rural 36.2 31.5 6.8 21.8 3.7 100.0 17,317 1.2 Division Barisal 24.8 35.2 9.7 23.3 7.0 100.0 1,480 2.8 Chittagong 34.8 29.5 6.5 23.9 5.2 100.0 4,374 1.7 Dhaka 34.6 30.0 7.0 21.3 7.1 100.0 6,836 1.5 Khulna 29.0 32.4 6.0 27.2 5.4 100.0 2,544 2.6 Rajshahi 37.4 30.6 5.2 22.2 4.6 100.0 5,387 1.1 Sylhet 40.8 27.5 10.3 18.0 3.3 100.0 1,628 0.7 Total 34.4 30.5 6.8 22.6 5.6 100.0 22,249 1.6 Note: Total includes eight females missing information on age. Total includes a small proportion missing education level. 1 Primary complete is defined as completing grade 5. 2 Secondary complete or higher is defined as completing grade 10 or more. As expected, educational attainment is higher in urban areas than in rural areas. For example, 72 percent of females and 80 percent of males in urban areas have some education, compared with 64 and 71 percent of females and males, respectively, in rural areas. Differences in the median number of years of schooling between urban and rural persons are around two years for females and males. However, the urban-rural gap is narrowing: Figure 2.3 shows that since 1993-1994, education has improved more rapidly among women and men in rural areas than in urban areas. 16 │ Household Population and Housing Characteristics Table 2.4.2 Level of education of household population: men Percent distribution of the de facto male household population age six and over by highest level of education attended or completed, according to background characteristics, Bangladesh 2004 Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number of men Median number of years Age 6-9 15.5 84.0 0.0 0.4 0.0 100.0 2,726 0.1 10-14 8.7 56.4 5.9 29.0 0.0 100.0 3,194 3.1 15-19 13.3 20.0 12.1 45.7 8.9 100.0 2,449 5.0 20-24 15.8 17.4 12.1 30.9 23.8 100.0 1,858 5.3 25-29 27.9 17.1 9.3 25.1 20.6 100.0 1,701 4.4 30-34 34.7 16.5 8.7 20.5 19.5 100.0 1,712 3.8 35-39 40.2 17.2 7.9 17.6 16.8 100.0 1,535 2.3 40-44 43.0 19.2 7.9 18.6 11.2 100.0 1,445 1.3 45-49 41.3 17.5 6.9 19.4 14.8 100.0 1,135 2.1 50-54 42.3 16.4 7.5 16.5 17.3 100.0 879 2.2 55-59 39.4 17.0 7.8 16.9 18.7 100.0 564 2.5 60-64 45.7 20.4 8.4 15.3 10.0 100.0 652 0.3 65+ 50.0 19.0 9.2 13.8 7.9 100.0 1,303 0.0 Residence Urban 20.1 27.3 7.2 25.1 20.2 100.0 4,762 4.2 Rural 28.6 33.8 7.8 21.3 8.5 100.0 16,397 2.1 Division Barisal 18.0 39.3 7.1 22.3 13.0 100.0 1,312 3.2 Chittagong 25.9 33.2 7.4 23.2 10.2 100.0 3,910 2.7 Dhaka 26.9 32.0 7.9 20.8 12.3 100.0 6,640 2.6 Khulna 23.7 30.4 7.0 26.2 12.6 100.0 2,539 3.5 Rajshahi 29.6 31.3 6.6 22.0 10.4 100.0 5,236 2.3 Sylhet 29.8 32.3 12.2 19.0 6.8 100.0 1,522 2.0 Total 26.7 32.3 7.6 22.2 11.1 100.0 21,159 2.7 Note: Total includes seven males missing information on age. Total includes a small proportion missing education level. 1 Primary complete is defined as completing grade 5. 2 Secondary complete or higher is defined as completing grade 10. The proportion of the population that has achieved some education varies among administrative divisions. The proportions of women and men with some education are the highest in Barisal division (75 percent of women and 82 percent of men) and the lowest in Rajshahi and Sylhet divisions (around six in ten women and seven in ten men). The positive impact of different interventions to encourage women to attend school is also evident from the data available through the various surveys. In 2004, 70 percent of women age 15-19 had completed at least primary education, compared with 44 percent in 1993-1994, and 16 percent of women age 20-24 had completed at least secondary education, compared with 9 percent ten years ago. This steady increase in female education has narrowed the gap in education levels between males and females in younger cohorts. In fact, the 2004 BDHS indicates that a higher percentage of women age 15-19 have Household Population and Housing Characteristics │ 17 completed at least primary education, compared with men in the same age group. Nevertheless, men are still more likely than women to have completed secondary school. The difference, however, has narrowed in the last ten years. In 1993-1994, men age 20-24 were 2.3 times more likely than women in the same age group to have completed secondary school; in 2004 this ratio had declined to 1.5 times. 2.3.1 School Attendance Data for school attendance by age group, sex, and place of residence are presented in Table 2.5. In the whole country, more than eight in ten (84 percent) children age 6-10 years are in school. More than two-thirds of children age 11-15 years are attending school. School attendance of both age groups is higher for girls than for boys. Also, boys and girls age 6-15 years are more likely to attend school in rural areas than in urban areas. For those age 16-20, school attendance drops sharply from levels seen at younger ages, and attendance is higher for males than for females, and in urban areas than in rural areas. Table 2.5 School attendance Percentage of the de facto household population age 6-24 years attending school, by age, sex, and residence, Bangladesh 2004 Male Female Total Age Urban Rural Total Urban Rural Total Urban Rural Total 6-10 81.1 83.0 82.6 83.2 86.9 86.2 82.1 84.9 84.4 11-15 63.0 66.9 66.1 65.9 71.3 70.1 64.6 69.2 68.2 6-15 72.6 75.5 74.9 74.0 79.4 78.2 73.3 77.4 76.6 16-20 33.3 29.2 30.2 32.2 22.0 24.4 32.7 25.3 27.0 21-24 26.2 14.5 17.6 11.3 5.1 6.7 17.6 8.8 11.1 Over the last decade, school attendance has increased both for girls and boys in the younger age group (6-15 years), but the increases have been higher for girls than for boys. The data suggest that for 18 │ Household Population and Housing Characteristics those age 16-20, school attendance has actually fallen for males, while for females it has seen a slight increase. 2.4 EMPLOYMENT The 2004 BDHS Household Questionnaire included questions on whether each person age eight and above in the sampled households was working at the time of the survey and how he or she was compensated (or if at all) for work. Table 2.6 shows the percentage of women and men age eight and over working at the time of survey, by age and residence. Men are much more likely than women to be employed, regardless of age group or residence. Overall, 68 percent of men eight years or older are employed, compared with only 15 percent of female household members. Employment is higher in urban than in rural areas for males and females. Female employment rates are highest for women age 25-44; at least one in four women in this age group is working. Half of men age 65 and over are employed. Table 2.6 Employment status Percentage of female and male household population age eight and over working at the time of the survey, by age, sex, and residence, Bangladesh 2004 Female Male Age Urban Rural Total Urban Rural Total 8-9 2.3 0.4 0.8 2.6 2.3 2.3 10-14 10.4 3.1 4.7 19.7 17.6 18.0 15-19 17.7 7.4 9.7 54.5 58.0 57.2 20-24 22.0 15.4 17.0 71.2 79.6 77.5 25-29 26.1 24.9 25.2 89.6 92.5 91.8 30-34 30.7 26.9 27.8 97.8 96.8 97.0 35-39 32.3 26.8 28.1 98.4 98.6 98.6 40-44 31.5 24.5 26.2 97.3 98.2 98.0 45-49 23.1 21.5 21.8 98.1 98.3 98.3 50-54 19.1 14.7 15.5 94.3 94.8 94.7 55-59 12.9 8.7 9.4 86.2 93.8 92.1 60-64 11.3 7.7 8.4 71.6 79.4 77.8 65+ 2.2 4.2 3.9 49.0 53.2 52.5 Total 19.9 13.8 15.2 68.4 67.2 67.5 Number of persons 4,628 16,365 20,994 4,614 16,051 20,665 Table 2.7 presents the percent distribution of employed women and men by type of earnings, according to background characteristics. Almost 80 percent of working women and about 70 percent of the employed men work for cash only. The proportion of employed women who work for cash only is markedly higher for those who have completed secondary education. Employed men in urban areas and those who have completed secondary education are much more likely to be working for cash only. Household Population and Housing Characteristics │ 19 Table 2.7 Form of earnings Percent distribution of currently employed men and women age eight and over by type of earnings (cash, in kind, no payment), according to background characteristics, Bangladesh 2004 Women Men Background characteristic Earns cash only Earns kind only Both cash and kind Not paid Don’t know/ missing Total Number of employed women Earns cash only Earns kind only Both cash and kind Not paid Don’t know/ missing Total Number of employed men Age 8-9 * * * * * 100.0 9 (51.0) (14.0) (7.1) (27.9) (0.0) 100.0 31 10-14 51.7 7.6 35.2 4.5 1.0 100.0 154 58.3 13.3 7.9 20.3 0.2 100.0 589 15-19 76.7 5.0 12.1 5.5 0.7 100.0 319 67.3 16.9 6.7 9.1 0.0 100.0 1,488 20-24 84.6 3.3 8.6 3.5 0.0 100.0 440 75.8 14.7 5.9 3.6 0.0 100.0 1,503 25-29 84.3 5.4 6.9 3.1 0.3 100.0 537 76.4 17.5 5.2 0.8 0.0 100.0 1,644 30-34 82.7 5.5 10.0 1.8 0.0 100.0 500 78.3 16.9 4.4 0.2 0.2 100.0 1,739 35-39 77.1 8.7 11.3 2.4 0.5 100.0 416 76.0 17.4 6.2 0.4 0.0 100.0 1,610 40-44 81.1 6.4 10.1 2.3 0.0 100.0 306 75.8 18.7 5.4 0.0 0.0 100.0 1,494 45-49 76.4 9.2 11.1 3.3 0.0 100.0 242 72.7 20.8 6.4 0.0 0.2 100.0 1,194 50-54 73.8 10.0 14.9 1.3 0.0 100.0 107 69.1 24.5 6.3 0.1 0.0 100.0 876 55-59 64.8 19.1 16.2 0.0 0.0 100.0 65 60.5 32.8 6.7 0.0 0.0 100.0 549 60-64 (61.4) (10.8) (23.6) (4.1) (0.0) 100.0 50 56.2 34.3 9.3 0.1 0.1 100.0 529 65+ (54.7) (6.4 (34.9 (3.9) (0.0) 100.0 37 48.7 39.4 10.9 0.9 0.1 100.0 705 Residence Urban 80.7 2.8 14.9 1.7 0.0 100.0 922 89.3 5.2 3.8 1.6 0.1 100.0 3,157 Rural 77.2 8.1 10.7 3.6 0.3 100.0 2,262 65.8 24.4 7.0 2.8 0.1 100.0 10,793 Division Barisal 71.2 10.1 12.3 5.2 1.1 100.0 110 76.2 16.4 5.7 1.5 0.2 100.0 786 Chittagong 74.6 6.5 13.8 4.6 0.5 100.0 481 75.4 15.9 6.6 2.0 0.1 100.0 2,384 Dhaka 82.2 4.8 9.8 3.0 0.1 100.0 1,071 72.9 20.4 4.4 2.2 0.0 100.0 4,350 Khulna 79.3 6.4 8.8 5.6 0.0 100.0 374 71.7 19.4 5.8 3.0 0.1 100.0 1,799 Rajshahi 78.4 8.1 12.1 1.5 0.0 100.0 965 64.5 23.7 8.3 3.4 0.0 100.0 3,650 Sylhet 65.1 7.7 24.7 1.3 1.3 100.0 183 72.0 19.4 7.1 1.4 0.1 100.0 982 Education No education 73.4 7.8 16.1 2.6 0.1 100.0 1,649 69.6 21.6 7.9 0.8 0.0 100.0 4,858 Primary incomplete 74.8 8.1 12.4 4.2 0.4 100.0 642 69.6 21.0 5.9 3.4 0.1 100.0 3,090 Primary complete 84.3 5.1 7.8 2.8 0.0 100.0 193 67.8 23.6 6.4 2.1 0.0 100.0 1,348 Secondary incomplete 87.4 3.8 3.6 4.5 0.7 100.0 451 69.5 20.2 5.5 4.8 0.1 100.0 2,946 Secondary complete or higher 97.7 0.8 1.1 0.5 0.0 100.0 248 83.5 11.0 3.3 2.0 0.2 100.0 1,702 Wealth index Lowest 69.0 11.3 16.6 3.0 0.1 100.0 839 50.1 18.8 6.6 2.1 0.0 100.0 2,723 Second 82.0 6.0 7.6 4.4 0.1 100.0 688 64.9 24.4 7.8 2.8 0.1 100.0 2,827 Middle 80.7 7.3 7.9 3.7 0.4 100.0 540 65.3 25.9 5.6 3.1 0.0 100.0 2,858 Fourth 85.0 4.5 7.1 3.0 0.4 100.0 482 69.2 22.0 6.2 2.6 0.0 100.0 2,741 Highest 79.1 1.9 17.5 1.2 0.3 100.0 635 83.9 9.0 5.1 1.8 0.2 100.0 2,801 Total 78.2 6.6 11.9 3.1 0.2 100.0 3,184 71.1 20.1 6.3 2.5 0.1 100.0 13,951 Note: Total includes one woman and seven men missing information on education. Figures in parentheses are based on 25-49 unweighted cases; an asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 20 │ Household Population and Housing Characteristics 2.5 HOUSING CHARACTERISTICS In the Household Questionnaire, respondents were asked about characteristics of their house- holds, including access to electricity, source of drinking water, type of sanitation facilities, fuel used for cooking, and main housing materials. Table 2.8 summarizes this information by residence. In Bangladesh, 41 percent of households have access to electricity. Coverage of electricity has increased by 9 percentage points since 1999-2000. There is a wide urban-rural gap with regard to access to electricity, with three in four households in urban areas and less than one in three households in rural areas having electricity. This gap, though wide, has narrowed since 1999-2000. Information on household source of drinking water is important because potentially fatal diseases, including typhoid, cholera, and dysentery, are prevalent in unprotected water sources. Tubewells are the predominant source of drinking water throughout Bangladesh. Almost seven in ten households in urban areas and more than nine in ten households in rural areas obtain drinking water from tubewells. Piped water is accessible only in urban areas; around one-third of urban households drink piped water, mainly piped inside the dwelling. The household drinking water was also tested for levels of arsenic. The results are presented in the last section of this chapter. Access to adequate sanitation facilities is an important determinant of health conditions. Table 2.8 shows that 86 percent of Bangladeshi households have some type of sanitation facility, including 59 percent that have hygienic toilets (septic tank/modern toilets, water-sealed/slab latrines, and pit latrines). As expected, sanitation facilities vary between rural and urban areas. Only 55 percent of rural households have hygienic toilets, compared with 71 percent of urban households. Moreover, 16 percent of rural households have no facility at all, compared with only 4 percent of urban households. A question about fuel used for cooking was also asked in the Household Questionnaire. Two types of fuel are predominantly used for cooking in Bangladesh: wood and crop residue. More than one- third of all households (35 percent) use wood; almost half use crop residue or straw for cooking. In urban areas, wood (40 percent) is the primary fuel used for cooking, followed by liquid gas or gas (31 percent), whereas the majority of rural residents depend on crop residue (56 percent), followed by wood (34 percent). In urban areas, one in five households uses crop residue as fuel for cooking. Tin is the most common roofing material in Bangladesh, accounting for 72 percent of rural households and 86 percent of urban households. However, urban and rural households vary widely in the use of cement or concrete for roofs. In urban areas, 23 percent of households live in dwellings with cement or concrete roofs, while in rural areas only 4 percent of household roofs are made of the same material. Since 1999-2000, tin roofing has become more popular in both urban and rural areas; in rural areas, the use of bamboo or thatch for roofing has declined dramatically. Almost half of all households in Bangladesh live in structures with walls made of natural materials, such as jute, bamboo, or mud. Seventeen percent live in houses with brick or cement walls, and 34 percent live in houses with tin walls. Tin as a material for walls has become almost twice as popular both in urban and rural areas in 2004 compared with 1999-2000. Urban households live in more solid dwellings than rural households. More than four in ten urban households live in structures with brick or cement walls, compared with only 9 percent of rural households. Household Population and Housing Characteristics │ 21 Table 2.8 Household characteristics Percent distribution of households by household characteristics, according to residence, Bangladesh 2004 Residence Household characteristic Urban Rural Total Electricity Yes 76.6 30.4 40.6 No 23.4 69.5 59.4 Total 100.0 100.0 100.0 Source of drinking water Piped inside dwelling 23.3 0.0 5.1 Piped outside dwelling 7.8 0.1 1.8 Tubewell 65.5 92.9 86.8 Shallow tubewell 0.1 0.3 0.3 Deep tubewell 2.4 3.2 3.0 Surface well/other well 0.1 1.2 1.0 Pond/tank/lake 0.8 1.9 1.6 River/stream 0.1 0.4 0.3 Total 100.0 100.0 100.0 Sanitation facility Septic tank/modern toilet 29.5 3.2 9.0 Water-sealed/slab latrine 18.5 12.8 14.1 Pit latrine 23.1 39.0 35.5 Open latrine 23.0 26.7 25.9 Hanging latrine 1.7 1.9 1.9 No facility/bush/field 4.2 16.4 13.7 Total 100.0 100.0 100.0 Cooking fuel Wood 40.2 34.0 35.3 Crop residue 20.2 56.3 48.3 Dung cakes 5.5 8.8 8.1 Liquid gas/gas 30.9 0.5 7.2 Other 3.2 0.4 1.0 Total 100.0 100.0 100.0 Main roof material Katcha (bamboo/thatch) 4.2 9.7 8.5 Tin 72.1 86.4 83.3 Cement, concrete, or tile 23.4 3.8 8.1 Total 100.0 100.0 100.0 Main wall material Jute/bamboo/mud (katcha) 30.1 52.5 47.6 Wood 1.2 1.8 1.6 Brick/cement 44.4 9.2 16.9 Tin 24.3 36.5 33.8 Total 100.0 100.0 100.0 Floor material Earth/bamboo (katcha) 52.5 93.7 84.6 Wood 1.5 0.2 0.5 Cement/concrete 45.9 5.9 14.7 Total 100.0 100.0 100.0 Food consumption Deficit in whole year 8.5 13.4 12.3 Sometimes deficit 29.5 38.6 36.6 Neither deficit nor surplus 42.9 35.2 36.9 Surplus 19.1 12.8 14.2 Total 100.0 100.0 100.0 Number of households 2,306 8,194 10,500 22 │ Household Population and Housing Characteristics The type of material used for flooring is an indicator of economic standing of the household as well as an indicator of potential exposure to disease-causing agents. The most commonly used floor materials in Bangladesh are earth or bamboo. The other floor materials used in the country are cement or concrete. Forty-six percent of urban households have cement floors; earth flooring is almost universal in rural areas (94 percent). In order to get a measure of a household’s economic vulnerability, the Household Questionnaire asked respondents whether they thought their household was a surplus or deficit household in terms of food consumption. One in eight households seems to experience food deficit throughout the year, while almost half of the households face food deficit at least some time in the year. Rural households are more likely than urban households to face food deficit at least sometimes in the year (52 versus 38 percent). Since 1999-2000, economic vulnerability, measured in terms of food deficit faced by the households, seems to have decreased. About 18 percent of respondents in 1999-2000 reported that their household faced food shortages throughout the year, compared with 12 percent in 2004. 2.6 HOUSEHOLD POSSESSIONS Information on possession of durable goods, a homestead, and land is presented in Table 2.9. Ownership of a radio or television is a measure of access to mass media; telephone ownership measures access to efficient communication; and bicycle and motorcycle ownership is a measure of access to means of transportation. In general, ownership of these items has a bearing on households’ access to information and health; along with other data, this information can also be used to rank households according to economic status. Table 2.9 Household durable goods and land ownership Percentage of households possessing various durable consumer goods, and ownership of land, according to residence, Bangladesh 2004 Residence Ownership Urban Rural Total Durable goods Almirah or wardrobe 46.9 24.1 29.1 Table 65.5 61.5 62.3 Chair/bench 67.9 63.7 64.7 Watch/clock 79.3 62.2 66.0 Cot/bed 93.5 91.1 91.7 Radio 36.5 28.6 30.4 Television 49.1 15.5 22.9 Bicycle 18.3 25.8 24.2 Motorcycle 4.0 1.3 1.9 Sewing machine 12.6 3.3 5.4 Telephone 15.6 1.8 4.8 None of the above 4.0 5.7 5.3 Land ownership Owns a homestead 90.2 95.5 94.3 Owns other land 38.5 56.3 52.4 Neither of the above 9.0 4.0 5.1 Number of households 2,306 8,194 10,500 Household Population and Housing Characteristics │ 23 More than 90 percent of households in urban and rural areas own a cot or bed. More than 60 percent of households own a watch or clock, a chair or bench, or a table. Almost 30 percent have an almirah or wardrobe. The urban-rural differentials in ownership of the above durable goods are small except for ownership of a watch or clock, or an almirah, which is markedly higher in urban areas. Thirty percent of households have radios, and 23 percent have a television. As for the two items of means of transportation, 24 percent of households own a bicycle, and 2 percent own a motorcycle. Only 1 in 20 households has a telephone or a sewing machine. Rural households are more likely to own bicycles than are urban households. Not surprisingly, urban households are more likely to own televisions, radios, telephones, motorcycles, and sewing machines. Ownership of almost all durable consumer goods has increased in rural areas since 1999-2000, in urban areas, there has been no increase in ownership of various items and for some items, a smaller proportion of households own the item. For example, ownership of radios in urban areas has decreased from 45 to 37 percent, while it has remained unchanged in rural areas at 29 percent. In rural areas, the proportion of households with television has increased from 10 to 16 percent, whereas television penetration in urban areas is at 49 percent, the same as in 1999-2000. Respondents were also asked about their household’s ownership of a house and other land. Ninety-four percent of households own a homestead, and slightly more than half own land other than a homestead. Ownership of a homestead or land is less common in urban areas than in rural areas. In the past four years, ownership of a homestead has increased by almost 10 percentage points from 81 to 90 percent in urban areas and from 88 to 96 percent in rural areas. 2.7 WEALTH INDEX In this report, an index of household economic status was created and used as a background characteristic with information on household ownership of assets and use of selected services.1 The economic status index used here was developed and tested in a large number of countries in relation to inequities in household income, use of health services, and health outcomes (Gwatkin et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The wealth index was constructed using principal components analysis (Rutstein and Johnson, 2004). Asset information was collected with the 2004 BDHS Household Questionnaire and covered information on household ownership of a number of consumer items, ranging from a television to a bicycle, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and type of material used for flooring. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed for the whole sample; indexes were not prepared for urban and rural populations. 1 Variables include ownership of items listed in Table 2.9, except homestead; household characteristics in Table 2.8, except food consumption; and whether a household has at least one domestic worker. 24 │ Household Population and Housing Characteristics 2.8 ARSENIC IN HOUSEHOLD DRINKING WATER Arsenic in drinking water is a hazard to human health. It has attracted much attention since recognition in the 1990s of its wide occurrence in well water in Bangladesh. The main source of arsenic in drinking water is arsenic-rich rocks through which the water has filtered. It may also occur because of mining or industrial activity in some areas. In Bangladesh, water is considered to have an unsafe level of arsenic if the measured level of arsenic is equal to or greater than 50 parts per billion (ppb). A public health program has been undertaken throughout Bangladesh to test tubewell water for arsenic levels. The tubewells that have had their water tested are marked either red or green; a red mark means its water has an unsafe level of arsenic, and green implies that the water is not highly contaminated with arsenic. In addition, mass media communication strategies have been used to make communities aware of the importance of avoiding drinking arsenic- contaminated water. The Bangladesh Arsenic Mitigation Water Supply Project (BAMWSP) reports that 29 percent of the 4.9 million tubewells tested using Aqua kit had arsenic contamination at or greater than 50 ppb (BAMWSP). BAMWSP’s indicator, “proportion of tubewells having arsenic-contaminated water” provides only an indication of the proportion of the population exposed to arsenic-contaminated water—it is not an actual measure of the proportion of households consuming arsenic-contaminated water. To provide such an estimate for Bangladesh, specially trained interviewers tested the household drinking water using Hach’s EZ Arsenic Kit.2 Household drinking water was tested in 10,465 of the 10,500 households surveyed. In addition, the survey collected information on respondents’ awareness of the significance of arsenic in water and of the meaning of the color marking on the tubewells for those obtaining drinking water from a tubewell. The results show that, overall, 84 percent of household respondents had heard about the problem of arsenic in water. This included 75 to 78 percent of households in Barisal, Sylhet, and Rajshahi divisions and more than 90 percent in Dhaka and Khulna divisions (Figure 2.4). The awareness of the problem of arsenic in water increases from 69 percent among households in the lowest wealth quintile to 97 percent among those in the highest quintile. 2 Respondents to the Household Questionnaire were asked to provide a glass of the water that the household uses for drinking. Interviewers poured 50 milliliters of that water into a special testing vessel, added two reagents in the prescribed order, and quickly closed the vessel with a lid to which a testing strip was attached. Twenty minutes later, the testing strip was removed and matched with a color chart to determine the level of arsenic in the water. Household Population and Housing Characteristics │ 25 Table 2.10 shows that one in twelve households had elevated arsenic levels (equal to or greater than 50 ppb) in their drinking water on the day of the interview. Overall, households in Chittagong division, followed by Sylhet division, are most likely to have arsenic-contaminated drinking water (22 and 12 percent, respectively). Arsenic levels are not associated with wealth index quintile. Although households in the highest wealth quintile are least likely to drink water with high arsenic levels, those in the fourth quintile are most likely to have arsenic in their drinking water. According to Table 2.11, households with higher levels of arsenic in drinking water are more likely to be aware of the problem. 26 │ Household Population and Housing Characteristics Table 2.10 Level of arsenic in household drinking water Percent distribution of households by level of arsenic in drinking water, according to background characteristics, Bangladesh 2004 Level of arsenic (parts per billion) Background characteristic <50 ≥50 Total Number of households tested for arsenic Residence Urban 93.1 6.9 100.0 2,293 Rural 91.1 8.9 100.0 8,173 Division Barisal 98.7 1.3 100.0 631 Chittagong 78.0 22.0 100.0 1,811 Dhaka 92.3 7.7 100.0 3,357 Khulna 93.1 6.9 100.0 1,288 Rajshahi 97.7 2.3 100.0 2,748 Sylhet 88.5 11.5 100.0 630 Source of drinking water1 Piped into residence 99.2 0.8 100.0 535 Piped outside residence 98.1 1.9 100.0 189 Tubewell 90.4 9.6 100.0 9,089 Shallow tubewell (89.1) (10.9) 100.0 27 Deep tubewell 99.1 0.9 100.0 317 Surface well, pond, lake, river or stream 99.1 0.9 100.0 308 Wealth index Lowest 90.7 9.3 100.0 2,360 Second 92.1 7.9 100.0 2,203 Middle 90.6 9.4 100.0 2,021 Fourth 90.3 9.7 100.0 1,951 Highest 93.9 6.1 100.0 1,930 Heard of arsenic Yes 90.3 9.7 100.0 8,781 No 97.9 2.1 100.0 1,664 Total 91.5 8.5 100.0 10,465 Note: Total includes 20 households missing information on “heard of arsenic”; they are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Water that was used for arsenic testing Table 2.11 presents data on households that obtain their drinking water from tubewells. Six out of ten of these households reported that the tubewells they use for drinking water are not marked. A puzzling finding was that almost half (45 percent) of the households that obtain drinking water from a red-marked tubewell did not have unsafe levels of arsenic when their drinking water was tested. This may indicate that arsenic levels can vary over time, or that there was some error in the original marking of the tubewell, or that there were measurement errors associated with the use of the test kits. Household Population and Housing Characteristics │ 27 Table 2.11 Arsenic levels and knowledge of arsenic and markings on tubewells Percent distribution of households that obtain their drinking water from tubewells by level of arsenic in water, according to whether they had heard of arsenic in drinking water and the reported marking on the tubewell used by the household for drinking water, Bangladesh 2004 Level of arsenic (ppb) Knowledge of arsenic/ marking on tubewell <50 ≥50 Total Number of households tested Heard of arsenic Yes 89.3 10.7 100.0 7,890 No 97.7 2.3 100.0 1,517 Marking on tubewell Red 45.2 54.8 100.0 614 Green 94.0 6.0 100.0 2,962 Not marked 93.6 6.4 100.0 5,611 Don’t know 95.8 4.2 100.0 241 Total 90.7 9.3 100.0 9,427 Note: Table includes 19 households with missing information on awareness of arsenic in drinking water. ppb = parts per billion The results of the 2004 BDHS and BAMWSP water testing efforts suggest a need to explore the following possibilities: (1) Awareness of unsafe levels of arsenic in drinking water may have caused some households to shift to safer sources of water. (2) Arsenic levels in water may be different when measured directly from the source and after storage of the same water. It is thought that iron in water may reduce the arsenic in stored water. (The International Centre for Diarrhoeal Disease Research, Bangladesh [ICDDR,B] is currently testing this hypothesis in Matlab.) (3) Measurements of arsenic levels in water vary over time. Tests of water from the same source can show different levels of arsenic when measured on different dates; results in Table 2.11 indicate some support for this statement. Characteristics of Survey Respondents │ 29 CHARACTERISTICS OF SURVEY RESPONDENTS 3 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Information on the basic characteristics of women and men interviewed in the survey is essential for the interpretation of findings presented later in the report. The 2004 BDHS interviewed 11,440 ever- married women under the age of 50 years, and 4,297 men in the age group 15-54 for information on individual respondents. Table 3.1.1 shows the distribution of ever-married and currently married women respondents by various background characteristics. More than nine in ten (93 percent) ever-married women under 50 years of age are currently married; almost three in four women reported having a marriage certificate. The age distribution of ever-married women is very similar to that found in the last three BDHS surveys; a little more than half are under 30 years of age. Twenty-three percent of the women live in urban areas. The distribution of female respondents by division is similar to that of the 1999-2000 BDHS. Nearly one-third live in Dhaka and about one-quarter in Rajshahi. Eighteen percent of the women respondents live in Chittagong and 12 percent in Khulna. The proportion of respondents from Sylhet and Barisal are smaller─6 percent from each division. There has been an increase in women’s educational attainment. The percentage of ever-married women with at least some secondary education has increased from 18 percent in 1996-1997 to 29 percent in 2004. On the other hand, the 2004 BDHS shows that about 40 percent of female respondents still have no education. Nine out of ten women are Muslim, with most of the remainder being Hindu. The 2004 BDHS interviewed both never-married and ever-married men in the age group 15-54 by randomly selecting one eligible man in every other household included in the sample for the 2004 survey. The 2004 survey is the first of the four BDHS surveys to include never-married men in the sample. About one-third of the male respondents in the 2004 BDHS have never married. The distribution of the male respondents by background characteristics is presented in Table 3.1.2. About 25 percent of the ever- married male respondents are in age group 15-29, compared with 95 percent of the never-married males. Less than 2 percent of the ever-married males are divorced, separated or widowed, compared to nearly 8 percent of the female respondents. The urban-rural distribution of ever-married males is similar to the urban-rural distribution of female respondents. However, the proportion of never-married men living in urban areas is slightly higher (26 percent) than the proportion of ever-married men (23 percent). The distribution of ever-married male respondents by administrative division shows that Dhaka (31 percent) and Rajshahi (29 percent) have the largest proportions of respondents, while Sylhet and Barisal have the smallest proportions. The distribution by division of never-married men is slightly different. The largest proportion of never- married male respondents is in Dhaka (31 percent), followed by Chittagong (21 percent) and Rajshahi (20 percent). About three in ten ever-married men have at least some secondary education, while another three in ten have no education. The educational attainment of never-married men is higher than ever-married men, perhaps because most of the never-married men belong to a relatively younger cohort; never- married men are almost twice as likely to have at least some secondary education compared to ever- married men. The distribution of male respondents by religion is similar to that of the women respondents; nine out of ten respondents are Muslims. 30 │ Characteristics of Survey Respondents Table 3.1.1 Background characteristics of respondents: women Percent distribution of ever-married women and currently married women age 10-49, by selected background characteristics, Bangladesh 2004 Ever-married women Currently married women Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted Number Age 10-14 1.3 150 140 1.4 145 136 15-19 14.0 1,598 1,563 14.5 1,536 1,498 20-24 19.2 2,202 2,202 20.0 2,121 2,112 25-29 17.6 2,013 2,012 18.3 1,935 1,929 30-34 15.7 1,793 1,783 15.9 1,683 1,673 35-39 12.7 1,457 1,480 12.4 1,309 1,330 40-44 10.1 1,160 1,185 9.3 982 1,005 45-49 9.3 1,066 1,075 8.2 870 870 Marital status Married 92.5 10,582 10,553 100.0 10,582 10,553 Divorced, separated or widowed 7.5 858 887 na na na Has marriage certificate Yes 73.1 8,360 8,234 73.8 7,810 7,675 No 26.9 3,073 3,198 26.2 2,768 2,874 Residence Urban 22.6 2,586 3,904 22.4 2,372 3,578 Rural 77.4 8,854 7,536 77.6 8,210 6,975 Division Barisal 6.3 719 1,360 6.4 674 1,271 Chittagong 17.8 2,041 2,069 17.7 1,877 1,898 Dhaka 31.2 3,570 2,589 31.3 3,315 2,399 Khulna 12.2 1,397 1,708 12.2 1,296 1,587 Rajshahi 26.2 2,994 2,564 26.3 2,782 2,376 Sylhet 6.3 719 1,150 6.0 638 1,022 Education No education 41.2 4,713 4,419 39.6 4,187 3,896 Primary incomplete 20.5 2,348 2,327 20.6 2,176 2,152 Primary complete 8.8 1,011 1,054 9.1 958 996 Secondary incomplete 22.2 2,541 2,648 23.2 2,457 2,547 Secondary complete or higher 7.2 827 992 7.6 804 962 Religion Islam 90.1 10,310 10,182 90.0 9,524 9,389 Hinduism 9.0 1,032 1,192 9.1 961 1,100 Buddhism 0.1 12 13 0.1 11 12 Christianity 0.7 80 47 0.8 80 46 Other/none/missing 0.1 6 6 0.1 6 6 Total 100.0 11,440 11,440 100.0 10,582 10,553 na = Not applicable Characteristics of Survey Respondents │ 31 Table 3.1.2 Background characteristics of respondents: men Percent distribution of ever-married men and never-married men age 15-54, by selected background characteristics, Bangladesh 2004 Ever-married men Never-married men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted Number Age 15-19 1.0 28 30 53.9 794 586 20-24 8.0 227 237 29.4 433 336 25-29 14.7 416 431 11.7 173 150 30-34 17.7 499 604 3.6 53 46 35-39 16.1 456 582 1.3 19 11 40-44 17.4 491 579 0.1 1 1 45-49 16.4 464 474 0.1 1 2 50-54 8.6 242 228 0.0 0 0 Marital status Never married na na na 100.0 1,474 1,132 Married 98.5 2,780 3,133 na na na Divorced, separated or widowed 1.5 43 32 na na na Residence Urban 23.3 657 1,106 26.1 385 408 Rural 76.7 2,166 2,059 73.9 1,090 724 Division Barisal 5.3 148 329 5.2 77 123 Chittagong 15.1 426 474 21.2 313 236 Dhaka 31.2 880 752 31.4 462 260 Khulna 13.8 388 524 12.5 184 174 Rajshahi 29.0 819 803 20.0 295 196 Sylhet 5.7 160 283 9.7 143 143 Education No education 31.2 879 964 12.1 178 124 Primary incomplete 30.1 850 950 20.5 302 243 Primary complete 7.6 213 228 8.9 131 94 Secondary incomplete 18.0 508 576 36.4 537 391 Secondary complete or higher 13.2 372 447 22.2 327 280 Religion Islam 89.4 2,523 2,822 88.3 1,302 999 Hinduism 9.8 276 328 10.3 152 122 Buddhism 0.0 1 2 0.1 2 3 Christianity 0.7 21 11 1.1 16 7 Other/none/missing 0.8 24 15 1.3 20 11 Total 100.0 2,823 3,165 100.0 1,474 1,132 1 na = Not applicable Because the men interviewed in the BDHS survey were selected from a sub-sample of households in which ever-married women were interviewed, it is possible to match married male respondents with their wives to obtain a set of matched couples. Figure 3.1 shows the husband-wife differential in age for 2,533 couples. It is not surprising that for almost all couples, the husband is older than the wife, because it is the tradition in Bangladesh. However, it is noteworthy that the husband is at least ten years older than the wife among 44 percent of the couples, including 13 percent in which the wife is at least 15 years younger than the husband. 32 │ Characteristics of Survey Respondents 3.2 EDUCATIONAL ATTAINMENT Tables 3.2.1 and 3.2.2 present the distributions of female and male respondents, respectively, by the highest level of education completed or attended, according to age, urban-rural residence, division, and wealth index. A large majority of females and a majority of male respondents have not gone beyond the primary level of education. Generally, younger persons have reached higher levels of schooling than older people, as have urban residents. For example, 40 percent of women in urban areas have attended at least some secondary school, compared with 26 percent of rural women. Among the divisions, Barisal division has the largest and Sylhet division the lowest proportion of women and men who have completed secondary school. The educational level of women in Sylhet is worrisome, as a majority of women reported that they did not attend school at all, and only 17 percent of women had attended or completed secondary education. As expected, the level of education increases with the wealth index. For example, among women and men in the lowest quintile, only 6 and 12 percent, respectively, have at least some secondary education, compared with almost 60 percent of women and 70 percent of men in the highest quintile. Characteristics of Survey Respondents │ 33 Table 3.2.1 Level of education by background characteristics: women Percent distribution of ever-married women by highest level of schooling attended or completed, and median number of years of schooling, according to background characteristics, Bangladesh 2004 Highest level of schooling attended or completed Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number of women Median years of schooling Age 10-14 12.3 20.5 18.7 48.4 0.0 100.0 150 4.6 15-19 15.3 22.5 10.7 46.2 5.2 100.0 1,598 4.7 20-24 26.5 19.4 9.7 32.2 12.2 100.0 2,202 4.3 25-29 41.4 21.0 9.2 18.5 9.9 100.0 2,013 1.6 30-34 49.4 22.0 7.7 14.4 6.5 100.0 1,793 0.0 35-39 55.7 21.2 6.7 11.5 5.0 100.0 1,457 0.0 40-44 57.3 17.9 8.0 12.4 4.4 100.0 1,160 0.0 45-49 62.8 18.4 8.1 7.4 3.3 100.0 1,066 0.0 Residence Urban 33.0 18.8 8.0 25.0 15.2 100.0 2,586 3.7 Rural 43.6 21.0 9.1 21.4 4.9 100.0 8,854 1.1 Division Barisal 25.3 27.3 13.3 24.5 9.5 100.0 719 3.7 Chittagong 40.4 18.3 8.8 24.4 8.2 100.0 2,041 2.4 Dhaka 42.1 19.8 9.0 20.3 8.8 100.0 3,570 1.5 Khulna 32.9 23.7 7.7 28.9 6.7 100.0 1,397 3.2 Rajshahi 45.4 20.9 6.9 21.4 5.4 100.0 2,994 0.5 Sylhet 53.0 16.3 13.7 13.5 3.5 100.0 719 0.0 Wealth index Lowest 67.9 21.0 4.8 6.1 0.2 100.0 2,279 0.0 Second 51.9 24.4 7.5 14.9 1.3 100.0 2,290 0.0 Middle 40.1 23.9 9.1 23.6 3.2 100.0 2,267 1.9 Fourth 28.9 19.9 13.0 30.6 7.6 100.0 2,307 4.1 Highest 17.4 13.5 9.6 35.7 23.7 100.0 2,297 6.3 Total 41.2 20.5 8.8 22.2 7.2 100.0 11,440 1.8 1 Primary complete is defined as completing grade 5 2 Secondary complete is defined as completing grade 10 Regarding educational differences between spouses, in half of the couples both have some education, and in one in five couples the wife has no education and neither does the husband (Figure 3.2). As in 1999-2000, for three in ten couples, only one partner is educated. However, there is a slight decrease in the proportion of couples in which only the husband is educated. 34 │ Characteristics of Survey Respondents Table 3.2.2 Level of education by background characteristics: men Percent distribution of men by highest level of schooling attended or completed, and median number of years of schooling, according to background characteristics, Bangladesh 2004 Highest level of schooling attended or completed Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number of men Median years of schooling Age 15-19 12.0 21.6 10.7 43.4 12.5 100.0 822 6.5 20-24 15.0 28.9 8.8 23.4 23.8 100.0 660 4.7 25-29 24.0 24.6 6.5 24.6 20.3 100.0 589 4.2 30-34 29.8 26.6 7.1 21.8 14.8 100.0 552 3.0 35-39 34.6 28.2 7.4 13.8 16.0 100.0 475 1.4 40-44 31.6 31.5 8.1 17.9 10.9 100.0 491 2.1 45-49 33.8 27.7 5.2 18.1 15.2 100.0 465 1.7 50-54 31.9 30.7 9.2 13.0 15.2 100.0 242 2.2 Residence Urban 18.5 22.2 7.5 25.2 26.6 100.0 1,042 6.0 Rural 26.6 28.3 8.2 24.1 12.9 100.0 3,255 3.2 Division Barisal 13.2 31.4 5.7 26.3 23.4 100.0 225 4.9 Chittagong 25.2 26.7 7.6 23.7 16.8 100.0 739 3.6 Dhaka 27.2 23.7 8.7 24.7 15.7 100.0 1,342 3.8 Khulna 18.8 27.5 9.7 26.6 17.4 100.0 573 4.4 Rajshahi 27.6 27.4 6.5 22.4 16.1 100.0 1,114 3.2 Sylhet 20.4 33.4 10.6 25.6 10.0 100.0 304 3.6 Wealth index Lowest 49.5 34.0 4.4 10.5 1.6 100.0 717 0.0 Second 33.4 34.7 7.8 18.4 5.6 100.0 869 1.5 Middle 22.6 29.3 11.6 25.6 10.9 100.0 846 3.8 Fourth 16.5 24.0 8.0 32.9 18.6 100.0 892 6.1 Highest 7.5 14.9 7.8 30.8 38.9 100.0 973 9.3 Total 24.6 26.8 8.0 24.3 16.2 100.0 4,297 3.8 1 Primary complete is defined as completing grade 5 2 Secondary complete is defined as completing grade 10 Characteristics of Survey Respondents │ 35 3.3 EXPOSURE TO MASS MEDIA Information access is essential to increase people’s knowledge and awareness of what is taking place around them, which may affect their perceptions and behavior. In the survey, exposure to media was assessed by asking respondents how frequently they read a newspaper, watched television, or listened to a radio. It is important to know the subgroups that are more or less likely to be reached by the media for purposes of planning programs intended to spread information about health and family planning. Tables 3.3.1 and 3.3.2 show the percentage of female and male respondents, respectively, who are exposed to different types of mass communication media, by background variables. Table 3.3.1 Exposure to mass media: women Percentage of ever-married women who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Bangladesh 2004 Background characteristic No media Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media Number of women Age 10-14 32.4 4.8 49.0 48.1 2.9 150 15-19 31.8 7.7 52.7 44.6 3.6 1,598 20-24 33.7 9.3 53.7 38.7 4.9 2,202 25-29 38.9 7.5 49.3 32.9 3.1 2,013 30-34 44.5 5.8 43.7 30.4 2.1 1,793 35-39 46.6 5.5 40.4 28.7 1.9 1,457 40-44 50.5 6.2 38.0 27.0 2.2 1,160 45-49 59.4 3.7 29.1 22.8 1.2 1,066 Residence Urban 21.5 15.4 72.6 33.4 5.5 2,586 Rural 47.7 4.3 37.7 33.4 2.2 8,854 Division Barisal 49.4 7.4 29.2 36.7 3.3 719 Chittagong 41.5 7.4 45.5 35.1 3.4 2,041 Dhaka 36.2 8.1 53.3 33.4 3.0 3,570 Khulna 38.0 6.6 48.9 37.2 3.1 1,397 Rajshahi 46.2 4.8 40.9 31.4 2.2 2,994 Sylhet 51.4 7.4 37.3 25.6 3.8 719 Education No education 58.9 0.0 30.1 23.4 0.0 4,713 Primary incomplete 43.3 0.7 43.0 34.2 0.3 2,348 Primary complete 33.7 3.4 50.8 38.4 1.6 1,011 Secondary incomplete 22.8 13.3 63.0 45.5 6.7 2,541 Secondary complete or higher 7.4 47.7 81.1 44.8 17.2 827 Wealth index Lowest 71.7 0.3 19.4 16.2 0.1 2,279 Second 56.7 1.1 28.9 28.5 0.5 2,290 Middle 41.9 2.9 38.7 37.4 1.3 2,267 Fourth 27.2 6.5 58.2 44.7 3.3 2,307 Highest 11.7 23.4 82.3 39.9 9.5 2,297 Total 41.8 6.8 45.6 33.4 2.9 11,440 36 │ Characteristics of Survey Respondents Table 3.3.2 Exposure to mass media: men Percentage of men who usually read a newspaper at least once a week, watch television at least once a week, and listen to the radio at least once a week, by background characteristics, Bangladesh 2004 Background Characteristic No media Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media Number of men Age 15-19 8.1 37.8 82.6 62.7 20.3 822 20-24 8.9 42.2 83.2 58.1 21.1 660 25-29 13.8 34.0 75.1 52.9 16.7 589 30-34 18.9 32.7 69.5 49.2 17.3 552 35-39 19.5 28.9 67.9 46.8 14.7 475 40-44 22.5 30.8 63.7 44.3 14.4 491 45-49 31.5 25.3 55.4 43.7 12.9 465 50-54 32.4 28.8 48.8 40.1 12.9 242 Residence Urban 9.3 50.8 84.3 45.8 21.4 1,042 Rural 19.8 28.2 67.2 53.6 15.6 3,255 Division Barisal 20.8 34.6 59.4 58.3 20.5 225 Chittagong 11.9 35.7 79.1 53.8 15.9 739 Dhaka 19.2 30.9 68.9 49.3 15.0 1,342 Khulna 15.3 44.6 74.8 56.9 27.0 573 Rajshahi 19.2 29.3 69.0 49.6 14.2 1,114 Sylhet 15.0 35.8 74.2 50.6 17.8 304 Education No education 35.3 0.2 51.9 42.6 0.1 1,057 Primary incomplete 21.8 11.4 65.9 51.6 5.5 1,152 Primary complete 10.1 42.8 76.9 55.9 18.3 345 Secondary incomplete 5.9 53.3 84.7 57.6 28.7 1,045 Secondary complete or higher 2.7 87.0 86.9 55.0 43.7 698 Wealth index Lowest 35.8 9.0 48.9 43.9 4.2 717 Second 24.7 15.7 61.9 48.0 8.0 869 Middle 16.7 30.4 68.2 55.3 13.6 846 Fourth 10.4 39.2 79.9 57.4 23.5 892 Highest 3.5 65.7 91.1 52.5 31.5 973 Total 17.2 33.7 71.3 51.7 17.0 4,297 For both men and women, exposure to television is higher than exposure to radio or newspapers. Exposure to any media varies by gender; men are more likely to be exposed to any type of mass media than women (Figure 3.3). Seven percent of women and 34 percent of men read newspapers at least once a week, 46 percent of women and 71 percent of men watch television at least once a week, and 33 percent of women and 52 percent of men listen to the radio once a week. Only 3 percent of women and 17 percent of men are exposed to all three of these media sources. Forty-two percent of women and 17 percent of men have no access to mass media. Since 1999-2000, the proportion of women listening to the radio has increased moderately but it is still below the 1996-97 survey level. However, the exposure to television continues to increase substantially during the same period─around 30 percent during each interval between the surveys. On the other hand, in spite of progress in women’s education, the proportion of ever-married women who reported reading newspapers has declined. Characteristics of Survey Respondents │ 37 Although listening to the radio is more common among rural men than urban men, it is no surprise that urban residents are more likely to have access to television than rural residents. Exposure to television is found to be the least in Barisal division compared with the other administrative divisions. Listening to the radio and watching television are both negatively related to respondent’s age. Exposure to media is positively associated with educational attainment; the proportion with access to all three media outlets increases with increasing educational level of respondents. Similarly, access to all three media outlets increases as wealth increases for both sexes. 3.4 EMPLOYMENT 3.4.1 Employment Status The BDHS asked respondents whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. Tables 3.4.1 and 3.4.2 show that 22 percent of ever-married women and 87 percent of men are currently employed. Most men and women who are employed work year-round. 38 │ Characteristics of Survey Respondents Table 3.4.1 Employment status: women Percent distribution of ever-married women by employment status and continuity of employment, according to background characteristics, Bangladesh 2004 Currently employed Background characteristic Not employed Work all year Work seasonally Work occasionally Total Number of women Age 10-14 95.6 4.2 0.2 0.0 100.0 150 15-19 90.1 7.1 1.7 1.0 100.0 1,598 20-24 82.9 12.9 2.4 1.6 100.0 2,202 25-29 74.8 19.0 4.0 2.1 100.0 2,013 30-34 71.0 23.4 3.7 1.9 100.0 1,793 35-39 71.6 22.5 4.2 1.7 100.0 1,457 40-44 71.8 23.3 3.6 1.2 100.0 1,160 45-49 77.4 18.1 2.7 1.7 100.0 1,066 Residence Urban 74.4 21.6 2.2 1.9 100.0 2,586 Rural 78.7 16.3 3.4 1.6 100.0 8,854 Division Barisal 86.8 9.5 2.1 1.4 100.0 719 Chittagong 84.3 11.6 3.1 1.0 100.0 2,041 Dhaka 77.3 18.3 2.9 1.5 100.0 3,570 Khulna 76.3 17.2 3.7 2.8 100.0 1,397 Rajshahi 71.6 23.0 3.6 1.8 100.0 2,994 Sylhet 80.7 15.7 2.5 1.1 100.0 719 Education No education 70.7 22.8 4.6 1.9 100.0 4,713 Primary incomplete 78.5 15.8 3.1 2.5 100.0 2,348 Primary complete 85.4 11.3 2.2 1.2 100.0 1,011 Secondary incomplete 86.4 11.0 1.6 1.0 100.0 2,541 Secondary complete or higher 79.7 19.2 0.7 0.4 100.0 827 Wealth index Lowest 70.5 20.4 6.5 2.6 100.0 2,279 Second 73.6 20.6 3.7 2.1 100.0 2,290 Middle 78.3 17.7 2.8 1.2 100.0 2,267 Fourth 83.2 13.7 1.8 1.2 100.0 2,307 Highest 82.9 15.1 1.0 1.0 100.0 2,297 Total 77.7 17.5 3.1 1.6 100.0 11,440 The proportion currently employed among both men and women increases with age, and then plateaus after age 30. The lower employment among men under 25 is probably because many of them are enrolled in schools and colleges. Characteristics of Survey Respondents │ 39 Table 3.4.2 Employment status: men Percent distribution of men by employment status and continuity of employment, according to background characteristics, Bangladesh 2004 Currently employed Background characteristic Not employed Work all year Work seasonally Work occasionally Total Number of men Age 15-19 40.7 47.3 7.6 4.4 100.0 822 20-24 20.8 67.8 8.5 2.9 100.0 660 25-29 6.7 80.5 9.6 3.2 100.0 589 30-34 3.0 86.9 8.1 2.0 100.0 552 35-39 0.9 89.0 8.7 1.2 100.0 475 40-44 1.8 89.7 7.3 1.2 100.0 491 45-49 2.8 88.9 7.4 0.9 100.0 465 50-54 0.9 91.5 6.2 1.3 100.0 242 Residence Urban 15.5 77.7 3.8 2.9 100.0 1,042 Rural 12.1 76.2 9.4 2.3 100.0 3,255 Division Barisal 16.3 74.4 6.4 2.9 100.0 225 Chittagong 15.4 72.3 10.5 1.8 100.0 739 Dhaka 14.3 75.2 7.3 3.2 100.0 1,342 Khulna 12.4 79.0 7.7 0.8 100.0 573 Rajshahi 9.1 80.3 7.8 2.8 100.0 1,114 Sylhet 13.7 76.0 8.3 1.9 100.0 304 Education No education 2.3 87.2 8.4 2.2 100.0 1,057 Primary incomplete 3.0 83.4 10.3 3.2 100.0 1,152 Primary complete 5.5 82.7 11.0 0.9 100.0 345 Secondary incomplete 25.3 64.5 7.1 3.1 100.0 1,045 Secondary complete or higher 30.7 64.2 3.9 1.2 100.0 698 Wealth index Lowest 3.7 84.1 10.3 1.9 100.0 717 Second 6.4 79.9 9.1 4.6 100.0 869 Middle 10.4 77.3 9.5 2.6 100.0 846 Fourth 19.2 71.3 7.8 1.7 100.0 892 Highest 22.1 72.2 4.4 1.4 100.0 973 Total 12.9 76.5 8.1 2.4 100.0 4,297 There are some divisional variations in the proportion currently employed. Men and women in Rajshahi division are most likely to be employed (91 and 28 percent, respectively), while those in Barisal are least likely to be employed; women in Barisal are only half as likely to be employed as their counterparts in Rajshahi. Current employment for men shows a negative relation with educational level but for women the relationship of education to employment is not clear. Men with primary or lower education are generally fully employed compared with 75 percent or fewer of those who have attended secondary or higher education. The proportion currently employed decreases as the wealth status of respondents increases; however, the variations in employment by household economic status are much larger for men than for women. 40 │ Characteristics of Survey Respondents 3.4.2 Control over Women’s Earnings Women who were working and receiving cash earnings were asked who decides how their earnings are used. Out of 2,550 women who were currently employed, 2,291 earned cash. Table 3.5 shows that slightly less than half (47 percent) of working women decide by themselves how their cash earnings are used, while 40 percent make the decision jointly with someone else. One in eight women is not involved in making decisions on how her earnings are used. Table 3.5 Decision on use of earnings Percent distribution of currently employed, ever-married-women who receive cash earnings by person who decides how earnings are to be used, according to background characteristics, Bangladesh 2004 Person who decides how earnings are used Background characteristic Respondent only Respondent jointly with others1 Someone else only2 Missing Total Number of women Age 15-19 39.2 40.6 20.2 0.0 100.0 134 20-24 42.1 43.9 14.0 0.0 100.0 344 25-29 41.3 44.6 14.1 0.0 100.0 461 30-34 44.9 40.4 14.7 0.0 100.0 474 35-39 52.0 37.2 10.0 0.7 100.0 362 40-44 58.8 34.2 7.0 0.0 100.0 301 45-49 52.1 39.6 8.4 0.0 100.0 211 Marital status Married 39.3 46.5 14.2 0.0 100.0 1,910 Divorced/separated/widowed 85.7 9.5 4.2 0.7 100.0 382 Number of living children 0 47.5 36.4 16.1 0.0 100.0 193 1-2 48.4 40.6 10.7 0.2 100.0 1,035 3-4 44.7 41.2 14.0 0.0 100.0 773 5+ 47.5 40.0 12.5 0.0 100.0 290 Residence Urban 54.6 36.6 8.9 0.0 100.0 628 Rural 44.1 41.8 13.9 0.2 100.0 1,663 Division Barisal 48.4 33.5 18.1 0.0 100.0 85 Chittagong 52.5 35.5 12.0 0.0 100.0 285 Dhaka 51.7 37.3 10.6 0.4 100.0 719 Khulna 55.0 35.0 10.0 0.0 100.0 298 Rajshahi 38.3 49.1 12.6 0.0 100.0 776 Sylhet 41.0 32.9 26.1 0.0 100.0 127 Education No education 47.8 37.1 14.9 0.2 100.0 1,221 Primary incomplete 44.5 47.3 8.2 0.0 100.0 443 Primary complete 42.4 47.0 10.6 0.0 100.0 138 Secondary incomplete 46.5 40.5 13.0 0.0 100.0 322 Secondary complete or higher 52.7 40.0 7.3 0.0 100.0 167 Wealth index Lowest 46.4 37.5 16.2 0.0 100.0 568 Second 42.4 44.8 12.3 0.5 100.0 543 Middle 40.6 45.1 14.2 0.0 100.0 437 Fourth 54.1 36.4 9.6 0.0 100.0 360 Highest 55.0 36.7 8.2 0.0 100.0 383 Total 47.0 40.4 12.5 0.1 100.0 2,291 Note: Total includes five women age 10-14, who are not shown separately. 1 Husband or someone else 2 Includes husband Characteristics of Survey Respondents │ 41 Table 3.5 also shows how women’s degree of control over their earnings varies by background characteristics. Irrespective of age, most respondents make their own decisions (either alone or jointly with others) on how their cash earnings are used. However, the sole control over earnings generally increases and having no control at all over earnings declines, with increasing age. Currently married women, compared with other ever-married women, are much more likely to involve another person in making the decision or to have no say at all in decisions about the use of her earnings. Urban women are more independent than rural women in making their own decisions without involving anyone else (55 and 44 percent, respectively). Comparatively, few women in both rural (14 percent) and urban areas (9 percent) report that they are not involved in decisions as to the use of their earnings. There are variations by divisions in the way decisions are made on how women’s earnings are used. The percentage of women who make decisions on their earnings by themselves alone ranges from 52-55 percent in Dhaka, Chittagong, and Khulna divisions, to 38 percent in Rajshahi division. There are no clear patterns by education or wealth index, although the percentages of women deciding about their earnings are higher for the two highest wealth quintiles and also higher for women who have completed secondary education; 50 percent or more of these women have complete control over their earnings. In the 2004 BDHS, each man whose wife earned cash was asked who decides how her earnings are used. Table 3.6 shows that according to husbands, two-thirds of couples jointly decide how her Table 3.6 Decision on use of wife’s earnings Percent distribution of currently married men whose wives earn cash for work by person who decides how her earnings are to be used, according to background characteristics, Bangladesh 2004 Person who decides how wife’s earnings are used, according to husband Background characteristic Husband only Wife only Husband jointly with wife Total Number of men Age 20-24 (5.9) (19.1) (75.0) 100.0 22 25-29 (14.2) (26.5) (59.2) 100.0 41 30-34 16.0 16.2 67.8 100.0 76 35-39 11.9 30.0 58.1 100.0 70 40-44 15.2 28.3 56.5 100.0 84 45-49 8.0 14.5 77.5 100.0 85 50-54 6.0 25.2 68.8 100.0 50 Residence Urban 10.1 26.1 63.9 100.0 104 Rural 12.6 21.6 65.8 100.0 326 Division Barisal (9.7) (10.3) (80.1) 100.0 19 Chittagong 9.0 24.5 66.5 100.0 43 Dhaka 8.8 19.6 71.6 100.0 142 Khulna 7.4 22.7 69.9 100.0 58 Rajshahi 12.4 26.6 61.0 100.0 148 Sylhet (53.5) (23.3) (23.2) 100.0 20 Education No education 14.1 25.2 60.7 100.0 145 Primary incomplete 16.3 16.2 67.5 100.0 130 Primary complete (11.5) (19.9) (68.6) 100.0 38 Secondary incomplete 7.3 19.1 73.5 100.0 58 Secondary complete or higher 1.9 36.0 62.1 100.0 59 Total 12.0 22.7 65.4 100.0 430 Note: Based on data obtained from male respondents. Total includes one man age 15-19, who is not shown separately. Figures in parentheses are based on 25-49 men. 42 │ Characteristics of Survey Respondents earnings are used. One in eight husbands says that he has control over her earnings. Husbands age 35-49 and those most educated are more likely to report that their wives by themselves decide how their earnings are used. Some of these results are inconsistent with what married women report (see Table 3.5). For example, according to husbands one in four wives decides by herself how her earnings are used compared with almost four in ten married women who say that they decide without anyone else’s participation. 3.5 WOMEN’S EMPOWERMENT In addition to information on women’s education, employment status, and control over earnings, the 2004 BDHS survey collected information from women and men on other measures of women’s autonomy and status. In particular, questions were asked about women’s roles in making household decisions. Such information provides insight into women’s control over their environment and their attitudes towards gender roles, both of which are relevant to understanding women’s demographic and health behavior. 3.5.1 Women’s Participation in Decisionmaking: Women’s Perspective To assess women’s decisionmaking autonomy, the 2004 BDHS sought information on women’s participation in six different types of household decisions: on the respondents’ own health care; on child health care; on making large household purchases; on making household purchase for daily needs; on visits to family or relatives; and on what food to cook each day. Table 3.7 shows the percent distribution of women according to who in the household usually has the final say on each aspect, according to current marital status. Table 3.7 Women’s participation in household decisionmaking Percent distribution of women by person who has the final say in making specific decisions, according to current marital status and type of decision, Bangladesh 2004 Currently married women Formerly married women1 Household decision Respondent only Respondent jointly with husband Respondent jointly with someone else Husband only Someone else only Total Respondent Respondent jointly with someone else Someone else only Missing Total Own health care 17.6 23.5 4.6 47.9 6.4 100.0 58.3 13.5 28.2 0.0 100.0 Child health care 17.4 32.7 4.9 31.8 5.6 100.0 54.1 11.9 19.9 14.2 100.0 Large household purchases 8.8 38.8 8.0 34.2 10.3 100.0 46.7 23.1 30.1 0.0 100.0 Daily household purchases 18.1 30.4 7.0 34.0 10.4 100.0 50.0 18.8 31.0 0.1 100.0 Visits to family or relatives 12.4 36.6 6.8 35.7 8.5 100.0 55.6 21.1 23.2 0.1 100.0 What food to cook each day 74.2 4.6 8.8 3.4 8.9 100.0 60.5 16.9 22.4 0.1 100.0 Note: Table is based on 10,582 currently married women and 858 formerly married women. 1 Divorced, separated or widowed women Characteristics of Survey Respondents │ 43 Among currently married women, few women independently make decisions on any of the aspects asked about, except on the decision on what food to cook. In fact, a large proportion of women have no final say even on decisions that concern their own health (54 percent) or their child’s health (37 percent). Close to half of the women also said that they have no say on large or daily household purchases, and on whether they could visit family members. Ever-married women who are currently not married have slightly less control over what food to cook than married women. However, they have much more independence in other decisionmaking. More than 70 percent are involved in decisions on their own health care, with 58 percent deciding alone and 14 percent deciding with someone else. The other decisions are also made mostly by either the respondents themselves (47 to 56 percent) or jointly with someone else. Interestingly, each of the six decisions is made by someone else alone for 20-30 percent of formerly married women. In Table 3.8, the autonomy of currently married women can be gauged either by their independently making such decisions or jointly deciding on such issues. The table shows that 28 percent of women have a say in all the six areas of decisionmaking, while 7 percent have no say at all in any of the specified areas. Generally, women’s participation in making all of the specified decisions is higher in urban areas than in rural areas (35 percent as compared to 26 percent) and increases with age and also by wealth. For example, the proportion of women who participate in all decisionmaking increases from 12 percent among women age 10-14 years to a peak of 34 percent among those in age group 40-44 years. Women without children, most of whom are young, are least likely to participate in all the six household decisionmaking factors. Women in Sylhet are least likely to have the final say (alone or jointly) on decisions regarding their child’s health, large household purchases or daily household purchases, and visiting relatives, compared with the other divisions. Less than half of the Sylheti women are involved in these decisions. Women in Rajshahi are least likely to make decisions about their own health care—only four in ten women reported that they are involved in the final say. Thirty-one percent of women who are employed for cash participate in making all decisions, compared with 27 percent of unemployed women. Except for deciding about what food to cook, urban women, the highest educated women, women employed for cash, and women in the wealthiest households are generally more likely to participate in final decisions on household matters. Nevertheless, between 43 and 49 percent of these women do not participate in final decisions concerning their own health care. 44 │ Characteristics of Survey Respondents Table 3.8 Women’s participation in decisionmaking by background characteristics Percentage of currently married women who say that they alone or jointly have the final say in specific decisions, by background characteristics, Bangladesh 2004 Alone or jointly have final say in: Background characteristic Own health care Child health care Large household purchases Daily household purchases Visits to family or relatives What food to cook each day All specified decisions No specified decisions Number of women Age 10-14 31.9 22.6 32.4 31.4 31.4 42.3 12.3 44.5 145 15-19 37.0 36.9 45.4 45.0 43.4 70.3 18.1 18.8 1,536 20-24 41.9 52.1 52.0 51.4 51.8 84.3 23.4 8.8 2,121 25-29 47.4 59.6 59.0 59.2 57.7 91.5 30.2 4.8 1,935 30-34 49.3 62.1 59.4 61.1 61.1 93.6 31.3 4.1 1,683 35-39 50.1 63.6 62.8 64.5 64.5 95.1 33.5 2.5 1,309 40-44 52.9 61.5 60.2 58.7 61.8 95.3 34.1 2.1 982 45-49 47.0 55.0 54.1 52.8 56.6 94.3 30.0 3.8 870 Number of living children 0 36.5 19.5 42.2 42.7 43.8 64.0 11.4 23.8 1,246 1-2 45.7 59.4 56.7 56.4 56.2 87.2 28.4 6.9 4,542 3-4 48.4 61.0 60.1 60.2 59.8 94.0 31.6 3.6 3,303 5+ 47.5 57.7 52.9 53.4 55.5 94.6 31.1 3.8 1,490 Residence Urban 53.2 61.7 64.1 64.3 65.2 87.3 34.5 6.6 2,372 Rural 43.5 53.0 53.0 53.0 53.0 87.7 25.8 7.7 8,210 Division Barisal 47.7 56.4 54.2 55.5 57.2 84.0 29.7 9.7 674 Chittagong 50.7 59.4 58.1 59.0 59.7 87.4 31.7 7.3 1,877 Dhaka 46.9 54.5 55.7 55.9 58.0 87.6 29.3 7.8 3,315 Khulna 49.6 58.5 57.0 55.7 54.3 86.0 29.1 8.2 1,296 Rajshahi 39.3 52.0 54.8 54.3 52.1 91.0 22.7 5.0 2,782 Sylhet 42.6 48.5 48.1 48.9 49.9 81.3 25.4 12.2 638 Education No education 43.3 52.8 53.4 53.7 53.5 92.1 26.5 5.5 4,187 Primary incomplete 46.5 57.6 56.7 56.5 55.3 89.4 29.1 6.4 2,176 Primary complete 47.2 56.0 60.4 60.6 60.0 86.3 29.6 7.6 958 Secondary incomplete 45.0 53.6 52.7 52.4 54.2 80.9 25.9 11.2 2,457 Secondary complete or higher 56.6 62.5 66.2 66.6 68.4 81.9 34.4 8.5 804 Current employment Not employed 44.4 53.6 53.7 53.5 54.2 86.4 26.9 8.3 8,455 Employed for cash 51.2 61.5 63.2 64.2 61.8 93.5 31.1 3.2 1,910 Employed not for cash 45.4 51.1 59.3 58.9 62.2 84.7 30.2 9.0 213 Wealth index Lowest 42.6 50.1 51.9 52.0 50.8 90.4 24.7 6.7 2,042 Second 42.4 53.3 53.5 52.8 51.9 89.5 23.9 6.1 2,112 Middle 43.9 54.2 53.1 53.7 53.7 87.3 27.0 8.2 2,112 Fourth 46.2 54.7 55.3 54.7 57.0 86.4 28.0 7.8 2,168 Highest 53.1 62.2 63.5 64.4 65.0 84.7 34.9 8.2 2,148 Total 45.7 55.0 55.5 55.6 55.7 87.6 27.8 7.4 10,582 Note: Total includes three women with missing information on employment, who are not shown separately. Characteristics of Survey Respondents │ 45 3.5.2 Wife’s Participation in Decisionmaking: Husbands’ Perspective All married men interviewed in the 2004 BDHS survey were asked whether they take their wife’s opinion into account when making decisions on large household expenses, minor daily household expenses, and when they wish to visit family, friends, or relatives. An overwhelming majority of currently married men—almost nine in ten—assert that they take their wife’s opinion into account in deciding about large household expenses and also about visiting family, friends, and relatives (Table 3.9). The wife’s opinion is not as widely sought for making daily household expenses; seven in ten men say that they seek their spouse’s opinion on minor household expenses. Only 5 percent of men said that they do not seek their wife’s opinion when making any of the above decisions. Differentials by all background characteristics for specific decisions are minimal. Table 3.9 Wife’s participation in decisionmaking Percentage of currently married men who take their wife’s opinion into account in making specific decisions, according to background characteristics, Bangladesh 2004 Decision Background characteristic Large household expenses Daily household expenses Visiting family, friends or relatives None of the specified decisions Number of currently married men Age 15-19 (72.1) (64.6) (77.9) (15.6) 28 20-24 81.7 64.9 85.3 7.0 221 25-29 81.3 65.3 87.3 7.5 401 30-34 88.0 68.9 90.4 4.7 493 35-39 89.5 71.6 89.4 5.2 446 40-44 90.9 70.1 91.3 4.8 490 45-49 92.4 79.6 94.9 1.6 462 50-54 90.8 75.4 91.2 3.1 240 Residence Urban 87.1 70.5 89.5 5.7 655 Rural 88.4 71.1 90.5 4.6 2,125 Division Barisal 93.7 64.6 89.9 3.1 146 Chittagong 86.0 68.3 88.8 6.3 422 Dhaka 87.7 74.1 91.0 4.4 866 Khulna 84.5 62.0 90.3 5.9 384 Rajshahi 90.6 73.0 90.3 4.0 805 Sylhet 86.4 78.5 90.0 6.1 157 Education No education 85.8 72.4 86.4 6.8 866 Primary incomplete 87.2 71.1 92.4 4.0 831 Primary complete 93.2 68.3 93.2 2.8 209 Secondary incomplete 87.7 68.3 90.7 4.9 504 Secondary complete or higher 93.0 72.8 91.8 3.2 370 Total 88.1 71.0 90.2 4.8 2,780 Note: Figures in parentheses are based on 25-49 men. 3.5.3 Freedom of Movement Table 3.10 gives information on another dimension of women’s autonomy measured in this BDHS survey: women’s freedom of movement. Currently married women were asked whether they go alone or can go alone outside the village/town/city and to a health center or hospital. The data show that 46 │ Characteristics of Survey Respondents 31 percent of women say that they go or can go alone outside village/town/city and the exactly the same proportion state that they go or can go alone to the hospital or health center. Seventeen percent of women say that they go or can go alone to both these places. By age, the proportion of women who have no freedom (those who can go to neither place alone) varies little except that the teenagers are slightly more restricted. Overall, urban women, women in Khulna division, the best-educated women, and the wealthiest women have more freedom of movement. On the other hand, women in Sylhet and Barisal divisions have the least freedom of all subgroups shown in Table 3.10. Table 3.10 Freedom of movement Percentage of currently married women who say they go or can go outside the village or town, or to a hospital or health center, according to background characteristics, Bangladesh 2004 Background characteristic Goes or can go alone outside village Goes or can go alone to a health center or hospital Goes or can go to both places Goes or can go to at least one place Goes or can go to neither place Number of women Age 10-14 35.4 16.1 12.4 39.0 61.0 145 15-19 34.7 19.2 12.1 41.8 58.2 1,536 20-24 31.8 26.9 14.0 44.8 55.2 2,121 25-29 27.0 33.7 15.8 44.9 55.1 1,935 30-34 29.4 36.8 18.6 47.6 52.4 1,683 35-39 28.7 35.9 18.4 46.1 53.9 1,309 40-44 33.8 36.7 23.5 47.0 53.0 982 45-49 34.0 33.0 20.9 46.0 54.0 870 Residence Urban 37.6 42.6 24.8 55.4 44.6 2,372 Rural 29.1 27.6 14.4 42.2 57.8 8,210 Division Barisal 21.5 30.4 13.1 38.7 61.3 674 Chittagong 32.3 30.0 17.4 44.9 55.1 1,877 Dhaka 31.3 30.6 16.8 45.0 55.0 3,315 Khulna 34.3 40.0 22.4 51.9 48.1 1,296 Rajshahi 32.7 30.1 16.0 46.8 53.2 2,782 Sylhet 21.6 21.5 10.3 32.9 67.1 638 Education No education 27.7 29.9 16.0 41.6 58.4 4,187 Primary incomplete 26.9 29.3 14.2 42.0 58.0 2,176 Primary complete 27.9 29.4 14.7 42.6 57.4 958 Secondary incomplete 34.2 31.3 17.2 48.3 51.7 2,457 Secondary complete or higher 52.9 41.6 28.9 65.6 34.4 804 Wealth index Lowest 27.0 27.2 13.9 40.4 59.6 2,042 Second 27.1 27.6 13.8 40.9 59.1 2,112 Middle 29.9 28.4 15.5 42.9 57.1 2,112 Fourth 31.9 31.0 16.2 46.7 53.3 2,168 Highest 38.6 40.3 24.3 54.7 45.3 2,148 Total 31.0 31.0 16.8 45.2 54.8 10,582 3.6 MEN’S ATTITUDES TOWARDS WIFE-BEATING Domestic violence is not uncommon in Bangladesh. Although questions on domestic violence were not asked of female respondents, currently married men were asked whether they thought it was Characteristics of Survey Respondents │ 47 justified for a husband to beat his wife in the following four situations: if she goes out without telling him, if she neglects the children, if she argues with him, and if she fails to provide food on time. Table 3.11 shows that many currently married men find wife-beating to be justified in certain circumstances. Overall, more than half (55 percent) of Bangladeshi men agree that at least one of these factors is sufficient justification for wife-beating. This is not unexpected because many traditional customs in Bangladesh teach and expect women to accept, tolerate, and even rationalize wife-beating. This custom impedes women’s empowerment and has serious health consequences. The most widely accepted reason for wife-beating in Bangladesh is a wife going out without informing her husband; almost half of currently married men agree with this reason for wife-beating. Nearly three in ten currently married men think that if a wife argues with her husband it is a justifiable reason for beating. Only one in six men think that neglecting the children is a justification for wife- beating. An even smaller proportion believes that failing to provide food on time is a justifiable reason to hit or beat the wife. Table 3.11 Men’s attitude towards spousal violence Percentage of currently married men who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Bangladesh 2004 Husband is justified in hitting or beating his wife if she: Background characteristic Goes out without telling him Neglects the children Argues with him Fails to provide food on time Percentage who agree with at least one of the specified reasons Percentage who agree with none of the specified reasons Number of currently married men Age 15-19 (55.0) (24.2) (23.6) (6.0) (56.2) (43.8) 28 20-24 54.1 20.7 32.8 6.2 60.8 39.2 221 25-29 48.5 18.5 32.5 9.5 57.9 42.1 401 30-34 49.4 13.4 25.4 6.6 56.0 44.0 493 35-39 47.2 17.1 27.0 8.5 54.2 45.8 446 40-44 46.3 14.8 28.8 10.4 53.2 46.8 490 45-49 47.2 18.3 24.5 6.6 52.6 47.4 462 50-54 51.5 14.5 25.1 9.4 56.9 43.1 240 Residence Urban 39.1 11.4 19.8 4.6 45.8 54.2 655 Rural 51.6 18.2 30.1 9.3 58.3 41.7 2,125 Division Barisal 55.0 23.0 34.7 12.3 59.7 40.3 146 Chittagong 42.1 12.7 20.9 6.3 47.6 52.4 422 Dhaka 51.5 17.0 27.6 6.4 59.3 40.7 866 Khulna 48.1 13.3 25.6 6.1 54.6 45.4 384 Rajshahi 50.1 19.8 32.7 11.4 56.9 43.1 805 Sylhet 38.0 10.7 18.8 8.4 44.7 55.3 157 Education No education 56.0 20.5 34.9 11.9 64.2 35.8 866 Primary incomplete 53.1 19.3 33.1 9.3 60.7 39.3 831 Primary complete 50.1 15.5 29.2 7.9 56.4 43.6 209 Secondary incomplete 40.3 14.4 21.1 3.8 46.6 53.4 504 Secondary complete or higher 31.8 4.9 6.6 3.1 34.0 66.0 370 Wealth index Lowest 54.3 22.5 35.1 13.1 64.4 35.6 552 Second 56.0 17.6 32.6 9.3 62.9 37.1 599 Middle 53.0 19.1 33.4 9.3 60.0 40.0 555 Fourth 44.8 15.3 24.7 6.3 51.1 48.9 520 Highest 34.3 8.3 11.9 2.6 37.6 62.4 554 Total 48.6 16.6 27.7 8.2 55.4 44.6 2,780 Note: Figures in parentheses are based on 25-49 men. 48 │ Characteristics of Survey Respondents The table also shows attitudes towards wife-beating by background characteristics. Acceptance of wife-beating for each specified reason is lower among urban men and generally among those in Sylhet and Chittagong divisions. Men’s acceptance of wife-beating declines as their level of education increases. The acceptance of wife-beating is almost one-half as much among the most educated men as among the uneducated men. For each reason, poorer men (in the two lowest quintiles) are more likely than their wealthier counterparts to hold the attitude that wife-beating is justified. Since 1999-2000, attitudes toward wife-beating have changed for the worse. More than half of currently married men (55 percent) in 2004, compared with 37 percent earlier, agree with at least one specified reason justifying a husband beating his wife. The most noticeable change in men’s attitudes since 1999-2000 is a greater restriction on women’s movement. The percentage of men who consider wife-beating justified if a wife goes out without telling her husband has doubled from 25 percent to 49 percent. On the other hand, in the same period, the proportion of men who agree that a husband may beat his wife if she neglects her children has dropped from 23 to 17 percent. Fertility │ 49 FERTILITY 4 4.1 INTRODUCTION A major objective of the 2004 Bangladesh Demographic and Health Survey (BDHS) is to examine fertility levels, trends, and differentials in Bangladesh. The focus on fertility is due to its important role in determining Bangladesh’s population growth rate and its impact on economic development. This chapter presents a description of current and past fertility, cumulative fertility and family size, birth intervals, age at first birth, and reproductive behavior of adolescents. Most of the fertility measures are based on the birth histories collected from ever-married women age 15-49 interviewed during the survey. Each woman was asked a series of questions to give a retrospective history of all of her births. To encourage complete reporting, the interviewer asked the respondent about the number of sons and daughters living with her, the number living elsewhere, and the number who had died. She was then asked for a history of all of her births, including the month and year of birth, name, sex, and survival status of each birth. For children who had died, age at death was recorded. Interviewers were given extensive training in probing techniques designed to help respondents report this information accurately. The following measures of current fertility are derived from the birth history data: • Age-specific fertility rates1 (ASFR) are expressed as the number of births per thousand women in the age group and represent a valuable measure for assessing the current age pattern of childbearing. They are defined in terms of the number of live births during a specific period to women in the particular age group divided by the number of woman-years lived in that age group during the specified period. • Total fertility rate (TFR) is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed rates of age-specific fertility. The TFR is obtained by summing the age-specific fertility rates and multiplying by five. • General fertility rate (GFR) is the number of live births occurring during a specified period per 1,000 women of reproductive age. • Crude birth rate (CBR) is the number of births per 1,000 population during a specified period. 1 Numerators for 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 for the rates are the number of woman-years lived in each of the specified five-year age groups during the period 1-36 months preceding the survey. Since only women who had ever married were interviewed in the BDHS, the number of women in the denominator of the rates was inflated by factors calculated from information in the Household Questionnaire on the proportions ever married to produce a count of all women. Never-married women are presumed not to have given birth. 50 │ Fertility The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to the calendar period 2001-2003. A three-year period was chosen because it reflects the current situation, without unduly increasing sampling error. Despite measures to improve the data quality, BDHS information is subject to the same types of error that are inherent in all retrospective sample surveys, namely, possible omission of some births (especially births of children who died at a very young age) and the difficulty of determining the date of birth of each child accurately. These difficulties can bias estimates of fertility trends. A brief discussion of the quality of the BDHS fertility data appears in Appendix C.3 and shows that such errors are minimal. 4.2 CURRENT FERTILITY LEVELS Table 4.1 presents information on the current fertility levels for Bangladesh as a whole and for urban and rural areas. According to the 2004 BDHS results, the total fertility rate for women age 15-49 is 3.0. This means that a Bangladeshi woman would have, on average, 3.0 children in her lifetime if the current age- specific fertility rates remained constant. Table 4.1 Current fertility rates Age-specific fertility rates, the total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by urban-rural residence, Bangladesh 2004 Residence Age group Urban Rural Total 15-19 110 142 135 20-24 154 204 192 25-29 112 143 135 30-34 82 84 83 35-39 31 44 41 40-44 12 18 16 45-49 1 3 3 TFR 15-49 2.5 3.2 3.0 GFR 97 122 117 CBR 25.8 29.5 28.7 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased because of truncation. TFR: Total fertility rate for women age 15-49, expressed per woman GFR: General fertility rate (births divided by the number of women age 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population The general fertility rate in Bangladesh is 117. This means that there were 117 births for every 1,000 women of reproductive age during the three-year period preceding the survey. Data also show a crude birth rate of 29 births per 1,000 population for the period under review. Bangladeshi women have a pattern of early childbearing. According to current fertility rates, on average, women will have 22 percent of their births before reaching age 20 and will complete 76 percent of their childbearing before age 30. Fertility │ 51 4.3 FERTILITY DIFFERENTIALS Table 4.2 shows differentials in fertility by residence, administrative division, educational attainment, and wealth index. The total fertility rate for rural women (3.2 births) is almost one child higher than for urban women. The urban-rural difference is especially large at younger ages, which probably reflects longer education and later marriage of women in urban areas (Figure 4.1). Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 40-49 years, by background characteristics, Bangladesh 2004 Background characteristic Total fertility rate1 Mean number of children ever born to women age 40-49 Residence Urban 2.5 4.4 Rural 3.2 5.3 Division Barisal 2.9 5.5 Chittagong 3.7 5.6 Dhaka 2.9 4.9 Khulna 2.8 4.5 Rajshahi 2.6 4.9 Sylhet 4.2 5.8 Education No education 3.6 5.3 Primary incomplete 3.3 5.4 Primary complete 2.9 5.0 Secondary incomplete 2.7 4.3 Secondary complete or higher 2.2 2.8 Wealth index Lowest 4.0 5.4 Second 3.2 5.6 Middle 3.0 5.3 Fourth 2.3 5.1 Highest 2.5 4.3 Total 3.0 5.1 1 Women age 15-49 years 52 │ Fertility Fertility varies widely by administrative divisions (Figure 4.2). Sylhet and Chittagong divisions have the highest TFRs (4.2 and 3.7, respectively), while the lowest TFRs are in Rajshahi and Khulna (2.6 and 2.8, respectively). As expected, the educational attainment of women is strongly associated with fertility. The TFR decreases steeply from 3.6 for women with no education to 2.2 for women with secondary complete or higher Fertility │ 53 education. Fertility is also negatively related with wealth; the disparity in fertility between women in the lowest and highest wealth quintiles is 1.5 children per woman. Table 4.2 also presents a crude assessment of trends in fertility in the various subgroups by comparing the TFRs 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. Overall, comparison of past and present fertility indicators suggests a decline of two children per woman, from 5.1 to 3.0 children. There has been a substantial decline in fertility in urban and rural areas, and in all administrative divisions. The fertility declined by two or more children in three of the six divisions: Barisal, Dhaka, and Rajshahi. 4.4 FERTILITY TRENDS Trends in fertility in Bangladesh since the early 1970s can be examined by observing a time series of estimates produced from demographic surveys fielded over the last two and half decades, beginning with the 1975 Bangladesh Fertility Survey (BFS). The estimates shown in Table 4.3 describe the ongoing Bangladeshi fertility transition. Fertility has declined sharply, from 6.3 in 1971-1975 to 3.0 in 2001-2003 (Figure 4.3). During this period, fertility declined rapidly in the late 1980s and early 1990s, and plateaued at around 3.3 for most of the 1990s. The 2004 BDHS data indicate that after almost a decade-long stagnation, the TFR declined slightly from 3.3 to 3.0 between 1997-1999 and 2001-2003. Since 1997-1999, a small decline in fertility was observed in all divisions except Sylhet and Khulna. Investigation of the age pattern of fertility shows no anomalies; the decline since the mid-1980s has been fairly uniform over all age groups of women. Table 4.3 Trends in current fertility rates Age-specific fertility rates (per 1,000 women) and total fertility rates (TFRs) among women age 15-49, selected sources, Bangladesh, 1975- 2004 Survey and approximate time period 1975 BFS 1989 BFS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS Age group 1971-1975 1984-1988 1989-1991 1991-1993 1994-1996 1997-1999 2001-2003 15-19 109 182 179 140 147 144 135 20-24 289 260 230 196 192 188 192 25-29 291 225 188 158 150 165 135 30-34 250 169 129 105 96 99 83 35-39 185 114 78 56 44 44 41 40-44 107 56 36 19 18 18 16 45-49 35 18 13 14 6 3 3 TFR 15-49 6.3 5.1 4.3 3.4 3.3 3.3 3.0 Note: For the 1975 Bangladesh Fertility Survey (BFS) and 1989 BFS, the rates refer to the five-year period preceding the survey; for the other surveys, the rates refer to the three-year period preceding the survey. The BFS and Bangladesh Demographic and Health Survey (BDHS) utilized full birth histories, while the 1991 Contraceptive Prevalence Survey (CPS) used an eight-year truncated birth history. Sources: 1975 BFS (MHPC, 1978:73), 1989 BFS (Huq and Cleland, 1990:103), 1991 CPS (Mitra et al., 1993 :34), 1993-1994 BDHS (Mitra et al., 1994:24), 1996-1997 BDHS (Mitra et al., 1997:30), and 1999-2000 BDHS (NIPORT et al., 2001:34) 54 │ Fertility Table 4.4 shows trends in the percentage 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 percent pregnant is an independent indicator of fertility change. In Bangladesh, the percent pregnant has generally declined over time, from 13 percent in 1975 to 7 percent in 2004. During this period, the percent pregnant declined in the late 1980s and early 1990s, and stalled around 8 percent for most of the 1990s. The 2004 BDHS results show that the percent pregnant has declined to 7 percent from 8 percent in 1996-1997 and 1999-2000. Table 4.4 Percent pregnant Percentage of currently married women who were pregnant at the time of interview, by age group, selected sources, Bangladesh 1975-2004 Age group 1975 BFS 1989 BFS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 15-19 15.2a 14.7a 19.6 17.1 14.7 15.9 14.3 20-24 15.5 13.3 16.2 13.0 10.3 11.8 9.9 25-29 14.9 10.4 11.2 9.0 8.9 8.5 7.8 30-34 11.2 8.3 7.1 7.0 5.1 4.8 4.8 35-39 10.7 4.8 4.2 2.7 3.4 2.4 2.3 40-44 u u 1.5 0.8 1.3 1.0 0.1 45-49 u u 0.2 0.0 0.0 0.4 0.2 Total 12.5 9.3 10.7 8.7 7.7 7.8 6.6 u = Unknown (not available) a Currently married women under age 20 Source: 1975 Bangladesh Fertility Survey (BFS) and 1989 BFS (Cleland et al., 1994:21), 1991 Contraceptive Prevalence Survey (CPS) (Mitra et al., 1993:39), 1993-1994 Bangladesh Demographic and Health Survey (BDHS) (Mitra et al., 1994:31), 1996-1997 BDHS (Mitra et al.1997:34), and 1999-2000 BDHS (NIPORT et al., 2001:36) Fertility │ 55 Table 4.5 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 2004 Number of years preceding the survey Marriage duration 0-4 5-9 10-14 15-19 0-4 253 279 260 266 5-9 205 229 249 282 10-14 143 175 202 242 15-19 86 109 166 [207] 20-24 45 75 [114] - 25-29 22 [45] - - Note: Duration-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Table 4.5 presents fertility rates for ever-married women by marital duration, the number of years since the first marriage, for five-year periods preceding the survey. The data confirm a sharp decline in fertility and indicate that fertility has declined at all marital durations. 4.5 CHILDREN EVER BORN AND LIVING Table 4.6 shows the distribution of all women and currently married women by age and number of children ever born. It 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 mean number of children ever born for all women is 2.5, which means that, on average, Bangladeshi women age 15-49 have had fewer than three births; currently married women have 3.0 births on average. Allowing for mortality of children, Bangladeshi women have, on average, 2.2 living children, while currently married women have an average of 2.6 living children. 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. Currently married women age 45-49 have given birth to an average of 5.8 children, of whom 4.7 survived. Among all women age 15-49, the average number of children who have died per woman is 0.35. Among currently married women, it is 0.41; that is, 14 percent of children born to currently married women had died. The proportion of children ever born who have died increases with women’s age. Among currently married women, for example, the proportion of children ever born who have died increases from 8 percent for women age 20-24 to 20 percent for women age 45-49. 56 │ Fertility Table 4.6 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, and mean number of children ever born and mean number of living children, according to age group, Bangladesh 2004 Number of children ever born Age 0 1 2 3 4 5 6 7 8 9 10+ Total Number of women Mean number of children ever born Mean number of living children ALL WOMEN 15-19 72.1 21.5 5.9 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 3,337 0.35 0.32 20-24 24.4 30.0 28.5 13.3 3.2 0.5 0.0 0.0 0.0 0.0 0.0 100.0 2,597 1.42 1.31 25-29 8.4 12.0 30.8 25.9 14.8 5.7 1.6 0.7 0.1 0.1 0.0 100.0 2,100 2.55 2.28 30-34 4.4 6.3 21.2 23.5 19.9 12.9 6.5 3.1 1.8 0.5 0.1 100.0 1,815 3.43 3.02 35-39 2.7 4.8 14.0 19.7 20.3 14.9 11.3 5.9 3.7 1.7 1.0 100.0 1,463 4.12 3.48 40-44 3.0 3.0 8.5 17.6 21.1 14.8 11.2 10.0 5.1 2.9 2.7 100.0 1,164 4.65 3.84 45-49 1.4 1.6 6.0 10.9 15.3 15.0 15.2 12.1 9.3 6.4 6.8 100.0 1,066 5.63 4.48 Total 25.0 14.7 17.3 14.3 10.8 6.8 4.5 3.0 1.8 1.0 0.9 100.0 13,542 2.50 2.15 CURRENTLY MARRIED WOMEN 15-19 40.8 45.3 12.9 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,536 0.74 0.68 20-24 10.3 35.0 34.0 16.2 3.9 0.6 0.0 0.0 0.0 0.0 0.0 100.0 2,121 1.70 1.56 25-29 3.8 11.9 32.2 27.7 15.8 6.1 1.6 0.7 0.1 0.1 0.0 100.0 1,935 2.69 2.41 30-34 2.6 5.3 20.9 24.4 20.7 13.7 6.8 3.2 1.9 0.5 0.1 100.0 1,683 3.55 3.14 35-39 1.8 3.7 13.2 19.7 20.7 16.0 11.7 6.4 3.8 1.8 1.0 100.0 1,309 4.25 3.61 40-44 1.8 2.5 8.1 16.5 21.4 15.9 11.8 10.3 5.1 3.5 3.0 100.0 982 4.81 4.01 45-49 1.1 0.8 5.2 9.7 15.4 15.4 15.7 12.7 9.8 6.8 7.6 100.0 870 5.82 4.67 Total 9.7 17.6 21.0 17.3 12.9 8.3 5.3 3.5 2.1 1.2 1.1 100.0 10,436 3.00 2.59 Nearly three-fourths of women age 15-19 have never given birth. However, this proportion declines to 4 percent for women age 30-34 years and rapidly decreases further for older women, indicating that childbearing among Bangladeshi women is nearly universal. The percentage of women in their forties 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 have children. The BDHS results suggest that primary infertility is low, less than 2 percent. (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 2004 BDHS and various other surveys is presented in Table 4.7. The comparison does not highlight recent changes in fertility, but rather is an indication of the cumulative changes in fertility over the decades preceding the 2004 BDHS. Despite the fluctuations between surveys, the data generally show only modest declines until the late 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 this was followed by little change between 1989 and 1991, the mean number of children again declined considerably between 1991 and 1993-1994, especially among women age 25 and above, and showed further decline between 1993-1994 and 1999-2000 at all ages except 15-19. The most recent data showed a decline in the mean number of children between 1999-2000 and 2004 among women age 30 and above. Fertility │ 57 Table 4.7 Trends in children ever born Mean number of children ever born by age group, selected sources, Bangladesh, 1975-2004 Age group 1975 BFS 1981 CPS 1983 CPS 1985 CPS 1989 BFS 1989 CPS 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS 2004 BDHS 15-19 0.6 0.5 0.6 0.4 0.4 0.4 0.4 0.3 0.4 0.4 0.4 20-24 2.3 2.0 2.2 2.0 1.7 1.8 1.7 1.6 1.5 1.4 1.4 25-29 4.2 3.7 3.8 3.6 3.1 3.3 3.2 2.9 2.8 2.6 2.6 30-34 5.7 5.4 5.5 5.1 4.7 4.7 4.5 4.1 3.9 3.6 3.4 35-39 6.7 6.4 6.5 6.5 5.9 5.9 5.7 5.2 4.8 4.3 4.1 40-44 7.1 7.3 7.4 7.4 6.6 7.0 6.7 6.4 5.6 5.1 4.7 45-49 6.7 7.6 7.5 7.2 7.3 7.5 7.4 6.9 6.4 6.1 5.6 Total u u u u u u 3.5 3.0 2.8 2.6 2.5 u = Unknown (not available) Source: 1975 Bangladesh Fertility Survey (BFS), 1983 and 1985 CPSs (Kantner and Frankenberg, 1988:21); 1991 CPS (Mitra et al., 1993:31); 1993-1994 BDHS (Mitra et al., 1994:33); 1996-1997 BDHS (Mitra et al., 1997: 36); 1999-2000 BDHS (NIPORT et al., 2001:39) all others (Cleland et al., 1994:11) 4.6 BIRTH INTERVALS Examination of birth intervals, defined as the length of time between two successive live births, is important in providing insights into birth spacing patterns and, subsequently, maternal and child health. Short birth intervals are associated with an increased risk of death for mother and child. Studies have shown that children born less than 24 months after a previous sibling risk poorer health and also threaten maternal health. Table 4.8 shows the percent distribution of non-first births that occurred in the five years preceding the BDHS by the number of months since the previous birth. Birth intervals are generally long in Bangladesh (the median birth interval is 39 months). The long period of breastfeeding in Bangladesh (an average of 32 months [Chapter 11]) and the corresponding long period of postpartum amenorrhea (an average of 9 months [Chapter 6]) are likely to contribute to the relatively high percentage of births occurring after an interval of 24 months or more. Almost six in ten non- first births occur three or more years after the previous birth, while one-fourth of births take place 24-35 months after the previous birth (Table 4.8). Nearly one in six children (16 percent) is born after a “too short” interval (less than 24 months). The median birth interval in the 2004 BDHS (39 months) is almost the same as in the 1999-2000 BDHS. However, it is longer than the median reported in the 1993-1994 BDHS (35 months) and in the 1996- 1997 BDHS (37 months). The median birth interval is substantially shorter for teenage mothers (27 months). More than one in three births to teenage mothers age 15-19 occurs after a “too short” interval of less than 24 months. 58 │ Fertility Table 4.8 Birth intervals Percent distribution of non-first births in the five years preceding the survey, by number of months since preceding birth, according to background characteristics, Bangladesh 2004 Months since preceding birth Background characteristic 7-17 18-23 24-35 36-47 48+ Total Number of non-first births Median number of months since preceding birth Age of mother 15-19 14.5 20.0 40.6 21.0 3.9 100.0 224 26.5 20-29 6.9 10.1 27.4 23.1 32.5 100.0 3,028 37.8 30-39 4.6 8.4 20.7 18.9 47.4 100.0 1,485 46.0 40-49 4.0 8.1 17.7 14.1 56.1 100.0 213 52.2 Birth order 2-3 6.0 9.4 24.6 21.9 38.0 100.0 3,018 40.3 4-6 6.9 10.2 26.9 20.7 35.3 100.0 1,516 38.5 7+ 8.1 12.8 27.4 19.6 32.0 100.0 417 36.7 Sex of prior birth Male 6.7 9.6 24.9 21.7 37.0 100.0 2,484 39.5 Female 6.2 10.3 26.2 21.0 36.3 100.0 2,467 39.1 Survival of prior birth Living 4.3 9.2 24.8 22.5 39.2 100.0 4,409 41.2 Dead 24.4 15.7 31.6 12.2 16.1 100.0 542 26.0 Residence Urban 6.5 10.2 21.3 20.1 41.9 100.0 939 42.8 Rural 6.5 9.9 26.5 21.7 35.5 100.0 4,012 38.7 Division Barisal 4.6 7.2 26.3 22.1 39.8 100.0 294 41.6 Chittagong 6.8 10.4 30.1 24.1 28.7 100.0 1,106 36.8 Dhaka 6.1 9.7 26.4 20.7 37.1 100.0 1,580 39.7 Khulna 6.8 7.8 14.8 18.1 52.5 100.0 480 49.4 Rajshahi 5.2 9.9 21.7 20.2 43.0 100.0 1,034 43.5 Sylhet 10.7 13.9 30.9 22.7 21.9 100.0 456 33.7 Education No education 5.7 10.2 26.8 21.5 35.7 100.0 2,454 38.8 Primary incomplete 5.1 9.3 25.6 25.2 34.8 100.0 965 39.5 Primary complete 8.5 9.4 24.1 19.8 38.1 100.0 455 39.5 Secondary incomplete 8.3 9.8 23.7 19.5 38.7 100.0 863 40.2 Secondary complete or higher 9.1 10.6 20.9 13.4 46.0 100.0 213 44.1 Wealth index Lowest 6.5 11.1 30.7 22.8 28.9 100.0 1,422 36.5 Second 5.7 9.4 25.4 23.4 36.1 100.0 1,056 39.1 Middle 6.8 9.3 25.2 20.3 38.3 100.0 947 39.5 Fourth 5.1 10.6 23.2 19.8 41.2 100.0 817 41.3 Highest 8.6 8.4 18.7 18.6 45.7 100.0 708 45.5 Total 6.5 9.9 25.5 21.4 36.7 100.0 4,951 39.3 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Fertility │ 59 The length of the birth interval is closely associated with the survival status of the previous sibling. The median birth interval is 15 months shorter for children whose previous sibling died than for children whose previous sibling is alive (26 and 41 months, respectively). The percentage of births occurring within a very short interval (less than 18 months) is six times higher for children whose prior sibling died than for children whose prior sibling survived (24 and 4 percent, respectively). The shorter intervals for the former group are partly due to a shortened period of breastfeeding (or no breastfeeding) for the preceding child, leading to an earlier return of ovulation and hence increased chance of pregnancy. Minimal use of contraception, presumably because of a desire to “replace” the dead child as soon as possible, could also be one of the factors responsible for the shorter birth interval in these cases. The median number of months since the preceding birth increases with household economic status; from 37 months in the lowest wealth quintile to 46 months for households in the highest wealth quintile. 4.7 AGE AT FIRST BIRTH The onset of childbearing has a direct effect on fertility. Early initiation into childbearing lengthens the reproductive period and subsequently increases fertility. In many countries, postponement of first births— reflecting an increase in the age at marriage—has contributed greatly to overall fertility decline. 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 4.9 presents the percent distribution of women by age at first birth according to current age.2 The median age at first birth is not shown for women age 15-19 because the large majority of these young girls had not become mothers before age 15. The median age at first birth is about 18 years across all age cohorts, except for women age 45-49 years, whose median age at first birth is 17 years, indicating a slight change in the age at first birth. This slight increase in age at first birth is reflected in the smaller proportion of younger women whose first birth occurred before age 15; 18 percent of women in their late forties report having had their first birth before age 15, compared with only 6 percent of women age 15-19. Comparison of data from the 1999-2000 BDHS and the 2004 BDHS shows little change in the median age at first birth for women age 20-49. Table 4.9 Age at first birth Percent distribution of women by age at first birth, according to current age, Bangladesh 2004 Age at first birth Current age Percent- age of women with no births <15 15-17 18-19 20-21 22-24 25+ Total Number of women Median age at first birth 15-19 72.1 6.4 na na na na na 100.0 3,337 a 20-24 24.4 10.2 35.8 17.7 na na na 100.0 2,597 18.4 25-29 8.4 13.4 40.7 19.5 9.3 6.7 2.0 100.0 2,100 17.7 30-34 4.4 13.2 40.7 19.9 10.4 7.2 4.2 100.0 1,815 17.7 35-39 2.7 11.5 43.0 19.5 12.3 5.6 5.5 100.0 1,463 17.7 40-44 3.0 13.7 42.2 19.0 11.4 5.9 4.8 100.0 1,164 17.6 45-49 1.4 17.7 47.6 14.6 8.4 6.0 4.4 100.0 1,066 16.9 na = Not applicable a = Omitted because less than 50 percent of the women had a birth before reaching age 15 2 The data are based on all women, including those who have never married (see footnote 1 for a description of the inflation factors used to estimate the total number of women). 60 │ Fertility Table 4.10 summarizes the median age at first birth for different age cohorts by background characteristics of respondents. For women age 20-49, the median is slightly higher in urban areas than in rural areas, and is highest in Sylhet division, compared with other divisions. Median age at first birth is about two years higher for women in the highest wealth quintile (19 years), compared with those in the lowest wealth quintile (17 years). Women with secondary or more education start childbearing later than those with less or no education. Among women age 25-49, the median age at first birth is 17 years for women with no education and 23 years for women who have completed secondary education. Table 4.10 Median age at first birth Median age at first birth among women age 20-49 years, by current age and background characteristics, Bangladesh 2004 Current age Women age Women age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Residence Urban 19.5 18.3 18.1 18.2 18.1 17.5 18.4 18.1 Rural 18.1 17.5 17.6 17.6 17.5 16.8 17.6 17.4 Division Barisal 18.9 17.0 18.4 17.5 17.7 17.7 17.8 17.7 Chittagong 19.2 18.0 18.0 18.1 17.5 17.4 18.2 17.8 Dhaka 18.3 17.9 17.5 17.5 17.7 17.1 17.7 17.6 Khulna 17.9 17.4 17.4 17.7 17.1 16.4 17.4 17.3 Rajshahi 17.7 17.1 17.5 17.5 17.5 16.4 17.3 17.2 Sylhet 19.9 19.0 18.9 18.7 18.6 17.3 18.9 18.6 Education No education 16.6 16.8 17.2 17.6 17.4 16.5 17.0 17.1 Primary incomplete 17.1 17.2 17.6 17.3 17.4 17.1 17.3 17.3 Primary complete 17.4 17.6 17.6 17.2 17.8 17.9 17.6 17.6 Secondary incomplete 19.0 18.3 18.6 18.0 18.0 17.7 18.6 18.3 Secondary complete or higher a 23.4 23.0 21.0 21.1 21.4 a 22.6 Wealth index Lowest 16.9 16.8 17.5 17.7 17.9 16.4 17.1 17.2 Second 17.4 17.2 17.3 17.6 17.7 16.7 17.3 17.3 Middle 18.6 17.4 17.7 17.3 17.1 17.0 17.6 17.3 Fourth 19.7 18.4 17.5 17.5 17.5 17.0 18.1 17.7 Highest 19.8 19.3 18.8 18.4 18.1 17.5 18.9 18.5 Total 18.4 17.7 17.7 17.7 17.6 16.9 17.7 17.6 Note: The medians for cohort 15-19 could not be determined because more than half of these women have not yet had a birth. a = Omitted because less than 50 percent of the women had a birth before reaching age 20 4.8 ADOLESCENT FERTILITY Adolescent fertility is a major social and health concern. 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, young mothers may not be sufficiently emotionally mature to bear the burden Fertility │ 61 of childbearing and rearing. Early entry into reproduction denies them the opportunity to pursue academic goals. This is detrimental to their prospects for good careers, which often lowers their status in society. Table 4.11 shows that one-third of adolescents age 15-19 have begun childbearing. Twenty-eight percent of these teenagers in Bangladesh have given birth, and another 5 percent are pregnant with their first child. As expected, the proportion of women age 15-19 who have begun childbearing rises rapidly with age. Early childbearing among teenagers is more prominent in rural areas, compared with urban areas, and in Rajshahi and Khulna divisions, compared with other divisions. Childbearing begins later in Sylhet, compared with the rest of the divisions, mainly because of relatively late marriage in Sylhet. Delayed childbearing is strongly related to education among women age 15-19. Only 16 percent of the teenagers who had completed secondary education had begun childbearing, compared with almost half of those with primary incomplete or no education. Childbearing begins earlier among adolescents in the poorest 40 percent of the households; in these households, four out of ten adolescents have begun childbearing. In contrast, three out of ten of the adolescents in the richest 20 percent of the households either have had births or are pregnant with their first child. Table 4.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who are mothers or pregnant with their first child, by background characteristics, Bangladesh 2004 Percentage who are: Background characteristic Mothers Pregnant with first child Percentage who have begun childbearing Number of women Age 15 7.5 4.0 11.5 778 16 18.3 3.9 22.2 706 17 30.8 6.4 37.2 660 18 36.9 5.9 42.8 629 19 54.8 4.0 58.8 563 Residence Urban 21.9 4.3 26.1 758 Rural 29.7 5.0 34.7 2,576 Division Barisal 25.9 3.6 29.5 215 Chittagong 23.7 4.0 27.7 725 Dhaka 27.2 4.2 31.5 956 Khulna 31.2 6.4 37.7 367 Rajshahi 35.7 6.6 42.3 797 Sylhet 16.2 2.8 19.0 271 Education No education 42.5 4.0 46.5 435 Primary incomplete 40.2 5.6 45.8 541 Primary complete 32.8 4.3 37.1 334 Secondary incomplete 22.3 5.0 27.2 1,760 Secondary complete or higher 10.9 4.6 15.5 253 Wealth index Lowest 37.7 3.2 40.9 559 Second 33.7 5.6 39.2 665 Middle 21.7 3.6 25.2 1,006 Fourth 17.4 4.5 21.9 949 Highest 23.0 5.6 28.5 492 Total 27.9 4.8 32.7 3,337 62 │ Fertility Between the 1999-2000 BDHS and the 2004 BDHS, the proportion of adolescents age 15-19 who had begun childbearing declined slightly, from 35 to 33 percent. Fertility Regulation │ 63 FERTILITY REGULATION 5 5.1 KNOWLEDGE OF FAMILY PLANNING METHODS Information on knowledge of family planning methods was collected by asking female respondents to name ways or methods by which a couple could delay or avoid pregnancy. If the respondent did not mention a particular method spontaneously, the interviewer described the method and asked whether the respondent had heard about the method. In this manner, knowledge was assessed for seven modern methods of family planning (the pill, IUD, injectables, Norplant, condoms, female sterilization, and male sterilization) and two traditional methods of family planning (periodic abstinence and withdrawal). Any other methods, if spontaneously mentioned by the respondent, were also recorded. Knowledge of family planning methods is widespread in Bangladesh (Table 5.1). All ever-married women know of at least one modern method of family planning, and eight out of every ten women know of at least one traditional method. On average, a woman has heard of 7.6 methods of family planning. There is virtually no difference in knowledge between ever-married and currently married women. Table 5.1 Knowledge of contraceptive methods Percentage of ever-married and currently married women who know any contraceptive methods, by specific method, Bangladesh 2004 Contraceptive method Ever-married women Currently married women Any method 100.0 100.0 Any modern method 100.0 100.0 Pill 99.9 99.9 IUD 84.9 85.0 Injectables 98.5 98.6 Norplant 76.0 76.7 Condom 91.6 92.2 Female sterilization 96.1 96.1 Male sterilization 72.7 72.9 Any traditional method 80.3 81.0 Periodic abstinence 70.4 71.0 Withdrawal 57.8 58.7 Other 7.3 7.6 Mean number of methods known 7.6 7.6 Number of women 11,440 10,582 Almost all respondents have heard of pills, injectables, and female sterilization. More than nine out of ten women know of condoms. Knowledge of other modern methods is also widespread; a majority of currently married women have heard of the IUD (85 percent), Norplant (77 percent), and male sterilization (73 percent). Knowledge of traditional methods is lower than modern methods. The data show similar levels of knowledge of specific methods for both currently married and ever-married women. 64 │ Fertility Regulation Since the 1999-2000 Bangladesh Demographic and Health Survey (BDHS), there has been little overall change in knowledge of contraceptives. However, knowledge of some specific methods has changed. For example, knowledge of implants has increased from 56 to 77 percent of currently married women and knowledge of condoms increased from 90 to 92 percent. 5.2 EVER USE OF CONTRACEPTION Respondents who said that they had heard of a method of family planning were asked whether they had ever used that method. Ever use of family planning methods in the 2004 BDHS 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 have special significance for family planning programs. These data indicate the proportion of the population who were exposed to contraceptive use at least once. Therefore, data on ever use reflect 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. Among ever-married women, four-fifths have used a contraceptive method at some time, three- fourths have used a modern method, and more than one-fourth have used a traditional method (Table 5.2). The pill is by far the most commonly used method; more than six out of ten ever-married women say they have used it. The next most commonly used method is injectables (26 percent). Very few women report having ever used male sterilization (less than 1 percent). As expected, currently married women are somewhat more likely than ever-married women to report ever use of a family planning method. Table 5.2 Ever use of contraception Percentage of ever-married and currently married women who have ever used any contraceptive method, by specific method and age, Bangladesh 2004 Modern method Traditional method Age Any method Any modern method Pill IUD Inject- ables Norplant Condom Female sterili- zation Male sterili- zation Any tradi- tional method Periodic absti- nence With- drawal Other Number of women EVER-MARRIED WOMEN 10-14 54.0 48.1 42.7 0.0 0.4 0.0 14.3 0.0 0.0 10.2 5.2 5.0 0.0 150 15-19 67.0 60.3 49.9 0.5 10.4 0.3 21.9 0.0 0.0 18.8 7.5 13.1 0.4 1,598 20-24 81.1 76.0 67.4 1.6 22.1 1.5 26.9 0.3 0.1 25.3 14.0 14.6 1.1 2,202 25-29 87.1 83.8 73.8 4.3 33.8 2.3 23.4 2.1 0.4 29.0 17.6 15.5 3.0 2,013 30-34 86.8 82.0 70.7 8.2 39.2 1.3 20.5 5.2 0.4 33.4 23.4 14.0 3.9 1,793 35-39 84.7 80.4 65.7 11.4 32.3 1.6 18.8 9.3 1.8 34.9 25.8 14.5 3.5 1,457 40-44 80.5 73.1 56.1 10.7 26.0 1.0 14.9 13.2 1.9 37.8 30.3 15.0 4.2 1,160 45-49 70.9 59.9 40.0 6.7 15.7 0.2 8.8 15.9 1.4 32.8 25.3 10.6 3.7 1,066 Total 80.2 74.5 62.4 5.6 26.0 1.3 20.5 5.2 0.7 29.3 19.3 14.0 2.6 11,440 CURRENTLY MARRIED WOMEN 10-14 54.6 48.6 43.0 0.0 0.4 0.0 14.7 0.0 0.0 10.5 5.4 5.1 0.0 145 15-19 68.5 61.8 51.2 0.5 10.8 0.3 22.5 0.0 0.0 19.1 7.6 13.3 0.4 1,536 20-24 82.0 77.1 68.4 1.7 22.5 1.5 27.5 0.3 0.1 25.8 14.3 14.8 1.1 2,121 25-29 88.9 85.6 75.5 4.4 34.5 2.4 23.8 2.2 0.4 29.4 17.6 16.0 3.1 1,935 30-34 88.8 84.5 73.1 8.6 40.8 1.4 21.4 5.4 0.5 34.4 24.0 14.5 4.2 1,683 35-39 89.2 84.7 69.9 12.0 34.7 1.8 19.8 9.6 1.8 37.1 27.4 15.6 3.8 1,309 40-44 86.1 79.4 61.3 12.0 29.5 1.2 16.4 14.1 1.9 40.7 32.7 16.2 4.8 982 45-49 75.5 65.4 44.3 7.9 18.1 0.2 10.2 16.7 1.5 35.2 27.1 11.3 4.1 870 Total 82.8 77.4 65.1 5.8 27.4 1.4 21.5 5.2 0.7 30.2 19.7 14.6 2.8 10,582 Fertility Regulation │ 65 The level of ever use of family planning has increased steadily in Bangladesh (Table 5.3). In 2004, 80 percent of ever-married women of reproductive age reported having used a family planning method at some time, compared with only 14 percent in 1975, registering a more than fivefold increase over the past three decades. Table 5.3 Trends in ever use of family planning methods Percentage of ever-married women age 10-49 who have ever used specific family planning methods, selected sources, Bangladesh 1975- 2004 Method 1975 BFS 1983 CPS 1985 CPS 1989 CPS 1989 BFS1 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS 2004 BDHS Any method 13.6 33.4 32.5 44.2 45.0 59.0 63.1 69.2 74.6 80.2 Any modern method u 23.8 25.9 37.5 u 49.2 56.4 63.0 67.9 74.5 Pill 5.0 14.1 14.3 23.3 22.0 34.1 42.0 48.9 55.4 62.4 IUD 0.9 2.2 2.7 4.6 4.0 6.2 7.3 6.9 6.9 5.6 Injectables u 1.2 1.3 2.8 2.0 6.6 11.0 15.7 20.1 26.0 Vaginal methods 0.5 2.2 1.6 2.4 1.0 2.9 u u u u Condom 4.8 7.1 5.7 9.3 6.0 13.4 13.9 15.0 18.6 20.5 Female sterilization 0.3 5.8 7.4 8.7 9.0 8.0 7.9 7.6 6.6 5.2 Male sterilization 0.4 1.4 1.6 1.6 1.0 1.4 1.4 1.2 0.6 0.7 Any traditional method u 17.3 11.9 15.3 u 29.6 24.0 23.0 28.8 29.3 Periodic abstinence 4.5 11.0 7.8 9.7 13.0 21.5 16.5 16.7 18.9 19.3 Withdrawal 2.6 5.3 2.9 3.6 7.0 11.1 10.1 9.5 14.0 14.0 Number of women 6,515 8,523 8,541 10,293 11,907 10,573 9,640 9,127 10,544 11,440 u = Unknown (no information) 1 Published data were presented in whole numbers; the decimal was added to balance the table. Sources: 1975 Bangladesh Fertility Survey (BFS) (MHPC, 1978:A275); 1983 Contraceptive Prevalence Survey (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); 1993-1994 Bangladesh Demographic and Health Survey (BDHS) (Mitra et al., 1994:43); 1996-1997 BDHS (Mitra et al., 1997:47); and 1999-2000 BDHS (NIPORT et al., 2001:50) 5.3 KNOWLEDGE AND EVER USE OF MENSTRUAL REGULATION In the 2004 BDHS, women were asked if they knew about or had ever used menstrual regulation (MR). MR is a procedure used to bring on menses in women who have missed their menstrual cycle. According to Government of Bangladesh policy, the MR procedure can be performed within eight weeks from the first day of the last menstrual period (LMP) by a paramedic (namely, a trained family welfare visitor) or within ten weeks from the first day of the LMP by a trained medical doctor. Eight in ten ever-married and currently married women know about MR (Table 5.4). Although rates of ever use of MR have been rising since the 1996-1997 BDHS, they remain low, with 6 percent of women reporting they had ever used MR. Rates of ever use are highest among women in their thirties— 9 percent for currently married women and 8 percent for ever-married women. 66 │ Fertility Regulation Table 5.4 Menstrual regulation Percentage of ever-married and currently married women who know of menstrual regulation (MR) and the percentage who have ever used MR, by age group, Bangladesh 2004 Ever-married women Currently married women Age Know of MR Ever used MR Number of women Know of MR Ever used MR Number of women 10-14 51.3 0.0 150 52.6 0.0 145 15-19 75.1 1.3 1,598 75.3 1.4 1,536 20-24 81.9 3.6 2,202 81.8 3.6 2,121 25-29 83.8 7.0 2,013 83.8 7.1 1,935 30-34 84.6 8.2 1,793 85.0 8.6 1,683 35-39 84.0 8.1 1,457 85.4 9.0 1,309 40-44 82.7 6.7 1,160 83.2 7.4 982 45-49 76.3 5.0 1,066 77.2 5.9 870 Total 81.1 5.6 11,440 81.5 5.9 10,582 5.4 CURRENT USE OF CONTRACEPTION In BDHS surveys, current use of contraception is defined as the proportion of currently married women who report that they are currently using a family planning method. Overall, 58 percent of currently married women in Bangladesh are using a contraceptive method, with 47 percent using a modern method and 11 percent relying on traditional methods (Table 5.5). Table 5.5 Current use of contraception Percent distribution of currently married women by contraceptive method currently used, according to age, Bangladesh 2004 Modern method Traditional method Age Any method Any modern method Pill IUD Inject- ables Norplant Condom Female sterili- zation Male sterili- zation Any tradi- tional method Periodic absti- nence With- drawal Other Not currently using Total Number of women 10-14 29.1 21.9 15.5 0.0 0.4 0.0 6.0 0.0 0.0 7.2 4.1 3.1 0.0 70.9 100.0 145 15-19 42.2 34.1 23.1 0.3 6.2 0.3 4.2 0.0 0.0 8.1 3.4 4.5 0.1 57.8 100.0 1,536 20-24 52.9 46.8 31.3 0.4 8.8 1.1 4.8 0.3 0.1 6.2 3.2 2.6 0.3 47.1 100.0 2,121 25-29 61.3 54.2 33.2 0.6 11.9 1.5 4.5 2.2 0.4 7.0 3.8 2.8 0.5 38.7 100.0 1,935 30-34 68.6 56.6 31.2 0.6 13.7 0.8 4.5 5.4 0.5 12.1 7.8 3.1 1.1 31.4 100.0 1,683 35-39 72.1 56.9 25.3 1.4 13.6 0.7 4.4 9.6 1.8 15.2 10.7 3.6 0.9 27.9 100.0 1,309 40-44 64.7 43.9 17.1 1.0 6.7 0.5 3.1 14.1 1.4 20.9 13.8 5.7 1.3 35.3 100.0 982 45-49 47.3 32.2 8.1 0.1 4.0 0.0 1.8 16.7 1.5 15.1 9.6 4.8 0.8 52.7 100.0 870 Total 58.1 47.3 26.2 0.6 9.7 0.8 4.2 5.2 0.6 10.8 6.5 3.6 0.6 41.9 100.0 10,582 Note: If more than one method is used, only the most effective method is considered in this tabulation. Oral contraceptive pills continue to be by far the most popular method of contraception, with over a quarter of currently married women using the method. It now accounts for 45 percent of all contraceptive use and 55 percent of modern method use in the country. Other commonly used methods are injectables (10 percent of currently married women), periodic abstinence (7 percent), female sterilization (5 percent), and Fertility Regulation │ 67 condoms and withdrawal (4 percent each). Less than 1 percent of married women report the use of Norplant, the IUD, or male sterilization. Current use of contraception varies by age. Use of any contraceptive rises with age, from 29 percent among currently married women age 10-14, to a peak of 72 percent at age 35-39, and then drops to 47 percent at age 45-49. This inverted U-shaped pattern of contraceptive use by age is typical of most countries. The drop in current use among older women is usually attributed to their declining fecundity─whether perceived or real—while lower levels of use among younger women are usually attributed to their desire to have (more) children. Younger women in Bangladesh are increasingly becoming aware and appreciative of the advantages of deliberately controlling childbirth early in marriage. Contraceptive use among women age 15-19 has increased from 25 percent in 1993-94 to 42 percent in 2004. There are also variations in the use of specific methods by age. The pill is the most popular method among married women in all age groups, except for those in the oldest age group, who are more likely to be sterilized. Injectables are the second most popular modern method after the pill for women age 15-39. 5.4.1 Trends in Current Use of Family Planning The contraceptive prevalence rate in Bangladesh has increased from 8 percent in 1975 to 58 percent of currently married women in 2004 (Table 5.6 and Figure 5.1). This translates to more than a sevenfold increase. The increase in the use of modern methods is even more dramatic—a more than ninefold increase (from 5 to 47 percent) in three decades. Table 5.6 Trends in current use of contraceptive methods Percentage of currently married women age 10-49 who are currently using specific family planning methods, selected sources, Bangladesh 1975-2004 Method 1975 BFS 1983 CPS 1985 CPS 1989 BFS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS Any method Any modern method Pill IUD Injectables Norplant Vaginal methods Condom Female sterilization Male sterilization Any traditional method Periodic abstinence Withdrawal Other traditional methods Number of women 7.7 19.1 25.3 30.8 39.9 44.6 49.2 53.8 5.0 13.8 18.4 23.2 31.2 36.2 41.5 43.4 2.7 3.3 5.1 9.6 13.9 17.4 20.8 23.0 0.5 1.0 1.4 1.4 1.8 2.2 1.8 1.2 u 0.2 0.5 0.6 2.6 4.5 6.2 7.2 u u u u u u 0.1 0.5 0.0 0.3 0.2 0.1 u u u u 0.7 1.5 1.8 1.8 2.5 3.0 3.9 4.3 0.6 6.2 7.9 8.5 9.1 8.1 7.6 6.7 0.5 1.2 1.5 1.2 1.2 1.1 1.1 0.5 2.7 5.4 6.9 7.6 8.7 8.4 7.7 10.3 0.9 2.4 3.8 4.0 4.7 4.8 5.0 5.4 0.5 1.3 0.9 1.8 2.0 2.5 1.9 4.0 1.3 1.8 2.2 1.8 2.0 1.1 0.8 0.9 u 7,662 7,822 10,907 9,745 8,980 8,450 9,720 58.1 47.3 26.2 0.6 9.7 0.8 u 4.2 5.2 0.6 10.8 6.5 3.6 0.6 10,582 u = Unknown (not available) Sources: 1975 Bangladesh Fertility Survey (BFS) (Islam and Islam, 1993:43); 1983 Contraceptive Prevalence Survey (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); 1993-1994 Bangladesh Demographic and Health Survey (BDHS) (Mitra et al., 1994:45); 1996-1997 BDHS (Mitra et al., 1997:50); and 1999-2000 BDHS (NIPORT et al., 2001:53) 68 │ Fertility Regulation Between the 1999-2000 BDHS and the 2004 BDHS, overall contraceptive use increased by 4 percentage points, from 54 to 58 percent of currently married women. This increase has been almost entirely due to the higher use of modern methods, namely, the pill and injectables. Condom use has remained unchanged since the 1999-2000 BDHS, while the use of traditional methods shows a slight increase. A decade-long decline in the use of long-lasting contraceptive methods continues. In 2004, only 7 percent of currently married women were using sterilization, IUD, or Norplant, compared with 11 percent in 1993-94. With the use of long-term methods declining and that of short-term methods, especially the pill, increasing, the proportional share that each method contributes to the overall use of contraception—known as the “method mix”—has changed over time. For example, the pill now accounts for 45 percent of total contraceptive use, compared with 35 percent in 1991 (Figure 5.2). In contrast, long-lasting methods (sterilization, Norplant, and IUD) now account for 12 percent of total contraceptive use, compared with 30 percent in 1991. Fertility Regulation │ 69 5.4.2 Differentials in Current Use of Family Planning Current use of contraceptive methods varies by urban-rural areas, administrative divisions, and the other background characteristics of women (Table 5.7). The level of current contraceptive use is higher in urban than in rural areas, 63 versus 57 percent. The urban-rural gap has, however, narrowed with contraceptive use rising more rapidly in the rural areas. The urban-rural differences are predominantly due to higher proportions of couples using condoms in urban areas (8 percent) than in rural areas (3 percent). There is little variation in use of other methods between the rural and urban areas. Differentials in current contraceptive use by the six administrative divisions of the country are large. Contraceptive use is highest in Rajshahi division (68 percent) and lowest in Sylhet division (32 percent). In 2004, only two divisions, namely Chittagong and Sylhet, had contraceptive prevalence rates below 50 percent. Since the 1999-2000 BDHS, contraceptive use has increased in Rajshahi, Dhaka, and Chittagong divisions. The largest increase was in Rajshahi, 10 percentage points. During this period, contraceptive use remained unchanged in Khulna and decreased slightly in Barisal and Sylhet. 70 │ Fertility Regulation Table 5.7 Current use of contraception by background characteristics Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Bangladesh 2004 Modern method Traditional method Background characteristic Any method Any modern method Pill IUD Inject- ables Norplant Condom Female sterili- zation Male sterili- zation Any tradi- tional method Periodic absti- nence With- drawal Other Not currently using Total Number of women Residence Urban 62.9 51.6 26.9 0.5 9.1 1.0 8.3 5.3 0.5 11.3 6.5 4.1 0.7 37.1 100.0 2,372 Rural 56.7 46.0 26.0 0.6 9.8 0.7 3.0 5.2 0.7 10.6 6.5 3.5 0.6 43.3 100.0 8,210 Division Barisal 54.2 42.7 22.5 0.6 12.8 0.4 1.9 3.8 0.6 11.5 7.3 3.4 0.8 45.8 100.0 674 Chittagong 47.1 37.4 19.4 0.6 8.3 0.5 4.8 3.6 0.2 9.7 5.7 3.1 0.9 52.9 100.0 1,877 Dhaka 59.3 48.5 27.3 0.5 8.0 1.2 4.9 6.2 0.4 10.8 6.7 3.4 0.7 40.7 100.0 3,315 Khulna 63.8 50.7 28.6 0.7 11.5 0.4 4.9 3.6 1.1 13.0 6.8 5.6 0.6 36.2 100.0 1,296 Rajshahi 68.3 57.8 33.1 0.6 12.2 0.7 3.4 6.5 1.2 10.5 6.3 3.7 0.5 31.7 100.0 2,782 Sylhet 31.8 22.0 9.6 0.9 4.1 1.2 2.5 3.7 0.1 9.8 7.6 1.8 0.4 68.2 100.0 638 Education No education 58.8 48.3 23.1 0.7 12.2 1.2 1.5 8.5 1.0 10.5 7.1 2.4 1.1 41.2 100.0 4,187 Primary incomplete 56.8 45.4 25.4 0.4 11.0 0.5 2.5 4.9 0.8 11.4 7.0 3.8 0.6 43.2 100.0 2,176 Primary complete 58.9 47.4 31.1 0.5 7.1 0.9 4.1 3.1 0.6 11.5 7.5 3.7 0.3 41.1 100.0 958 Secondary incomplete 56.3 46.7 31.0 0.6 7.0 0.4 5.9 1.7 0.1 9.7 4.6 4.9 0.2 43.7 100.0 2,457 Secondary complete or higher 62.0 49.1 24.0 1.0 3.9 0.2 17.8 2.1 0.1 12.9 7.0 5.8 0.2 38.0 100.0 804 Number of living children 0 23.4 17.1 10.2 0.0 0.3 0.0 5.9 0.1 0.6 6.4 2.5 3.8 0.1 76.6 100.0 1,246 1 54.2 46.1 30.5 0.4 7.7 0.7 4.6 1.6 0.5 8.1 4.7 3.1 0.2 45.8 100.0 2,028 2 64.3 55.3 32.9 0.6 10.9 1.2 4.7 4.4 0.5 9.0 5.5 3.3 0.2 35.7 100.0 2,514 3 69.7 57.9 28.5 0.7 12.8 1.0 4.5 9.7 0.7 11.9 7.8 3.3 0.8 30.3 100.0 2,002 4+ 62.4 46.8 22.6 1.0 11.9 0.7 2.4 7.5 0.8 15.5 9.7 4.3 1.5 37.6 100.0 2,791 Wealth index Lowest 53.6 44.7 22.9 0.3 11.9 0.9 1.2 6.1 1.2 9.0 5.5 2.5 1.0 46.4 100.0 2,042 Second 57.6 47.7 26.5 0.8 11.8 1.0 1.7 5.1 0.7 10.0 6.4 3.0 0.6 42.4 100.0 2,112 Middle 57.8 46.6 27.4 0.4 9.0 0.6 2.5 5.9 0.7 11.2 6.9 3.5 0.8 42.2 100.0 2,112 Fourth 58.5 47.4 28.3 0.7 9.0 0.7 3.8 4.6 0.3 11.1 7.0 3.7 0.5 41.5 100.0 2,168 Highest 62.5 50.0 25.8 0.7 6.7 0.7 11.4 4.3 0.2 12.5 6.9 5.3 0.4 37.5 100.0 2,148 Total 58.1 47.3 26.2 0.6 9.7 0.8 4.2 5.2 0.6 10.8 6.5 3.6 0.6 41.9 100.0 10,582 Note: If more than one method is used, only the most effective method is considered in this tabulation. There is little variation in contraceptive use by education levels of women; only those who have completed at least secondary education are more likely to report a higher use rate than others. The pill is the most widely used method among women in all educational categories. Injectables are the second most widely used method among women who have no education or have an incomplete primary education, while condoms are the second most popular method among those who have completed at least secondary education. Since Fertility Regulation │ 71 1999-2000, contraceptive use has increased among women with little or no education; the increase in use was highest among women with no education (8 percentage points). Women who had at least some secondary education had no increase in contraceptive use. There are notable variations in contraceptive use among women by number of living children. Only 23 percent of women use contraception before having a child. After the first child, contraceptive use increases sharply to 54 percent, increases to 64 percent after two children, and peaks at 70 percent after three children. The slight drop in use that follows may be due to declining fecundity associated with the older age of women. The pill is the most widely used method across all categories of women by number of living children, followed by injectables, except for women who have no children, who are more likely to use condoms. Women generally report higher use of contraception if they are from economically better-off households, upholding the relationship that contraceptive use increases with the improved economic status of women. Sixty-three percent of women in the highest wealth quintile reported that they use a contraceptive method, compared with only 54 percent of those in the lowest wealth quintile. The pill is the most widely used method among women across all wealth quintiles. The second most widely used methods are condoms among women in households in the highest quintile and injectables among women in households in the other four wealth quintiles. Figure 5.3 shows the level of current use of contraceptive methods by two women’s status indicators. The likelihood of women using a contraceptive method rises with their increasing status. Women are more likely to use a method if they participate in the decisionmaking in their family. Only 41 percent of women having no say in any decision in the family report using a contraceptive method. The proportion rises sharply to 55 percent among women who have a final say in one or two decisions and then rises further to over 60 percent among women who have a final say in three or more decisions. 72 │ Fertility Regulation Similarly, current use of contraceptive methods increases with freedom of movement. The proportion of women who report using a method is higher among women who go or can go alone to a hospital or clinic than those who cannot. 5.5 NUMBER OF CHILDREN AT FIRST USE OF CONTRACEPTION The BDHS included a question for all women who had ever used a method as to how many living children they had when they first used a method. Table 5.8 shows the distribution of ever-married women in the 2004 BDHS by the number of living children they had when they first used contraception, according to five-year age groups. 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. 5.8 Number of children at first use of contraception Percent distribution of ever-married women by number of living children at time of first use of contraception and median number of children at first use, according to current age, Bangladesh 2004 Number of living children at time of first use of contraception Age Never used contra- ception 0 1 2 3 4+ Total Number of women Median number of children at first use 10-14 46.0 52.2 1.8 0.0 0.0 0.0 100.0 150 0.0 15-19 33.0 41.3 22.8 2.8 0.1 0.0 100.0 1,598 0.0 20-24 18.9 31.3 37.5 9.2 2.7 0.4 100.0 2,202 0.2 25-29 12.9 19.7 38.7 17.7 7.7 3.4 100.0 2,013 0.6 30-34 13.2 13.2 30.9 19.2 12.5 10.9 100.0 1,793 1.0 35-39 15.3 9.6 21.0 18.7 16.0 19.4 100.0 1,457 1.6 40-44 19.5 6.0 17.4 14.4 17.5 25.2 100.0 1,160 2.1 45-49 29.1 3.3 10.0 11.2 13.2 33.2 100.0 1,066 2.8 Total 19.8 20.1 27.4 13.2 8.9 10.5 100.0 11,440 0.7 Overall, 61 percent of women initiated contraceptive use when they had fewer than three living children, with 20 percent initiating use before having the first child. The results also indicate that Bangladeshis are adopting family planning methods at an earlier age than before. Younger cohorts of women show a tendency to initiate family planning use at lower parities. For example, although 23 percent of women age 35 and older initiated family planning use before having two children, the proportion rises with younger cohorts, reaching 67 percent among women age 15-24. Comparison of information available through the various BDHS surveys indicates that Bangladeshi women are initiating family planning use at lower parities than before. For example, in 2004, almost half of the women reported that they initiated family planning use before they had two children, compared with 27 percent in 1993-94. Although a few women initiate family planning to delay starting childbearing, that proportion has also been increasing over the last decade. In 1993-94 about one in nine women reported using family planning to delay the first birth; in 2004, one in five women reported adopting family planning before having the first child. 5.6 PROBLEMS WITH CURRENT METHOD In this survey, women currently using modern family planning methods were asked whether they were having any health-related or other problems in using the method they were currently using and, if so, Fertility Regulation │ 73 what those problems were. Problems in using a family planning method may reduce the effectiveness with which it is used or even lead to termination of its use. Identifying problems associated with the use of specific methods therefore has important implications both for educational and publicity campaigns and for efforts toward improving delivery of family planning services in Bangladesh. Table 5.9 presents information on the problems as reported in the 2004 BDHS. Table 5.9 Problems with current method of contraception Among women who are currently using a modern method of family planning, percentage who are having problems with their method, by specific method and type of problem, Bangladesh 2004 Contraceptive method Problem Pill IUD Injectables Condom Female sterilization Norplant Total Any problem 23.4 17.7 41.8 3.2 33.0 40.6 26.7 Weight gain 0.7 0.0 1.1 0.0 0.6 1.1 0.7 Weight loss 1.2 2.8 2.4 0.0 4.5 4.8 1.8 Excessive bleeding 0.4 3.6 2.5 0.0 2.6 8.7 1.3 Hypertension 0.4 3.0 0.2 0.0 0.7 1.8 0.4 Headache 13.3 1.3 9.6 0.4 5.4 8.8 10.2 Nausea 5.5 1.3 1.7 0.0 0.6 3.5 3.5 No menstruation 1.2 0.0 25.2 0.0 1.6 15.7 6.3 Weak/tired 10.8 5.9 16.6 0.3 15.8 15.5 11.7 Dizziness 2.3 1.3 3.7 0.2 3.9 6.2 2.6 Husband disapproves 0.1 0.0 0.1 0.5 0.2 0.0 0.1 Inconvenient to use 0.1 0.0 0.1 0.2 0.4 0.0 0.1 Abdominal pain 0.5 6.8 2.2 1.6 15.9 1.2 2.9 Other 0.5 6.8 2.2 1.6 16.2 1.2 2.9 Number of users 2,775 65 1,022 442 599 83 4,987 Note: Male sterilization has been omitted. Among women using modern methods, more than a quarter report having problems with their methods. Injectable and Norplant users are most likely (four out of ten) to report problems associated with the method. Their most common complaints are amenorrhea and feeling weak or tired. One in three sterilized women complains about problems related to sterilization; the most common complaints are abdominal pain and feeling weak or tired. Among pill users, one in five had some complaints; the most frequent complaints are headaches and feeling weak or tired. IUD users tend to complain of abdominal pain and feeling weak or tired. Condom users rarely report problems. Overall, feeling weak or tired is a frequently cited complaint across users of most modern methods. Problems with specific methods seem to have changed little between 1999-2000 and 2004. 74 │ Fertility Regulation 5.7 USE OF SOCIAL MARKETING BRANDS Bangladesh has an active contraceptive social marketing program that distributes pills, condoms, and oral rehydration salts (ORS) through a network of retail outlets (pharmacies, small shops, and kiosks) spread across the country. The Social Marketing Company carries several brands of oral contraceptives, namely Maya, Ovacon, Norquest, Nordette, Femicon, and Minicon. To obtain information on the number of users purchasing the social marketing brands, the BDHS interviewer asked current pill users to show her a packet of the pills they were using. If the user had the packet available, the interviewer recorded the brand on the questionnaire. If not, the interviewer showed the woman a chart depicting all major pill brands and asked the user to identify which brand she was currently using. As shown in Table 5.10, overall, 40 percent of pill users use social marketing brands, compared with 56 percent using the government-supplied brand, Shuki. The government-supplied brand is provided free of charge through government fieldworkers and clinics and at a nominal charge from nongovernmental service providers. Femicon is the most widely used social marketing brand of pills, used by three in ten pill users in both rural and urban areas. The next most widely used social marketing brand is Nordette, used more by urban pill users (13 percent) than by rural pill users (5 percent). Minicon, a new brand of pills introduced by the Social Marketing Company, is used by 3 percent of pill users, with little variation between urban and rural areas. Few women report the use of any other social marketing brand. The percentage of pill users using a social marketing brand has consistently increased, from 14 percent in 1993-94 to 40 percent in 2004. Table 5.10 Use of pill brands Percent distribution of current pill users by brand of pill used, according to urban-rural residence, Bangladesh 2004 Residence Pill brand Urban Rural Total Social marketing 47.7 38.0 40.1 Maya 0.3 0.3 0.3 Ovacon 0.2 0.1 0.1 Norquest 0.1 0.0 0.0 Nordette 12.8 5.3 7.0 Femicon 31.9 29.7 30.2 Minicon 2.4 2.6 2.5 Government Shuki 43.6 59.4 55.8 7.8 2.2 3.5 Private Marvelon 2.5 0.2 0.7 Ovostat 5.2 1.4 2.3 Lyndiol 0.1 0.0 0.0 Ovral 0.0 0.6 0.5 Don't know 0.8 0.5 0.6 Total 100.0 100.0 100.0 Number of pill users 638 2,138 2,775 To assess the social marketing program’s reach in condom use, the 2004 BDHS gathered information to estimate the proportion of condom users using a social marketing brand. Interviewers showed a chart depicting all major condom brands to women who reported that their husband was currently using condoms. They were asked to identify the brand they use. Men would presumably be a more reliable source of data on condom brands; however, because of the larger sample of women than men in the BDHS survey, the data shown in Table 5.11 are derived from women. Fertility Regulation │ 75 Table 5.11 Use of condom brands Percent distribution of current condom users by brand of condom used, according to urban-rural residence, Bangladesh 2004 Residence Condom brand Urban Rural Total Social marketing brand 72.6 60.1 65.7 Raja 13.8 31.5 23.6 Panther 43.5 23.9 32.6 Sensation 15.3 4.7 9.5 Government Nirapad 10.5 24.5 18.3 Private and others 11.3 7.9 9.3 Carex 1.7 1.9 1.8 Titanic 0.7 0.0 0.3 Lotus 0.3 1.3 0.9 Feelings 0.6 0.0 0.2 Expot 0.4 0.0 0.2 Lubricant 2.4 3.5 3.0 Greenlove 4.9 1.2 2.8 Romeo 0.3 0.0 0.1 Don’t know 5.8 7.3 6.6 Total 100.0 100.0 100.0 Number of users 197 245 442 Note: Table is based on women’s reports. Condom brands sold by the Social Marketing Company have a high market share. Two out of three condom users use a social marketing brand, with 33 percent using Panther, 24 percent using Raja, and another 10 percent using Sensation. The Panther and Sensation brands are more popular among urban users, while Raja is predominant among rural users. The proportion of condoms supplied through the Social Marketing Company has decreased slightly in the last four years, from 71 to 66 percent. 5.8 AGE AT STERILIZATION AND STERILIZATION REGRET Table 5.12 shows the distribution of sterilized women by the age at which they had the procedure, according to the number of years preceding the survey that the procedure was done. However, because data on age at sterilization are derived from a question on the month and year of the operation, it is possible that the data are distorted by recall errors in reporting either the date of the operation or the date of birth and/or age of the woman. 76 │ Fertility Regulation Table 5.12 Timing of sterilization Percent distribution of sterilized women by age at the time of sterilization and median age at sterilization, according to the number of years since the operation, Bangladesh 2004 Age at time of sterilization Years since operation <25 25-29 30-34 35-39 40-44 Total Number of women Median age1 <2 (8.6) (44.2) (31.0) (15.8) (0.4) 100.0 28 29.8 2-3 (38.3) (20.1) (24.4) (7.4) (9.9) 100.0 34 27.5 4-5 (23.5) (31.5) (26.9) (18.0) (0.0) 100.0 42 29.1 6-7 (27.5) (26.7) (34.0) (7.7) (4.0) 100.0 50 28.2 8-9 28.1 31.6 23.0 14.0 3.4 100.0 52 28.6 10+ 47.0 32.4 18.4 2.2 0.0 100.0 394 a Total 39.8 31.6 21.7 5.7 1.2 100.0 599 26.5 Note: Figures in parentheses are based on 25-49 unweighted cases. a = Not calculated because of censoring 1 Median ages are calculated only for women sterilized at less than 40 years of age to avoid problems of censoring. Women who decide to get sterilized generally have the procedure early in their reproductive years. Seven out of ten sterilized women had the procedure done before age 30. The median age of sterilization is 27 years, and this has not changed over the last decade. As in the earlier BDHS surveys, women who had been sterilized or whose husband had been sterilized were asked whether they regretted having had the operation and, if so, why. The results are presented in Table 5.13. Although some level of regret is expected to occur with any permanent method of contraception, a high level could be viewed as an indication of poor quality of care in the sense that women and men who are sterilized at a young age and/or low parity or who are not adequately counseled are more likely to regret having the operation (Loaiza, 1995). Overall, a higher percentage (15 percent) of the women in the 2004 BDHS survey reported that they regretted that they or their husband had been sterilized compared with 11 percent in the 1999-2000 BDHS. Fertility Regulation │ 77 Table 5.13 Sterilization regret Percentage of currently married women who are sterilized or whose husbands are sterilized and who regret the operation, by reasons for regret and selected background characteristics, Bangladesh 2004 Reason for regretting sterilization Background characteristic Percentage who regret the operation Respondent wants another child Husband wants child Side effects Child died Other reason Number of women Residence Urban 9.7 6.7 2.1 0.6 0.2 0.0 137 Rural 16.5 10.8 2.5 0.5 1.5 1.1 480 Division Barisal 16.2 13.4 1.2 0.0 1.6 0.0 30 Chittagong 14.1 9.2 3.2 0.0 0.0 1.7 70 Dhaka 12.8 7.0 3.4 0.0 2.4 0.0 217 Khulna 11.6 8.3 1.9 1.4 0.0 0.0 60 Rajshahi 18.9 13.5 1.7 1.2 0.7 1.9 215 Sylhet (8.6) (6.5) (0.9) (0.0) (1.3) (0.0) 24 Education No education 16.3 10.4 2.7 0.5 1.3 1.3 396 Primary incomplete 13.0 9.8 1.7 1.1 0.4 0.0 122 Primary complete (10.1) (9.2) (1.0) (0.0) (0.0) (0.0) 36 Secondary incomplete 13.3 4.9 3.7 0.0 4.7 0.0 45 Number of living children <2 (70.6) (54.0) (4.9) (0.0) (3.8) (7.8) 51 2 22.8 15.1 4.3 0.0 3.4 0.0 124 3 8.4 5.1 2.0 0.6 0.7 0.0 210 4+ 4.4 1.7 1.2 0.9 0.0 0.5 232 Total 15.0 9.9 2.4 0.5 1.2 0.8 617 Note: Total includes 17 women who have completed secondary education. Figures in parentheses are based on 25 to 49 women. A woman with fewer children is more likely to regret having had the procedure. Less than 5 percent of women with four or more living children regret having had the operation, compared with 23 percent of those having two living children. The number of living children, of course, refers to the current number and not the number at the time of sterilization. Presumably, many of those who regret being sterilized include unfortunate cases in which couples decide on sterilization and subsequently lose one or more of their children. Sterilization regret is more common among rural women than urban women. Sterilization regret also varies by division (from 9 to 19 percent) and by education (from 10 to 16 percent). The most common reason for regret is the desire to have another child, stated by two-thirds of women regretting sterilization. 78 │ Fertility Regulation 5.9 SOURCE OF FAMILY PLANNING SERVICES To ascertain the coverage of different sources of family planning methods in Bangladesh, women who report using a modern method of contraception at the time of the survey were asked where they obtained the method last time. Since women often do not know into which category the source they use falls (hospital, upazila health complex, family welfare center, or private clinic), interviewers were instructed to write the name of the source in the questionnaire. Team supervisors were instructed to verify that the name and the type of source coded were consistent. In Table 5.14, sources of family planning methods are classified into four major categories: public sector sources (including government hospitals, upazila health complexes, family welfare centers, satellite/EPI clinics, maternal and child welfare centers, and government fieldworkers), NGO sector sources (including static clinics, satellite clinics, depot holders, and fieldworkers), private medical sources (including private hospitals/clinics, doctors—qualified or traditional, and pharmacies), and other private sources (including shops and friends/relatives). Table 5.14 and Figure 5.4 show the percentage of current users of modern methods who obtained their method from a specific source. Table 5.14 Source of supply of modern contraceptive methods Percent distribution of current users of modern contraceptive methods by most recent source of supply, according to specific method, Bangladesh 2004 Contraceptive method Source of supply Pill IUD Injectables Norplant Condom Female sterilization Male sterilization Total Public sector 47.6 85.7 79.1 70.0 16.8 85.7 92.4 57.3 Government hospital 0.4 4.2 1.6 13.7 0.3 25.4 37.4 4.4 Family welfare center 4.3 34.0 26.3 9.4 2.6 11.7 4.8 9.9 Upazila health complex 1.9 34.1 11.1 45.5 0.3 41.4 49.7 10.1 Satellite clinic or EPI outreach site 4.4 6.1 22.5 1.0 0.4 0.1 0.0 7.1 Maternal and child welfare center 0.2 2.0 1.4 0.5 0.3 7.0 0.5 1.3 Community clinic 1.4 3.3 4.4 0.0 0.1 0.0 0.0 1.7 Government fieldworker 35.0 1.9 11.8 0.0 12.7 0.0 0.0 22.7 Nongovernmental organization (NGO) sector 3.3 8.6 13.5 28.1 4.7 5.4 2.0 6.2 Static clinic 1.1 8.6 7.9 28.1 3.2 5.4 2.0 3.7 Satellite clinic 0.3 0.0 3.6 0.0 0.3 0.0 0.0 0.9 Depot holder 0.8 0.0 0.0 0.0 0.5 0.0 0.0 0.5 Fieldworker 1.1 0.0 2.0 0.0 0.7 0.0 0.0 1.1 Private medical sector 42.6 3.9 7.1 1.9 63.5 8.0 0.8 31.4 Private hospital or clinic 0.0 3.9 1.2 1.9 0.0 8.0 0.8 1.3 Qualified doctor 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.1 Traditional doctor 0.8 0.0 1.3 0.0 0.0 0.0 0.0 0.7 Pharmacy 41.7 0.0 4.1 0.0 63.5 0.0 0.0 29.3 Other private 6.1 0.0 0.0 0.0 13.5 0.0 0.0 4.5 Shop 4.1 0.0 0.0 0.0 13.0 0.0 0.0 3.4 Friend/relatives 2.0 0.0 0.0 0.0 0.5 0.0 0.0 1.1 Other 0.4 0.7 0.1 0.0 0.5 0.9 2.7 0.4 Don’t know 0.1 0.0 0.0 0.0 0.6 0.0 2.1 0.1 Missing 0.0 1.0 0.1 0.0 0.3 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,775 65 1,022 83 442 599 67 5,053 Fertility Regulation │ 79 The public sector is the predominant source of family planning methods. Nearly six out of ten modern contraceptive method users obtain their methods from a public sector source, with 34 percent obtaining them from a public facility and 23 percent from a government fieldworker. Thirty-six percent of modern contraceptive users acquire their supplies from a private source. Thirty-one percent of users get their contraceptive methods from private medical sources such as pharmacies, private doctors, and hospitals or clinics; an additional 5 percent use nonmedical private sources such as shops and friends or relatives. Only 6 percent of users obtain their contraceptive methods from an NGO source. Over the years, there has been a substantial decline in the proportion of users obtaining methods from government fieldworkers, from 42 percent in 1993-1994, 39 percent in 1996-1997, and 28 percent in 1999- 2000, to 23 percent in 2004. Conversely, more couples now seem to procure their methods from pharmacies; 29 percent of users in 2004 reported that they obtain their method from pharmacies, compared with 21 percent in 1999-2000. The source a woman uses is related to the type of method she is using. Pill and condom users are most likely to get supplies from a pharmacy. In 2004, 42 percent of pill users and 64 percent of condom users were getting their supplies from pharmacies. Another one-third of the pill users obtain their method from government fieldworkers. About four out of five users of injectables get their method from government health facilities, while one in nine obtains it from NGO facilities. Most IUD users get their method from government facilities. Both female and male sterilization procedures are mainly performed in government facilities. 5.10 CONTRACEPTIVE DISCONTINUATION Couples can realize their reproductive goals only when they consistently and correctly use contraceptive methods. A key concern for family planning programs is the rate at which contraceptive users discontinue using their method and the reasons for such discontinuation. Life table contraceptive discontinuation rates are presented in Table 5.15. These rates are based on information collected in the five- year, month-by-month calendar in the 2004 BDHS questionnaire. All episodes of contraceptive use between June 1998 (the third month of the Bengali year 1405) and the date of interview were recorded in the calendar, along with the main reason for any discontinuation of use during this period. Thus, the discontinuation rates 80 │ Fertility Regulation presented here are based on all segments of use that started between June 1998 and three months prior to the date of interview. The month of interview and the two preceding months are ignored in order to avoid the bias that might be introduced by an unrecognized pregnancy. The rates presented in Table 5.15 are cumulative one-year discontinuation rates and represent the proportion of users who discontinue using a method within 12 months after they start. The rates are calculated by dividing the number of discontinuations at each duration of use in single months by the number of months of exposure at that duration. The single-month rates are then cumulated to produce a one-year rate. In calculating rates, the reasons for discontinuation are treated as competing risks (net rates). For this table, the reasons are classified into four main categories: method failure (resulting in a pregnancy), desire to become pregnant, side effects or health concerns, and all other reasons. Switching from one method to another is included in the last category. Table 5.15 Contraceptive discontinuation rates Percentage of contraceptive users who discontinued use of a method within 12 months after beginning its use, by reason for discontinuation and specific method, Bangladesh 2004 Reason for discontinuation Method Method failure Desire to become pregnant Side effects or health problem Other reasons Total Pill 3.9 8.5 20.8 13.3 46.5 Injectables 0.4 5.2 33.6 9.5 48.7 Condom 6.3 11.4 6.8 46.9 71.5 Periodic abstinence 10.7 5.7 0.1 24.9 41.4 Withdrawal 8.2 13.5 0.8 37.0 59.6 All methods 4.5 8.1 17.5 19.3 49.4 Note: Table is based on episodes of contraceptive use that began 3-59 months prior to the survey. The results indicate that nearly half of all contraceptive users in Bangladesh stop using their method within 12 months of starting. Nearly 5 percent of users stop using because of method failure, while 8 percent discontinue because they want to become pregnant. Eighteen percent discontinue using their method as a result of side effects or health concerns, and another 19 percent discontinue for other reasons. Discontinuation rates are highest for condoms (72 percent) and lowest for periodic abstinence (41 percent). There has been little change in discontinuation rates since 1996-1997. Further information on reasons for contraceptive discontinuation is presented in Table 5.16. This table shows the percent distribution of all discontinuations occurring during the five years preceding the survey, regardless of whether they occurred during the first 12 months of use or not. Side effects are the most common reason for discontinuation, accounting for 28 percent of all discontinuations. The next most common reason for discontinuation is the desire to become pregnant (22 percent), followed by accidental pregnancies (11 percent). There are variations in reasons for discontinuation by method. Side effects are the most common reason of discontinuation for the pill, the IUD, injectables, and Norplant. Although desire to become pregnant is an important reason of discontinuation for every reversible method, it accounts for more discontinuations among users of periodic abstinence, the pill, withdrawal, and condoms than for users of other methods. Husband’s disapproval is cited as a major reason of discontinuation of condoms, as well as the two traditional methods. Method failure (“became pregnant”) is a major reason for discontinuing periodic abstinence. Fertility Regulation │ 81 Table 5.16 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason for discontinuation, according to specific method, Bangladesh 2004 Method Reason for discontinuation Pill IUD Injectables Norplant Condom Periodic abstinence With- drawal Other All methods Became pregnant 11.2 1.6 1.4 (0.0) 10.6 25.5 15.9 (55.2) 11.2 Wanted to become pregnant 24.8 11.3 14.9 (13.6) 20.4 19.6 24.1 (11.3) 21.8 Husband disapproved 0.8 2.1 1.2 (0.0) 24.1 13.2 12.0 (0.0) 5.8 Side effects 33.6 54.6 52.5 (64.0) 4.5 0.1 0.3 (7.0) 27.7 Health concerns 6.5 9.1 9.9 (2.1) 4.0 0.1 1.1 (0.0) 5.7 Access/availability 1.4 0.0 5.8 (0.0) 2.0 0.1 0.0 (3.2) 1.9 Wanted a more effective method 2.7 0.0 1.1 (1.9) 8.8 21.4 19.3 (12.6) 6.1 Inconvenient to use 3.2 7.6 0.9 (2.5) 13.9 2.8 11.1 (0.8) 4.8 Infrequent sex/husband away 9.9 2.7 3.9 (4.1) 5.1 5.6 11.8 (2.9) 7.9 Cost too much 0.4 0.0 0.2 (0.0) 0.4 0.0 0.0 (0.0) 0.3 Fatalistic 0.1 0.0 0.0 (0.0) 0.1 0.1 0.0 (0.0) 0.1 Difficult to get pregnant/menopausal 0.8 3.0 2.5 (4.1) 0.6 6.3 1.8 (2.4) 1.7 Marital dissolution/separation 0.8 0.0 0.7 (0.0) 0.2 1.4 0.9 (0.0) 0.7 Other 3.2 8.0 4.7 (7.7) 4.1 2.7 1.0 (4.6) 3.4 Missing 0.6 0.0 0.4 (0.0) 1.2 1.1 0.7 (0.0) 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 4,632 134 1,348 39 1,165 808 556 43 8,729 Note: Total includes 5 male sterilization discontinuations. Figures in parentheses are based on 25-49 discontinuations. 82 │ Fertility Regulation 5.11 FUTURE INTENTIONS TO USE FAMILY PLANNING 5.11.1 Future Use of Contraception Currently married women who were not using contraception at the time of survey─defined as nonusers—were asked about their intention to use family planning in the future. The results are presented in Table 5.17, according to the number of living children the women had. Table 5.17 Future use of contraception Percent distribution of currently married women who are not using a contraceptive method by intention to use in the future, according to number of living children, Bangladesh 2004 Number of living children1 Future intention 0 1 2 3 4+ Total Intends to use 84.0 88.3 82.9 72.2 45.4 73.2 Unsure 4.1 1.5 1.5 1.4 1.0 1.7 Does not intend to use 11.7 10.1 15.2 25.9 53.4 24.8 Missing 0.1 0.1 0.4 0.4 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 676 1,019 957 659 1,125 4,437 1 Includes current pregnancy An important indicator of the changing demand for family planning is the extent to which nonusers of contraception plan to use family planning in the future. Among nonusers, nearly three-fourths intend to use family planning methods. Only a few nonusers (2 percent) say they are unsure of their intention. Intention to use varies with the number of children. The proportion of nonusers who say they intend to use family planning in the future peaks at 88 percent for women with one child and falls sharply to 45 percent among women with four or more children. The proportion of nonusers intending to use family planning in the future has remained practically unchanged between the 1999-2000 BDHS and the 2004 BDHS. 5.11.2 Reasons for Not Intending to Use Contraception Table 5.18 presents the main reasons for not intending to use contraception in the future as reported by nonintenders (nonusers who do not intend to use family planning in the future). Nearly eight out of ten nonintenders do not plan to use family planning for reasons related to fertility. The most common fertility- related reason for nonuse is infecundity, cited by 51 percent of nonintenders, who are either menopausal/have had a hysterectomy or are subfecund. Fifteen percent do not intend to use a contraceptive method because of fatalistic attitudes (believing that having children depends on God’s will), while 12 percent stated that infrequent sex or not having sex was the reason for not intending to use family planning. Fertility Regulation │ 83 Table 5.18 Reason for not intending to use contraception Percent distribution of currently married women who are not using a contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, Bangladesh 2004 Age Reason 10-29 30-49 Total Fertility related 50.2 82.2 78.4 Not having sex 0.0 5.1 4.5 Infrequent sex 3.7 8.2 7.7 Menopausal or hysterectomy 9.2 51.1 46.2 Subfecund or infecund 4.5 5.2 5.1 Postpartum amenorrheic 2.2 0.2 0.4 Fatalistic 30.5 12.4 14.6 Opposition to use 30.5 6.2 9.1 Respondent opposed 6.9 1.3 1.9 Husband opposed 10.5 1.9 2.9 Others opposed 0.0 0.1 0.1 Religious prohibition 13.2 2.9 4.1 Knows no source 1.2 0.1 0.2 Method related 10.2 6.2 6.7 Health concerns 4.6 1.3 1.7 Fear of side effects 2.6 3.8 3.7 Costs too much 0.7 0.0 0.1 Inconvenient to use 0.0 0.1 0.1 Interferes with body’s normal process 2.3 1.1 1.2 Other 7.9 4.9 5.2 Don’t know 0.0 0.1 0.1 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Number of women 130 969 1,099 Other major reasons for nonuse are opposition to family planning and method-related reasons. Nine percent of nonintenders do not intend to use contraceptives because of opposition to family planning─by themselves, their husband, or others or because of religious prohibitions. Only 7 percent do not intend to use because of method-related reasons, mainly fear of side effects. Between the 1999-2000 BDHS and the 2004 BDHS, the proportion of women citing fatalistic attitude as the reason for not using family planning rose from 9 to 15 percent, and those reporting themselves as menopausal, infecund, or subfecund rose from 44 to 51 percent. These increases were associated with a drop in the proportion of women citing infrequent sex or not having sex (from 16 to 12 percent) and opposition to family planning by the women themselves or their husbands. 5.11.3 Preferred Method for Future Use In assessing future demand for specific contraceptive methods, currently married women who were not using contraception but said they intended to use a contraceptive method in the future were asked which method they would prefer to use. The results on method preferences are presented in Table 5.19. The largest proportion of prospective users mentioned the pill (45 percent) as their preferred method, and 18 percent 84 │ Fertility Regulation favored injectables. There are only minor variations in method preference between the 1999-2000 BDHS and the 2004 BDHS. Table 5.19 Preferred method of contraception for future use Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to age, Bangladesh 2004 Age Method 10-29 30-49 Total Pill 45.3 44.8 45.2 IUD 0.4 0.9 0.5 Injectables 18.8 16.9 18.4 Norplant 1.0 1.3 1.1 Condom 2.4 2.0 2.3 Female sterilization 1.6 2.8 1.9 Periodic abstinence 0.8 3.2 1.4 Withdrawal 0.5 1.1 0.6 Other 0.2 0.3 0.2 Unsure 29.0 26.6 28.4 Total 100.0 100.0 100.0 Number of women 2,457 793 3,250 5.12 FAMILY PLANNING OUTREACH SERVICES Fieldworkers and satellite clinics are two crucial elements in the provision of family planning services in Bangladesh. The extent of coverage of both these services, as assessed in the 2004 BDHS, is presented in Table 5.20 for fieldworkers and in Table 5.21 for satellite clinics. Only 18 percent of currently married women reported having been visited for family planning services by a fieldworker in the six months preceding the survey (Table 5.20), with most of them saying they were visited by a government family planning fieldworker (15 percent). Fieldworker visits are not uniform across all groups of women. Younger (age 10-19) and older (age 40 and over) women are less likely to be visited than women in the prime reproductive ages. Fieldworkers’ visits also vary by the number of children women have; fieldworkers are least likely to visit women with no children and most likely to visit those who have two or three children. Fieldworkers’ visits for family planning are more common for women in rural areas (19 percent) than in urban areas (14 percent). Women in Khulna are most likely (one in five), while women in Chittagong and Sylhet are least likely (about one in eight) to be visited by fieldworkers providing family planning services. Fieldworker visits varied by contraceptive method use status of the woman. Fieldworkers mostly visit pill and IUD users; nonusers and sterilized women receive the fewest visits. Fertility Regulation │ 85 Table 5.20 Contact with family planning fieldworkers and health fieldworkers Percentage of currently married women who reported being visited by a government fieldworker or a nongovernmental organization (NGO) fieldworker for family planning (FP) services and for health services in the six months preceding the survey, by selected background characteristics and contraceptive use status, Bangladesh 2004 Fieldworker visit for family planning services Fieldworker visit for health services Background characteristic No one Govern - ment FP worker Govern- ment health worker NGO worker Total No one Govern- ment FP worker Govern- ment health worker NGO worker Total Not visited by either type of fieldworker in last 6 months Number of women Age 10-14 91.2 6.4 1.9 0.9 100.0 96.7 0.4 2.3 1.0 100.0 89.9 145 15-19 86.3 11.4 0.9 1.6 100.0 89.5 3.7 5.6 1.3 100.0 79.7 1,536 20-24 80.6 15.7 1.7 2.0 100.0 86.7 4.6 7.2 1.7 100.0 72.6 2,121 25-29 78.3 17.4 1.9 2.6 100.0 88.7 3.7 6.3 1.5 100.0 72.1 1,935 30-34 77.8 19.1 1.3 1.8 100.0 89.6 3.6 5.8 1.2 100.0 72.4 1,683 35-39 79.0 17.8 1.7 1.9 100.0 91.7 3.1 4.1 1.1 100.0 75.1 1,309 40-44 85.6 11.9 0.8 1.7 100.0 94.4 1.3 3.5 0.9 100.0 82.3 982 45-49 91.2 7.4 0.6 1.1 100.0 96.1 1.4 2.7 0.1 100.0 89.4 870 Residence Urban 85.6 9.6 1.1 3.7 100.0 93.0 2.2 3.1 1.8 100.0 81.7 2,372 Rural 80.7 16.6 1.5 1.4 100.0 89.4 3.7 6.1 1.1 100.0 74.8 8,210 Division Barisal 82.4 13.9 2.7 1.3 100.0 83.4 4.8 10.5 1.2 100.0 72.8 674 Chittagong 87.3 9.9 1.0 2.0 100.0 89.0 4.4 5.3 1.5 100.0 81.3 1,877 Dhaka 82.1 14.7 1.3 2.0 100.0 91.9 2.6 4.5 1.2 100.0 77.1 3,315 Khulna 76.5 19.2 2.0 2.5 100.0 89.8 2.8 6.7 1.0 100.0 72.0 1,296 Rajshahi 78.9 18.3 1.0 1.8 100.0 92.1 2.4 4.2 1.3 100.0 74.6 2,782 Sylhet 87.4 10.2 1.9 1.1 100.0 84.5 7.6 7.8 1.5 100.0 77.8 638 Education No education 83.4 13.8 1.3 1.6 100.0 91.7 3.0 4.5 1.0 100.0 78.4 4,187 Primary incomplete 80.3 16.7 1.2 1.9 100.0 88.4 3.7 6.6 1.4 100.0 73.9 2,176 Primary complete 77.9 18.4 2.3 1.8 100.0 88.4 3.1 7.2 1.4 100.0 71.0 958 Secondary incomplete 81.5 15.1 1.4 2.2 100.0 89.5 3.9 5.4 1.5 100.0 76.1 2,457 Secondary complete or higher 83.6 12.9 1.3 2.5 100.0 91.2 2.5 5.1 1.3 100.0 78.8 804 Number of living children 0 92.7 6.0 1.1 0.2 100.0 98.5 0.5 0.8 0.3 100.0 91.8 968 1 83.4 13.3 1.2 2.2 100.0 88.4 3.9 6.1 1.9 100.0 76.9 2,118 2 78.7 17.9 1.4 2.1 100.0 88.6 4.1 6.5 1.0 100.0 71.9 2,574 3 77.8 18.1 1.5 2.8 100.0 89.8 3.2 5.5 1.7 100.0 72.8 2,055 4+ 82.7 14.6 1.6 1.4 100.0 90.5 3.3 5.5 1.0 100.0 77.1 2,866 Current contraceptive use Pill 69.2 26.6 2.2 2.2 100.0 88.8 4.1 6.0 1.2 100.0 63.9 2,775 IUD 72.3 23.5 5.0 3.0 100.0 87.1 2.4 10.5 0.0 100.0 67.5 65 Injections 78.0 17.1 1.0 4.1 100.0 88.0 4.1 5.9 1.8 100.0 72.3 1,022 Norplant 82.1 15.7 0.0 2.2 100.0 90.7 3.0 6.2 0.0 100.0 81.3 83 Condom 78.8 18.2 0.9 2.6 100.0 93.7 2.0 3.7 0.7 100.0 76.5 442 Female sterilization 94.8 3.4 0.9 1.0 100.0 96.4 1.2 2.0 0.5 100.0 92.3 550 Male sterilization 92.7 6.2 0.0 1.1 100.0 96.4 0.8 2.8 0.0 100.0 92.0 67 Periodic abstinence 81.2 14.9 1.5 2.5 100.0 89.5 3.0 6.9 0.9 100.0 75.3 690 Withdrawal 83.2 14.3 1.7 1.3 100.0 91.3 2.9 3.6 2.2 100.0 79.2 382 Other 95.7 4.3 0.0 0.0 100.0 83.3 5.8 10.3 0.6 100.0 80.5 68 Not using 89.1 8.7 1.1 1.3 100.0 90.5 3.2 5.3 1.3 100.0 82.7 4,437 Total 81.8 15.0 1.4 1.9 100.0 90.2 3.3 5.4 1.2 100.0 76.3 10,582 86 │ Fertility Regulation Fieldworker visits have been declining since the 1996-1997 BDHS. The proportion of currently married women visited for family planning services by fieldworkers in the six months before a survey dropped from 35 percent in 1996-97 to 18 percent in 2004. Fieldworkers are less likely to visit women for health services than for family planning services. Only 10 percent of women were visited for health services in the 2004 BDHS, compared with 18 percent who were visited for family planning services. Differentials in visitation for health services by fieldworkers show almost for the same patterns as those for family planning services. As shown in Table 5.21, nearly three-fourths of ever-married women interviewed in the 2004 BDHS were found to be aware of the satellite clinic in their community (including those who obtained their contraceptive method from a community clinic). Awareness of satellite clinics is lower among younger women, women in urban areas, women in Sylhet division, and among women who completed at least secondary education. Table 5.21 Satellite clinics Percentage of ever-married women who reported a satellite clinic in their community in the past three months, the percentage who visited a clinic, and the percentage who reported various types of services provided at the clinic, by background characteristics, Bangladesh 2004 Of those reporting a clinic in community: Of those who visited a clinic, percentage reporting availability of various services: Background characteristic Percentage reporting a clinic in community Number of women Percentage who visited clinic Number of women Family planning methods1 Child immunization Child growth monitoring Vitamin A for children Other Don't know/missing Number of women Age 10-14 56.6 150 11.5 85 * * * * * * 10 15-19 67.5 1,598 40.4 1,079 9.1 69.0 0.9 19.7 20.8 0.9 436 20-24 73.8 2,202 47.5 1,625 10.5 72.4 0.9 28.8 12.0 1.5 773 25-29 75.4 2,013 42.3 1,517 15.5 66.9 0.6 28.9 10.0 1.5 642 30-34 73.3 1,793 32.3 1,314 19.2 55.9 0.5 27.5 12.9 2.2 425 35-39 74.5 1,457 22.3 1,085 27.1 49.4 0.0 27.7 14.9 3.1 242 40-44 75.6 1,160 14.5 878 19.1 59.9 0.0 17.5 17.5 5.9 127 45-49 73.8 1,066 13.5 787 12.8 58.5 0.0 18.2 19.2 4.7 106 Residence Urban 65.9 2,586 28.3 1,704 12.0 67.5 1.0 23.6 11.5 2.3 482 Rural 75.3 8,854 34.2 6,664 15.3 64.4 0.6 26.6 14.4 1.9 2,278 Division Barisal 74.2 719 30.8 534 21.4 68.6 0.0 11.4 10.8 2.7 165 Chittagong 72.9 2,041 36.3 1,489 10.1 72.0 0.4 35.2 13.7 1.9 540 Dhaka 71.5 3,570 31.7 2,552 13.8 61.0 1.2 23.7 13.6 1.8 809 Khulna 75.6 1,397 30.2 1,056 14.7 68.3 0.3 13.6 10.9 1.0 319 Rajshahi 75.1 2,994 34.9 2,248 18.6 63.1 0.1 32.6 14.0 1.9 784 Sylhet 68.1 719 29.0 490 7.9 59.1 2.9 14.6 25.1 5.1 142 Education No education 73.2 4,713 31.1 3,451 19.6 60.7 0.2 28.4 10.9 1.7 1,074 Primary incomplete 76.5 2,348 33.6 1,796 15.9 65.2 0.4 24.9 15.1 2.0 604 Primary complete 77.0 1,011 34.5 779 10.4 64.8 1.3 25.1 18.7 2.9 269 Secondary incomplete 71.9 2,541 36.5 1,827 9.3 70.6 1.2 24.7 14.7 2.1 667 Secondary complete or higher 62.5 827 28.2 517 6.3 69.1 1.4 22.4 17.5 2.1 146 Total 73.2 11,440 33.0 8,369 14.7 64.9 0.7 26.1 13.9 2.0 2,760 Note: An asterisk indicates that the figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes those who obtained contraceptive supplies from satellite clinic in past three months. Fertility Regulation │ 87 Only one-third of those aware of satellite clinics reported to have visited a clinic in the three months before the 2004 BDHS. About two-thirds of women who visited a satellite clinic knew that the clinic provided immunization services for children. However, it seems there has been a substantial decline in awareness that immunization services are available at these sites (from 83 percent in 1999-2000 to 65 percent in 2004). About one-quarter of the women who visited a satellite clinic knew that the clinic provided vitamin A for children, but only 15 percent knew that the clinic provided family planning methods. 5.13 DISCUSSION ABOUT FAMILY PLANNING BETWEEN SPOUSES Discussion between husbands and wives about family planning is an important intermediate step towards eventual adoption and sustained use of contraception. Use of family planning methods is facilitated when husbands and wives discuss the issue and share their views. On the other hand, lack of discussion may reflect a lack of personal interest, hostility to the subject, or a customary reticence in talking about sex-related matters. To assess the extent to which couples discuss family planning, interviewers asked currently married women who were not sterilized and who knew a contraceptive method, how often they had talked with their husband about family planning in the three months preceding the survey. The results are presented in Table 5.22. Table 5.22 Discussion of family planning with husband Percent distribution of currently married nonsterilized women who know a contraceptive method by the number of times they discussed family planning with their husband in the past three months, according to current age, Bangladesh 2004 Number of times family planning discussed Age Never Once or twice More than twice Missing Total Number of women 10-14 56.4 33.7 9.9 0.0 100.0 145 15-19 51.4 39.8 8.7 0.1 100.0 1,536 20-24 50.8 40.3 8.6 0.3 100.0 2,113 25-29 53.5 39.8 6.6 0.1 100.0 1,893 30-34 56.3 37.1 6.5 0.1 100.0 1,591 35-39 61.1 32.7 6.2 0.0 100.0 1,183 40-44 69.0 27.1 3.6 0.2 100.0 843 45-49 79.6 17.5 2.8 0.2 100.0 725 Total 57.2 35.9 6.8 0.1 100.0 10,030 About six in ten (57 percent) of the women questioned had not talked with their husband about family planning in the past three months, 36 percent had discussed it once or twice, and only 7 percent had discussed it more than twice. Interspousal discussion about family planning was generally less common among younger women than among older women. 5.14 EXPOSURE TO FAMILY PLANNING MESSAGES In assessing the reach of family planning messages, women in the 2004 BDHS were asked whether they had heard or seen a message about family planning on the radio, television, newspaper or magazine, or a billboard or poster in the month before the survey. Table 5.23 presents the proportion of ever-married women who had heard or seen such a message from a media source, according to background characteristics. 88 │ Fertility Regulation Overall, 44 percent of women have had exposure to family planning messages disseminated through the media in the month preceding the survey. Television and radio are the two major sources of exposure to family planning messages. Among women, one-third reported hearing or seeing a family planning message on television, and one-quarter reported hearing a message on the radio. Exposure to messages from other media sources, namely, poster/billboards (8 percent), newspaper/magazines (5 percent), and community events (3 percent) is low. Table 5.23 Exposure to family planning messages Percentage of ever-married women who heard or saw a family planning message in the media during the month preceding the interview, according to background characteristics, Bangladesh 2004 Background characteristic Radio Television Newspaper/ magazine Poster/ billboard/ leaflet Community event At least one of these media sources None of these media sources Number of women Age 10-14 32.1 35.0 4.8 8.8 1.7 51.6 48.4 150 15-19 31.9 38.8 4.6 8.5 3.2 51.5 48.5 1,598 20-24 28.2 40.5 6.0 10.3 3.2 51.0 49.0 2,202 25-29 25.8 36.0 5.5 9.4 3.0 46.5 53.5 2,013 30-34 22.2 32.6 4.2 7.7 3.1 42.3 57.7 1,793 35-39 21.0 30.4 4.2 7.3 3.1 41.8 58.2 1,457 40-44 19.6 27.5 3.8 5.3 3.7 38.2 61.8 1,160 45-49 14.5 21.3 2.2 4.7 2.5 29.1 70.9 1,066 Residence Urban 24.4 55.5 10.6 16.9 4.1 62.0 38.0 2,586 Rural 24.3 27.4 2.9 5.5 2.8 39.3 60.7 8,854 Division Barisal 33.2 28.8 7.4 8.7 4.6 46.4 53.6 719 Chittagong 26.7 35.9 5.7 6.8 2.5 45.6 54.4 2,041 Dhaka 21.8 36.6 5.0 10.4 3.2 45.6 54.4 3,570 Khulna 26.3 36.9 5.1 8.2 4.5 48.1 51.9 1,397 Rajshahi 23.1 29.4 2.5 5.7 2.4 40.8 59.2 2,994 Sylhet 22.4 30.8 4.7 8.9 3.2 41.2 58.8 719 Education No education 15.8 19.9 0.3 2.0 1.9 28.7 71.3 4,713 Primary incomplete 24.8 31.4 1.1 4.9 2.9 43.4 56.6 2,348 Primary complete 27.6 37.0 3.0 6.9 2.7 48.3 51.7 1,011 Secondary incomplete 34.2 49.2 7.9 13.4 3.7 61.1 38.9 2,541 Secondary complete or higher 37.2 67.8 31.4 36.3 9.2 80.6 19.4 827 Wealth index Lowest 11.9 11.0 0.3 1.9 1.6 19.4 80.6 2,279 Second 20.6 19.9 0.8 2.7 2.9 32.9 67.1 2,290 Middle 25.3 26.0 2.2 5.6 2.4 40.7 59.3 2,267 Fourth 33.3 45.3 4.2 9.0 3.7 56.5 43.5 2,307 Highest 30.3 66.2 15.5 21.0 4.8 72.3 27.7 2,297 Total 24.3 33.8 4.6 8.1 3.1 44.4 55.6 11,440 Younger women, women in urban areas, those who have more education, and women who live in wealthier households are more likely to have had exposure to family planning messages through at least one mass media source, compared with other women. Fertility Regulation │ 89 Overall, exposure to family planning messages through the media has remained largely unchanged since 1999-2000. However, exposure to family planning messages through television increased considerably between the two surveys, from 29 to 34 percent. There was also an increase in exposure to poster/billboards (6 to 8 percent). Exposure to family planning messages through radio and newspaper/magazines has remained largely unchanged. Efforts to disseminate family planning messages through community events appear to have declined between the two surveys, with only 3 percent of women reporting that they heard a message at a community event in 2004, compared with 6 percent in 1999-2000. Other Proximate Determinants of Fertility | 91 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6 6.1 INTRODUCTION This chapter addresses the principal factors—other than contraception—that influence fertility. Marriage is among the most important of these proximate determinants because it is a primary indicator of women’s exposure to the risk of pregnancy. Populations in which age at marriage is low also tend to experience early childbearing, a longer period of exposure to the risk of pregnancy, and, thus, higher fertility levels. The early initiation of childbearing associated with early marriage may also adversely affect the health of women and their children. Besides marriage, this chapter explores three other factors that influence fertility: postpartum amenorrhea, postpartum abstinence, and menopause. Postpartum amenorrhea and postpartum abstinence determine the length of time a woman is insusceptible to pregnancy after childbirth, which affects the length of the birth interval and, thus, fertility levels. Menopause is important because it marks the end of a woman’s period of exposure to the risk of pregnancy. These factors taken together determine the length and pace of reproduction; hence they are important in understanding fertility levels and differences. 6.2 MARITAL STATUS In the 2004 BDHS, only women who had ever been married were interviewed with the Individual Questionnaire. However, a number of the tables presented in this chapter are based on all women, both ever-married and never-married. For these tables, the number of ever-married women interviewed in the survey is multiplied by an inflation factor that is equal to the ratio of all women to ever-married women, as reported in the Household Questionnaire. This procedure expands the denominators in the tables so that they represent all women. The inflation factors are calculated by single years of age, and where the results are presented by background characteristics, single-year inflation factors are calculated separately for each category of the characteristic. As both ever-married and never-married men were interviewed, the results for men are based on those who were interviewed; no inflation factors were employed. It is important to take note of the definition of marriage that was used in the 2004 BDHS. In Bangladesh, it is common for a woman to wait several months or even years after formal marriage before going to live with her husband. Since the researchers who designed the 2004 BDHS were interested in marriage mainly as it affects exposure to the risk of pregnancy, interviewers were instructed to ask the questions about marriage not in the sense of formal marriage, but as cohabitation. The distribution of women age 10-49 by marital status at the time of survey is presented in Table 6.1. In Bangladesh, most women in this age group are married. Twenty-three percent of women age 10- 49 have never been married; most never-married women are age 10-19. The low proportion (1 percent or less) of women over age 30 who have never been married indicates that marriage is universal in Bangladesh and that almost all women marry before age 30. Divorce and separation (2 percent) are uncommon in Bangladesh, and even among women over age 30, only 3 or 4 percent are divorced or separated. Widowhood is limited until older ages. Twelve percent of women age 40-44 and 15 percent of those age 45-49 are widowed. 92 | Other Proximate Determinants of Fertility Table 6.1 Current marital status Percent distribution of women and men by current marital status, according to age, Bangladesh 2004 Marital status Age Never married Married Divorced Separated Widowed Total Number WOMEN 10-14 88.6 11.0 0.1 0.2 0.0 100.0 1,317 15-19 52.1 46.0 0.8 0.9 0.1 100.0 3,337 20-24 15.2 81.7 1.1 1.3 0.7 100.0 2,597 25-29 4.2 92.1 1.2 1.3 1.2 100.0 2,100 30-34 1.2 92.7 1.1 1.9 3.1 100.0 1,815 35-39 0.4 89.4 1.6 2.2 6.3 100.0 1,463 40-44 0.3 84.4 1.5 2.1 11.7 100.0 1,164 45-49 0.0 81.6 0.6 2.3 15.4 100.0 1,066 Total 23.0 71.2 1.0 1.4 3.3 100.0 14,859 MEN 15-19 96.6 3.4 0.0 0.0 0.0 100.0 822 20-24 65.6 33.4 0.3 0.4 0.2 100.0 660 25-29 29.4 68.0 2.1 0.4 0.2 100.0 589 30-34 9.5 89.3 0.6 0.3 0.3 100.0 552 35-39 4.0 94.0 1.0 0.6 0.4 100.0 475 40-44 0.2 99.7 0.2 0.0 0.0 100.0 491 45-49 0.3 99.3 0.0 0.0 0.4 100.0 465 50-54 0.0 99.0 0.0 0.0 1.0 100.0 242 Total 34.3 64.7 0.5 0.2 0.2 100.0 4,297 One-third of the interviewed men age 15-54 have never been married; about two-thirds of the men are currently married; and only 1 percent are separated, divorced, or widowed. A greater proportion of men, compared with women, have never been married (11 percentage points more). Table 6.2 shows trends in the proportion of women reported as never married by age group from previous surveys in Bangladesh. Between 1975 and 2000, the proportion of never-married women in age groups 15-19 and 20-24 increased, but this upward trend did not continue beyond 2000. In 2004, the overall proportion of never-married women age 10-49 (23 percent) was lower than that reported in 1999- 2000 (30 percent) and 1996-1997 (34 percent). The decline in the percentage of never-married women among those age 10-14 and 20-24 accounts for the decrease in the overall percentage of never-married women age 10-49. Other Proximate Determinants of Fertility | 93 Table 6.2 Trends in proportion never married Percentage of women who have never married, by age group, as reported in various surveys, Bangladesh 1975-2004 Age 1975 BFS 1983 CPS 1985 CPS 1989 BFS 1989 CPS 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS 2004 BDHS 10-14 91.2 98.0 98.7 96.2 96.4 98.5 95.2 95.2 92.7 88.6 15-19 29.8 34.2 47.5 49.0 45.8 46.7 50.5 49.8 51.9 52.1 20-24 4.6 4.0 7.1 12.0 9.3 12.3 12.4 17.2 18.5 15.2 25-29 1.0 0.7 1.0 2.3 1.6 2.8 2.2 3.4 4.2 4.2 30-34 0.2 0.4 0.1 0.3 0.5 0.5 0.3 0.5 0.1 1.2 35-39 0.4 - - 0.1 0.5 0.1 0.3 0.0 0.2 0.4 40-44 0.1 0.1 - 0.2 0.2 0.3 0.7 0.0 0.0 0.3 45-49 0.0 0.1 - 0.1 0.1 - 0.2 0.0 0.0 0.0 - = Less than 0.1 percent Sources: 1975 Bangladesh Fertility Survey (BFS) (MHPC, 1978:49); 1983, 1985, 1989, and 1991 Contraceptive Preva- lence Surveys (CPSs) (Mitra et al., 1993:24); 1989 BFS (Huq and Cleland, 1990:43); 1993-1994 Bangladesh Demo- graphic and Health Survey (BDHS) (Mitra et al, 1994:72); 1996-1997 BDHS (Mitra et al., 1997:82); and 1999-2000 BDHS (NIPORT et al., 2001:78) 6.3 AGE AT FIRST MARRIAGE Marriage in most Asian societies defines the onset of the socially acceptable time for childbearing. Women who marry early will have, on average, a longer period of exposure to pregnancy, often leading to a higher number of children ever born. Table 6.3.1 shows the percentage of women who were first married by specific ages, and the median age at first marriage, according to current age. The data show that median age at first marriage has been increasing over time. The median age at first marriage rises from 13.9 years for women age 45-49 to 16.0 years for those age 20-24. The proportion of women marrying by age 15 has declined by almost half over time, from 71 percent among women in the oldest cohort to 37 percent among women age 20-24. Table 6.3.1 Age at first marriage: women Percentage of women age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Bangladesh 2004 Percentage first married by exact age: Current age 12 15 18 20 22 25 Percentage never mar- ried Number of women Median age at first mar- riage 15-19 0.4 26.7 na na na na 52.1 3,337 a 20-24 0.6 37.3 68.4 78.6 na na 15.2 2,597 16.0 25-29 1.1 50.5 79.7 87.6 91.3 94.4 4.2 2,100 15.0 30-34 1.1 54.2 83.7 90.5 94.1 97.1 1.2 1,815 14.7 35-39 1.9 58.7 84.6 93.5 96.3 97.8 0.4 1,463 14.5 40-44 3.0 61.6 88.7 95.0 97.2 98.3 0.3 1,164 14.2 45-49 2.4 71.4 91.7 95.8 97.5 99.0 0.0 1,066 13.9 20-49 1.4 52.4 80.5 88.4 na na 5.0 10,205 14.8 25-49 1.7 57.6 84.7 91.7 94.7 97.0 1.6 7,608 14.5 na = Not applicable a = Omitted because less than 50 percent of the women married for the first time before reaching age 15 94 | Other Proximate Determinants of Fertility Still, more than half of all women age 20-49 enter marriage before their 15th birthday. Comparison of data from the four BDHS surveys since 1993 indicates that although the median age at first marriage for women age 20-49 has increased over time, there was a decrease from a median of 15.0 years at the time of the 1999-2000 BDHS to 14.8 years in 2004. In Bangladesh the legal age of marriage is 18 years for women; however a large proportion of marriages still take place before the legal age. Figure 6.1 shows that in the 2004 BDHS, 68 percent of women age 20-24 were married before age 18. Data indicate that over the last two decades, the proportion of women marrying before the legal age had been gradually declining; but in recent years, it has increased again. Table 6.3.2 shows the distribution of age at first marriage for men. Only 17 percent of men marry before their 20th birthday, and a little more than half marry before age 25. The trend of rising median age at marriage among men ceased a few years ago and is now reversed; the median age at marriage was 22.3 years for men in their early fifties, increased to around 25 years for men age 35-44, and then declined to 24.4 years for men in their late twenties. Table 6.3.2 Age at first marriage: men Percentage of men age 15-54 who were first married by specific exact ages and median age at first marriage, according to current age, Bangladesh 2004 Percentage first married by exact age: Current age 15 18 20 22 25 Percentage never married Number of men Median age at first marriage 15-19 0.2 na na na na 96.6 822 a 20-24 0.4 4.4 15.3 na na 65.6 660 a 25-29 1.1 5.3 14.9 30.1 54.0 29.4 589 24.4 30-34 0.4 5.7 15.9 28.7 52.8 9.5 552 24.6 35-39 0.3 6.9 14.9 28.1 48.5 4.0 475 25.1 40-44 0.5 5.1 13.1 29.3 49.7 0.2 491 25.0 45-49 0.2 5.8 18.0 32.8 56.6 0.3 465 23.7 50-54 0.8 10.3 29.2 47.6 64.8 0.0 242 22.3 25-54 0.5 6.1 16.5 31.3 53.5 8.8 2,815 24.5 30-54 0.4 6.3 17.0 31.6 53.3 3.3 2,225 24.5 na = Not applicable a = Omitted because less than 50 percent of the men married for the first time before reaching the beginning of the age group Other Proximate Determinants of Fertility | 95 Table 6.4.1 further examines the median age at first marriage for women age 20-49 and 25-49, by background characteristics. Urban women tend to marry almost one year later than their rural counterparts. The variation by division is larger. Women in Sylhet and Chittagong divisions generally enter into marriage at least one year later than women in Rajshahi and Khulna divisions. Median age at first marriage for women age 25-49 is highest for women in Sylhet (15.5 years) and lowest for those in Rajshahi division (14.0 years). The median age at marriage increases with level of education and with household economic status. For example, among women age 25-49, the median age at first marriage is 14.0 years for those with no education and 19.8 years for those who have at least completed secondary education. Likewise, for the same age group, the median age at marriage is 14.2 years for women in the lowest wealth quintile and 15.8 years for those in the highest wealth quintile. Table 6.4.1 Median age at first marriage: women Median age at first marriage among women age 20-49, by current age and background charac- teristics, Bangladesh 2004 Current age Background characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Women age 20-49 Women age 25-49 Residence Urban 17.1 15.7 15.3 15.1 14.7 14.0 15.6 15.1 Rural 15.7 14.8 14.6 14.3 14.1 13.8 14.7 14.4 Division Barisal 16.4 14.9 15.5 14.6 14.8 14.0 15.0 14.8 Chittagong 17.1 15.5 15.6 15.4 14.5 14.5 15.6 15.2 Dhaka 15.9 15.3 14.5 14.4 14.0 13.9 14.9 14.5 Khulna 15.3 14.5 14.5 14.1 14.0 13.7 14.5 14.2 Rajshahi 15.3 14.2 14.3 14.1 14.0 13.6 14.2 14.0 Sylhet 17.4 16.5 15.6 15.4 14.8 14.7 15.9 15.5 Education No education 14.4 14.1 14.2 14.1 13.9 13.7 14.0 14.0 Primary incomplete 14.7 14.2 14.5 14.3 14.1 13.8 14.3 14.2 Primary complete 15.2 15.1 14.7 14.7 14.5 14.7 14.9 14.8 Secondary incom- plete 16.7 15.9 15.9 15.5 15.6 14.7 16.1 15.7 Secondary complete or higher a 21.1 19.9 18.4 17.9 18.9 a 19.8 Wealth index Lowest 14.6 14.4 14.4 14.1 14.1 13.7 14.3 14.2 Second 14.9 14.3 14.3 14.2 14.1 13.7 14.3 14.1 Middle 15.9 14.5 14.8 14.3 13.9 13.9 14.6 14.3 Fourth 16.9 15.6 14.6 14.5 14.0 13.9 15.1 14.6 Highest 18.3 17.0 16.3 15.4 15.2 14.7 16.5 15.8 Total 16.0 15.0 14.7 14.5 14.2 13.9 14.8 14.5 a = Omitted because less than 50 percent of the women married for the first time before reach- ing age 20 Table 6.4.2 shows a difference of slightly more than one year in the median age at first marriage between men age 30-54 in urban areas (25.3 years) and in rural areas (24.1 years). The divisional difference between the highest (Sylhet) and lowest (Rajshahi) median age at marriage is 2.8 years. As in the case of women, men with lower levels of education and those who are relatively poor also enter into marriage earlier than other men. 96 | Other Proximate Determinants of Fertility Table 6.4.2 Median age at first marriage: men Median age at first marriage among men age 25-54, by current age and background characteris- tics, Bangladesh 2004 Current age Background characteristic 25-29 30-34 35-39 40-44 45-49 50-54 Men age 25-54 Men age 30-54 Residence Urban 24.7 25.5 25.5 25.6 24.4 24.1 a 25.3 Rural 24.3 24.2 25.0 24.7 23.6 22.1 24.2 24.1 Division Barisal a 23.2 25.2 25.9 24.3 23.3 24.3 24.3 Chittagong a 26.3 25.5 26.7 24.1 25.6 a 25.6 Dhaka 24.6 24.7 25.6 24.3 23.4 22.9 24.5 24.5 Khulna 24.1 24.8 25.3 24.5 25.2 20.5 24.6 24.8 Rajshahi 23.2 23.2 23.2 24.2 22.7 20.5 23.0 23.0 Sylhet a 27.4 25.7 28.5 24.9 22.4 a 25.8 Education No education 22.7 23.4 24.3 24.4 22.9 20.8 23.2 23.3 Primary incomplete 22.3 23.9 24.4 25.2 23.7 22.8 23.8 24.3 Primary complete 23.3 23.4 24.9 23.0 22.7 20.8 23.3 23.4 Secondary incom- plete a 25.1 25.2 24.5 22.9 25.1 a 24.6 Secondary complete or higher a 28.4 28.6 27.3 26.6 24.9 a 27.4 Wealth index Lowest 22.8 24.1 24.2 24.0 24.0 22.9 23.7 23.8 Second 24.4 22.9 25.3 23.8 22.9 20.7 23.8 23.5 Middle 24.1 24.7 24.6 25.2 22.9 22.1 24.4 24.5 Fourth 23.8 24.5 24.7 25.4 24.8 20.9 24.3 24.4 Highest a 25.9 25.8 25.4 24.2 24.6 a 25.5 Total 24.4 24.6 25.1 25.0 23.7 22.3 24.5 24.5 a = Omitted because less than 50 percent of the men married for the first time before reaching age 25 6.4 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY The risk of pregnancy after a birth is largely influenced by two factors: breastfeeding and sexual abstinence. Postpartum protection from conception can be prolonged by breastfeeding through its effect on the length of amenorrhea (the period prior to the return of menses). Postpartum amenorrhea is defined as the period between childbirth and the return of ovulation, generally approximated by the resumption of menstruation following childbirth. The risk of conception in this period is very low. Delaying the resumption of sexual relations after a birth also prolongs the period of postpartum protection. The duration of the postpartum amenorrhea and the period of sexual abstinence following birth jointly determine the length of the insusceptibility period. Thus, women are considered insusceptible if they are abstaining from sex following childbirth and/or are amenorrheic. Women who gave birth since June 1998 were asked about the duration of amenorrhea and sexual abstinence following the most recent birth. The results presented in Table 6.5 pertain to the most recent birth in the three years preceding the survey. Almost all women are insusceptible to pregnancy within the first two months following childbirth. After the second month, the contribution of abstinence is greatly Other Proximate Determinants of Fertility | 97 reduced. At six to seven months after birth, about half of all women are still amenorrheic, but only 6 percent are abstaining. At 14 to 15 months after birth, the proportion amenorrheic drops sharply to 16 percent. After 20 months, only about 4 percent are amenorrheic, and at most, 6 percent are still insusceptible to the risk of pregnancy. Table 6.5 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Bangladesh 2004 Percentage of births for which the mother is postpartum: Months since birth Amenor- rheic Abstaining Insuscep- tible Number of births <2 98.4 88.6 99.6 170 2-3 68.2 19.4 71.6 288 4-5 55.3 9.8 57.4 257 6-7 45.3 6.3 47.6 251 8-9 41.9 1.2 42.7 172 10-11 39.0 2.4 40.9 188 12-13 29.9 3.4 31.7 245 14-15 16.2 3.3 19.0 270 16-17 9.8 1.5 11.1 273 18-19 8.0 3.9 11.8 203 20-21 1.6 1.7 3.4 166 22-23 4.1 2.2 6.3 188 24-25 2.7 3.4 5.6 274 26-27 1.3 3.2 4.1 280 28-29 0.5 4.3 4.8 274 30-31 0.9 2.6 3.5 221 32-33 0.6 1.8 2.4 189 34-35 0.0 0.4 0.4 178 Total 23.3 8.1 25.6 4,088 Median 6.1 2.0 6.5 na Mean 8.7 3.5 9.5 na Note: Estimates are based on status at the time of the survey. na = Not applicable The principal determinant of the length of the period of insusceptibility is postpartum amenorrhea. The median duration of amenorrhea is 6.1 months; abstinence, 2.0 months; and insusceptibility, 6.5 months. The duration of abstinence has remained constant since 1993-1994 presumably because of the Muslim tradition of abstaining for 40 days after birth. However, the median period of amenorrhea continues to decline from more than 10 months in 1993-1994 to 8.4 months in 1996-1997 to 7.9 months in 1999-2000; and to 6.1 months in 2004 (Mitra et al., 1994:77, Mitra et al., 1997:86; NIPORT et al., 2001:82) Table 6.6 shows the median durations of postpartum amenorrhea, abstinence, and insusceptibility, by background characteristics of the respondents. The median duration of abstinence in Bangladesh does not vary by background characteristics; therefore, insusceptibility varies directly according to duration of amenorrhea. Older women (age 30-49), compared with younger women (age less than 30), have a longer median period of insusceptibility. Women living in urban areas have a shorter median duration of 98 | Other Proximate Determinants of Fertility amenorrhea than women in rural areas and hence a shorter period of insusceptibility. There are considerable variations by division in the period of insusceptibility. The median duration in Chittagong division (9.7 months) is much higher than in Dhaka division (5.5 months). Although the median duration of insusceptibility has decreased across all divisions except Chittagong since 1999-2000, the declines in Dhaka, Sylhet, and Barisal divisions have been the largest. Table 6.6 Median duration of postpartum insusceptibility by background charac- teristics Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Bangladesh 2004 Postpartum: Background characteristic Amenor- rhea Abstinence Insuscep- tibility Number of births Age <30 5.8 1.9 6.2 3,244 30-49 8.0 2.0 8.9 844 Residence Urban 4.4 1.9 5.4 804 Rural 6.4 2.0 6.9 3,284 Division Barisal 6.1 1.9 6.7 235 Chittagong 8.9 2.0 9.7 913 Dhaka 5.3 1.9 5.5 1,237 Khulna 5.3 1.8 6.3 447 Rajshahi 7.1 2.1 7.1 893 Sylhet 6.2 2.3 7.0 362 Education No education 10.6 2.1 10.7 1,451 Primary incomplete 8.6 1.9 8.7 872 Primary complete 3.9 2.0 4.0 377 Secondary incomplete 4.2 1.8 4.6 1,070 Secondary complete or higher 5.6 2.2 6.4 317 Wealth index Lowest 10.1 1.9 10.0 1,024 Second 7.6 2.0 7.9 822 Middle 5.3 1.9 5.9 843 Fourth 6.2 2.0 6.7 714 Highest 3.6 1.9 4.3 685 Total 6.1 2.0 6.5 4,088 Note: Medians are based on status at the time of the survey. There is no relationship between the median duration of amenorrhea or insusceptibility and the level of education; however, the duration of postpartum amenorrhea is much higher among mothers who have no education or have not completed primary school, as compared with other mothers. The median duration of postpartum amenorrhea declines as wealth status increases. The poorest women have the longest duration of amenorrhea, and hence insusceptibility. Other Proximate Determinants of Fertility | 99 6.5 TERMINATION OF EXPOSURE TO PREGNANCY While the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a given population. One indicator of infecundity is the onset of menopause. Menopausal women are defined by the BDHS as women who are neither pregnant nor postpartum amenorrheic, but who have not had a menstrual period in the six months preceding the survey. Women who report that they had a hysterectomy are also defined as menopausal. The prevalence of menopause increases with age, typically from around age 30. Table 6.7 shows the percentage of ever-married women age 30-49 who are menopausal—the indicator for termination of exposure to pregnancy. The percent menopausal increases from 5 percent among women age 30-34, to 41 percent among women age 46-47, and then to 64 percent among women age 48-49. Seventeen percent of women age 30-49 were reported to be menopausal in 2004, compared with 14 percent in 1999-2000. Since 1999-2000, the proportion of women over 34 years who are menopausal has increased in all age categories; the largest increase is among women age 42-43 (from 13 to 22 percent), indicating earlier termination of exposure to pregnancy among Bangladeshi women due to menopause. Table 6.7 Menopause e Percentage of ever-married women age 30-49 who are menopausal, Bangladesh 2004 Age Percentage menopausal1 Number of women 30-34 4.8 1,793 35-39 8.7 1,457 40-41 16.9 526 42-43 21.6 440 44-45 25.2 434 46-47 41.4 422 48-49 63.9 406 Total 17.2 5,477 1 Percentage of all women who are not pregnant and not postpartum amenorrheic and whose last menstrual period occurred six or more months preceding the survey Fertility Preferences | 101 FERTILITY PREFERENCES 7 The subject of future reproductive preferences is of fundamental importance for population policy and for family planning programs. Whether couples want to cease childbearing or delay the next pregnancy determines the demand for family planning. In the 2004 BDHS, as in the previous BDHS surveys, women were asked a series of questions to ascertain fertility preferences. These data are utilized in this chapter to quantify fertility preferences and, in combination with data on contraceptive use, to permit estimation of unmet need for family planning, for both spacing and limiting births. Another indicator of fertility preferences, which pertains to both past and future reproductive behavior, perhaps the most common measure of fertility preference, is ideal number of children (i.e., how many children a woman would want in total if she could start afresh). The information on ideal family size (ideal number of children) provides two measures. First, for men and women who have not yet started a family, the data provide an idea of future fertility (to the extent that couples are able to realize their fertility desires). Second, for all women, the excess of past fertility over the ideal family size provides a measure of unwanted fertility. Two other topics are discussed in this chapter: fertility planning in the past and the effect of unwanted births on fertility rates. 7.1 DESIRE FOR MORE CHILDREN In order to obtain information on fertility preferences, the 2004 BDHS asked currently married, nonpregnant, nonsterilized women: “Would you like to have (a/another) child or would you prefer not to have any (more) children?” Pregnant respondents were asked, “After the child you are expecting, would you like to have another child or would you prefer not to have any more children?” Women who expressed a desire for additional children were asked how long they would like to wait before the birth of their next child. Table 7.1 and Figure 7.1 show the percent distribution of currently married women by desire for another child, according to the number of living children. Table 7.1 Fertility preferences by number of living children Percent distribution of currently married women by desire for children, according to number of living children, Bangladesh 2004 Number of living children1 Desire for children 0 1 2 3 4 5 6+ Total Have another soon2 63.3 20.3 7.9 4.0 1.7 1.0 0.2 12.9 Have another later3 29.2 63.7 17.7 5.2 2.5 1.0 0.4 21.2 Have another, undecided when 1.8 1.8 1.2 0.5 0.4 0.2 0.4 1.0 Undecided 1.4 2.2 3.6 1.9 0.8 1.1 1.0 2.1 Want no more 0.5 9.0 62.6 75.2 79.5 80.8 82.1 53.5 Sterilized4 0.9 2.0 4.8 10.2 9.7 8.9 4.3 5.8 Declared infecund 2.7 1.0 2.1 3.0 5.4 6.8 11.6 3.6 Missing 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 968 2,118 2,574 2,055 1,343 771 752 10,582 1 Includes current pregnancy 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 102 | Fertility Preferences Overall, six in ten currently married women age 10-49 either do not want another child (54 percent) or are sterilized (6 percent). Thirty-five percent of women want to have a child at some time in the future; only 13 percent want one within two years, 21 percent would prefer to wait two or more years, and 1 percent could not decide on the timing. Thus, the vast majority of married women want either to space their next birth or to limit childbearing altogether. Since 1999-2000, there is no change in the proportion that wants to limit childbearing. The desire to stop childbearing (including those sterilized) increases with the number of living children (Figure 7.2), reaching 67 percent among women with two living children and 86 percent among those with six or more children. Among women who want to have another child, the reverse is observed; that is, the proportion of women who want to have another child decreases with the number of living children. Fertility Preferences | 103 Table 7.2 shows the percent distribution of currently married women by desire for children, according to age. As expected, the proportion of women who want no more children increases with age. Twelve percent of women age 15-19 want no more children, compared with 73 percent of women age 45- 49 years who either want to cease childbearing or are sterilized. The proportion that wants to delay the next birth for two or more years declines with age, as does the proportion of women who want the next birth within two years. The proportion reporting that they are unable to have more children (infecund) is 1 percent or less among women under 35, but this proportion rises to 10 percent of women age 40-44 and 26 percent of older women. Table 7.2 Fertility preferences by age Percent distribution of currently married women by desire for children, according to age, Bangladesh 2004 Age of woman Desire for children 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Have another soon1 36.4 24.4 17.2 14.1 10.8 6.0 3.0 0.6 12.9 Have another later2 59.0 60.0 38.6 16.4 4.8 0.8 0.2 0.0 21.2 Have another, undecided when 3.1 1.9 1.7 0.8 0.8 0.3 0.2 0.2 1.0 Undecided 1.0 1.9 3.8 3.1 1.7 0.9 0.2 0.4 2.1 Want no more 0.4 11.8 38.2 62.5 74.7 78.5 70.9 55.1 53.5 Sterilized3 0.0 0.0 0.4 2.5 5.9 11.4 15.5 18.2 5.8 Declared infecund 0.0 0.0 0.1 0.4 1.1 2.1 10.0 25.5 3.6 Missing 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 145 1,536 2,121 1,935 1,683 1,309 982 870 10,582 1 Wants next birth within two years 2 Wants to delay next birth for two or more years 3 Includes both male and female sterilization 7.2 DESIRE TO LIMIT CHILDBEARING The desire to stop childbearing by residence, division, education, and wealth index is shown in Table 7.3 and Figure 7.3. Women in rural areas have the same preference for not having more children as urban women; however, rural women already have more children than urban women do (Chapter 4). Among women living in urban areas, the desire to have no more children is higher at almost all levels of current family size than in rural areas. Some divisional variations are observed in the desire for more children. Less than half of currently married women with two children in Barisal and Sylhet divisions do not want to have another child, compared with 78 percent of women in Rajshahi. 104 | Fertility Preferences Table 7.3 Desire to limit childbearing Percentage of currently married women age 10-49 who want no more children, by number of living children and back- ground characteristics, Bangladesh 2004 Number of living children1 Background characteristic 0 1 2 3 4 5 6+ Total Residence Urban 1.3 14.6 69.6 90.3 91.2 89.8 90.1 59.4 Rural 1.4 9.8 66.8 84.0 88.7 89.7 85.8 59.3 Division Barisal 1.0 9.0 67.5 81.8 88.1 91.1 83.2 58.8 Chittagong 1.4 8.2 45.9 76.6 89.9 90.2 89.1 56.0 Dhaka 1.3 10.3 67.9 85.3 86.5 89.4 87.6 59.6 Khulna 0.0 12.6 75.0 92.5 91.7 92.0 90.0 60.5 Rajshahi 2.2 13.3 78.2 90.6 94.3 92.3 85.3 62.6 Sylhet 1.6 8.2 46.2 73.7 79.0 79.4 76.9 51.6 Education No education 6.3 21.9 69.2 83.7 88.4 87.5 85.8 72.5 Primary incomplete 0.0 11.8 65.4 86.2 91.4 93.0 86.5 63.3 Primary complete 0.6 6.8 64.8 88.1 87.8 92.4 84.1 56.9 Secondary incom- plete 0.2 7.4 64.3 86.9 89.3 95.6 (95.6) 40.9 Secondary complete or higher 0.0 7.6 76.5 90.4 * * * 38.8 Wealth index Lowest 4.6 15.5 64.2 79.7 88.2 85.2 86.9 61.2 Second 1.5 9.7 67.3 83.6 87.2 92.0 88.5 61.3 Middle 0.0 7.9 65.8 86.8 91.1 89.2 88.0 58.4 Fourth 1.4 11.2 68.2 88.5 88.0 90.9 86.1 59.5 Highest 0.2 11.1 71.0 88.4 92.8 90.9 77.6 56.3 Total 1.4 11.0 67.5 85.4 89.2 89.7 86.4 59.3 Note: Women who have been sterilized are considered to want no more children. Figures in parentheses are based on 25-49 unweighted cases; an asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes current pregnancy Major differences in fertility preferences among women by levels of education are apparent. For example, 73 percent of married women with no education want to stop childbearing, compared with 39 percent of those who have completed secondary education. This is because the educated women have not yet achieved their ideal family size. Moreover, at all parities above one, the proportions of women wanting no more children are higher for more educated women than for less educated women. There are only small differences in fertility preferences by wealth index. Fertility Preferences | 105 7.3 NEED FOR FAMILY PLANNING SERVICES Fecund women who are currently married and who say that they either do not want any more children or that they want to wait two or more years before having another child, but are not using contraception, are considered to have an unmet need for family planning. Women who are using family planning methods are said to have a met need for family planning. Women with unmet need and met need constitute the total demand for family planning. Table 7.4 presents information for currently married women on unmet need, met need, and total demand for family planning, according to whether the need or demand is for spacing or limiting births. Eleven percent of currently married women in Bangladesh have an unmet need for family planning: 5 percent for spacing and 6 percent for limiting. Because 58 percent of currently married women are using a contraceptive method, 11 percent have an unmet need for contraception, and 2 percent of currently married women had the last pregnancy while using a contraceptive method, it implies that the total demand for family planning comprises 71 percent of married women in Bangladesh, which is at about the same level estimated in 1999-2000. However, unmet need has dropped from 15 percent to 11 percent during that period. The data in this table show that 84 percent of this total demand among married women is satisfied. Unmet need declines with age, from 23 percent among the youngest cohort to 4 percent among the oldest cohort. Analysis of the unmet need for spacing and limiting reveals the expected patterns: Unmet need for spacing declines with age, while that for limiting increases. Unmet need for family planning is higher in rural areas (12 percent) than urban areas (9 percent). By division (Figure 7.4), unmet need remains highest in Sylhet division (21 percent) and dropped substantially in Rajshahi (7 percent) and Khulna (8 percent) divisions since 1999-2000. Unmet need is lowest among women with the most education and does not vary much among those with lower levels of education. Differentials by wealth show a similar pattern—the unmet need is lowest among the wealthiest women. 106 | Fertility Preferences Table 7.4 Need for family planning services Percentage of currently married women with unmet need, met need, and the total demand for family planning services, by background characteristics, Bangladesh 2004 Unmet need for family planning1 Met need for family planning2 (currently using) Total demand for family planning3 Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Percent- age of demand satisfied Number of women Age 10-14 23.3 0.0 23.3 28.7 0.4 29.1 52.0 0.4 52.5 55.5 145 15-19 14.4 0.8 15.1 36.9 5.2 42.2 53.9 6.0 60.0 74.7 1,536 20-24 8.3 4.1 12.5 31.3 21.6 52.9 42.3 26.4 68.7 81.9 2,121 25-29 3.4 9.5 12.9 16.5 44.7 61.3 20.9 55.8 76.7 83.2 1,935 30-34 1.8 9.6 11.4 6.3 62.4 68.6 8.6 73.5 82.1 86.1 1,683 35-39 0.6 9.0 9.7 1.1 71.0 72.1 1.7 81.0 82.7 88.3 1,309 40-44 0.0 6.8 6.8 0.3 64.4 64.7 0.3 71.4 71.7 90.5 982 45-49 0.0 3.6 3.6 0.1 47.2 47.3 0.1 51.0 51.1 92.9 870 Residence Urban 3.2 6.2 9.4 19.0 43.9 62.9 23.4 50.8 74.2 87.4 2,372 Rural 5.6 6.3 11.9 15.4 41.2 56.7 22.2 48.4 70.6 83.2 8,210 Division Barisal 5.5 7.2 12.7 15.8 38.4 54.2 23.0 47.0 69.9 81.8 674 Chittagong 7.9 9.1 17.0 13.7 33.5 47.1 22.4 43.4 65.8 74.2 1,877 Dhaka 4.2 6.5 10.7 16.5 42.8 59.3 21.9 50.2 72.1 85.1 3,315 Khulna 3.4 4.9 8.3 19.4 44.4 63.8 24.2 50.1 74.3 88.8 1,296 Rajshahi 4.0 3.2 7.2 18.1 50.2 68.3 23.3 54.2 77.5 90.7 2,782 Sylhet 9.3 11.3 20.6 8.5 23.3 31.8 18.4 34.9 53.4 61.4 638 Education No education 3.5 7.6 11.1 7.4 51.4 58.8 11.4 60.0 71.4 84.4 4,187 Primary incomplete 5.0 7.3 12.2 13.5 43.3 56.8 19.7 51.6 71.3 82.8 2,176 Primary complete 5.2 6.9 12.0 18.9 40.0 58.9 25.3 47.6 72.9 83.5 958 Secondary incom- plete 7.9 3.8 11.7 27.2 29.1 56.3 36.8 33.4 70.2 83.3 2,457 Secondary complete or higher 4.7 3.2 7.9 32.7 29.3 62.0 40.4 32.8 73.2 89.2 804 Wealth index Lowest 5.6 7.4 13.0 12.6 41.0 53.6 19.3 49.4 68.7 81.1 2,042 Second 5.2 6.5 11.7 14.5 43.2 57.6 20.8 50.5 71.3 83.6 2,112 Middle 5.8 5.8 11.7 17.0 40.9 57.8 23.8 47.7 71.5 83.7 2,112 Fourth 5.3 6.0 11.3 15.7 42.8 58.5 22.5 49.4 71.8 84.2 2,168 Highest 3.4 5.2 8.6 21.2 41.4 62.5 25.8 47.2 73.0 88.3 2,148 Total 5.1 6.3 11.3 16.2 41.8 58.1 22.5 48.9 71.4 84.1 10,582 1 Unmet need for spacing includes pregnant women whose pregnancy was mistimed, amenorrheic women who are not using family planning and whose last birth was mistimed, and fecund women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say they want to wait two or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth. unless they say it would not be a problem if they discovered they were pregnant in the next few weeks. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted, and fecund women who are neither pregnant nor amenorrheic, who are not using any method of family plan- ning, and who want no more children. Excluded from the unmet need category are pregnant and amenorrheic women who became pregnant while using a method (these women are in need of a better method of contraception). 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Total demand includes pregnant or amenorrheic women and women whose pregnancy was the result of a contraceptive failure; they account for 2.0 percent of currently married women. Fertility Preferences | 107 Demand for family planning is also associated with demographic and socioeconomic indicators. Demand increases with age and peaks at age 30-39 (82 to 83 percent), and it is much lower in Sylhet division (53 percent) than other divisions (over 65 percent). The percentage of demand that is satisfied is highest in Rajshahi and Khulna divisions. Differentials in demand by education and wealth index are minimal. Similar patterns are observed for the percentage of demand satisfied. 7.4 IDEAL FAMILY SIZE Women and men who were interviewed in the 2004 BDHS were asked two questions for determining ideal family size. Respondents who did not have any living children were asked, “If you could choose exactly the number of children to have in your lifetime, how many would that be?” For respondents who had living children, the question was rephrased as follows, “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your lifetime, how many would that be?” The results for women and men are presented in Tables 7.5.1 and 7.5.2. respectively. One minor difference in the two tables is that in Table 7.5.2 (for men), wife’s current pregnancy, if any, is not considered. Results indicate that the vast majority of both women and men gave a numeric response; less than 5 percent of women and men failed to give a numeric response. Among ever-married women, 62 percent prefer a two-child family, 21 percent consider a three-child family ideal, and 1 percent said they would choose five or more children. Data are similar for all men and currently married men. A majority of men prefer a two-child family, irrespective of their current family size. 108 | Fertility Preferences Table 7.5.1 Ideal and actual number of children: women Percent distribution of ever-married women by ideal number of children, and mean ideal number of children for ever-married women and for currently married women, according to number of living children, Bangladesh 2004 Number of living children1 Ideal number of children 0 1 2 3 4 5 6+ Total 0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 4.7 5.7 1.4 1.7 1.3 0.5 0.6 2.5 2 71.2 73.9 72.7 55.9 54.5 42.7 33.6 62.3 3 13.9 14.3 18.8 28.9 21.0 32.7 27.8 21.3 4 6.1 3.7 5.0 9.5 17.3 15.2 20.5 9.1 5 0.4 0.3 0.5 0.5 1.2 1.7 2.9 0.8 6+ 0.2 0.1 0.1 0.3 0.1 0.3 1.1 0.2 Non-numeric responses 3.3 1.9 1.5 3.1 4.6 6.8 13.5 3.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of ever-married women 1,117 2,302 2,746 2,198 1,432 834 812 11,440 Mean ideal number of children for2: Ever-married women 2.2 2.2 2.3 2.5 2.6 2.7 2.9 2.4 Number 1,080 2,257 2,704 2,130 1,367 777 702 11,017 Currently married women 2.2 2.2 2.3 2.5 2.6 2.8 2.9 2.4 Number 939 2,080 2,542 2,001 1,283 724 660 10,227 1 Includes current pregnancy 2 Means are calculated excluding the women giving non-numeric responses. Among both the ever-married and currently married women who gave a numeric response, the mean ideal family size is 2.4 children. For currently and ever-married women, there has been no change at all in the mean ideal family size over the last ten years. As in the 1999-2000 BDHS, ideal family size was 0.1 children lower for currently married men. The ideal number of children increases with the number of living children; it is also consistently lower than the actual number of living children at the higher parities. Women with six or more children have an average ideal family size of 2.9, compared with a desired family size of 2.2 for those with no children or only one child. Among all men, ideal family size ranges from 2.1 for those with one or two children to 2.6 for men with at least six living children. As in the 1999- 2000 BDHS, a majority of both ever-married women and currently married men embrace the two-child family as an ideal. Slightly more men prefer a two-child family than women do; however, there is not much difference in the proportion of currently married men and ever-married women who prefer a two- or three-child family as the ideal family size. Fertility Preferences | 109 Table 7.5.2 Ideal and actual number of children: men Percent distribution of all men and currently married men by ideal number of children, and mean ideal number of children, according to number of living children, Bangladesh 2004 Number of living children Ideal number of children 0 1 2 3 4 5 6+ Total ALL MEN 0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 1 4.9 7.9 4.8 3.1 1.2 1.3 0.8 4.5 2 71.0 71.5 78.3 59.5 58.7 50.2 53.5 68.2 3 14.5 14.5 12.9 25.4 12.6 22.1 22.2 16.1 4 4.1 3.1 2.3 6.7 15.5 6.9 8.4 5.1 5 0.9 0.3 0.3 1.5 1.9 8.2 1.1 1.2 6+ 0.5 0.0 0.2 0.0 0.5 1.1 2.1 0.4 Non-numeric responses 4.2 2.7 1.0 3.8 9.7 10.2 11.9 4.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 1,826 550 696 534 323 192 176 4,297 Mean ideal number1 2.2 2.1 2.1 2.4 2.6 2.7 2.6 2.3 Number of men 1,750 535 689 514 291 173 155 4,107 CURRENTLY MARRIED MEN 1 6.0 8.0 4.9 3.1 1.2 1.3 0.8 4.4 2 67.9 71.2 78.3 59.5 58.7 49.5 53.4 66.3 3 16.7 14.7 12.9 25.4 12.6 22.4 22.5 17.3 4 4.8 3.1 2.3 6.7 15.5 7.0 8.0 5.8 5 0.1 0.3 0.3 1.5 1.9 8.3 1.2 1.3 6+ 0.3 0.0 0.2 0.0 0.5 1.1 2.1 0.4 Non-numeric responses 4.1 2.7 0.9 3.8 9.7 10.4 12.0 4.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of men 328 544 687 534 323 190 174 2,780 Mean ideal number1 2.2 2.1 2.1 2.4 2.6 2.7 2.6 2.3 Number of currently married men 315 530 681 514 291 170 153 2,653 1Means are calculated excluding the men giving non-numeric responses. Table 7.6 presents data on the mean ideal number of children for ever-married women and all men and currently married men, by age, according to background characteristics. The ideal family size for both men and women increases with age, from 2.2 for women age 10-14 to 2.7 for women age 45-49. For men, the highest ideal family size of 2.4 is for the oldest cohort (45-54 years), and the lowest is for men under age 25 (about 2.2). Ideal family size for both men and women is minimally higher in rural areas, compared with urban areas, and it decreases with the level of education. A similar trend is observed with the wealth index. Overall, divisional variations in ideal family size for both women and men are the greatest. All men and ever-married women have the highest ideal family size in Chittagong and Sylhet (2.7 and 2.6, respectively) and the lowest in Khulna (2.1). Similar differences are observed across all age groups in divisions. 110 | Fertility Preferences Table 7.6 Mean ideal number of children by background characteristics Mean ideal number of children for ever-married women, all men, and currently married men, by age and background charac- teristics, Bangladesh 2004 Age Background characteristic 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Ever- married women All men Currently married men Residence Urban (2.1) 2.2 2.2 2.2 2.3 2.3 2.6 2.6 2.3 2.1 2.2 Rural 2.2 2.3 2.4 2.4 2.5 2.5 2.6 2.7 2.5 2.3 2.3 Division Barisal * 2.3 2.3 2.4 2.4 2.6 2.6 2.8 2.4 2.3 2.3 Chittagong * 2.5 2.5 2.7 2.7 2.7 2.9 2.9 2.7 2.6 2.7 Dhaka (2.2) 2.3 2.3 2.3 2.5 2.5 2.6 2.7 2.4 2.3 2.3 Khulna (2.0) 2.1 2.1 2.2 2.2 2.3 2.4 2.5 2.2 2.1 2.1 Rajshahi (2.2) 2.2 2.1 2.2 2.3 2.4 2.5 2.6 2.3 2.2 2.2 Sylhet * 2.6 2.7 2.7 2.8 2.8 2.9 2.9 2.7 2.6 2.6 Education No education * 2.4 2.4 2.5 2.5 2.6 2.6 2.7 2.6 2.5 2.4 Primary incomplete (2.2) 2.3 2.4 2.4 2.5 2.4 2.6 2.7 2.4 2.4 2.4 Primary complete (2.3) 2.3 2.3 2.4 2.5 2.5 2.4 2.7 2.4 2.2 2.3 Secondary incom- plete 2.1 2.2 2.3 2.3 2.2 2.4 2.5 2.6 2.3 2.2 2.2 Secondary complete or higher nc 2.1 2.1 2.1 2.1 2.1 2.3 2.2 2.1 2.0 2.1 Wealth index Lowest (2.3) 2.4 2.5 2.5 2.6 2.7 2.7 2.7 2.6 2.5 4.0 Second (2.2) 2.3 2.3 2.4 2.6 2.5 2.6 2.8 2.5 2.4 3.2 Middle (2.1) 2.3 2.3 2.4 2.5 2.6 2.7 2.6 2.4 2.3 3.0 Fourth (2.3) 2.2 2.2 2.3 2.4 2.4 2.4 2.7 2.4 2.2 2.3 Highest * 2.2 2.2 2.2 2.3 2.3 2.5 2.7 2.3 2.1 2.5 Total for ever-married women 2.2 2.3 2.3 2.4 2.5 2.5 2.6 2.7 2.4 na na Total for all men na 2.2 2.2 2.3 2.3 2.3 2.3 2.41 na 2.3 na Total for currently married men na 2.0 2.2 2.3 2.3 2.3 2.3 2.4 1 na na 2.3 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk indicates that the number is based on fewer than 25 unweighted cases and has been suppressed. 1 Age 45-54 na = Not applicable nc = No cases Fertility Preferences | 111 7.5 WANTED AND UNWANTED FERTILITY There are two ways of estimating levels of unwanted fertility from the BDHS data. One is based on responses to a question as to whether each birth in the five years preceding the survey was planned (wanted then), mistimed (wanted but at a later time), or unwanted (wanted no more children). These data are likely to result in underestimates of unplanned childbearing since women may rationalize unplanned births and declare them as planned once they are born. Another way of measuring unwanted fertility uses the data on ideal family size to calculate what the total fertility rate would be if all unwanted births were avoided. This measure may also suffer from underestimation to the extent that women are unwilling to report an ideal family size lower than their actual family size. Data using these two approaches are presented below. Interviewers asked women a series of questions regarding children born in the five years preceding the survey date and any current pregnancy to determine whether each birth or current pregnancy was wanted then, wanted later, or unwanted. These questions provide a powerful indicator of the degree to which couples successfully control fertility. Also, the data can be used to gauge the effect of the prevention of unwanted births on fertility rates. Table 7.7 shows the percent distribution of births in the five years preceding the survey by whether the birth was wanted by the mother then, wanted later, or not wanted at all. Table 7.7 Fertility planning status Percent distribution of births in the five years preceding the survey (including current pregnancies), by fertility planning status, according to birth order and mother’s age at birth, Bangladesh 2004 Planning status of birth Birth order and mother's age at birth Wanted then Wanted later Not wanted Missing Total Number of births Birth order 1 85.6 14.3 0.0 0.0 100.0 2,302 2 74.6 23.9 1.3 0.2 100.0 1,952 3 66.1 16.8 17.2 0.0 100.0 1,378 4+ 52.5 9.2 38.1 0.1 100.0 2,094 Mother’s age at birth <20 78.8 20.3 0.8 0.1 100.0 2,499 20-24 73.7 18.6 7.6 0.1 100.0 2,466 25-29 65.6 11.6 22.8 0.1 100.0 1,494 30-34 56.2 7.1 36.5 0.3 100.0 809 35-39 48.2 4.9 46.9 0.0 100.0 324 40-44 43.0 4.5 51.9 0.6 100.0 102 Total 70.4 15.8 13.7 0.1 100.0 7,725 Note: Birth order includes current pregnancy. Total includes 12 births to mothers age 45-49 at birth. The data indicate that nearly three out of ten births in Bangladesh are either unwanted (14 percent) or mistimed or wanted later (16 percent). Figure 7.5 shows that in the last four years, unplanned births have been reduced because mistimed births decreased. Unplanned births increase with increasing birth order and mother’s age at birth. For first- and second-order births, almost no birth is considered unwanted, and 14 to 24 percent are considered mistimed. Third-order births are equally likely to be 112 | Fertility Preferences considered mistimed or unwanted (17 percent). In contrast, for fourth- or higher-order births, more than four-fifths of unplanned births are unwanted. Similarly, a larger proportion of births to older women are reported as unwanted, compared with births to younger women. This is because the older women have large families, and younger women have not achieved their desired family size. Less than 10 percent of births in the five years preceding the survey to mothers age 20-24 are unwanted, compared with nearly half of all births to mothers 35 years or older. Table 7.8 presents wanted fertility rates. These rates are calculated in the same manner as the total fertility rate (TFR), but unwanted births are excluded from the numerator. For this purpose, unwanted births are defined as those that exceed the number considered ideal by the respondent. Women who did not report a numeric ideal family size were assumed to want all of their births. These rates represent the level of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been prevented. A comparison of the total wanted fertility rate (TWFR) and the actual total fertility rate (TFR) suggests the potential demographic impact of the elimination of unwanted births. Fertility Preferences | 113 Table 7.8 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Bangladesh 2004 Background characteristic Total wanted fertility rate Total fertility rate Residence Urban 1.6 2.5 Rural 2.1 3.2 Division Barisal 1.7 2.9 Chittagong 2.3 3.7 Dhaka 1.9 2.9 Khulna 1.9 2.8 Rajshahi 1.7 2.6 Sylhet 2.9 4.2 Education No education 2.3 3.6 Primary incomplete 2.0 3.2 Primary complete 1.9 2.9 Secondary incom- plete 1.8 2.7 Secondary complete or higher 2.0 2.2 Wealth index Lowest 2.6 4.1 Second 1.9 3.2 Middle 2.1 3.3 Fourth 1.7 2.5 Highest 1.6 2.2 Total 2.0 3.0 Note: Rates are based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 4.2. The total wanted fertility rate for Bangladesh is 2.0, which is one-third lower than the actual TFR, as was the TWFR observed in the 1999-2000 BDHS. If women’s fertility desires could be met, the TFR in all divisions except Chittagong and Sylhet would be below the replacement level of 2.1 children per woman. Of the other characteristics shown in Table 7.8, only two other subgroups have total wanted fertility rates above replacement level: uneducated women and the poorest women. The gap between the wanted and observed total fertility rates measured as a ratio of observed fertility rate to wanted fertility rate indicates a larger gap for women in Barisal and Chittagong divisions, for those who have attended school but have not completed primary school, and also for women in households in the three lowest wealth quintiles. For all these women, the actual fertility rate is at least 60 percent higher than the wanted fertility rate. The gap is narrowest for women who have completed secondary school or who live in the wealthiest households (the TFR is higher than the corresponding TWFR by 10 and 38 percent, respectively). Infant and Child Mortality │ 115 INFANT AND CHILD MORTALITY 8 8.1 INTRODUCTION Infant and child mortality rates reflect a country’s level of socioeconomic development and quality of life and are used for monitoring and evaluating population and health programs and policies. The rates are also important for monitoring the progress of the United Nations Millennium Development Goal to reduce child mortality. This chapter provides information on mortality of children under the age of five. Specifically, it presents information on levels, trends, and differentials in neonatal, postneonatal, infant, and child mortality. Information on patterns of fertility associated with high mortality is also provided. Mortality estimates are disaggregated by socioeconomic characteristics, such as urban-rural residence, division, mother’s education, and wealth index, and also by selected demographic characteristics, to identify segments of the population requiring special attention. The data for mortality estimates were collected in the birth history section of the Women’s Questionnaire. In the 2004 BDHS, all ever-married women age 10-49 were asked to provide a complete history of their births including for each live birth the sex, month and year of birth, survival status, and age at the time of the survey or age at death. Age at death was recorded in days for children dying in the first month of life, in months for children dying before their second birthday, and in years for children dying at later ages. In this chapter, the following direct estimates of infant and child mortality1 were used: • Neonatal mortality (NN): The probability of dying in the first month of life • Postneonatal mortality (PNN): The probability of dying after the first month of life but before the first birthday • Infant mortality (1q0): The probability of dying before the first birthday • Child mortality (4q1): The probability of dying between the first and fifth birthdays • Under-five mortality (5q0): The probability of dying before the fifth birthday. All rates are expressed per 1,000 live births, except for child mortality, which is expressed per 1,000 children surviving to their first birthday (12 months of age). 8.2 ASSESSMENT OF DATA QUALITY The reliability of mortality estimates calculated from retrospective birth histories depends upon the completeness with which deaths of children are reported and the extent to which birth dates and ages at death are accurately reported and recorded. Estimated rates of infant and child mortality are subject to both sampling and nonsampling errors. While sampling errors for various mortality estimates are provided in Appendix B, this section describes the results of various checks for nonsampling errors—in particular, underreporting of deaths in early childhood (which would result in an underestimate of mortality) and 1A detailed description of the method for calculating the probabilities presented here is given in Rutstein (1984). The mortality estimates are not rates but are true probabilities calculated according to the conventional life-table approach. Deaths and exposure in any calendar period are first tabulated for the age intervals 0, 1-2, 3-5, 6-11, 12-23, 24-35, 36-47, and 48-59 months. Then age-interval-specific probabilities of survival are calculated. Finally, probabilities of mortality for larger age segments are produced by multiplying the relevant age-interval survival probabilities together and subtracting the product from one: i=x+n nqx = 1 – Σ(1 – qi) i=x 116 │ Infant and Child Mortality misreporting of the date of birth or age at death (which could distort the age pattern of under-five mortality). Both problems are likely to be more pronounced for children born further in the past than for children born recently. Underreporting of infant deaths is usually most serious for deaths that occur very early in infancy. If deaths in the early neonatal period are selectively underreported, there will be an abnormally low ratio of deaths under seven days to all neonatal deaths and an abnormally low ratio of neonatal to infant mortality. Changes in these ratios over time can be examined to test the hypothesis that underreporting of early infant deaths is more common for births that occurred further in the past than for births that occurred more recently. Failure to report deaths will result in mortality figures that are low, and if underreporting is more severe for children born longer ago than for children born recently, any decline in mortality will tend to be understated. Results from Table C.5 in Appendix C suggest that early neonatal deaths have not been seriously underreported in the 2004 BDHS because the ratios of deaths under seven days to all neonatal deaths are acceptable—72 percent for the most recent period, 0 to 4 years preceding the survey, and 65 percent for the periods 10 to 14 years and 15 to 19 years preceding the survey.2 A ratio of about 70 percent is often considered as normal. The ratios of neonatal to infant deaths (Table C.6 in Appendix C) are also consistently high (between 60 and 66 percent) for the various periods preceding the survey. Another problem inherent in most retrospective surveys is heaping of age at death on certain digits (e.g., 6, 12, and 18 months). If the net result of misreporting is the transference of deaths between age segments for which the rates are calculated, misreporting of the age at death will bias estimates of the age pattern of mortality. For instance, an overestimate of child mortality relative to infant mortality may result if children dying during the first year of life are reported as having died at age one or older. Thus, heaping at 12 months can bias the mortality estimates because a certain fraction of these deaths, which are reported to have occurred after infancy (i.e., at age 12-23 months), may have actually occurred during infancy (i.e., at age 0-11 months). In such cases, heaping would bias infant mortality (1q0) downward and child mortality (4q1) upward. In the 2004 BDHS, there appears to be a preference for reporting age at death at 3, 7, 10, 14 and 21 days (Table C.5 in Appendix C). An examination of the distribution of deaths under age 2 during the 15 years preceding the survey by month of death (Table C.6 in Appendix C) indicates a slight heaping of deaths at 3, 6, 12, and 18 months of age. Some heaping on 12 months is found despite the strong emphasis on this problem during the training of interviewers for the BDHS fieldwork.3 However, this brief assessment of the internal consistency of childhood mortality data suggests that the extent of digit preference is such that it will not substantially alter the rates. It is seldom possible to establish mortality levels with confidence for a period of more than 15 years before a survey. Even within the recent 15-year period considered here, apparent trends in mortality rates should be interpreted with caution for several reasons. First, there may be differences in the completeness of death reporting related to the length of time before the survey. Second, the accuracy of reports of age at death and of date of birth may deteriorate with time. Third, sampling variability of mortality rates tends to be high, especially for groups with relatively few births. Fourth, mortality rates are truncated as they go back in time because women currently age 50 or above who were bearing children during earlier periods were not included in the survey. This truncation affects mortality trends in particular. For example, for the period 10 to 14 years before the survey, the rates do not include any births for women age 40-49 since these women were over age 50 at the time of the survey and not eligible to be interviewed. Since these excluded births to older women were likely to be at a somewhat greater risk of dying than births to younger women, the mortality rates for the period may be slightly underestimated. Estimates for more recent periods are less affected by truncation bias since fewer older women are excluded. The extent of this bias depends on the proportion of births omitted, however. Table 7.7 (Chapter 7) shows that very few of the children born in the five years before the survey 2 There are no models for mortality patterns during the neonatal period. However, one review of data from developing countries concluded that, at neonatal mortality of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma, 1988). 3 Interviewers were trained to probe for the exact number of months lived by the child if the age at death was reported as “one year.” Infant and Child Mortality │ 117 were born to women age 35 and above. Given the small proportion of births excluded, selection bias for infant and child mortality statistics as far back as 15 years before the survey should be negligible. 8.3 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Mortality rates for children under five years of age are presented in Table 8.1 for the five-year period preceding the four BDHS surveys. The under-five mortality rate for the most recent five-year period (which roughly corresponds to the period 1999-2003) is 88 deaths per 1,000 live births, and infant mortality is 65 deaths per 1,000 life births. This means that 1 in 11 children born in Bangladesh dies before reaching the fifth birthday, while 1 in 15 children dies before reaching the first birthday. A child’s risk of dying is highest during the first month of life. Almost half of all under-five deaths occur during the neonatal period, about a quarter occur during the postneonatal period, and another quarter occur between ages 1 and 4 years. Table 8.1 Trend in early childhood mortality rates Neonatal, postneonatal, infant, child, and under-five mortality rates for the five-year period preceding the surveys, BDHS surveys 1993-2004 Data source Approximate reference period Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) BDHS 2004 1999-2003 41 24 65 24 88 BDHS 1999-2000 1995-1999 42 24 66 30 94 BDHS 1996-1997 1992-1996 48 34 82 37 116 BDHS 1993-1994 1989-1993 52 35 87 50 133 1 Computed as the difference between the infant and neonatal mortality rates Comparisons of mortality estimates over time show continued declines in child (age 1-4 years) and under-five mortality (Table 8.1 and Figure 8.1). Between the two most recent five-year periods, there was a 20 percent decline in child mortality and a 6 percent decline in under-five mortality. Infant mortality seems to have leveled off during recent years. For infant mortality to decline significantly, the Bangladesh program may need to focus on reducing neonatal deaths since most infant deaths occur during the first month of life. 118 │ Infant and Child Mortality 8.4 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Differentials in childhood mortality for the ten years preceding the survey by selected background characteristics are presented in Table 8.2 and Figure 8.2. There is very little difference in mortality levels in urban and rural areas among children who are less than one year of age. Child mortality is still somewhat higher in rural areas than in urban areas. Over the years, mortality levels at various ages among children under five have declined faster in the rural areas than in the urban areas, reducing the urban-rural differentials in all measures of childhood mortality. Table 8.2 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by socioeconomic characteristics, Bangladesh 2004 Socioeconomic characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Residence Urban 44 28 72 21 92 Rural 47 26 72 27 98 Division Barisal 32 29 61 32 92 Chittagong 41 27 68 39 103 Dhaka 47 28 75 27 99 Khulna 47 19 66 13 78 Rajshahi 48 22 70 17 86 Sylhet 63 37 100 29 126 Education No education 51 30 81 35 113 Primary incomplete 44 26 70 18 87 Primary complete 51 32 82 15 96 Secondary incomplete 38 10 48 19 66 Secondary complete or higher 35 22 57 14 70 Wealth index Lowest 55 35 90 34 121 Second 43 23 66 34 98 Middle 50 25 75 23 97 Fourth 39 20 59 23 81 Highest 42 24 65 7 72 1 Computed as the difference between the infant and neonatal mortality rates The 2004 BDHS data show wide variations in mortality by division. Sylhet division has the highest mortality rates for all mortality indicators except child mortality. Child mortality is highest in Chittagong division. Khulna division has the lowest rates for postneonatal, child, and under-five mortality, and Barisal division has the lowest rates for neonatal and infant mortality. Infant and Child Mortality │ 119 Mother’s level of education is inversely related to her child’s risk of dying. Higher levels of educational attainment are generally associated with lower mortality risks, since education exposes mothers to information about better nutrition, use of contraception to limit and space births, and childhood illnesses and their treatment. The 2004 BDHS shows that under-five mortality declines sharply with increased level of mother’s education; the rate is almost 40 percent lower for children whose mothers have at least some secondary education, compared with those who have no education. Also, a child’s chance of dying in neonatal and postneonatal periods is much lower when the mother has at least some secondary education. The mortality risk of children is associated with the economic status of the household. All childhood mortality rates are highest for those in the lowest wealth quintile. Under-five mortality declines steadily with increasing economic status of the household, dropping from a high of 121 deaths per 1,000 live births in households in the lowest wealth quintile to 72 deaths per 1,000 live births in households in the highest wealth quintile. 120 │ Infant and Child Mortality 8.5 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY This section examines differentials in mortality of children under age five at various ages by demographic characteristics of the child and mother. Table 8.3 and Figure 8.3 present mortality rates for the ten-year period preceding the survey by sex of the child, age of mother at birth, birth order, and previous birth interval. Table 8.3 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-five mortality rates for the ten-year period preceding the survey, by demographic characteristics, Bangladesh 2004 Demographic characteristic Neonatal mortality (NN) Postneonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Child's sex Male 52 28 80 24 102 Female 40 24 64 29 91 Mother's age at birth <20 58 28 86 22 106 20-29 37 23 60 25 84 30-39 48 34 83 35 115 Birth order 1 63 26 88 16 103 2-3 36 21 57 24 80 4-6 42 29 71 34 102 7+ 53 49 102 46 144 Previous birth interval2 <24 months 66 36 101 43 140 24-35 months 39 33 72 35 104 36-47 months 31 20 51 29 79 48 months or more 27 19 46 14 59 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births Male children experience higher neonatal and postneonatal mortality than female children, while female children experience higher child mortality than males. The pattern of gender differentials in neonatal mortality is expected because neonatal mortality (which reflects largely congenital conditions) tends to be higher for boys than for girls. With the exception of the 2004 BDHS, all previous BDHS surveys reported both higher postneonatal and child mortality for females than for males—a pattern that has been observed in other countries of South Asia where strong son preference is thought to result in relative nutritional and medical neglect of female children (Das Gupta, 1987; Basu, 1989). In the most recent ten-year reference period, some changes in the postneonatal and under-five mortality patterns by sex of the child are observed, compared with the patterns reported for the ten-year reference periods preceding the 1999-2000 BDHS, the 1996-1997 BDHS, and the 1993-1994 BDHS. The 2004 BDHS indicates that there are no longer more female deaths than male deaths in the postneonatal period and that the under-five mortality of male children is now higher than that of female children. Infant and Child Mortality │ 121 The relationship between mother’s age at birth and childhood mortality rates exhibits a U-shaped pattern—children of both the youngest and oldest mothers experience the highest mortality risks. The 2004 BDHS shows a similar pattern for all mortality estimates except child mortality. Childhood mortality rates also tend to have a U-shaped relationship with birth order, with first births and very high order births having elevated mortality rates. In Table 8.3, birth order shows the expected U- shaped pattern for neonatal, postneonatal, infant, and under-five mortality rates, with rates being higher for first births and birth orders four or higher than for second- and third-order birth. Child mortality tends to increase with birth order. The increase in the child mortality rate with birth order may reflect a more intense competition faced by higher birth order children for the caregiver’s time, for utilization of health care, and for nutritious food once children are weaned. Short birth intervals are associated with an increased risk of dying. Retherford and others (1989) observe an association between short birth interval (less than 24 months) and increased mortality, even after controlling for other demographic and socioeconomic variables. In Table 8.3, all childhood mortality rates show a sharp decline as the birth interval gets longer. The neonatal, infant, child and under-five mortality rates are more than twice as high for children born after an interval of less than 24 months, compared with children who are born after an interval of 48 months or more. 8.6 PERINATAL MORTALITY Perinatal deaths are composed of pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths within the first seven days of life (early neonatal deaths). The perinatal death rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. The distinction between a stillbirth and an early neonatal death is a delicate one, often depending on the observed presence or absence of some signs of life after delivery. The causes of stillbirths and early neonatal deaths are overlapping, and examining just one or the other can understate the true level of mortality around delivery. For this reason, it is suggested that both events be combined and examined together. In the BDHS, information on stillbirths is available for the five years preceding the survey and is collected using the calendar at the end of the Women’s Questionnaire. Table 8.4 presents the number of stillbirths and early neonatal deaths, as well as the perinatal mortality rate for the five-year period preceding the 2004 BDHS, by selected demographic and socioeconomic 122 │ Infant and Child Mortality characteristics. The data indicate that the perinatal mortality rate in Bangladesh is 65 deaths per 1,000 pregnancies and that the rate is slightly higher than it was in the 1999-2000 BDHS (57 deaths per 1,000 pregnancies). Perinatal mortality is higher among teenage mothers and during first pregnancies. There are virtually no urban-rural differences in perinatal mortality. Rajshahi division has the highest perinatal mortality rate among all divisions. Variations in perinatal mortality by mother’s education and household wealth index are small. 8.7 HIGH-RISK FERTILITY BEHAVIOR Many studies have found a strong relationship between children’s chances of dying and certain fertility behaviors. In general, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short birth interval, or if they are born to mothers with high parity. For this analysis, mothers are classified as too young if they are less than 18 years of age and too old if they are over 34 years of age at the time of delivery. A short birth interval is defined as a birth occurring within 24 months of a previous birth, and a high birth order is defined as occurring after 3 or more previous births (birth order 4 or higher). After cross-classification of births by combinations of all three characteristics, a birth may have from zero to three high-risk characteristics. Table 8.5 shows the percent distribution of births in the five-year period preceding the survey and the distribution of all currently married women across various risk categories. It also shows the relative risk of children dying across the different risk categories. The purpose of this table is to identify areas in which changes in reproductive behavior would be likely to effect a reduction in infant and child mortality. Mortality risk is represented by the proportion of children born during the five years preceding the survey who had died by the time of the survey. The “risk ratio” is the ratio of the proportion of dead children in a given high-risk category to the proportion of dead children not in any high-risk category. Among children born in the five years preceding the survey, more than half fell in one of the avoidable high-risk categories; only one-third were not in any of the high-risk categories. One in ten births were in one of the multiple high-risk categories, while four in ten births were in one of the single high-risk categories. In the avoidable high-risk category, most births were to mothers younger than 18 years or mothers who had three or more children. About 65 percent of the women who gave birth in the five years preceding the survey were in one of the avoidable high-risk categories (last column of Table 8.5). About one-third of the women had a single high-risk factor, while another one-third had multiple high-risk factors. Risk ratios, which describe the relationship between a particular risk category and a reference category, are used to compare risk categories. Children born to mothers age 35 or older are three times more likely to die, compared with those born to mothers who are not in any high-risk category. This child mortality risk is further elevated and is the highest for births to older women who have three or more children and whose preceding birth interval is less than 24 months; fortunately, only about 1 percent of the births are to women in this multiple high-risk category. About 17 percent of the children are born to women who are younger than 18 years; these children are almost twice as likely to die as those born to mothers who are not in any high-risk category. Births to mothers who have three or more children and a short preceding birth interval have over twice the mortality risk of births to mothers who are not in any high-risk category. About 4 percent of the births occur in this high-risk category. Infant and Child Mortality │ 123 Table 8.4 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Bangladesh 2004 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate (per 1,000 pregnancies) Number of pregnancies of 7+ months duration3 Mother's age at birth <20 108 83 80 2,396 20-29 115 85 54 3,699 30-39 43 35 73 1,064 40-49 3 4 * 113 Previous pregnancy interval in months First pregnancy 108 84 99 1,937 <15 21 16 (89) 414 15-26 52 19 52 1,352 27-38 33 28 48 1,258 39+ 56 59 50 2,310 Residence Urban 54 43 67 1,446 Rural 216 163 65 5,826 Division Barisal 9 7 (40) 419 Chittagong 53 33 54 1,581 Dhaka 87 65 67 2,262 Khulna 29 22 68 760 Rajshahi 64 59 76 1,624 Sylhet 26 20 73 625 Education No education 121 83 69 2,971 Primary incomplete 50 36 62 1,386 Primary complete 16 25 60 677 Secondary incomplete 32 24 59 945 Secondary complete or higher 52 38 70 1,292 Wealth index Lowest 79 50 69 1,871 Second 57 39 64 1,501 Middle 44 47 64 1,425 Fourth 45 32 59 1,287 Highest 45 38 70 1,187 Total 270 206 65 7,271 Note: Rates based on 250-499 pregnancies are in parentheses. An asterisk indicates that a rate is based on fewer than 250 pregnancies and has been suppressed. 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration. 124 │ Infant and Child Mortality Table 8.5 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of dying and the risk ratio, and percent distribution of currently married women by category of risk of child death, Bangladesh 2004 Births in the five years preceding the survey Risk category Percentage of births Risk ratio Percentage of currently married women1 Not in any high-risk category 34.0 1.00 29.3a Unavoidable risk category First-order births between ages 18 and 34 years 13.9 1.43 6.2 Single high-risk category Mother’s age <18 17.1 1.82 5.1 Mother’s age >34 0.6 3.28 3.7 Birth interval <24 months 5.2 1.73 7.5 Birth order >3 18.3 1.36 16.8 Subtotal 41.2 1.62 33.1 Multiple high-risk category Mother’s age <18 and birth interval <24 months2 1.4 1.33 1.5 Mother’s age >34 and birth interval <24 months 0.1 * 0.1 Mother’s age >34 and birth order >3 4.4 1.54 23.1 Mother’s age >34 and birth interval <24 months & birth order >3 0.7 4.17 1.0 Birth interval <24 months and birth order >3 4.3 2.32 5.8 Subtotal 10.8 1.97 31.5 In any avoidable high-risk category 52.0 1.70 64.6 Total 100.0 na 100.0 Number of births 7,002 na 10,582 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that a rate is based on fewer than 25 cases and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category mother’s age <18 and birth order >3 a Includes sterilized women Causes of Under-five Deaths │ 125 CAUSES OF DEATH IN CHILDREN UNDER FIVE YEARS OF AGE 9 Shams El Arifeen, Tasnima Akhter, Hafizur Rahman Chowdhury, Kazi Mizanur Rahman, Enayet Karim Chowdhury, NurulAlam, D M Emdadul Haque, Abdullah H Baqui 9.1 INTRODUCTION Knowledge of causes of death among children under five is important because it pertains to policy and programs. Patterns and trends in causes of under-five mortality help decisionmakers assess programmatic needs, prioritize interventions, and monitor progress. However, data on causes of death tend to be limited in developing countries, including Bangladesh. The vital registration systems are deficient in coverage and most deaths occur outside the health system, where cause of death is unreported. Verbal autopsy is a method of assessing the cause of death based on an interview with the next of kin or other caregivers who were present at the time of death or who are knowledgeable about the events leading up to the death. Verbal autopsies have been used previously in Bangladesh to provide important data on causes of child death (Chen et al., 1980; Zimicki et al., 1985; D’Souza, 1985; Bhatia, 1989; Fauveau et al., 1994; Snow et al., 1992; Kalter et al., 1990; Kamal et al., 1989; Salway et al., 1994; Baqui et al., 1998). Baqui and others have reported on causes of death under age five based on verbal autopsy interviews in the 1993-1994 and 1996-1997 BDHS sample (Baqui et al., 1998; Baqui et al., 2001). Causes of deaths were assigned using predefined computer algorithms. The verbal autopsy study in the BDHS 1993-94 revealed that about one-quarter of deaths among children under five years were associated with acute respiratory infections (ARI) and about one-fifth of the deaths were associated with diarrhea (Baqui et al., 1998). Drowning was a major cause of death in children age 1-4 years. Neonatal tetanus and measles were the other important causes of death. The same verbal autopsy instrument and cause of death algorithms were used in the 1996-1997 BDHS. Comparison of the two surveys revealed that deaths due to almost all causes declined. The exceptions were deaths due to neonatal tetanus, diarrhea, and malnutrition (Baqui et al., 2001). The reduction in ARI-related deaths was almost entirely limited to children 1-4 years old; there was almost no decline in ARI deaths in the neonatal and postneonatal periods. In both surveys, cause of death could not be assigned to a substantial proportion of deaths, particularly those occurring in the neonatal period. In the 1996- 97 BDHS, 21 percent of deaths were classified as early neonatal and another 15 percent were not identified. This reflects the limitations of the algorithms used to assign cause of death. A verbal autopsy assessment was not included in the 1999-2000 BDHS, and thus we have no national data on cause of death for children in Bangladesh since the mid-1990s. The 2004 BDHS shows that the under-five mortality rate declined by about 6 percent since the 1999-2000 survey and by 24 percent since the 1996-97 survey. This impressive decline in child mortality warrants further investigation. An assessment of the cause structure of child deaths may help explain this decline while guiding attention towards those causes of death that remain persistently high. This chapter presents information on the proportional distribution of causes of neonatal, postneonatal, infant, and child deaths. The cause of death distribution is disaggregated by the sex of the child, urban-rural residence, division, and mother’s education. During the survey, information on deaths of children under five in the sampled households was obtained from the birth history section of the questionnaire that was administered to eligible women. If a child under age five died in a household in the five years preceding the survey (which corresponds roughly to calendar years 1999-2003), a verbal autopsy questionnaire was administered by a supervisor of data collectors, or a specially trained data collector, within a day of identification of the death. This process is different from that used in the two previous verbal autopsy studies, 126 │ Causes of Under-five Deaths where information on the deceased was collected by revisiting those households with reported deaths after the main survey was completed. 9.2 DESCRIPTION OF THE DATA COLLECTION INSTRUMENT The verbal autopsy instrument was developed from several instruments, including the questionnaire used in the two previous BDHS verbal autopsy surveys (Baqui et al., 1998; Baqui et al., 2001), the WHO verbal autopsy questionnaire, and the instrument being used since 2003 in the Matlab Health and Demographic Surveillance System (HDSS). This last instrument was developed based on the work done by the In-Depth Verbal Autopsy Working Group, which used the verbal autopsy questionnaire from the Adult Morbidity and Mortality Project (AMMP) in Tanzania, which, in turn, had evolved out of the WHO questionnaire. The final questionnaire was pre-tested and is somewhat different from the instrument used in the two previous surveys. The differences were primarily in terms of the structure of the instrument and in the level of specificity of the information collected. An entirely separate module on neonatal deaths (0-28 days old at death) was used. For the module on older children (age at death between 29 days and 5 years), sections were added to obtain addition information in cases with convulsions, unconsciousness, rash, malnutrition, glandular swellings, jaundice, vomiting, abdominal pain, mass in the body, urine color and amount, and any surgery. This was a structured instrument with sections allowing for collection of open-ended information including narrative stories. The complete instrument had the following sections: 1) identification including detailed address of respondent; 2) informed consent; 3) information on age of the deceased child; 4) information about caretaker or respondent of deceased child; 5) information on prenatal care, labor, delivery, and obstetrical complications; 6) open-ended section allowing the respondent to provide a narrative history; 7) information about accidental deaths; 8) detailed signs and symptoms preceding death; 9) and information about treatment preceding death, and on direct, underlying and contributing causes of death from the death certificate, if available. 9.3 ASSIGNING CAUSE OF DEATH The death of a child often has more than one cause. The assignment of cause of death followed a hierarchical process whereby certain diagnoses were viewed as more certain than others—and thus given priority—with the possibility of assigning multiple causes of death included in the hierarchical process. The hierarchical process followed several mutually exclusive tiers applied in sequence (Figure 9.1). In tier 1, neonatal tetanus was assigned as the cause in a child whose age at death was between 4 and 14 days, who had had convulsions any time during this period, and who either cried normally after birth and stopped crying at least one day before the final illness, or who suckled normally after birth and stopped suckling at least one day before the final illness. Tier 2 was limited to deaths before the age of 29 days. The cause of death of a child was confirmed as death due to congenital abnormality if the child had a reported malformation at birth. Tier 3 applied to accidental deaths at or after the age of 29 days, including drowning deaths. Tiers 4 and 5 applied to neonatal deaths at age 7 days or less. In tier 4, birth asphyxia was assigned as the cause of death if the child was not able to cry normally after birth and the baby was either not able to breathe after birth or not able to suckle normally after birth. In tier 5, deaths due to bruises or marks of injury on the body or head at birth were considered as birth injury. Tier 6 allowed for the assignment of multiple causes of death simultaneously. ARI was assigned for neonates if difficult or rapid breathing started at least 1 day before death and lasted until death and the child had at least two of the following three specific symptoms: grunting, nostril flaring, and chest indrawing. ARI was confirmed for postneonatal and child deaths if the child had a cough that started at least three days before death and lasted at least until the day before death and at least two of the following six specific symptoms: noisy breathing, stridor, grunting, wheezing, nostril flaring, or chest indrawing. ARI was also assigned for Causes of Under-five Deaths │ 127 non-neonatal deaths if the child had difficult breathing or rapid breathing that started at least one day before death and lasted until death and had at least two of the six specific symptoms listed above for cough. Source: Baqui et al., 1998; Baqui et al., 2001 Diarrhea for neonates was assigned if frequent liquid or watery or loose or soft stools or diarrhea was reported with a peak of six or more stools in 24 hours. Diarrhea for older child deaths was assigned if there had been frequent loose or liquid stools starting from 1 to 13 days before death and continuing until death and with a peak number of six or more stools in 24 hours, and at least two of the four following specific symptoms were reported: dry mouth, sunken eyes, loose skin, and no or very little urine. Diarrhea for deaths at age 29 days to 59 months was also confirmed if frequent loose or liquid stools started from at least 14 days prior to death and continued until death. A child whose age at death was six months or more, and had a rash all over the body and on the face that appeared during the three months before death, and was accompanied by fever, with no water in the rash, and with at least one of the three following specific symptoms reported: dry cough, red or runny eyes and running nose during the illness, was assigned as measles. Any combinations of these causes were allowed in this tier. Tier 7 was used to classify deaths due to other serious infections. Possible serious infection was assigned as cause of death if the child had at least two signs of serious infection. Among neonates, the signs included: child had stopped suckling, child had stopped crying, difficult breathing, rapid breathing, chest indrawing, convulsions, fever, child was cold to touch, child was lethargic, child was unresponsive or unconscious, bulging fontanelle, redness or drainage from the umbilical cord stump, skin rash with bumps containing pus, vomiting everything. Among postneonates, the signs included: difficult breathing, rapid 128 │ Causes of Under-five Deaths breathing, chest indrawing, convulsions, fever, child was unresponsive or unconscious or stopped being able to grasp or stopped being able to respond to a voice or stopped being able to follow movements with the eyes, stiff neck, bulging fontanelle, and vomiting everything. In order to understand overlaps of possible serious infection with ARI and diarrhea, we used cause of death definitions of possible ARI and possible diarrhea. Among those with possible serious infection, possible ARI was classified if cough, difficult breathing or rapid breathing had been present before death. Possible diarrhea was assigned if frequent loose or liquid stools were reported. Tier 8 was used if age at death was less than 29 days and pregnancy ended early or the baby was reported to be very small or smaller than usual. In these cases, the death was confirmed as due to prematurity or low birth weight (LBW). In tier 9, if the child was reported to have been very thin or the child's feet were reported to have been swollen, the cause of death was confirmed as due to malnutrition. If no cause of death had been assigned in tiers 1 to 9, then a physician review process was used to assign cause of death. All the verbal autopsies in this category were independently reviewed by any two physicians from a panel of three. These three physicians had received guidance from the investigators on the cause of death assignment process. They were required to assign direct and underlying causes of death based on the International Classification of Diseases version 10 (ICD-10). If the two physicians agreed on the direct and underlying cause, that cause was accepted. In the event of disagreement, the verbal autopsy was reviewed by the third physician. If his/her assigned cause of death agreed with that of either of the other two physicians then that cause was accepted. If there was still disagreement, a "not determined" cause of death was assigned. The physicians were allowed to assign "unspecified" as a cause of death if they felt there was not enough information to lead to a definite cause of death. If any two physicians agreed on "unspecified" as cause of death then that was assigned. This algorithm is somewhat different from the one used in the two previous surveys (Baqui et al., 1998; Baqui et al., 2001). There are three differences. The case definitions used in the current survey, for deaths due to ARI and diarrhea, differ from previous definitions because of differences in the questionnaires. For ARI, the current questionnaire asked about rapid and difficult breathing in two separate questions; while previously, the queries were included in one question. Unlike the previous questionnaire, the current one does not ask about cough, noisy breathing, stridor, and wheezing in neonates, resulting in different algorithms for neonates. In the diarrhea set of algorithms, there are differences in three of the specific symptoms used to confirm the assignment of diarrhea as cause of death. The symptoms of weakness and depressed fontanel present in the previous questionnaire were not present in the new one, while the symptom of loose skin used in the new questionnaire was not collected previously. None of the specific symptoms were available for neonates in the new questionnaire. The diagnosis of persistent diarrhea is now made only for postneonates and children age 1-4 years. The tiers were also modified in order to reduce the number of unspecified causes of death as shown in the chart (Figure 9.1). The physician review was added for the same reason. The two major changes in the tiers are the following: 1. The previous first tier—grouping together all neonatal deaths during 0-3 days of life—was dropped. Such a broad category did not allow understanding the causes of the large number deaths in this age group and, consequently, was not useful for policy or program purposes. The tier of birth asphyxia was added as a specific cause of death that contributed the most to these very early deaths; and 2. The inclusion of “possible serious infection” as a cause of death tier, replacing the previous possible ARI and diarrhea causes. This was done in an attempt to capture infections and sepsis as cause of death, as well as to reduce the number of deaths where a cause could not be assigned. Causes of Under-five Deaths │ 129 9.4 CAUSES OF DEATH AMONG CHILDREN UNDER FIVE The percent distribution of children under five years by cause of death is presented in Table 9.1 by age group. Possible serious infection is the most important cause of death among neonates (33 percent), followed by birth asphyxia (21 percent), prematurity/LBW (11 percent) and ARI (10 percent). This large category of possible serious infection included 9 cases classified as such by the physician review. Of the remaining 102 cases in this category, 46 were also premature/LBW and 61 had possible ARI. Among neonates, 135 (39 percent) of the deaths were associated with prematurity/LBW (not presented in the table). Of these 135 cases, the direct causes of death indicated in Table 9.1 are: neonatal tetanus (4), congenital abnormality (7), birth Asphyxia (16), birth injury (5), diarrhea (2), ARI (15), possible serious infection (46), and prematurity/LBW (42). Among infants aged 29 days-11 months, ARI was associated with almost half of the deaths (ARI alone: 43 percent and ARI and diarrhea 5 percent). A quarter of the post-neonatal deaths were due to possible serious infections, and diarrhea (with or with out ARI) contributed 15 percent of deaths in this age group. Among older children (12-59 months), possible serious infection was the most important killer (37 percent), followed by injuries (22 percent) ─ particularly drowning (19 percent) ─ ARI (17 percent), malnutrition (11 percent) and diarrhea (9 percent). This large category of possible serious infection among post-neonates and children aged 12-59 months (n=78) was examined. In 64 of these cases, the child had fever along with at least one other symptom. Half of these 78 cases were malnourished, 28 had possible ARI, 13 had possible diarrhea, and 14 had possible ARI and diarrhea. Overall among all under-five children, possible serious infections (31 percent) and ARI (21 percent) were responsible for most of the deaths. This was followed by birth asphyxia (12 percent), diarrhea (7 percent) and prematurity/LBW (7 percent). Malnutrition was associated with 131 (22 percent) of all under- five deaths (not presented in the table). Of these 131 cases, the direct causes of death indicated in Table 9.1 are: injuries (2), measles with ARI diarrhea (1), diarrhea (16), ARI (47), ARI and diarrhea (5), Possible serious infection (39), and malnutrition alone (21). Overall, a cause could not be assigned to 31 (6 percent) of the under-five deaths. Compared to the cause of death pattern observed in the 1996-97 survey, several differences are observed in even the current survey, limiting this comparison to those unlikely to be complicated by the changes in methodology. A big difference has been the reduction of the number of post-neonatal and child deaths. In 1996-97, deaths at ages 0-28 days, 1-11 months, and 12-59 months were 42 percent, 30 percent and 28 percent respectively; in 2004 this distribution was 56 percent, 31 percent and 13 percent respectively. Drowning is responsible for about 19 percent of deaths at 12-59 months, similar to the proportion in 1996-97. The proportion of neonatal deaths attributed to neonatal tetanus shows a dramatic decline from 17 to 4 percent. Of considerable interest is the reduction of “confirmed” Diarrhea as a cause of death from 13 percnt in 1996-97 to 7 percent in 2004. 130 │ Causes of Under-five Deaths Table 9.1 Causes of death among children under five by age group Percent distribution of deaths among children under five years, by cause of death according to age group, Bangladesh 2004 Age group Cause of death Neonatal (0-28 days) Postneonatal 29 days - 11 months Child 12-59 months Under five years total Neonatal tetanus 4.2 0.0 0.0 2.3 Congenital abnormality 5.1 0.0 0.0 2.8 Injury 0.0 3.2 22.3 4.1 Drowning 0.0 0.9 19.3 3.0 Birth asphyxia 21.1 0.0 0.0 11.7 Birth injury 3.9 0.0 0.0 2.2 Measles 0.0 0.4 1.6 0.3 Measles followed by ARI or diarrhea 0.0 0.0 1.8 0.3 Diarrhea 1.2 10.3 9.3 5.1 ARI 10.3 42.7 17.0 21.1 ARI and diarrhea 0.5 4.9 0.0 1.8 Possible serious infection1 33.2 24.6 37.3 31.2 Premature birth/LBW 10.9 1.2 0.0 6.5 Malnutrition 0.0 7.1 10.7 3.6 Other causes2 2.3 1.0 0.0 1.6 Unspecified 3.9 3.5 0.0 3.2 Undetermined 3.4 1.1 0.0 2.3 Total 100.0 100.0 100.0 100.0 Number of deaths 326 183 78 587 Note: Estimates are weighted. 1 Possible serious infections include possible ARI and diarrhea. 2 Causes includes umbilical hemorrhage (1), hemorrhage disorder of newborn (3), otitis media (1), neonatal malnutrition (1), intestinal obstruction (1), aspiration pneumonia (1), and congenital heart disease (1). 9.5 DIFFERENTIALS IN CAUSE OF UNDER-FIVE DEATHS Differentials in cause of death by sex of child, urban-rural residence, mother’s education and administrative division are presented in Tables 9.2-9.4. There are some differences between boys and girls in terms of causes of death (Table 9.2). Birth asphyxia and possible serious infections are more common causes of death among boys, while ARI is more common among girls. However, the confidence intervals are wide and overlapping therefore these differences are not statistically significant. In the 1996-97 BDHS, drowning deaths were more common in boys. This was still true in 2004 but the difference is smaller. ARI deaths were also more common among girls in 1996-97. An interesting change that has occurred between 1996-97 and 2004 that while in the previous BDHS, death to girls outnumbered deaths to boys (348 vs. 330); this was reversed in 2004 with 321 deaths to boys to 266 deaths to girls. Urban-rural comparisons reveal that ARI is a more common cause of death in rural areas, while malnutrition as a cause of death is more common in urban areas (Table 9.2). The other causes do not differ when all under-five children are considered. However, data disaggregated by age at death (not presented) indicate that birth asphyxia contributes to higher percentage of neonatal deaths in urban areas (27 percent versus 20 percent), and drowning is almost twice as common among 12-59 month old children in rural areas (22 percent vs. 12 percent). Causes of Under-five Deaths │ 131 Table 9.2 Causes of death among children under five by sex of child and residence Percent distribution of deaths among children under five years by cause of death, according to sex of child and residence, Bangladesh 2004 Sex of child Residence Cause of death Male Female Rural Urban Neonatal tetanus 1.5 3.4 2.4 2.2 Congenital abnormality 2.3 3.5 3.2 1.6 Injury 4.3 3.9 4.1 4.0 Drowning 3.3 2.5 3.1 2.4 Birth asphyxia 13.0 10.1 11.4 12.9 Birth injury 1.9 2.4 2.2 2.2 Measles 0.2 0.5 0.3 0.6 Measles followed by ARI or diarrhea 0.0 0.6 0.2 0.5 Diarrhea 4.5 5.9 4.7 6.3 ARI 19.1 23.5 22.3 16.8 ARI and diarrhea 1.8 1.8 1.5 2.7 Possible serious infection1 33.8 27.9 31.2 31.0 Premature birth/LBW 7.2 5.6 6.7 5.6 Malnutrition 4.6 2.4 2.3 8.3 Other causes 1.5 1.8 1.6 1.7 Unspecified 2.6 4.0 3.8 1.3 Undetermined 1.8 2.8 2.3 2.3 Total 100.0 100.0 100.0 100.0 Number of deaths 321 266 408 179 Note: Estimates are weighted. 1Possible serious infections include possible ARI and diarrhea Congenital abnormalities, injuries including drowning, prematurity/LBW and birth asphyxia are more important causes of death among children whose mothers had at least secondary education compared to those with no education (Table 9.3). Malnutrition, possible serious infections, ARI and diarrhea are associated with a larger proportion of deaths among children of mothers with no education. Small numbers and wide confidence intervals make it difficult to be conclusive about the divisional variations in cause death presented in Table 9.4. Barisal, and Khulna divisions are presented together due to small numbers and because they were part of same division previously. Several patterns are of interest: possible serious infections are the most important cause of childhood death in all divisions. Malnutrition is important in Dhaka and Chittagong divisions while ARI deaths are proportionately more common in Sylhet and least common in Rajshahi divisions. Diarrhea deaths were relatively more common in Chittagong and Sylhet divisions, and asphyxia deaths in Barisal/Khulna and Rasjshahi divisions. Drowning deaths contribute more to under-five deaths in Chittagong and Rajshahi divisions. 132 │ Causes of Under-five Deaths Table 9.3 Causes of death among children under five by mother’s education Percent distribution of deaths among children under five years by cause of death, according to mother’s level of education, Bangladesh 2004 Mother’s education Cause of death None Primary complete Secondary complete or higher Neonatal tetanus 3.4 2.3 0.0 Congenital abnormality 2.6 2.3 4.5 Injury 3.6 1.2 10.2 Drowning 2.0 1.2 9.0 Birth asphyxia 6.7 13.9 22.0 Birth Injury 1.5 3.2 2.5 Measles 0.5 0.0 0.0 Measles followed by ARI or diarrhea 0.2 0.5 0.0 Diarrhea 5.8 5.2 3.8 ARI 23.0 21.4 15.4 ARI and diarrhea 1.8 2.0 1.7 Possible serious infection1 32.8 29.3 28.7 Premature birth/LBW 4.8 9.4 6.9 Malnutrition 3.9 4.0 1.7 Other causes 2.0 1.3 1.3 Unspecified 4.8 2.0 0.8 Undetermined 2.6 2.1 0.8 Total 100.0 100.0 100.0 Number of deaths 288 180 104 Note: Estimates are weighted. 1Possible serious infections include possible ARI and diarrhea Causes of Under-five Deaths │ 133 Table 9.4 Causes of death among children under five by division Percent distribution deaths among children under five years by cause of death, according to division, Bangladesh 2004 Division Cause of death Chittagong Dhaka Barisal/ Khulna Rajshahi Sylhet Neonatal tetanus 1.6 3.2 0.0 0.0 7.5 Congenital abnormality 2.2 3.0 2.4 3.3 2.8 Injury 6.4 2.0 2.9 8.0 0.9 Drowning 5.6 0.7 1.2 6.9 0.0 Birth asphyxia 8.8 10.0 20.0 15.3 7.4 Birth Injury 2.5 1.7 2.0 1.7 3.8 Measles 0.0 0.0 0.0 1.7 0.0 Measles followed by ARI or diarrhea 1.3 0.0 0.0 0.0 0.0 Diarrhea 8.5 4.8 4.4 2.1 6.2 ARI 21.3 22.3 20.3 17.5 24.2 ARI and diarrhea 1.1 3.6 0.8 1.1 0.0 Possible serious infection1 33.0 30.8 31.2 29.8 31.4 Premature birth/LBW 1.4 4.5 9.6 10.6 10.3 Malnutrition 5.3 5.4 2.8 1.1 0.6 Other causes 1.3 0.5 0.4 4.2 1.9 Unspecified 2.0 4.8 3.2 1.6 3.2 Undetermined 3.5 3.2 0.0 2.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 Number of deaths 124 153 101 102 107 Note: Estimates are weighted. 1 Possible serious infections include possible ARI and diarrhea Maternal and Child Health | 135 MATERNAL AND CHILD HEALTH 10 This chapter provides information from the 2004 BDHS on the use of various maternal and child health services and the prevalence of important childhood illnesses. Specifically, it presents findings on the use of antenatal care, delivery assistance and postnatal care, vaccination coverage, and particular childhood illnesses and their treatment. This information can be used to identify subgroups of women and children who are at risk because of nonuse of reproductive and child health services. The information will assist policymakers in the planning of appropriate strategies to improve reproductive and child health. The results in the following section are based on data obtained from mothers on live births that occurred in the five years preceding the survey. 10.1 ANTENATAL CARE The reproductive health care services that a mother receives during her pregnancy and at the time of delivery are important for the well-being of the mother and her child. A well-designed and implemented national antenatal care program facilitates detection and treatment of complications during pregnancy, and it provides an opportunity to disseminate health messages to women and their families. In addition, this early contact with the health care system can improve the timely and appropriate use of delivery care services. Antenatal care (ANC) can be assessed according to the type of service provider, the number of visits made, the stage of pregnancy at the time of first visit, and services and information received during pregnancy. 10.1.1 Antenatal Care Coverage Antenatal care from a medically trained provider is important to monitor the pregnancy and reduce the risks for the mother and child during pregnancy and at delivery. To be most effective, there should be regular antenatal care throughout pregnancy. Table 10.1 shows the percent distribution of women who had a live birth in the five years preceding the survey by source of antenatal care received during pregnancy, according to selected background characteristics. Interviewers were instructed to record all persons a woman had consulted for antenatal care for the most recent birth; but in Table 10.1, only the provider with the highest qualifications is considered if the woman had seen more than one provider. The 2004 BDHS shows that 56 percent of women who had a live birth in the five years preceding the survey received antenatal care from a provider at least once (trained or untrained) for the most recent birth, while 49 percent received care from medically trained providers (e.g., doctors, nurses or midwives) (Table 10.1). Antenatal coverage increased sharply in the four years between the 1999-2000 BDHS and the 2004 BDHS. In the 1999-2000 BDHS, only one-third of the women reported receiving antenatal care from a medically trained provider, compared with about half in the 2004 BDHS. There are sharp differences in antenatal care coverage among subgroups in Bangladesh. Antenatal care from a medically trained provider is received more often by young mothers than older mothers and for lower-order births than for higher-order births. Antenatal coverage also increases with level of mother’s education and the household economic status. Nine out of ten mothers who completed secondary education received antenatal care from a medically trained provider, compared with only three in ten mothers with no education. Women in households in the highest wealth quintile are more than three 136 | Maternal and Child Health times as likely to have received antenatal care from a medically trained provider as those in households in the lowest wealth quintile Table 10.1 Antenatal care Percent distribution of women who had a live birth in the five years preceding the survey by source of antenatal care (ANC) provider during pregnancy for the most recent birth, according to background characteristics, Bangladesh 2004 Medically trained provider Non-medically trained provider Background characteristic Received any ANC Qualified doctor Nurse/ midwife/ paramedic1 MA/ SACMO HA/ FWA Trained birth attendant Un- trained birth attendant Unquali- fied provider Other No one Total Number of women Age at birth <20 59.3 30.8 21.6 0.2 3.0 0.2 0.1 2.3 1.1 40.7 100.0 1,628 20-34 55.9 32.5 16.0 0.0 3.6 0.0 0.1 2.6 0.9 44.2 100.0 3,444 35-49 42.2 21.4 11.4 0.5 3.0 0.3 0.3 2.5 1.3 59.3 100.0 344 Birth order 1 68.2 42.0 20.0 0.1 2.9 0.1 0.2 2.0 1.0 31.8 100.0 1,491 2-3 57.7 32.2 18.2 0.2 3.5 0.1 0.1 2.5 0.9 42.3 100.0 2,376 4-5 47.1 22.3 16.1 0.1 4.2 0.1 0.0 3.4 1.0 52.7 100.0 984 6+ 31.1 14.7 9.4 0.2 2.7 0.1 0.2 2.3 1.5 68.9 100.0 565 Residence Urban 74.8 53.0 17.8 0.2 1.9 0.0 0.1 1.6 0.3 25.2 100.0 1,123 Rural 50.9 25.6 17.3 0.1 3.8 0.1 0.1 2.7 1.2 49.1 100.0 4,293 Division Barisal 46.8 27.0 12.5 0.0 3.4 0.0 0.2 2.7 1.0 53.2 100.0 333 Chittagong 54.3 32.7 14.4 0.3 1.7 0.4 0.2 3.1 1.5 45.7 100.0 1,115 Dhaka 56.1 32.9 15.7 0.1 4.5 0.0 0.1 2.0 0.9 43.9 100.0 1,677 Khulna 61.4 35.2 19.6 0.0 3.1 0.2 0.1 2.5 0.6 38.6 100.0 607 Rajshahi 59.1 25.9 25.2 0.1 4.2 0.0 0.1 2.5 1.0 40.8 100.0 1,285 Sylhet 48.2 35.2 8.6 0.0 1.2 0.1 0.0 2.4 0.7 51.8 100.0 400 Education No education 37.6 15.4 14.8 0.1 3.9 0.0 0.1 2.6 0.7 62.4 100.0 1,998 Primary incomplete 52.9 24.6 19.9 0.2 3.8 0.1 0.2 2.5 1.6 47.0 100.0 1,138 Primary complete 59.2 33.1 18.4 0.0 3.7 0.0 0.3 2.8 1.0 40.8 100.0 504 Secondary incomplete 72.5 44.9 20.7 0.3 2.8 0.2 0.0 2.8 0.8 27.5 100.0 1,371 Secondary complete or higher 93.6 79.4 10.7 0.0 1.6 0.3 0.0 0.6 1.0 6.4 100.0 406 Wealth index Lowest 33.7 12.3 12.5 0.1 4.4 0.1 0.2 3.4 0.8 66.3 100.0 1,298 Second 46.0 18.9 19.6 0.1 3.3 0.1 0.1 2.3 1.6 54.0 100.0 1,124 Middle 58.3 26.8 21.9 0.1 4.4 0.1 0.2 3.4 1.4 41.5 100.0 1,054 Fourth 66.5 42.0 18.5 0.1 2.8 0.1 0.1 2.0 0.9 33.5 100.0 998 Highest 84.1 65.6 15.4 0.1 1.6 0.1 0.0 1.0 0.3 15.9 100.0 943 Total 55.9 31.3 17.4 0.1 3.4 0.1 0.1 2.5 1.0 44.1 100.0 5,416 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. MA = medical assistant; SACMO = sub-assistant community medical officer; HA = health assistant; FWA = family welfare assistant 1 Including family welfare visitor (FWV) Maternal and Child Health | 137 The urban-rural differential in antenatal care coverage is quite large; overall, 71 percent of urban women received antenatal care from a medically trained person, compared with only 43 percent of rural women. Mothers in Barisal and Sylhet divisions are the least likely to receive antenatal care from a medically trained provider For births that did not receive an antenatal checkup during pregnancy, mothers were asked why they did not seek antenatal care. Almost two-thirds of the women who did not seek antenatal care reported that the checkup was not needed or that it provided no benefit (Figure 10.1). Another one in eight women mentioned that they did not know that antenatal care was needed during pregnancy. Almost one in five nonreceivers of antenatal care did not seek the service because they considered it to be expensive. 10.1.2 Number and Timing of Antenatal Visits Antenatal care can be more effective in avoiding adverse pregnancy outcomes when it is sought early in the pregnancy and continues through to delivery. The Bangladesh Maternal Health Strategy recommends at least three visits during pregnancy. The first visit is to be made soon after the woman realizes she is pregnant. The second visit should be made between the fifth and seventh months of pregnancy. The third visit should be made at the ninth month of pregnancy. Additional visits should be made if any problems or danger signs arise. Information about the number and timing of visits made by pregnant women is presented in Table 10.2. The 2004 BDHS findings show that not only are more women receiving antenatal care, they are also seeking more visits than before. The percentage of women who had three or more antenatal visits with any provider increased from 16 to 27 percent between the 1999-2000 BDHS and the 2004 BDHS. Among those who sought care, the median number of visits has increased from 1.8 to 2.9 during the same period. Urban women are more than twice as likely as rural women to have three or more antenatal visits. In urban areas, the median number of visits is 3.7, one visit higher than in the rural areas. 138 | Maternal and Child Health Pregnant women seem to seek antenatal care rather late in their pregnancy. Among those who sought care, the median duration of pregnancy at first visit was 5.2 months. Table 10.2 Number of antenatal care visits and timing of first visit Percent distribution of women who had a live birth in the five years preceding the survey by number of antenatal care (ANC) visits for the most recent birth and by the timing of the first visit, according to residence, Bangladesh 2004 Residence Number and timing of ANC visits and median number of visits Urban Rural Total Number of ANC visits None 25.2 49.1 44.1 1 13.7 16.7 16.1 2 13.1 12.5 12.7 3 14.3 10.4 11.2 4+ 33.7 11.3 15.9 Total 100.0 100.0 100.0 Median number of visits 3.7 2.7 2.9 Number of months pregnant at time of first ANC visit No antenatal care 25.2 49.1 44.1 <4 months 32.8 16.0 19.5 4-5 months 24.6 17.0 18.5 6-7 months 12.6 12.4 12.5 8+ months 4.8 5.4 5.3 Total 100.0 100.0 100.0 Median months pregnant at first visit (for those with ANC) 4.6 5.4 5.2 Number of women 1,123 4,293 5,416 10.1.3 Health Services Received during Pregnancy Pregnancy complications are an important cause of maternal and child morbidity and mortality, and monitoring these complications is a crucial component of safe motherhood. A number of health care procedures are recommended to be performed to monitor and check the development of pregnancies in mothers. For women who had a live birth in the five years preceding the survey, the 2004 BDHS included a series of questions on whether they were told about the signs of pregnancy complications, whether they were weighed, whether their height and blood pressure were measured, whether urine and blood samples were taken, whether their eyes were examined, and whether they received iron tablets or syrup at any time during the pregnancy of their most recent live birth. Table 10.3 shows the various health services received during pregnancy by women for their most recent birth in the five years preceding the survey. Only three out of ten mothers were informed about the signs of pregnancy complications by any health provider at any time during the pregnancy. Half of the mothers received iron supplementation, and the same proportion had their blood pressure measured at least once during the most recent pregnancy; 44 percent had their weight measured. Other health services (e.g., urine test, blood test, ultrasonic test) were much less likely to have been received. One in four women had a urine sample taken, less than one in five had a blood sample taken, and about one in eight Maternal and Child Health | 139 women had an ultrasonic test. The levels of use reported in the 2004 BDHS for all services mentioned above are notably higher than the levels reported in the 1999-2000 BDHS. Table 10.3 Health care during pregnancy Percentage of women who had a live birth in the five years preceding the survey by specific health services received during pregnancy of the most recent birth, according to background characteristics, Bangladesh 2004 Background characteristic Informed of signs of pregnancy complications Weight measured Height measured Eyes examined Blood pressure measured Urine sample taken Blood sample taken Received iron tablets or syrup Ultrasonic test Number of women Age at birth <20 32.1 48.9 20.2 45.1 52.9 25.3 17.1 52.4 11.5 1,628 20-34 30.7 43.2 20.2 45.3 50.4 27.2 19.5 50.3 14.2 3,444 35-49 18.9 28.6 8.8 31.5 36.1 14.8 9.5 34.8 7.7 344 Birth order 1 39.1 57.6 26.0 54.5 62.1 34.1 26.0 61.4 19.1 1,491 2-3 30.6 44.8 20.2 46.5 51.2 26.4 18.2 51.8 13.5 2,376 4-5 24.7 33.8 14.8 35.5 42.4 21.2 13.1 38.9 8.2 984 6+ 16.4 22.6 7.3 24.1 28.6 9.9 5.9 31.7 3.3 565 Residence Urban 42.2 60.3 28.4 60.8 68.4 43.6 33.8 64.2 28.5 1,123 Rural 27.3 39.7 17.1 40.1 45.5 21.2 14.1 46.3 8.9 4,293 Division Barisal 27.9 37.4 17.8 38.4 43.8 22.9 17.0 46.1 9.5 333 Chittagong 31.1 38.2 14.5 45.8 48.4 25.8 20.0 48.8 13.2 1,115 Dhaka 29.4 45.6 21.0 42.7 50.7 26.5 19.8 48.5 16.9 1,677 Khulna 32.7 51.1 26.2 54.5 57.9 26.3 20.4 53.2 17.3 607 Rajshahi 32.7 48.4 19.8 42.7 50.7 25.5 13.0 52.9 7.6 1,285 Sylhet 23.8 33.9 16.8 41.9 45.8 25.7 20.1 48.8 9.5 400 Education No education 17.8 29.8 12.4 27.6 32.2 12.9 7.1 33.8 3.2 1,998 Primary incomplete 26.9 41.5 19.9 40.9 47.2 22.2 13.3 48.8 8.4 1,138 Primary complete 31.3 41.9 18.7 43.8 52.9 25.2 16.5 50.7 9.2 504 Secondary incomplete 41.8 56.3 23.2 59.7 66.1 34.5 25.7 63.3 20.3 1,371 Secondary complete or higher 62.6 81.9 41.0 85.6 91.2 71.4 62.3 87.3 54.2 406 Wealth index Lowest 18.8 26.9 12.7 24.6 30.0 11.4 6.6 31.6 1.9 1,298 Second 21.9 34.5 14.3 33.9 40.2 14.3 7.0 44.6 3.7 1,124 Middle 30.5 45.2 19.0 45.6 50.1 22.4 12.8 48.1 8.5 1,054 Fourth 35.2 51.8 21.9 54.2 59.8 30.2 22.3 57.3 17.4 998 Highest 51.2 69.3 32.8 72.2 80.2 58.8 48.9 76.1 39.9 943 Total 30.4 44.0 19.4 44.4 50.3 25.8 18.1 50.0 13.0 5,416 140 | Maternal and Child Health 10.1.4 Tetanus Toxoid Vaccinations Tetanus toxoid injections are given during pregnancy for the prevention of neonatal tetanus, historically one of the principal causes of death among infants in many developing countries. To achieve protection for herself and her newborn baby, typically, a pregnant woman should receive at least two doses of tetanus toxoid. On the other hand, if a woman was fully vaccinated during a previous pregnancy, she may only require one dose during her current pregnancy to achieve such protection. Five doses are considered adequate to provide lifetime protection. To estimate the extent of tetanus toxoid coverage during pregnancy, the 2004 BDHS collected data for the last birth in the five years preceding the survey as to whether the mother received any tetanus toxoid vaccinations during that pregnancy and, if so, how many. These results are presented in Table 10.4. The data may underestimate the actual extent of protection from tetanus, since women were asked about vaccinations received only during the most recent pregnancy. Women who had received prior tetanus toxoid vaccinations may not have received additional injections because they were considered unnecessary. Table 10.4 Tetanus toxoid injections Percent distribution of women who had a live birth in the five years preceding the survey by number of tetanus toxoid injections received during pregnancy for the most recent birth, according to background characteristics, Bangladesh 2004 Number of tetanus toxoid injections Background characteristic None One injection Two or more injections Don’t know/missing Total Number of women Age at birth <20 10.2 15.5 74.1 0.2 100.0 1,628 20-34 15.9 23.9 60.1 0.2 100.0 3,444 35-49 28.9 22.4 48.7 0.0 100.0 344 Birth order 1 8.4 10.9 80.5 0.2 100.0 1,491 2-3 11.6 24.7 63.4 0.2 100.0 2,376 4-5 23.0 26.7 50.3 0.0 100.0 984 6+ 32.7 24.3 42.6 0.3 100.0 565 Residence Urban 11.9 21.2 66.6 0.3 100.0 1,123 Rural 15.8 21.3 62.8 0.1 100.0 4,293 Division Barisal 13.9 14.0 72.2 0.0 100.0 333 Chittagong 16.9 20.6 62.5 0.0 100.0 1,115 Dhaka 13.1 23.4 63.3 0.2 100.0 1,677 Khulna 13.4 25.9 60.1 0.6 100.0 607 Rajshahi 13.4 19.5 66.9 0.2 100.0 1,285 Sylhet 26.1 18.5 55.4 0.1 100.0 400 Education No education 21.8 21.5 56.5 0.3 100.0 1,998 Primary incomplete 15.4 22.1 62.5 0.0 100.0 1,138 Primary complete 11.8 22.6 65.4 0.2 100.0 504 Secondary incomplete 8.6 19.6 71.7 0.2 100.0 1,371 Secondary complete or higher 6.3 21.8 71.9 0.0 100.0 406 Wealth index Lowest 22.5 21.4 56.0 0.1 100.0 1,298 Second 17.7 20.8 61.2 0.3 100.0 1,124 Middle 13.2 23.3 63.5 0.0 100.0 1,054 Fourth 11.1 19.1 69.6 0.2 100.0 998 Highest 7.6 21.4 70.7 0.2 100.0 943 Total 15.0 21.2 63.6 0.2 100.0 5,416 Maternal and Child Health | 141 The data indicate that tetanus toxoid coverage is relatively widespread in Bangladesh. Overall, 64 percent of the mothers received two or more tetanus toxoid injections during pregnancy, while another 21 percent received one injection. The remaining 15 percent of mothers did not receive any tetanus toxoid injection. The proportion of mothers who did not receive any tetanus toxoid injection during pregnancy decreased from 19 percent in 1999-2000 to 15 percent in 2004. Mothers giving birth at a younger age and those with low birth order children are more likely to have received two or more tetanus toxoid injections. For example, three-fourths of mothers below age 20 received two or more doses, compared with half of mothers age 35-49. These patterns occur because older, higher parity mothers most likely received tetanus toxoid injections during previous pregnancies. Women in Sylhet are less likely to have had a tetanus vaccination during their most recent pregnancy. Women with more education and those in households in the higher wealth quintiles are more likely to receive two or more doses of tetanus toxoid, compared with less educated women and women in households in the lower wealth quintiles. 10.2 DELIVERY CARE The objective of providing safe delivery services is to protect the life and health of the mother and her child by ensuring safe delivery. Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that may cause death or serious illness to the mother, the newborn, or both. The Bangladesh Maternal Health Strategy encourages women to deliver under the care of medically trained birth attendants. In the 2004 BDHS, women were asked to provide information on the place and type of assistance during delivery for all children born in the five years preceding the survey. In this section, two topics related to delivery are discussed: place of delivery and type of assistance during delivery. 10.2.1 Place of Delivery Table 10.5 presents the distribution of live births in the five years preceding the survey by place of delivery. Only 9 percent of births occur at a health facility, while almost all others are delivered at home. The proportion of births delivered at a facility has hardly changed between the 1999-2000 BDHS and the 2004 BDHS. The likelihood of delivering at a health institution is higher for first births, for women in urban areas, and for women in Khulna division. Women who have completed secondary education and those in households in the higher wealth quintiles have a substantially greater likelihood of delivering at a facility (44 and 30 percent, respectively). 142 | Maternal and Child Health Table 10.5 Place of delivery Percent distribution of live births in the five years preceding the survey by place of delivery, according to background characteristics, Bangladesh 2004 Place of delivery Background characteristic Public health facility Private health facility Home Other Total Number of births Age at birth <20 6.7 2.1 90.5 0.7 100.0 2,287 20-34 5.9 4.0 89.3 0.9 100.0 4,313 35-49 4.1 1.9 93.7 0.2 100.0 402 Birth order 1 10.5 5.6 82.7 1.2 100.0 2,042 2-3 5.6 2.9 90.7 0.8 100.0 3,026 4-5 2.7 1.6 95.4 0.3 100.0 1,223 6+ 1.5 0.6 97.7 0.2 100.0 711 Residence Urban 12.8 9.1 76.5 1.5 100.0 1,392 Rural 4.4 1.8 93.2 0.6 100.0 5,610 Division Barisal 3.6 1.3 94.0 1.0 100.0 410 Chittagong 4.8 2.5 92.4 0.2 100.0 1,527 Dhaka 7.1 4.3 87.7 0.9 100.0 2,175 Khulna 9.2 6.0 83.4 1.4 100.0 731 Rajshahi 5.8 2.1 91.1 1.0 100.0 1,560 Sylhet 4.3 1.9 93.8 0.1 100.0 599 Education No education 2.0 0.5 97.3 0.1 100.0 2,688 Primary incomplete 4.3 1.4 93.2 1.1 100.0 1,499 Primary complete 6.0 2.1 91.2 0.7 100.0 661 Secondary incomplete 9.3 4.6 85.0 1.1 100.0 1,678 Secondary complete or higher 23.5 20.8 53.2 2.3 100.0 475 Antenatal care visits None 1.7 0.5 97.7 0.1 100.0 2,389 1-3 6.9 2.5 89.6 1.0 100.0 2,163 4+ 18.8 15.1 64.0 2.0 100.0 863 Wealth index Lowest 1.8 0.2 97.6 0.5 100.0 1,791 Second 2.5 0.7 96.7 0.1 100.0 1,444 Middle 4.6 0.9 93.3 1.1 100.0 1,381 Fourth 8.4 3.5 87.4 0.7 100.0 1,243 Highest 16.7 13.6 67.9 1.7 100.0 1,142 Total 6.1 3.2 89.9 0.8 100.0 7,002 Note: Figures are for all births in the period 0-59 months preceding the survey. Total includes three cases with missing information on antenatal care visits. Maternal and Child Health | 143 10.2.2 Assistance during Delivery Assistance by medically trained birth attendants during delivery is considered to be effective in the reduction of maternal and neonatal mortality. Women who had a live birth in the five years preceding the survey were asked who assisted with the delivery. Interviewers recorded multiple responses if more than one person assisted during delivery; however, for the purpose of this tabulation, only the most qualified attendant was considered if there was more than one in attendance. Medically trained providers, (e.g., doctors, trained nurses or midwives, or family welfare visitors) assist in the delivery of only 13 percent of births (Table 10.6). Traditional birth attendants continue to play a major role, assisting with 77 percent of deliveries. Relatives and friends assist in 9 percent of births. Table 10.6 Assistance during delivery Percent distribution of live births in the five years preceding the survey by type of assistance during delivery, according to background characteristics, Bangladesh 2004 Medically trained Non-medically trained Background characteristic Qualified doctor Nurse/ midwife/ paramedic1 HA/FWA Tradidtional birth attendant Untrained birth attendant Relatives and friends Other No one Total Number of births Age at birth <20 6.5 5.9 0.3 14.4 63.4 8.7 0.2 0.6 100.0 2,287 20-34 8.4 5.8 0.2 13.4 62.4 8.7 0.3 1.0 100.0 4,313 35-49 4.3 3.4 0.0 14.3 67.3 9.0 0.0 1.8 100.0 402 Birth order 1 13.3 8.6 0.4 13.8 57.1 6.4 0.1 0.3 100.0 2,042 2-3 6.4 5.4 0.1 14.2 62.9 9.7 0.3 0.9 100.0 3,026 4-5 3.7 3.5 0.2 14.7 67.2 9.6 0.1 1.2 100.0 1,223 6+ 2.3 2.3 0.0 10.1 73.1 10.1 0.4 1.6 100.0 711 Residence Urban 19.4 10.0 0.2 12.8 51.0 5.1 0.3 1.1 100.0 1,392 Rural 4.6 4.6 0.2 14.0 65.9 9.6 0.2 0.8 100.0 5,610 Division Barisal 4.4 6.7 0.3 8.6 72.8 6.4 0.1 0.9 100.0 410 Chittagong 6.4 5.1 0.2 13.4 69.5 4.7 0.0 0.7 100.0 1,527 Dhaka 9.4 5.3 0.2 17.2 58.5 8.2 0.2 0.9 100.0 2,175 Khulna 12.1 8.4 0.7 12.7 56.3 8.4 0.6 0.9 100.0 731 Rajshahi 5.4 5.2 0.0 12.6 62.1 13.4 0.2 1.1 100.0 1,560 Sylhet 5.4 5.7 0.0 10.2 66.3 10.8 0.8 0.8 100.0 599 Education No education 1.9 2.4 0.1 12.3 70.3 11.7 0.3 1.1 100.0 2,688 Primary incomplete 3.9 4.6 0.2 14.0 68.3 7.8 0.3 1.0 100.0 1,499 Primary complete 4.7 7.3 0.4 13.8 61.6 10.8 0.1 1.3 100.0 661 Secondary incomplete 11.3 9.0 0.4 16.6 56.2 6.0 0.1 0.4 100.0 1,678 Secondary complete or higher 41.3 13.8 0.1 11.1 31.0 2.0 0.2 0.5 100.0 475 Wealth index Lowest 0.8 2.5 0.1 12.5 71.8 11.1 0.1 1.0 100.0 1,791 Second 2.0 2.3 0.2 14.3 68.9 11.0 0.4 0.9 100.0 1,444 Middle 4.7 5.5 0.3 15.3 64.1 8.9 0.3 0.8 100.0 1,381 Fourth 8.9 8.1 0.4 12.7 61.4 7.0 0.3 1.2 100.0 1,243 Highest 26.9 12.6 0.1 14.3 41.9 3.8 0.1 0.4 100.0 1,142 Total 7.5 5.7 0.2 13.8 63.0 8.7 0.2 0.9 100.0 7,002 Note: Figures are for all births in the period 0-59 months preceding the survey. If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. HA = health assistant; FWA = family welfare assistant 1 Including family welfare visitor (FWV) 144 | Maternal and Child Health Although there are substantial differences in delivery assistance by background characteristics, and some subgroups of women have noticeably higher levels than others, the use of a medically trained provider for delivery is generally low for all women. Even among women in households in the highest wealth quintile, only two out of five births are delivered with assistance from health professionals, and in the poorest 40 percent of households this figure drops to 4 percent. Use of a medically trained provider for delivery is highest (55 percent) among women who have completed secondary education. However, even among this group of women, an unacceptably large proportion of births are delivered without assistance from medically trained providers. In terms of variations by geographic location, attendance during delivery by trained health professionals is higher (one in three) in urban than in rural areas and higher in Khulna (one in five) than in other divisions. The proportion of births assisted by medically trained personnel has hardly changed since the 1999-2000 BDHS. 10.3 CAESAREAN SECTION Table 10.7 shows the percentage of live births during the five years preceding the survey that were delivered by caesarean section. The number of births by caesarean section is sometimes considered to be a proxy indicator of women’s access to care for complicated deliveries. Table 10.7 Delivery characteristics Percentage of live births in the five years preceding the survey delivered by caesarean section (C-section), according to background characteristics, Bangladesh 2004 Background characteristic Delivery by C- section Number of births Age at birth <20 2.7 2,287 20-34 4.0 4,313 35-49 2.5 402 Birth order 1 6.7 2,042 2-3 3.1 3,026 4-5 1.0 1,223 6+ 0.2 711 Residence Urban 10.5 1,392 Rural 1.7 5,610 Division Barisal 2.5 410 Chittagong 2.5 1,527 Dhaka 5.2 2,175 Khulna 4.5 731 Rajshahi 2.1 1,560 Sylhet 2.6 599 Education No education 0.7 2,688 Primary incomplete 1.6 1,499 Primary complete 1.7 661 Secondary incomplete 5.3 1,678 Secondary complete or higher 21.4 475 Wealth index Lowest 0.1 1,791 Second 0.9 1,444 Middle 1.7 1,381 Fourth 3.1 1,243 Highest 14.4 1,142 Total 3.5 7,002 Maternal and Child Health | 145 According to the 2004 BDHS, 3.5 percent of babies born are delivered by caesarean section. The results indicate that since the 1999-2000 BDHS, the proportion of births delivered by caesaerean section has increased by one percentage point (from 2.4 to 3.5 percent.) This is lower than the general estimate that 5 percent of all deliveries will require caesarean sections for life-threatening complications. Caesarean sections are more common among first births (7 percent), births to urban women (11 percent), births to mothers with secondary complete or higher education (21 percent), and births to women in the highest wealth quintile (14 percent). 10.4 POSTNATAL CARE A crucial component of safe motherhood is postnatal care. Postnatal care is important for mothers for treatment of complications arising from delivery, especially for births that occur at home. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their newborns. In order to assess the extent of postnatal care utilization, in the 2004 BDHS, women whose most recent live birth in the five years preceding the survey was delivered outside a health facility were asked whether they and/or the child received a postnatal checkup from a health provider and within how many days of delivery the checkup was received. It is assumed that deliveries in any health facility will receive a postnatal checkup for the mother and the child within the first two days of delivery, as a part of routine institutional delivery care. So, in the 2004 BDHS, questions on postnatal checkups for mothers were not asked for births delivered in a health facility. Table 10.8 shows that very few mothers in Bangladesh receive postnatal care. Only 18 percent of mothers received a postnatal checkup from a trained health service provider within 42 days of delivery, and most checkups were received within the first two days after delivery. Among mothers who did not deliver at a facility, only 8 percent received postnatal care from a medically trained provider (data not shown). Since the 1999-2000 BDHS, the proportion of mothers receiving a postnatal checkup from a medically trained provider has increased from 14 to 18 percent. Table 10.8 Postnatal care for mothers and children Percent distribution of last live births in the five years preceding the survey for which the mothers and/or the children received postnatal care from a trained provider, by timing of postnatal care, Bangladesh 2004 Received postnatal care from a trained provider Timing Children Mothers Within 2 days of delivery 12.1 14.5 3-6 days after delivery 1.2 0.6 7-41 days after delivery 4.3 2.6 Don't know/ missing 0.1 0.0 Within 42 days of delivery 17.5 17.8 Did not receive postnatal checkup 82.5 82.2 Total 100.0 100.0 Number 5,416 5,416 Note: Women and children are assumed to have received postnatal care within two days of delivery for births delivered at a health facility. 146 | Maternal and Child Health In Bangladesh, newborns are as likely as their mothers to have received postnatal care from a medically trained provider. Less than one in five newborns is checked by a health professional within six weeks of delivery. The timing of postnatal care for newborns is important since most neonatal deaths occur within two days of delivery. The data indicate that only 12 percent of babies receive a postnatal checkup by a trained health provider within the first two days of delivery. Table 10.9 presents information on postnatal checkups by background characteristics. The proportion of newborns receiving postnatal care from a medically trained provider within 42 days after birth is noticeably higher than the national average among first-order births (28 percent), births in urban areas (34 percent), births in Khulna division (23 percent), and births to women who have at least some secondary education (33 percent). The proportion of newborns receiving postnatal care is substantially higher for children of households in the highest wealth quintile (47 percent), or for children whose mothers have completed secondary education (58 percent), than for other subgroup. Patterns and levels of postnatal care for mothers are very similar to those of the children. Table 10.9 Postnatal care by background characteristics Percentage of last live births in the five years preceding the survey for which the mothers and the children received postnatal care (PNC) from a trained provider within 42 days of delivery, by background characteristics, Bangladesh 2004 Children Mothers Background characteristic Percentage with PNC Number of children Percentage with PNC Number of mothers Mother’s age at birth <20 18.6 1,628 17.6 1,628 20-34 17.7 3,444 18.4 3,444 35-49 10.4 344 12.1 344 Birth order 1 27.8 1,491 27.0 1,491 2-3 17.1 2,376 17.4 2,376 4-5 9.6 984 11.2 984 6+ 5.5 565 6.2 565 Residence Urban 34.3 1,123 34.1 1123 Rural 13.1 4,293 13.5 4,293 Division Barisal 14.2 333 15.0 333 Chittagong 19.1 1,115 17.4 1,115 Dhaka 17.2 1,677 17.6 1,677 Khulna 23.2 607 25.6 607 Rajshahi 13.7 1,285 14.5 1,285 Sylhet 20.3 400 20.4 400 Education No education 6.4 1,998 6.7 1,998 Primary incomplete 13.0 1,138 13.4 1,138 Primary complete 15.8 504 15.4 504 Secondary incomplete 26.0 1,371 26.8 1,371 Secondary complete or higher 57.8 406 56.9 406 Wealth index Lowest 5.6 1,298 5.1 1,298 Second 7.9 1,124 8.6 1,124 Middle 13.2 1,054 12.7 1,054 Fourth 20.3 998 22.3 998 Highest 47.1 943 46.9 943 Total 17.5 5,416 17.8 5,416 Note: Women and children are assumed to have received PNC for births delivered at a health facility. Maternal and Child Health | 147 10.5 COMPLICATIONS DURING PREGNANCY, DURING DELIVERY OR AFTER DELIVERY 10.5.1 Knowledge of Life-Threatening Maternal Conditions Ever-married female respondents were asked if they were aware of any maternal conditions during pregnancy, during delivery, or after delivery that may be potentially life-threatening for the woman. Only spontaneous mentions of various maternal complications were recorded. Awareness of potentially life-threatening conditions during pregnancy, during delivery, or after delivery is low among Bangladeshi women (Table 10.10). Awareness is highest for tetanus and prolonged/obstructed labor (57 and 52 percent of the women, respectively). Four in ten women mentioned retained placenta, and one in three women identified malpresentation of the baby to be life-threatening conditions. Although convulsions/eclampsia and excessive bleeding account for most of the maternal deaths in Bangladesh (as shown in the 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) (NIPORT et al., 2003)), very few women (28 and 22 percent, respectively) mentioned these conditions as life-threatening complications. Table 10.10 Knowledge of life-threatening maternal conditions Percentage of ever-married women who are aware of specific maternal conditions during pregnancy, during delivery, or after delivery that could be life-threatening for the mother, Bangladesh 2004 Residence Complication Urban Rural Total Preeclampsia or any symptoms of preeclampsia (severe headache/ blurry vision/high blood pressure) 16.1 11.6 12.6 Convulsions/eclampsia 31.9 27.3 28.4 Excessive bleeding 26.3 20.4 21.7 Tetanus 58.0 56.3 56.7 Malpresentation 36.0 32.2 33.1 Prolonged/obstructed labor 47.8 53.5 52.2 Retained placenta 39.1 43.4 42.4 Foul-smelling discharge with fever 0.9 0.6 0.7 Other 15.2 14.1 14.3 Don’t know 2.4 3.3 3.1 Number of ever-married women 2,586 8,854 11,440 Comparison of data from the 2004 BDHS and the 2001 BMMS indicates that knowledge levels of potentially life-threatening maternal complications may have increased slightly. 10.5.2 Experience of Specific Maternal Complications Women who had a live birth in the five years preceding the survey were asked whether they had experienced any of the following potentially life-threatening conditions around delivery: prolonged labor of over 12 hours; excessive bleeding; high fever with foul discharge; baby’s hands or feet came first; and convulsions. 148 | Maternal and Child Health Table 10.11 presents information on the percentage of live births for which mothers experienced maternal complications around the time of delivery. One in four births had at least one of the five specified complications. The most common complication was prolonged labor of over 12 hours, associated with 17 percent of live births. Eleven percent of the mothers experienced excessive bleeding, and 3 percent had convulsions. Table 10.11 Experience of complications around delivery Percentage of live births in the five years preceding the survey for which there were complications around delivery, by type of complication, Bangladesh 2004 Complication Percentage of births Prolonged labor 16.8 Excessive bleeding 10.5 Foul-smelling discharge with fever 4.5 Convulsion 3.2 Baby’s hands/feet came first 1.4 At least one of the above five complications 25.9 Two or more of the above five complications 7.8 None of the above five complications 74.1 Number of births 7,002 10.5.3 Treatment for Maternal Complications Table 10.12 provides information on the types of assistance sought for maternal complications (e.g., prolonged labor, excessive bleeding, malpresentation of the baby, high fever with discharge, convulsions). If multiple providers were seen, all types of assistance sought were recorded. For this table however, only the most qualified provider was considered. Treatment was sought from a medically trained provider for only 29 percent of the cases that had maternal complications around delivery. Another one-third sought assistance from a medically unqualified provider, like traditional birth attendants, unqualified doctors, and others. The rest (38 percent) did not seek care for complications. The 2004 BDHS findings are similar to those of the 2001 BMMS. Both surveys indicate two types of problems—a large proportion with potentially life-threatening maternal complications seek no health care, and among those who seek care, about half seek assistance from a medically unqualified provider. Treatment-seeking from a medically trained provider varied somewhat by type of complication; it was highest for convulsions (41 percent) and lowest for excessive bleeding (27 percent). The likelihood of seeking treatment from a medically trained provider for maternal complications increased with the level of women’s education and household economic status. Also, women having their first birth and those who live in urban areas have a higher likelihood of seeking treatment for life-threatening maternal complications. Maternal and Child Health | 149 Table 10.12 Treatment seeking for maternal complications Percentage of births in the five years preceding the survey who had at least one complication around delivery, by type of assistance sought for the complication, according to specific complication and background characteristic, Bangladesh 2004 Medically trained providers Non-medically trained providers Complication/ background characteristic Qualified doctor Nurse/ midwife/ FWV MA/ SACMO HA/ FWA Trained birth attendant Untrained birth attendant Unqualilfied doctor Relatives and friends Other No one Total Number of births Complication Long labor 22.9 7.1 0.3 0.8 1.5 4.6 22.6 0.4 3.9 35.8 100.0 1,180 Excessive bleeding 22.8 4.0 0.1 0.4 1.2 2.7 25.7 0.5 1.2 41.3 100.0 734 High fever 27.7 2.1 0.0 1.4 2.6 2.8 25.9 0.0 2.3 35.2 100.0 312 Convulsions 33.5 7.2 0.0 0.2 0.3 4.5 25.5 0.4 2.1 26.4 100.0 227 Hands and feet came first 23.4 4.6 0.0 1.2 9.2 19.6 14.7 0.0 0.0 27.3 100.0 99 At least two of the above complications 28.2 5.2 0.0 1.3 1.6 3.8 25.0 0.5 1.9 32.4 100.0 549 Age at birth <20 24.5 5.5 0.3 0.7 1.2 6.1 23.8 0.2 2.6 35.0 100.0 677 20-34 22.5 6.0 0.2 0.4 2.2 3.6 21.7 0.5 3.5 39.5 100.0 1,022 35-49 14.5 5.0 0.0 0.6 0.9 2.8 31.3 0.0 1.7 43.1 100.0 111 Birth order 1 30.8 6.9 0.1 1.0 1.3 4.4 23.0 0.2 2.5 29.8 100.0 628 2-3 21.0 5.6 0.3 0.2 1.9 5.8 22.3 0.5 2.8 39.4 100.0 699 4-5 15.4 5.5 0.0 0.7 2.2 2.5 23.2 0.3 5.4 44.9 100.0 297 6+ 13.9 2.7 0.5 0.0 1.6 3.2 26.0 0.0 2.2 49.7 100.0 185 Residence Urban 37.2 7.8 0.2 1.0 1.2 3.4 18.6 0.5 1.7 28.3 100.0 360 Rural 19.2 5.2 0.2 0.4 1.8 4.8 24.2 0.3 3.4 40.4 100.0 1,450 Division Barisal 20.8 6.9 0.7 0.0 0.5 2.5 13.7 0.0 5.0 49.8 100.0 124 Chittagong 22.8 4.7 0.2 1.2 1.2 3.4 29.0 0.2 2.8 34.4 100.0 443 Dhaka 18.5 6.5 0.2 0.4 3.2 5.4 19.8 0.3 3.3 42.5 100.0 557 Khulna 31.3 4.2 0.0 0.6 1.1 3.8 27.9 0.0 2.5 28.6 100.0 201 Rajshahi 23.8 6.3 0.4 0.2 1.1 4.8 26.1 0.2 1.8 35.3 100.0 334 Sylhet 26.2 5.8 0.0 0.5 1.2 6.5 12.7 1.5 4.7 41.1 100.0 151 Education No education 10.2 4.3 0.4 0.4 2.0 5.4 24.4 0.6 2.5 49.8 100.0 669 Primary incomplete 20.2 4.8 0.0 0.4 1.2 4.6 25.6 0.1 4.1 39.0 100.0 390 Primary complete 27.2 6.8 0.8 0.7 0.8 6.8 18.9 0.0 2.1 36.0 100.0 177 Secondary incomplete 32.8 8.2 0.0 0.7 1.9 3.0 23.3 0.2 3.3 26.5 100.0 451 Secondary complete or higher 56.4 6.2 0.0 1.0 2.3 1.6 13.1 0.6 2.9 16.0 100.0 122 Wealth index Lowest 10.5 3.5 0.0 0.0 1.7 5.2 25.0 0.1 2.8 51.2 100.0 472 Second 13.1 3.7 0.8 1.0 2.1 5.3 23.2 0.5 7.0 43.3 100.0 391 Middle 19.4 6.4 0.0 0.7 1.5 4.6 24.1 0.3 2.1 40.8 100.0 344 Fourth 32.5 10.3 0.0 0.4 1.9 2.6 24.0 0.2 0.6 27.5 100.0 311 Highest 49.1 6.4 0.3 0.9 1.4 4.3 17.5 0.7 1.9 17.5 100.0 291 Total 22.8 5.7 0.2 0.5 1.7 4.5 23.1 0.3 3.0 38.0 100.0 1,810 Note: If more than one provider mentioned, only the provider with the highest qualifications is considered. FWV = Family welfare visitor; MA = medical assistant, SACMO = sub-assistant community medical officer, HA = health assistant, and FWA = family welfare assistant 150 | Maternal and Child Health 10.6 CHILDHOOD VACCINATION Universal immunization of children under one year of age against the six vaccine-preventable diseases (tuberculosis; diphtheria, pertussis, and tetanus [DPT]; poliomyelitis; and measles) is one of the most cost-effective programs in reducing infant and child morbidity and mortality. The Expanded Program on Immunization (EPI) is a priority program for the government of Bangladesh. It follows the international guidelines recommended by the World Health Organization (WHO). The guidelines recommend that all children receive a BCG vaccination against tuberculosis; three doses of DPT vaccine for the prevention of diphtheria, pertussis (whooping cough), and tetanus; three doses of polio vaccine; and a vaccination against measles. WHO recommends that children receive all of these vaccines before their first birthday and that the vaccinations be recorded on a health card given to the parents. In the 2004 BDHS, data on childhood vaccinations were collected for all surviving children born during the five-year period before the survey. In Bangladesh, immunizations are routinely recorded on a child’s health card. For each child, mothers were asked whether they had the vaccination card for the child and, if so, to show the card to the interviewer. When the mother was able to show the vaccination card, the dates of vaccinations were transferred from the card to the questionnaire. If the vaccination card was not available (or a vaccination was not recorded), mothers were asked questions to determine whether the child had received each vaccine. In Table 10.13, the estimates of vaccination coverage among children age 12-23 months are based on information taken from the health card and, for those for whom a card was not seen (or a vaccination not recorded), on information provided by the mother. Mothers were able to provide health cards for 49 percent of the children age 12-23 months. 10.6.1 Vaccination Coverage Table 10.13 presents information on vaccination coverage according to the source of information. The data are presented for children age 12-23 months, thereby including only those children who have Table 10.13 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccinations at any time before the survey, by source of information (health card or mother’s report), and percentage vaccinated by 12 months of age, Bangladesh 2004 Percentage of children who received: Source of of information BCG DPT 1 DPT 2 DPT 3 Polio 01 Polio 1 Polio 2 Polio 3 Measles All2 No vacci- nations Number of children Vaccinated at any time before survey Vaccination card 49.4 49.3 47.7 45.8 0.4 49.3 47.7 45.8 41.7 41.4 0.0 625 Mother's report 44.0 43.7 39.5 35.2 1.6 47.1 40.7 36.5 34.0 31.6 3.3 640 Either source 93.4 93.1 87.2 81.0 1.9 96.4 88.3 82.3 75.7 73.1 3.3 1,265 Vaccinated by 12 months of age3 93.3 92.9 86.8 80.3 1.9 96.3 88.0 81.6 70.3 68.4 3.5 1,265 1 Polio 0 is the polio vaccination given at birth. 2 BCG (for tuberculosis), measles, and three doses each of diphtheria, pertusis, and tetanus (DPT) and polio vaccine (excluding polio vaccine given at birth) 3 For children whose information was based on the mother's report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. reached the age by which they should be fully vaccinated. The first indicator shows the proportion of these children who had been vaccinated at any age up to the time of the survey. These results are Maternal and Child Health | 151 presented according to the source of the information used to determine coverage, i.e., vaccination record or mother’s report. The second indicator shows the proportion of children who had been vaccinated by the age of 12 months, the age at which vaccination coverage is recommended to be completed. According to information from both the vaccination cards and mothers’ reports, 73 percent of Bangladeshi children age 12-23 months are fully vaccinated. Although the levels of coverage for BCG and the first two doses of DPT and polio are close to 90 percent or above, the proportions of children who go on to complete the third dose of DPT or polio vaccines fall to 81 and 82 percent, respectively. A much lower percentage (76 percent) receives the measles vaccine. Only 3 percent of children age 12-23 months have not received any childhood vaccinations. Vaccinations are most effective when given at the proper age; thus, it is recommended that children complete the schedule of immunizations during their first year of life (i.e., by 12 months of age). Overall, 68 percent of children age 12-23 months had received all the recommended vaccinations before their first birthday. 10.6.2 Differentials in Vaccination Coverage Table 10.14 and Figure 10.2 show vaccination coverage rates among children age 12-23 months by selected background characteristics. The figures refer to the proportion of children receiving the vaccinations at any time up to the date of the survey, and they are based on information from both the health cards and mothers’ reports. The data indicate that girls and boys are almost equally likely to receive the basic vaccinations. Birth order is negatively related to the likelihood of being fully vaccinated—as birth order increases, vaccination coverage decreases. The vaccination program has been more successful in urban areas than in rural areas; vaccination coverage is 10 percentage points higher in urban areas compared to rural areas. Among administrative divisions, vaccination coverage for children is highest in Khulna (83 percent), while children in Sylhet division are the least likely (62 percent) to have received all the basic vaccinations. As expected, mother’s education is positively associated with children’s likelihood of being fully vaccinated; 92 percent of children whose mothers have completed secondary or higher education are fully vaccinated, compared with 60 percent of children whose mothers have no education. Similarly, children in households in the highest wealth quintile are more likely to be fully vaccinated (87 percent), compared with those in the lowest quintile (57 percent). 10.6.3 Trends in Vaccination Coverage There has been significant improvement in vaccination coverage in recent years (Figure 10.3). The proportion fully vaccinated among children age 12-23 months has increased by 13 percentage points between 1999-2000 and 2004 (from 60 to 73 percent). Closer examination of the data by types of vaccines indicates that this trend is entirely due to a reduction in dropout rates from the first to the third doses for polio and DPT vaccines. Improvement in vaccination coverage has occurred in all divisions, but the greatest increase has been in Rajshahi (20 percentage points) and Sylhet divisions (17 percentage points). 152 | Maternal and Child Health Table 10.14 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccinations at any time before the survey (according to a health card or the mother's report), and percentage with a health card, by background characteristics, Bangladesh 2004 Percentage of children who received: Background characteristic BCG DPT 1 DPT 2 DPT 3 Polio 01 Polio 1 Polio 2 Polio 3 Measles All2 No vacci- nations Percen- tage with a health card seen Number of children Sex Male 93.4 93.3 88.0 81.2 1.5 97.6 89.1 82.6 75.6 73.4 2.4 46.8 589 Female 93.4 92.9 86.4 80.8 2.3 95.4 87.6 82.0 75.7 72.8 4.1 51.7 676 Birth order 1 97.1 96.7 92.2 88.1 1.8 97.9 92.7 90.4 81.8 79.6 1.9 52.7 381 2-3 93.3 93.1 87.4 81.3 2.7 96.5 88.8 82.2 75.9 73.6 3.4 49.5 540 4-5 93.0 92.3 83.3 76.2 1.5 97.8 84.4 75.9 72.5 68.7 1.6 45.5 220 6+ 83.3 83.3 77.8 66.5 0.0 89.5 79.9 69.0 61.4 58.5 10.5 46.2 125 Residence Urban 94.2 93.4 90.0 85.7 3.6 96.6 90.8 85.8 82.8 80.9 2.8 58.1 251 Rural 93.2 93.0 86.5 79.8 1.5 96.4 87.7 81.4 73.9 71.1 3.5 47.3 1,014 Division Barisal 96.2 95.4 90.0 81.5 4.0 98.0 91.5 84.6 77.3 72.5 1.2 49.6 75 Chittagong 93.1 91.9 88.4 84.3 2.7 94.0 89.2 84.4 77.1 75.1 5.3 48.9 268 Dhaka 95.5 95.7 85.7 78.1 2.0 98.5 87.2 79.5 72.0 68.8 1.5 43.0 375 Khulna 96.9 96.9 93.2 87.6 2.8 100.0 95.1 90.2 86.6 82.8 0.0 58.2 130 Rajshahi 91.1 90.8 87.2 82.9 0.9 95.0 87.7 84.2 77.0 76.4 4.8 53.4 313 Sylhet 87.1 86.8 79.6 68.3 0.6 94.0 81.1 69.5 66.3 61.5 6.0 50.9 105 Education No education 89.0 88.6 79.0 69.2 0.9 94.4 80.1 70.2 62.3 60.3 5.0 43.4 439 Primary incomplete 94.0 93.4 87.3 81.2 0.6 98.3 88.6 83.2 76.3 72.5 1.7 53.4 286 Primary complete 95.4 95.4 90.6 86.5 2.7 95.6 92.3 87.2 81.1 80.3 4.4 41.1 127 Secondary incomplete 96.3 96.1 93.3 89.8 2.6 97.2 94.5 90.8 85.4 82.2 2.8 53.4 304 Secondary complete or higher 98.8 98.8 98.6 96.8 6.6 98.8 98.8 98.6 94.2 92.2 1.2 62.1 109 Wealth index Lowest 87.1 87.1 77.3 70.7 0.7 93.5 79.1 70.8 59.5 57.4 5.9 43.9 323 Second 95.5 95.0 90.7 80.9 0.4 96.6 90.9 84.0 79.2 76.0 3.4 46.4 242 Middle 94.9 94.6 86.9 82.4 2.8 97.7 88.7 83.7 76.3 74.1 1.9 47.9 280 Fourth 94.2 93.0 89.4 84.9 2.0 96.1 90.3 86.4 80.5 78.7 3.9 52.3 210 Highest 97.9 97.9 96.2 91.1 4.4 99.4 97.1 91.7 90.5 86.7 0.6 60.7 211 Total 93.4 93.1 87.2 81.0 1.9 96.4 88.3 82.3 75.7 73.1 3.3 49.4 1,265 1 Polio 0 is the polio vaccination given at birth. 2 BCG (for tuberculosis), measles, and three doses each of diphtheria, pertussis, and tetanus (DPT) and polio vaccine (excluding polio vaccine given at birth) Maternal and Child Health | 153 154 | Maternal and Child Health 10.7 CHILDHOOD ILLNESS AND TREATMENT Two illnesses that are major contributors to childhood mortality in Bangladesh are discussed in this section: acute respiratory infection and diarrhea. Estimates of the prevalence of these illnesses and fever, as well as data concerning types of treatment, are presented. 10.7.1 Acute Respiratory Infection Acute respiratory infection (ARI) is one of the leading causes of morbidity and mortality among children in Bangladesh (see chapter 9). Common symptoms associated with severe respiratory infection include fever, cough, difficult or rapid breathing, or chest indrawing. Early diagnosis and treatment with antibiotics can prevent a large proportion of deaths from respiratory infections. The 2004 BDHS defines respiratory illness as cough with rapid or difficult breathing, or chest indrawing. Mothers of children under five were asked in the 2004 BDHS survey whether their children had symptoms (cough, rapid/difficult breathing, and chest indrawing) of respiratory illness, and/or fever during the two weeks preceding the survey. Those who said yes were asked where the treatment was sought. It bears mentioning that reports of disease prevalence are inherently imprecise, since they are based on a mother’s subjective assessment. The prevalence of ARI is also subject to seasonality. Information on the prevalence and treatment of ARI is presented in Table 10.15. One in five children under five was reported to have had symptoms of respiratory illness. ARI is slightly less common among children over 24 months old than among younger children. ARI seems more prevalent in Barisal division (27 percent) and less common in Dhaka and Rajshahi divisions (19 percent). ARI prevalence is lower for children of mothers who have completed secondary education and children in households in the highest wealth quintile. Use of a health facility or a medically trained provider for treatment of ARI is low in Bangladesh. Overall, one in five children who had symptoms of ARI was taken to a health facility or medically trained provider for treatment. Maternal and Child Health | 155 Table 10.15 Prevalence and treatment of acute respiratory infection Percentage of children under five years who were ill with acute respiratory infection (ARI) during the two weeks preceding the survey and the percentage of children with ARI for whom treatment was sought from a health facility or medically trained provider, by background characteristics, Bangladesh 2004 Background characteristic Percentage with ARI1 Number of children Among children with ARI,1 percentage taken to health facility or provider2 Number of children with ARI Age in months <6 28.3 687 26.5 194 6-11 29.5 592 27.9 175 12-23 24.9 1,265 23.4 314 24-35 20.0 1,312 18.9 263 36-47 15.7 1,343 8.9 211 48-59 14.9 1,300 16.2 193 Sex Male 22.0 3,294 23.3 723 Female 19.6 3,204 16.8 627 Residence Urban 19.3 1,284 35.4 248 Rural 21.1 5,215 16.8 1,103 Division Barisal 26.7 386 13.3 103 Chittagong 24.5 1,424 22.2 348 Dhaka 18.8 2,005 17.0 377 Khulna 21.7 694 23.7 150 Rajshahi 18.5 1,449 19.1 268 Sylhet 19.2 540 30.3 104 Education No education 21.0 2,447 12.5 514 Primary incomplete 25.2 1,410 21.6 356 Primary complete 18.9 612 20.1 115 Secondary incomplete 19.6 1,572 27.4 308 Secondary complete or higher 12.5 457 43.9 57 Wealth index Lowest 23.0 1,636 10.8 376 Second 24.2 1,351 15.5 326 Middle 22.1 1,265 18.7 279 Fourth 17.5 1,171 27.4 205 Highest 15.2 1,075 45.3 163 Total 20.8 6,498 20.3 1,350 1 Refers to cough with either rapid or difficult breathing or chest indrawing 2 Includes GOB/NGO/Private health facilities, as well as medically qualified doctor; excludes pharmacy, shop, and traditional practitioner 156 | Maternal and Child Health Male children are more likely than females to be taken to a health facility/trained provider when ill with ARI. Urban children are twice as likely to receive treatment at a health facility or by a medically trained provider as rural children. Treatment seeking for ARI from health professionals and/or facilities is higher in Sylhet than in other divisions. The likelihood of seeking treatment for ARI from a health facility/trained health provider rises with increased level of mother’s education and household economic status. Table 10.16 shows the type of health provider used for treatment of ARI. Overall treatment seeking for ARI is quite high: Seven in ten children with ARI are taken for treatment, but only two of these children are taken to a health facility or medically trained provider. Traditional doctors are the most popular choice for seeking treatment for ARI, accounting for 25 percent of the children with ARI. Data from various BDHS surveys show a declining trend in the proportion seeking care from a health facility or medically trained provider for children with ARI; the proportion decreased from 33 percent in 1996-97, to 27 percent in 1999-2000, and to 20 percent in 2004. Four in ten children under five were reported to have been ill with fever during the two weeks preceding the survey (Table 10.17). Those age 6-23 months were more likely to have been ill than younger or older children. Prevalence of fever is lowest among the children of mothers with complete secondary or higher education Sixty-four percent of children with fever were taken to a provider for treatment, but only 19 percent were taken to a medically trained provider/facility (Table 10.18). Traditional doctors are the most popular choice for treatment of fever; 22 percent of children with fever were taken to a traditional doctor. The use of a qualified provider is markedly higher in urban areas (34 percent), among mothers with at least a complete secondary education (36 percent), and in households in the highest wealth quintile (41 percent), compared with the national average. The use of traditional doctors is substantially higher in rural areas than in urban areas. The use of traditional doctors for fever does not vary by mother’s level of education. Maternal and Child Health | 157 Table 10.16 Treatment seeking for children with acute respiratory infection Percentage of children under five years with acute respiratory infection in the two weeks preceding the survey who were taken for treatment, by type of provider and background characteristics, Bangladesh 2004 Background characteristic Health facility and/or medically trained provider Pharmacy Traditional doctor Other No one Number of Children Age in months <6 26.5 10.3 19.2 11.7 32.9 194 6-11 27.9 15.2 26.8 6.0 26.5 175 12-23 23.4 17.4 30.9 7.1 23.7 314 24-35 18.9 21.0 23.0 7.7 31.2 263 36-47 8.9 27.9 27.0 4.0 34.4 211 48-59 16.2 14.0 22.2 4.1 44.3 193 Sex Male 23.3 17.4 25.8 5.4 29.9 723 Female 16.8 18.6 24.7 8.5 33.3 627 Residence Urban 35.4 16.5 15.5 9.1 25.5 248 Rural 16.8 18.3 27.5 6.3 32.8 1,103 Division Barisal 13.3 19.0 18.0 4.7 45.5 103 Chittagong 22.2 22.8 26.4 9.3 22.1 348 Dhaka 17.0 14.6 24.8 3.1 41.2 377 Khulna 23.7 13.7 26.4 8.7 31.1 150 Rajshahi 19.1 17.7 27.5 9.7 27.2 268 Sylhet 30.3 19.4 23.2 4.0 25.1 104 Education No education 12.5 19.2 25.3 6.0 38.5 514 Primary incomplete 21.6 15.8 23.8 7.0 33.2 356 Primary complete 20.1 20.3 28.4 7.6 27.2 115 Secondary incomplete 27.4 17.7 28.1 7.4 20.8 308 Secondary complete or higher 43.9 16.6 13.2 8.2 23.1 57 Wealth index Lowest 10.8 20.1 29.7 7.6 33.4 376 Second 15.5 13.4 26.2 5.9 39.6 326 Middle 18.7 21.5 23.6 7.9 31.5 279 Fourth 27.4 17.1 27.3 3.3 25.9 205 Highest 45.3 17.0 13.7 9.3 17.6 163 Total 20.3 18.0 25.3 6.8 31.5 1,350 158 | Maternal and Child Health Table 10.17 Prevalence of fever Percentage of children under five years of age who had fever in the two weeks preceding the survey, Bangladesh 2004 Background characteristic Percentage of children with fever Number of children Age in months <6 40.9 687 6-11 47.3 592 12-23 49.0 1,265 24-35 41.4 1,312 36-47 35.1 1,343 48-59 31.4 1,300 Sex Male 40.8 3,294 Female 39.3 3,204 Residence Urban 40.7 1,284 Rural 39.9 5,215 Division Barisal 38.9 386 Chittagong 43.1 1,424 Dhaka 37.2 2,005 Khulna 35.5 694 Rajshahi 45.4 1,449 Sylhet 35.6 540 Education No education 40.3 2,447 Primary incomplete 40.1 1,410 Primary complete 41.5 612 Secondary incomplete 41.1 1,572 Secondary complete or higher 33.8 457 Wealth index Lowest 42.4 23.0 Second 42.3 24.2 Middle 40.1 22.1 Fourth 36.5 17.5 Highest 37.6 15.2 Total 40.1 20.8 Maternal and Child Health | 159 Table 10.18 Treatment seeking for children with fever Percentage of children under five years with fever in the two weeks preceding the survey who were taken for treatment, by type of provider and by background characteristics, Bangladesh 2004 Background characteristic Health facility and/or medically trained provider Pharmacy Traditional doctor Other No one Number Age in months <6 20.9 12.2 16.2 11.8 39.0 281 6-11 25.7 16.2 23.2 6.4 30.4 280 12-23 22.4 18.5 24.1 5.8 29.5 621 24-35 19.7 19.7 22.6 6.4 32.0 544 36-47 10.5 23.0 19.2 4.0 44.4 471 48-59 13.8 18.0 21.1 4.8 42.7 408 Sex Male 19.8 19.2 22.0 5.8 34.0 1,344 Female 17.2 17.9 20.9 6.5 38.0 1,260 Residence Urban 33.7 18.1 12.4 7.2 29.7 522 Rural 14.7 18.7 23.8 5.9 37.5 2,082 Division Barisal 11.7 17.9 16.8 5.2 48.4 150 Chittagong 22.6 23.2 24.1 5.9 25.3 613 Dhaka 16.3 18.6 19.7 4.0 41.8 745 Khulna 23.6 13.3 22.9 8.6 32.8 246 Rajshahi 14.7 17.0 22.3 9.0 37.6 657 Sylhet 25.8 16.1 19.3 3.3 35.5 192 Education No education 12.0 19.4 20.7 4.6 43.4 985 Primary incomplete 17.6 18.1 21.4 7.0 36.5 565 Primary complete 16.5 21.1 22.7 4.4 36.9 254 Secondary incomplete 25.9 17.5 22.4 7.6 27.2 645 Secondary complete or higher 35.9 14.7 21.1 9.9 20.5 155 Wealth index Lowest 9.2 18.0 24.8 6.6 41.6 694 Second 12.7 15.1 23.0 5.7 43.5 572 Middle 17.6 23.4 18.6 7.3 34.3 507 Fourth 21.6 19.2 26.9 3.4 29.4 427 Highest 40.7 17.6 11.5 7.5 24.3 404 Total 18.5 18.5 21.5 6.2 35.9 2,604 160 | Maternal and Child Health 10.7.2 Childhood Diarrhea Dehydration from diarrhea is an important contributing cause of childhood mortality. The administration of oral rehydration therapy (ORT) is a simple means of countering the effects of dehydration. During diarrhea, the child is given a solution either prepared by mixing water with the commercially prepared packet of oral rehydration salts (ORS)—also called khabar, or packet saline, in Bangladesh—or by making a homemade solution of sugar, salt, and water—also called labon gur. ORT has a long history in Bangladesh since it was developed some 30 years ago by the Cholera Research Laboratory (now ICDDR,B: Center for Health and Population Research). Currently, ORS packets are available through health facilities and at shops and pharmacies, and many packets are distributed by the Social Marketing Company. In the 2004 BDHS, mothers of children under age five were asked whether their children had experienced an episode of diarrhea in the two weeks preceding the survey. If the child had had diarrhea, the mother was asked what she had done to treat the illness. Since the prevalence of diarrhea varies seasonally, the results pertain only to the period from January to May, when the BDHS interviewing took place. Table 10.19 presents information on recent episodes of diarrhea among young children and the actions that were taken to treat the illness. Overall, 8 percent of children under age five were reported to have had diarrhea in the two-week period preceding the survey. Diarrhea prevalence is highest among children age 6-23 months, a period during which solid, adult-type foods are being introduced. This pattern is believed to be associated with increased exposure to the illness as a result of both weaning and the greater mobility of the child, as well as with the immature immune system of children in this age group. Differences in the prevalence of diarrhea according to sex and residence are minimal. Diarrhea is less common among children whose mothers have secondary or higher education than those whose mothers have less education. Maternal and Child Health | 161 Table 10.19 Prevalence of diarrhea Percentage of children under five years who had diarrhea in the two weeks preceding the survey, by background characteristics, Bangladesh 2004 Background characteristic Percentage of children with diarrhea Number of children Age in months <6 3.9 687 6-11 12.1 592 12-23 12.5 1,265 24-35 7.7 1,312 36-47 4.9 1,343 48-59 4.8 1,300 Sex Male 7.7 3,294 Female 7.3 3,204 Residence Urban 6.7 1,284 Rural 7.7 5,215 Division Barisal 9.2 386 Chittagong 8.2 1,424 Dhaka 6.6 2,005 Khulna 8.0 694 Rajshahi 7.4 1,449 Sylhet 7.3 540 Education No education 7.6 2,447 Primary incomplete 9.0 1,410 Primary complete 6.6 612 Secondary incomplete 6.8 1,572 Secondary complete or higher 5.6 457 Wealth index Lowest 8.7 1,636 Second 7.4 1,351 Middle 7.5 1,265 Fourth 7.1 1,171 Highest 6.0 1,075 Total 7.5 6,498 10.7.3 Treatment of Diarrhea Table 10.20 shows data concerning treatment of recent episodes of diarrhea among children less than five years of age, as reported by the mothers. Four-fifths of the children with diarrhea received at least one of the following—ORS packets; homemade solution of sugar, salt, and water; or increased fluid intake. Three-fourths of the children with diarrhea were given ORT that included ORS packets or homemade solution. About one in ten children with diarrhea was given nothing to treat the diarrhea. 162 | Maternal and Child Health Table 10.20 Treatment of diarrhea Among children under five years who had diarrhea in the two weeks preceding the survey, percentage who were taken for treatment to a health provider, percentage who received oral rehydration therapy (ORT), and percentage given other treatments, by background characteristics, Bangladesh 2004 Oral rehydration therapy Other treatments Background characteristic Percentage taken to a health provider1 Received ORS packets Received RHF Received either ORS or RHF Increased fluids Received ORS, RHF, or increased fluids Pill/syrup Injection Intra- venous solution Home remedy/ herbs/ other No treatment Number of children with diarrhea Age in months <6 (19.1) (44.9) (4.7) (44.9) (36.3) (62.5) (29.2) (0.0) (0.0) (23.2) (30.7) 27 6-11 29.1 65.8 13.3 71.3 42.2 79.9 56.2 1.2 0.0 14.1 12.4 71 12-23 14.2 68.4 22.3 79.7 53.5 88.1 49.5 1.1 0.7 11.6 5.4 158 24-35 14.2 71.8 20.2 77.8 55.1 85.4 45.6 1.0 0.0 3.3 10.3 101 36-47 10.2 62.1 14.4 67.0 57.8 80.8 34.3 2.8 2.6 3.6 14.1 66 48-59 10.7 73.1 23.4 81.0 57.2 84.3 44.1 0.0 0.0 2.4 10.9 63 Sex Male 16.3 67.3 15.5 73.2 51.5 83.3 50.7 1.0 0.5 8.3 11.3 254 Female 15.1 67.1 22.1 76.1 53.1 83.5 40.5 1.3 0.7 8.9 10.2 232 Residence Urban 31.4 77.1 16.9 82.1 56.2 87.0 48.1 3.4 0.0 5.7 6.4 86 Rural 12.3 65.1 19.0 73.0 51.4 82.7 45.3 0.6 0.7 9.2 11.7 400 Division Barisal 6.9 52.3 15.9 59.4 44.6 70.6 28.9 1.9 0.0 7.6 18.3 36 Chittagong 13.5 78.9 25.0 83.4 53.5 88.8 61.2 0.8 0.0 5.3 5.9 116 Dhaka 15.7 63.7 19.1 73.2 59.0 83.7 42.1 2.3 1.3 8.5 11.0 132 Khulna 17.2 71.2 7.5 73.3 51.5 86.5 44.0 1.5 2.1 15.7 6.6 55 Rajshahi 19.8 60.7 17.6 73.1 50.5 83.9 39.0 0.0 0.0 9.0 12.5 107 Sylhet 16.7 69.9 18.8 72.8 38.9 72.8 49.0 0.0 0.0 8.8 18.4 40 Mother's education No education 8.9 64.3 25.7 72.3 48.2 81.4 36.6 0.5 0.0 9.0 14.0 187 Primary incomplete 12.6 59.0 12.6 64.8 53.2 75.7 44.7 2.4 2.3 11.0 16.2 126 Primary complete (18.1) (65.5) (15.8) (77.3) (42.5) (84.1) (59.6) (1.7) (0.0) (8.5) (8.0) 40 Secondary incomplete 25.9 76.7 14.0 83.8 58.9 92.8 55.6 0.8 0.0 6.5 2.0 107 Secondary complete or higher (33.9) (91.3) (20.8) (96.6) (64.3) (96.6) (55.9) (0.0) (0.0) (3.0) (1.4) 26 Wealth index Lowest 6.9 55.9 16.9 64.6 47.1 74.9 31.8 0.0 1.2 10.8 18.7 142 Second 17.2 61.0 27.9 71.4 45.4 82.0 48.9 1.9 0.0 13.1 11.5 101 Middle 17.8 69.4 18.7 76.9 53.8 83.9 49.4 2.2 1.2 8.0 5.9 95 Fourth 14.8 84.0 10.2 86.1 59.2 90.7 55.0 0.8 0.0 3.0 9.3 83 Highest 30.6 76.8 19.0 83.3 63.0 94.4 54.6 1.3 0.0 4.8 1.2 65 Total 15.7 67.2 18.6 74.6 52.3 83.4 45.8 1.1 0.6 8.6 10.7 486 Note: ORT includes solution prepared from oral rehydration salt (ORS) packets, recommended home fluids (RHF), and increased fluids. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes pharmacy, shop, and traditional practitioner Overall, one in six children with diarrhea was taken to a medically trained health provider for treatment of diarrhea. Children under one year of age, those who live in urban areas, children whose Maternal and Child Health | 163 mothers have at least some secondary education, and those who are from households in the highest wealth quintile have a much higher likelihood of seeking treatment for diarrhea from a health professional or a facility. There is no apparent discrimination between a male and female child in treatment of diarrhea. The data indicate important differences in the treatment of diarrhea cases by urban-rural residence. Not only are urban children with diarrhea more likely than rural children to be taken to a health facility, but they are also more likely to be treated with ORT and increased fluid intake. Among children in households in the lowest and highest wealth quintiles, there is a large difference in the proportion of children with diarrhea who receive any type of treatment for the illness, The BDHS survey also investigated the extent to which mothers made changes in the amount of fluids and food that a child received during a diarrheal episode. To obtain these data, mothers who had a child under age five with diarrhea during the two-week period preceding the survey were asked whether they had changed the amount that the child was given to drink and eat during the diarrheal episode. Table 10.21 indicates that 34 percent of children with diarrhea were given the same amount of fluids as usual and 52 percent received more fluids than usual; 13 percent received less fluids than usual. These results suggest that although the benefit of increasing fluid intake during a diarrheal episode is widely understood in Bangladesh, about one in eight mothers still engages in the dangerous practice of curtailing fluid intake when their children have diarrhea. One-third of children were given the same amount of food as before the illness, but more than one-third were given less than before. Table 10.21 Feeding practices during diarrhea Percent distribution of children under five years who had diarrhea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, Bangladesh 2004 Liquid/food offered Percentage Amount of liquids offered Same as usual 34.4 More than usual 52.3 Less than usual 13.0 Don’t know/missing 0.4 Total 100.0 Amount of food offered Same as usual 33.6 More than usual 29.5 Less than usual 36.2 Don’t know/missing 0.6 Total 100.0 Number of children 486 Although the proportion of children with diarrhea who received ORT has remained unchanged between 1999-2000 and 2004, there has been a switch toward greater use of commercially available ORS packets in 2004 (increased from 61 in 1999-2000 to 67 percent in 2004). The recommendation to increase fluid intake during diarrhea has yet to be practiced on a wide scale. About one in two mothers reported giving increased fluids to their children with diarrhea; and there was little change in this pattern between 1999-2000 and 2004. Infant Feeding and Nutritional Status of Children and Women │ 165 INFANT FEEDING AND NUTRITIONAL STATUS OF CHILDREN AND WOMEN 11 Nutritional status is the result of complex interactions between food consumption and the overall status of health and care practices. Poor nutritional status is one of the most important health and welfare problems facing Bangladesh. Young children and women of reproductive age are especially vulnerable to nutritional deficits and micronutrient deficiency disorders. At the individual level, inadequate or inappropriate feeding patterns lead to malnutrition. Numerous socioeconomic and cultural factors influence the decision on patterns of feeding and nutritional status. The 2004 BDHS collected data on feeding practices, that is, breastfeeding, exclusive breastfeeding, complementary feeding, and use of feeding bottles. Information was also collected on important nutritional issues that pertain to micronutrients—vitamin A in food and also as a supplement. Heights and weights of all children under five years and ever-married women age 10-49 were measured to determine the female and child nutritional status. This chapter presents the findings on infant feeding practices and nutritional status of women and children. 11.1 BREASTFEEDING AND SUPPLEMENTATION Feeding practices play a pivotal role in determining the optimal development of infants. Poor breastfeeding and infant feeding practices have adverse consequences for the health and nutritional status of children, which in turn have consequences on the mental and physical development of the child. Breastfeeding also affects mothers through the physiological suppression of the return to fertile status, thereby affecting the length of interval between pregnancies. UNICEF and WHO recommend that children be exclusively breastfed (no other complementary liquid or solid food or plain water) for the first six months of life and that children be given solid (semisolid) complementary food beginning with the seventh month of life. The standard indicator of exclusive breastfeeding is the percentage of children less than six months of age who are exclusively breastfeeding. The standard indicator of timely complementary feeding is the percentage of children age 6-9 months who are breastfeeding and receiving complementary foods. Giving other milk to children is acceptable after the first six months, but breastfeeding is recommended to be continued through the second year of life. 11.1.1 Initiation of Breastfeeding UNICEF and WHO recommend that children be fed colostrum (the first breast milk) immediately after birth and continue to be exclusively breastfed even if the regular breast milk has not yet come down. Early breastfeeding increases the chances of breastfeeding success and generally lengthens the duration of breastfeeding. Early initiation of breastfeeding also encourages bonding between the mother and newborn, and it helps to maintain the baby’s body temperature. Table 11.1 indicates that 98 percent of children are breastfed at some point, almost the same proportion as in the 1999-2000 BDHS. Overall, 24 percent of children are breastfed within one hour of birth, and 83 percent are breastfed within one day after delivery, indicating a substantial increase when compared with results from the 1999-2000 BDHS. The proportion of women initiating breastfeeding within one hour of birth is the highest in Sylhet division (32 percent) and the lowest in Barisal division (20 percent). However, initiation of breastfeeding within one day after birth is highest in Barisal division 166 │ Infant Feeding and Nutritional Status of Children and Women and lowest in Dhaka division. It is not surprising that assistance at birth by a medically trained provider is associated with greater likelihood of breastfeeding within an hour of birth. Table 11.1 Initial breastfeeding Percentage of children born in the five years preceding the survey who were ever breast- fed, percentage who started breastfeeding within one hour and within one day of birth, and percentage who received colostrum, by background characteristics, Bangladesh 2004 Percentage who started breastfeeding: Background characteristic Percentage ever breastfed Within one hour of birth Within one day of birth1 Percentage who received colostrum Number of children Sex Male 97.9 24.1 83.3 87.2 3,559 Female 98.4 23.3 82.8 86.9 3,442 Residence Urban 97.9 22.2 83.2 89.0 1,392 Rural 98.2 24.1 83.0 86.6 5,610 Division Barisal 99.0 19.8 89.0 86.7 410 Chittagong 98.5 20.8 85.3 86.9 1,527 Dhaka 98.0 20.6 78.0 86.6 2,175 Khulna 97.5 24.5 85.8 92.6 731 Rajshahi 98.2 28.4 84.3 90.0 1,560 Sylhet 97.5 31.8 85.3 74.7 599 Mother's education No education 97.9 19.8 80.3 82.9 2,688 Primary incomplete 98.6 21.4 84.1 85.9 1,499 Primary complete 97.9 26.0 84.8 86.0 661 Secondary incomplete 98.2 29.0 85.0 92.3 1,678 Secondary complete or higher 98.3 31.6 86.1 97.1 475 Assistance at delivery Medically trained2 96.4 31.5 83.1 93.0 924 Traditional birth attendant 98.3 26.3 84.3 87.8 964 Other 98.5 21.8 82.7 85.8 5,049 No one 95.4 23.8 86.3 84.3 61 Place of delivery Health facility 95.7 29.6 80.5 92.7 651 At home 98.4 23.0 83.3 86.4 6,295 Other 96.6 31.9 83.9 87.6 53 Wealth index Lowest 98.1 16.8 81.0 80.2 1,791 Second 98.4 23.2 81.4 86.4 1,444 Middle 98.1 24.4 83.3 89.1 1,381 Fourth 98.3 29.7 85.9 90.4 1,243 Highest 97.7 28.0 84.9 92.5 1,142 Total 98.1 23.7 83.0 87.0 7,002 Note: Table is based on all births whether the children are living or dead at the time of interview. Total includes three children with missing information on assistance at delivery, and two children with missing information on place of delivery. 1Includes children who started breastfeeding within one hour of birth. 2Doctor, nurse/midwife, family welfare assistant or visitor, or health assistant Infant Feeding and Nutritional Status of Children and Women │ 167 Table 11.1 shows that 87 percent of births in the five years preceding the survey received first milk or colostrum. The likelihood of a child receiving colostrum increases with mother’s education and household wealth. Children who are born in health facilities and whose delivery is assisted by health professionals are more likely to receive colostrum than other children. The children in Sylhet division are least likely to receive colostrum. 11.1.2 Age Pattern of Breastfeeding For optimal growth, it is recommended that infants should be exclusively breastfed for the first six months of life. Exclusive breastfeeding in the early months of life is correlated strongly with increased child survival and reduced risk of morbidity, particularly from diarrheal diseases. Table 11.2 and Figure 11.1 show the breastfeeding status of children up to three years of age. The data indicate that breastfeeding is widespread in Bangladesh and that newborns are breastfed for a long time. Even among children age 12-15 months, 96 percent are still breastfed, and among children age 20-23 months, the practice of breastfeeding is only slightly lower (90 percent). However, despite extensive breastfeeding, Table 11.2 Breastfeeding status by child’s age Percent distribution of children under three years living with the mother by breastfeeding status, and percentage of all children under three years using a bottle with a nipple, according to age in months, Bangladesh 2004 Breastfeeding and consuming: Age in months Not breast- feeding Exclusively breastfed Plain water only Water- based liquids/ juice Other milk Comple- mentary food Total Number of children Percentage using a bottle with a nipple1 Number of children <2 0.0 54.8 15.1 17.1 9.6 3.3 100.0 167 6.9 167 2-3 0.9 38.1 14.2 23.2 17.6 6.0 100.0 274 30.2 274 4-5 0.1 21.3 18.0 22.3 14.5 23.8 100.0 241 24.3 246 6-7 3.0 4.8 8.7 14.5 10.5 58.5 100.0 237 29.9 238 8-9 2.3 0.0 4.0 6.4 2.8 84.5 100.0 165 23.8 166 10-11 1.3 0.0 4.1 3.0 1.2 90.3 100.0 188 12.7 188 12-15 4.1 0.1 1.4 1.3 0.3 92.8 100.0 479 13.7 479 16-19 6.6 0.0 0.5 0.0 0.4 92.5 100.0 452 12.3 453 20-23 9.7 0.0 0.0 0.2 0.2 89.9 100.0 330 13.2 333 24-27 23.8 0.0 0.0 0.0 0.0 76.2 100.0 510 5.7 514 28-31 36.6 0.0 0.2 0.2 0.0 63.0 100.0 454 7.0 456 32-35 50.0 0.0 0.0 0.0 0.0 50.0 100.0 338 5.3 341 <6 0.4 36.2 15.8 21.4 14.5 11.6 100.0 682 22.4 687 6-9 2.7 2.8 6.8 11.1 7.4 69.2 100.0 402 27.4 403 Note: Breastfeeding status refers to the seven-day period before the survey. Children classified as “breastfeeding and consuming plain water only” consume no supplements. The categories not breastfeeding; exclusively breastfed; and breastfeeding and con- suming plain water, water-based liquids/juice, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and water-based liquids and who do not receive complementary foods are classified in the water-based liquid category, even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1Based on all children under three years the pattern of exclusive breastfeeding among children under six months is of concern. Only 55 percent of children under the age of two months are exclusively breastfed.1 Exclusive breastfeeding drops to 38 percent among children age 2-3 months, and to 21 percent among those age 4-5 months. Overall, only 36 1 Unlike the 1993-1994, 1996-1997 and 1999-2000 BDHS results, breastfeeding status in Table 11.2 refers to the seven-day period before the survey. 168 │ Infant Feeding and Nutritional Status of Children and Women percent of infants less than six months old are exclusively breastfed. From about six months of age, the introduction of complementary food is critical to meeting the protein, energy, and micronutrient needs of children. Although some young children are given complementary food early, among children age 6-9 months (all of whom should be receiving complementary food), only seven in ten children receive breast milk and complementary food. Bottle-feeding practices may result in increased morbidity because of unsafe water and preparation facilities. Table 11.2 shows that bottle-feeding is fairly common in Bangladesh. Feeding children with a bottle with a nipple starts at very young age, and three in ten infants age 2-3 months receive some food this way. The practice of feeding children with a bottle with a nipple remains very high (at least 24 percent) until children are age 8-9 months and fairly high (13 percent) for children age 10-23 months. Figure 11.2 examines the trends since the 1993-1994 BDHS in exclusive breastfeeding of children less than six months. To make the 2004 BDHS data comparable to earlier surveys, the percentage of exclusive breastfeeding was recalculated for the 24-hour period preceding the survey (Data in Table 11.2 refer to a period of seven days preceding the survey). Figure 11.2 shows that exclusive breastfeeding has not increased in the past ten years. It remained unchanged at around 45 percent between the 1993- 1994 BDHS and the 1999-2000 BDHS, and it declined to 42 percent in the 2004 BDHS. Figure 11.3 shows the trend in the standard indicator of timely complementary feeding: the percentage of children age 6-9 months who were breastfeeding and received complementary foods in the 24 hours preceding the survey. The proportion of children age 6-9 months who were breastfed and received complementary foods was rather low in the 1993-1994 BDHS (28.5 percent) and the 1996-1997 BDHS (28.4 percent), then it more than doubled to 58.9 percent in the 1999-2000 BDHS, and was slightly higher at 62 percent in the 2004 BDHS. Infant Feeding and Nutritional Status of Children and Women │ 169 11.1.3 Duration of Breastfeeding Table 11.3 indicates that the median duration of breastfeeding among Bangladeshi children is 32.4 months, which is slightly higher than the 1999-2000 BDHS estimate. The median duration of exclusive breastfeeding is estimated at 1.7 months, and the median duration of predominant breastfeeding is 5.4 months. The corresponding mean duration of any breastfeeding is 28.8 months, while the mean duration of exclusive breastfeeding is only 2.9 months and predominant breastfeeding is 5.7 months. As Table 11.3 and Figure 11.4 show, at the divisional level, duration of breastfeeding is longest in Khulna and Rajshahi (36 months) and shortest in Chittagong and Sylhet (26 and 27 months, respectively). Analysis by other background characteristics indicates that educational level and socioeconomic level as measured by the wealth index have no relationship except that mothers who have completed primary school only are likely to breastfeed for the longest period and mothers who have at least attended secondary school breastfeed for a slightly shorter duration than their lesser educated counterparts. 170 │ Infant Feeding and Nutritional Status of Children and Women Differentials in the median duration of exclusive breastfeeding are small except that Chittagong division stands out as having the highest median duration of exclusive breastfeeding (2.6 months). Table 11.3 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breast- feeding among children born in the four years preceding the survey, by background characteristics, Bangladesh 2004 Median duration (months) of breastfeeding1 Background characteristic Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Number of children Sex Male 32.4 1.1 4.3 2,066 Female 32.0 0.9 5.1 2,060 Residence Urban 32.0 0.8 4.9 815 Rural 32.6 1.1 4.7 3,310 Division Barisal 31.7 1.5 5.5 237 Chittagong 25.9 2.6 6.1 922 Dhaka 33.5 0.7 4.3 1,251 Khulna 35.5 0.6 4.9 451 Rajshahi 35.9 1.6 3.1 898 Sylhet 27.4 0.7 5.8 367 Mother's education No education 33.4 1.0 4.9 1,464 Primary incomplete 31.7 1.3 4.7 882 Primary complete 35.3 0.6 5.7 379 Secondary incom- plete 30.3 1.0 4.1 1,080 Secondary complete or higher 30.8 1.5 5.2 321 Wealth index Lowest 33.3 2.0 5.6 1,414 Second 32.6 1.6 5.4 1,126 Middle 31.1 2.5 5.6 1,135 Fourth 33.2 1.9 5.0 993 Highest 31.4 0.6 5.1 925 Total 32.4 1.7 5.4 5,593 Mean for all children 28.8 2.9 5.7 na Note: Median and mean durations are based on the seven-day period preceding the survey. na = Not applicable 1It is assumed that non-last-born children or last-born child not living with the mother are not currently breastfeeding. 2Either exclusively breastfed or received breast milk and plain water, water-based liquids, and/or juice only (excludes other milk) Infant Feeding and Nutritional Status of Children and Women │ 171 The median duration of exclusive breastfeeding for children under four years for the last three surveys2 shows little change. Results for children under four years from data referring to the 24-hour period before the survey show that median duration of exclusive breastfeeding has always been low. While it was higher in 1999-2000 (1.8 months) than in 1996-1997 (1.5 months), in 2004 it showed no increase (1.7 months). It should be noted that although medians are calculated from smoothed data, they are still dependent on the point at which the proportion breastfeeding dips below 50 percent, and are therefore volatile. 11.1.4 Complementary Feeding Given that babies need nutritious food in addition to breast milk from the age of six months, it is recommended that children should begin receiving complementary foods at this age. The 2004 BDHS collected data on certain foods given to breastfeeding and nonbreastfeeding children. Table 11.4 presents information on the types of complementary foods received by children less than three years of age in the seven days preceding the survey. Because of the small number of nonbreastfeeding children under 16 months of age, the table shows only three age categories for this group—16-19, 20-23, and 24-35 months. As observed in Table 11.4, the use of commercially produced baby formula has become much more popular since 1999-2000, particularly among breastfeeding infants age 2-7 months; most notably, the proportion of children age 4-7 months who consume baby formula has almost doubled since 1999-2000. It is not surprising that one-third of nonbreastfeeding children receive baby formula. 2 The results for the 1993-1994 are only for children born in the three years preceding the survey. 172 │ Infant Feeding and Nutritional Status of Children and Women Table 11.4 Foods consumed by children in the day preceding the interview Percentage of children under three years of age living with the mother who consumed specific foods in the seven days preceding the interview, by breastfeeding status and age, Bangladesh 2004 Age in months Baby formula Animal milk Other liquids1 Banana/ mango/ papaya Green leafy vege- tables Rice/ wheat/ porridge Meat/ fish/ eggs Dal Any solid or semi- solid food Number of children BREASTFEEDING CHILDREN <2 2.8 10.9 18.3 0.9 0.0 2.5 0.0 0.0 3.4 165 2-3 11.7 20.1 22.5 1.6 0.6 5.6 0.0 0.0 6.1 271 4-5 16.0 21.4 27.0 8.0 2.0 17.3 1.4 0.7 23.8 241 6-7 15.4 32.3 35.4 19.6 10.4 51.3 9.9 7.2 60.1 229 8-9 12.1 39.4 30.7 30.1 41.7 80.2 40.0 27.4 86.9 161 10-11 8.1 38.7 30.2 30.4 60.1 88.2 56.0 34.9 91.4 183 12-15 7.2 42.3 25.3 42.7 74.4 95.8 69.4 48.0 96.8 458 16-19 6.3 50.9 27.1 52.3 77.6 97.7 82.6 53.2 99.0 419 20-23 4.2 48.4 35.0 57.3 85.0 98.9 88.0 64.1 99.6 295 24-35 3.5 46.1 25.3 58.6 90.3 99.5 92.1 60.4 99.8 827 <6 11.0 18.3 23.1 3.7 1.0 9.0 0.5 0.2 11.7 677 6-9 14.0 35.2 33.5 24.0 23.3 63.2 22.3 15.5 71.1 390 NONBREASTFEEDING CHILDREN 16-19 (33.4) (50.8) (46.9) (65.3) (79.5 (95.0) (87.3) (56.0) (96.8) 30 20-23 (32.3) (47.3) (32.0) (76.0) (94.6) (100.0) (93.0) (72.7) (100.0) 32 24-35 7.9 49.8 24.3 56.3 91.2 99.1 94.6 65.8 99.3 457 Note: Breastfeeding status and food consumed refer to the seven-day period preceding the survey. Figures in parentheses are based on 25-49 unweighted cases. 1 Does not include plain water Twelve percent of breastfeeding children under six months receive solid or semisolid foods. The most commonly used complementary foods for these children include liquids other than water (23 percent), animal milk (18 percent), and baby formula (11 percent). Animal milk and other liquids are introduced to children at age 2-3 months (20 and 23 percent, respectively); by age 6-7 months, one-third are already receiving these foods. On the other hand, baby formula and foods made from cereals are mainly introduced to children age 4-5 months (16 to 17 percent), and cereals quickly become the complementary food for a majority of children at age 6-7 months. Consumption of green leafy vegetables and foods rich in protein (meat, fish, and eggs) generally begins at age 6-7 months (10 percent), is around 40 percent before 10 months of age, and then increases rapidly. Dal (or lentils) is also introduced at the same age as green leafy vegetables. More than one- quarter of children (27 percent) are given dal when they are age 8-9 months, and the proportion receiving dal increases with age. Fruits rich in vitamin A, such as banana, mango, and papaya, are introduced at a somewhat earlier age. By age 4-5 months, 8 percent of children eat fruit; this proportion rises to 42 percent by the first year of life and then continues to increase as does the consumption of dal. Comparison of feeding patterns of breastfeeding children and nonbreastfeeding children for whom the data are presented in Table 11.4 shows that although nonbreastfeeding children age 16-23 months are almost as likely to receive animal milk, they are more likely to consume all other foods. The differences between older (age 24-35 months) breastfeeding and nonbreastfeeding children in consuming other foods are smaller. Infant Feeding and Nutritional Status of Children and Women │ 173 11.2 MICRONUTRIENT INTAKE Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. High levels of vitamin A deficiency (VAD) can cause eye damage leading to blindness and can increase the severity of infections such as measles and diarrheal diseases in children. Deficiency in this crucial micronutrient can be avoided by giving children capsule supplements of vitamin A, usually every six months. Bangladesh has instituted such a program of supplementation through its health care system. Current policy is to begin vitamin A supplementation after a child completes the first nine months of life. Children age 9-11 months are first provided vitamin A supplementation at the time of measles vaccination, and those age 12-59 months receive the supplementation once every six months during National Immunization Days and vitamin A campaigns. 11.2.1 Micronutrient Intake among Children Table 11.5 shows the percentage of youngest children under three years who consumed foods rich in vitamin A in the seven days preceding the survey and the percentage of children age 9-59 months who received vitamin A supplements in the six months preceding the survey. Overall, 69 percent of children under three years consumed foods rich in vitamin A in the seven days preceding the survey. The consumption of foods rich in vitamin A increases with time since birth, from 38 percent among children age 6-9 months to 95 percent among two-year-old children. The proportion of children consuming foods rich in vitamin A is highest in Rajshahi division (74 percent) and lowest in Sylhet (60 percent); it varies little from the national average in the remaining four divisions. In the 2004 BDHS, mothers were asked if their children under age five had taken a vitamin A capsule during the six months preceding the survey; the analysis is confined to children between 9 and 59 months. The data show that 82 percent of targeted children had received vitamin A supplementation in the six months preceding the survey (Table 11.5). Children living in Sylhet are not only least likely to consume fruits and vegetables rich in vitamin A (60 percent), they are also disadvantaged in terms of receiving vitamin A supplementation (73 percent). Children in Barisal are almost as likely as children in Sylhet to receive vitamin A supplements (74 percent). Although there is only a small difference between children living in the wealthiest households and those living in the poorest households in consumption of fruits and vegetables rich in vitamin A, the corresponding difference among children receiving vitamin A supplements is larger: 88 percent of children in the wealthiest households compared with 77 percent in the poorest households received vitamin A supplements. Between the 1999-2000 BDHS and the 2004 BDHS, the likelihood of receiving vitamin A supplementation among children age 12-59 months increased from 80 to 84 percent, but among children age 9-11 months, supplementation declined from 73 to 38 percent (data not shown). 11.2.2 Micronutrient Intake and Deficiencies among Women Table 11.6 presents, among women with a birth in the five years preceding the survey, the percentage who received a vitamin A dose in the first two months after birth and who had night blindness during pregnancy. Overall, 15 percent received a postpartum vitamin A dose; this varies with residence, division, and educational attainment. Women in urban areas (21 percent) are more likely to receive vitamin A supplements than those in rural areas (13 percent). At the divisional level, the percentage of women who reported receiving a postpartum vitamin A dose is highest in Sylhet and Chittagong (22 and 21 percent, respectively) and is fairly high in Barisal (17 percent). Only 11 to 12 percent of women in the other three divisions received vitamin A in the postpartum period. 174 │ Infant Feeding and Nutritional Status of Children and Women Table 11.5 Micronutrient intake among children Percentage of children under age three living with the mother who consumed fruits and vegetables rich in vitamin A in the seven days preceding the survey, and percentage of children age 9-59 months who re- ceived vitamin A supplements in the six months preceding the survey, by background characteristics, Bang- ladesh 2004 Background characteristic Consumed fruits and vegetables rich in vitamin A1 Number of children under three years Consumed vitamin A supplements Number of children age 9-59 months Age in months <6 4.2 682 na na 6-9 37.8 402 27.0a 71 10-11 67.8 188 41.6 188 12-23 85.9 1,261 78.5 1,265 24-35 95.0 1,303 85.8 1,312 36-47 na na 86.8 1,343 48-59 na na 84.5 1,300 Sex Male 67.7 1,912 82.1 2,779 Female 69.4 1,925 81.4 2,700 Birth order 1 70.0 1,147 82.1 1,553 2-3 68.2 1,659 82.1 2,390 4-5 66.4 666 81.5 973 6+ 69.6 365 83.8 563 Residence Urban 70.9 721 85.2 1,079 Rural 68.0 2,876 80.9 4,399 Division Barisal 65.5 218 73.7 319 Chittagong 66.8 788 83.8 1,185 Dhaka 69.7 1,102 83.9 1,682 Khulna 66.2 406 83.5 581 Rajshahi 74.2 796 81.5 1,251 Sylhet 60.0 288 72.9 461 Mother's education No education 68.2 1,248 79.0 2,133 Primary incomplete 66.7 787 81.6 1,169 Primary complete 72.8 332 83.0 533 Secondary incom- plete 68.5 939 83.9 1,276 Secondary complete or higher 70.7 292 89.4 367 Mother's age at birth <20 69.2 1,139 79.1 1,785 20-24 66.6 1,183 83.0 1,739 25-29 69.0 695 83.6 1,063 30-34 70.0 385 86.0 572 35-49 72.1 196 76.5 320 Wealth index Lowest 68.5 883 77.2 1,410 Second 68.5 724 82.1 1,149 Middle 67.3 732 81.2 1,045 Fourth 67.4 645 83.2 979 Highest 71.5 614 87.6 895 Total 68.6 3,597 81.8 5,479 6 Note: Information on vitamin A supplements is based on mother’s recall. na = Not applicable 1Includes green leafy vegetables, banana, mango, and papaya a Includes children age 9 months only Infant Feeding and Nutritional Status of Children and Women │ 175 Table 11.6 Micronutrient intake and deficiency among mothers Percentage of women with a birth in the five years preceding the survey who received a vitamin A dose in the first two months after delivery, and percentage with night blindness during pregnancy, by background characteristics, Bangladesh 2004 Night blindness Background characteristic Received vitamin A dose postpartum1 Reported Adjusted2 Number of women Age at birth <20 13.9 4.8 2.1 1,628 20-24 15.0 5.7 3.0 1,754 25-29 16.1 7.5 3.7 1,078 30-34 13.2 8.4 4.1 611 35-49 12.8 11.6 4.9 344 Number of children ever born 1 17.1 4.1 2.0 1,491 2-3 15.0 5.7 2.7 2,376 4-5 11.9 9.9 5.4 984 6+ 10.6 10.0 3.7 565 Residence Urban 20.9 4.2 1.8 1,123 Rural 12.9 7.1 3.5 4,293 Division Barisal 17.2 8.5 3.7 333 Chittagong 20.5 5.1 1.7 1,115 Dhaka 12.0 5.5 2.7 1,677 Khulna 10.9 7.1 4.1 607 Rajshahi 11.5 6.7 2.8 1,285 Sylhet 21.6 11.2 7.5 400 Education No education 10.2 9.9 4.6 1,998 Primary incomplete 11.5 6.6 2.9 1,138 Primary complete 15.1 4.7 2.6 504 Secondary incom- plete 18.2 3.5 2.1 1,371 Secondary complete or higher 31.4 1.1 0.3 406 Wealth index Lowest 8.5 11.3 5.9 1,298 Second 8.9 7.0 3.2 1,124 Middle 14.7 6.1 2.7 1,054 Fourth 17.9 3.8 1.8 998 Highest 25.9 2.5 0.9 943 Total 14.5 6.5 3.1 5,416 Note: For women with two or more live births in the five-year period, data refer to the most recent birth. 1 In the first two months after delivery 2 Women who reported night blindness but did not report difficulty with vision during the day 176 │ Infant Feeding and Nutritional Status of Children and Women With regard to educational level, women with no education (10 percent) or those with incomplete primary education (12 percent) are less likely to receive vitamin A doses. The data show that 18 percent of women with some secondary education reported having received a postpartum vitamin A dose. Those who have completed secondary school are most likely to receive vitamin A and are three times as likely to receive vitamin A as women with no education. Vitamin A supplementation is also strongly associated with wealth, increasing from 9 percent among mothers in households in the two lowest quintiles to 26 percent among mothers in the wealthiest households. Table 11.6 shows that 3 percent of women with a recent birth experienced night blindness (with normal day vision), an indication of vitamin A deficiency. Night blindness during pregnancy is more prevalent when age at birth is 35 and over, mothers are uneducated, they have four or more births, they live in Sylhet division, and live in the poorest households. It is much lower among those living in urban areas and Chittagong division, as well as among highly educated women and those in the wealthiest households. 11.3 NUTRITIONAL STATUS OF CHILDREN UNDER FIVE The growth patterns of healthy and well-fed children are reflected in positive changes in their height and weight. Inadequate food supply, among other factors, often leads to malnutrition, resulting in serious consequences on the physical and mental growth and development of the children. In addition to questions about the feeding practices of infants and young children, the 2004 BDHS included an anthropometric component, in which all children under five years of age were both weighed and measured. Each interviewing team carried a scale and measuring board. The scales were lightweight, with a digital screen designed and manufactured under the authority of UNICEF. The measuring boards were specially produced by Shorr Productions for use in survey settings. Children younger than 24 months were measured lying down on the board (recumbent length), and standing height was measured for older children. In previous BDHS surveys, anthropometric measurements were restricted to children born to women interviewed with the Women’s Questionnaire. However, these data do not represent all children, since they exclude children whose mothers were not in the household (either because they did not live there or because they had died), children whose mothers were not eligible for the individual interview (i.e., under age 15 or age 50 and over), and children whose mothers did not complete an individual inter- view. To overcome these biases, in the 2004 BDHS, workers weighed and measured all children who were born in the five years preceding the survey and listed in the Household Questionnaire. Evaluation of nutritional status is based on the rationale that in a well-nourished population, there is a statistically predictable distribution of children of a given age with respect to height and weight. In any large population, there is variation in height and weight; this variation approximates a normal distribution. Use of a standard reference population as a point of comparison facilitates the examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. One of the most commonly used reference populations, and the one used in this report, is the U.S. National Center for Health Statistics (NCHS) standard, which is recommended for use by the World Health Organisation (WHO). The use of this reference population is based on the finding that young children of all population groups have similar genetic potential for growth. Infant Feeding and Nutritional Status of Children and Women │ 177 Three standard indices of physical growth that describe the nutritional status of children are presented: • Height-for-age (stunting) • Weight-for-height (wasting) • Weight-for-age (underweight). Each of the three nutritional indicators is expressed in standard deviations (Z-scores) from the mean of the reference population.3 Deviations of the indicators between below -2 and -3 standard deviations (SD) indicate that the children are moderately affected, while deviations below -3 SD indicate that the children are severely affected. A total of 6,528 (weighted) children under age five were eligible to be weighed and measured. Six percent of these children were missing height or weight information. The following analysis focuses on the 6,005 children under five for whom complete and plausible anthropometric data were collected. 11.3.1 Stunting Height-for-age is a measure of linear growth. A child who is below -2 SD from the median of the NCHS reference population in terms of height-for-age is considered short for his/her age, or “stunted,” a condition reflecting the cumulative effect of chronic malnutrition. If the child is below -3 SD from the reference median, then the child is considered to be severely stunted. A child between -2 and -3 SD is considered to be moderately stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and may also be caused by recurrent and chronic illness. Height-for-age, therefore, represents a measure of the long-term effects of malnutrition in a population and does not vary appreciably according to the season of data collection. Stunted children are not immediately obvious in a population; a stunted three-year-old child could look like a well-fed two-year-old. Table 11.7 shows the nutritional status of children under five as measured by stunting (height-for- age) indicators and various background characteristics. At the national level, 43 percent of children under five are stunted, and 17 percent severely stunted. Analysis of the indicator by various age groups shows that stunting generally increases with age from 10 percent of children under six months to 51 percent of children age 12-23 months, and after dropping at age 24-35 months, it again rises to the highest level among four-year-old children (Figure 11.5). Table 11.7 shows that severe stunting is highest for children age 48-59 months (23 percent) and lowest for those less than six months of age (2 percent). Stunting levels do not differ among children that are first- to third-order births, but increase steadily for higher- order births. First births and births occurring 48 or more months after a prior birth are less likely to be stunted than children born after a shorter birth interval. 3 The distribution of the standard reference population has been normalized; hence the mean and median coincide. 178 │ Infant Feeding and Nutritional Status of Children and Women The survey data show that children living in urban areas are less likely to be stunted than children in rural areas (38 and 44 percent, respectively) (Table 11.8 and Figure 11.6). At the divisional level, Barisal (49 percent) has the highest proportion of stunted children, while Khulna has the lowest (32 percent). Infant Feeding and Nutritional Status of Children and Women │ 179 Table 11.7 Nutritional status of children by demographic characteristics Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for- height, and weight-for-age, by demographic characteristics, Bangladesh 2004 Height-for-age Weight-for-height Weight-for-age Demographic characteristic Percentage below -3 SD Percentage below -2 SD1 Percentage below -3 SD Percentage below -2 SD1 Percentage below -3 SD Percentage below -2 SD1 Number of children Child’s age <6 months 1.5 10.4 0.6 3.1 0.9 8.3 581 6-9 months 6.5 23.5 1.3 8.3 7.1 29.4 378 10-11 months 5.0 28.3 1.3 12.9 13.3 42.9 181 12-23 months 20.4 50.9 2.8 24.0 17.8 58.5 1,170 24-35 months 16.0 44.7 1.9 13.4 16.8 54.6 1,222 36-47 months 21.0 49.2 0.4 10.6 13.4 51.1 1,249 48-59 months 22.5 51.2 0.4 10.0 10.8 51.1 1,224 Sex Male 16.6 42.5 1.4 13.2 11.9 46.4 3,041 Female 17.2 43.5 1.2 12.5 13.7 48.7 2,964 Birth order 1 15.4 40.1 1.2 12.8 11.8 44.9 1,688 2-3 14.1 40.1 1.1 13.0 10.9 45.7 2,616 4-5 20.5 48.9 1.5 13.1 17.1 52.0 1,019 6+ 25.3 53.8 1.6 12.7 17.0 55.0 573 Birth interval in months First birth 15.4 40.1 1.2 12.8 11.8 44.9 1,691 <24 20.4 49.0 1.2 11.2 13.8 54.7 645 24-47 20.0 48.1 1.4 13.5 14.8 51.7 1,974 48+ 12.4 37.1 1.2 13.1 10.9 42.1 1,586 Total 2 16.9 43.0 1.3 12.8 12.8 47.5 6,005 Total BDHS-2004 (mother interviewed) 16.7 43.0 1.3 12.9 12.8 47.5 5,896 Total BDHS-1999-2000 (mother interviewed) 18.3 44.7 1.1 10.3 12.9 47.7 5,421 Total BDHS 1996-1997 (mother interviewed) 28.0 54.6 3.7 17.7 20.6 56.3 4,787 Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO International Reference Population. The percentage of children who are more than three or more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown by background characteristics. Table is based on children who have a valid date of birth (month and year) and valid height and weight measurements. Total includes 21 children whose mother was in household but was not interviewed; they are not shown separately. 1Includes children who are below -3 SD 2Includes children whose mothers were not interviewed 1 6 . 9 180 │ Infant Feeding and Nutritional Status of Children and Women Table 11.8 Nutritional status of children by background characteristics Percentage of children under five years classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Bangladesh 2004 Height-for-age Weight-for-height Weight-for-age Background characteristic Percentage below -3 SD Percentage below -2 SD1 Percentage below -3 SD Percentage below -2 SD1 Percentage below -3 SD Percentage below -2 SD1 Number of children Residence Urban 13.6 37.6 1.2 11.5 12.0 42.2 1,174 Rural 17.7 44.3 1.3 13.2 13.0 48.8 4,832 Division Barisal 20.2 48.9 0.4 7.2 12.4 46.3 354 Chittagong 19.4 46.2 1.5 14.1 16.2 49.9 1,320 Dhaka 18.5 44.7 1.1 11.7 12.6 47.6 1,837 Khulna 8.6 31.7 1.9 14.2 8.3 40.3 662 Rajshahi 14.5 40.3 1.3 14.2 12.0 48.1 1,349 Sylhet 20.1 46.2 1.0 12.2 13.1 49.8 485 Mother’s education2 No education 22.8 50.5 1.3 13.9 17.0 55.4 2,217 Primary incomplete 16.9 45.2 1.0 13.4 12.5 48.6 1,292 Primary complete 20.0 46.2 1.8 13.0 14.3 48.8 563 Secondary incomplete 10.4 35.7 1.6 12.1 9.0 41.6 1,424 Secondary complete or higher 2.0 17.4 0.2 9.6 3.0 21.8 422 Mother's age 15-19 17.0 42.5 1.9 13.6 13.7 46.2 955 20-24 14.6 40.3 1.2 12.8 10.3 46.0 1,985 25-29 15.7 43.2 1.2 13.9 13.9 48.6 1,526 30-34 19.4 43.5 0.9 13.0 15.1 48.5 898 35-49 22.6 52.2 1.5 9.7 14.1 51.4 553 Mother's height2 <145 cm 28.0 62.3 1.1 16.0 23.5 63.6 935 145 cm or above 14.6 39.3 1.3 12.4 10.9 44.6 4,952 Mother's BMI2 <18.5 21.3 50.4 2.0 17.9 18.5 58.9 2,208 18.5 or above 14.0 38.5 0.8 10.0 9.5 40.8 3,679 Mother's initerview status3 Mother interviewed 16.7 43.0 1.3 12.9 12.8 47.5 5,896 Mother not interviewed, not in household3 27.9 42.8 1.5 6.2 10.1 42.9 89 Wealth index Lowest 25.7 54.4 1.3 15.5 18.2 59.3 1,512 Second 19.4 46.7 1.9 13.5 14.7 52.9 1,237 Middle 15.2 42.4 1.2 13.5 12.1 45.1 1,179 Fourth 13.3 39.9 1.1 10.8 10.2 43.4 1,091 Highest 6.5 25.0 0.7 9.4 5.9 30.2 987 Total4 16.9 43.0 1.3 12.8 12.8 47.5 6,005 Total BDHS-2004 (mother interviewed) 16.7 43.0 1.3 12.9 12.8 47.5 5,896 Total BDHS-1999-2000 (mother interviewed) 18.3 44.7 1.1 10.3 12.9 47.7 5,421 Total BDHS 1996-97 (mother interviewed) 28.0 54.6 3.7 17.7 20.6 56.3 4,787 Note: Table is based on children who stayed in the household the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the NCHS/CDC/WHO International Reference Population. The percentage of children who are more than three or more than two standard deviations below the median of the International Reference Population (-3 SD and -2 SD) are shown by background characteristics. Table is based on children who have a valid date of birth (month and year) and valid height and weight measurements. Total includes 21 children whose mother was in household but was not interviewed; they are not shown separately. 1Includes children who are below -3 SD 2Excludes children whose mothers were not interviewed. 3Includes children whose mothers are deceased 4Includes children whose mothers were not interviewed BMI = Body mass index (kg/m2) 1 6 . 9 Infant Feeding and Nutritional Status of Children and Women │ 181 Children of older mothers (above age 34) are more likely to be stunted than children of younger mothers. As expected, the mother’s level of education has a strong inverse relationship with stunting levels. For example, children whose mothers have completed secondary education are half as likely to be stunted as children of mothers with incomplete secondary education (36 percent), while children whose mothers have no education are three times as likely to be stunted as children of mothers with most education. The relationship between wealth index and stunting is similar; stunting declines as wealth increases. For both of these characteristics, the inverse relationship is even stronger for severe stunting (Table 11.8). The nutritional status of mothers affects the development of their children. Children whose mothers are short or malnourished are more likely to be stunted. 11.3.2 Wasting Weight-for-height measures body mass in relation to body length and describes current nutritional status. A child who is below -2 SD from the reference median for weight-for-height is considered to be too thin for his/her height, or “wasted,” a condition reflecting acute malnutrition. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or recent episodes of illness causing loss of weight and the onset of malnutrition. As with stunting, wasting is considered severe if the child is below -3 SD from the reference mean. Severe wasting is closely linked to an elevated risk of mortality. Prevalence of wasting may vary considerably by season. Table 11.7 also shows the nutritional status of children under five years as measured by wasting. In Bangladesh, 13 percent of children are wasted, and the proportion of severely wasted children is 1 percent. Wasting is highest at age 12-23 months (24 percent) and lowest in children under six months of age (3 percent). The survey data show few sharp differences in wasting by background characteristics (Table 11.8) except for children in Barisal division; those children are most likely to be stunted but least likely to be wasted. Other differentials for wasting are similar to the differentials in stunting; however, the differences are smaller. 182 │ Infant Feeding and Nutritional Status of Children and Women 11.3.3 Underweight Weight-for-age is a composite index of height-for-age and weight-for-height and, thus, does not distinguish between acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be underweight for his/her age because of stunting, wasting, or both. Weight-for-age is a useful tool in clinical settings for continuous assessment of nutritional progress and growth. Children whose weight-for- age is below -2 SD from the median of the reference population are classified as “underweight,” and those who fall below -3 SD are classified as “severely underweight.” As shown in Table 11.7, 48 percent of children under five are underweight. The proportion of severely underweight children is 13 percent. As with the other two indicators of nutrition, underweight of children increases with age and peaks at 59 percent for children age 12-23 months. The majority of older children are also underweight. Differentials by other background characteristics show the same pattern as for stunting. At the bottom of Tables 11.7 and 11.8, the results for children whose mothers were interviewed for the 1996-1997, 1999-2000, and 2004 BDHS surveys are presented. Despite the fact that child nutritional levels showed a substantial improvement from 1996-1997 to 1999-2000, no noticeable improvement has occurred since then (Figure 11.7) except that severe stunting has decreased slightly (Table 11.7) and overall wasting has increased from 10 to 13 percent. 11.3.4 Nutritional Status of Women The 2004 BDHS also collected data on the height and weight of ever-married women age 10-49.4 The data are used to derive two measures of nutritional status: height and body mass index (BMI). A woman’s height can be used to predict the risk of having difficulty in pregnancy, given the relationship between height and pelvic size. The risk of giving birth to low-weight babies is also higher among women of small stature. The cutoff point at which mothers can be considered at risk because of short stature is normally taken to be between 140 and 150 centimeters. The BMI or Quetelet index is used to measure thinness or obesity. It is defined as weight in kilograms divided by height in meters squared (kg/m2). The main advantage of the BMI is that it does not require a reference table from a well-nourished population. A cutoff point of 18.5 is used to define thinness or acute undernutrition. A BMI of 25 or above usually indicates overweight or obesity, and 30 or above indicates obesity. Table 11.9 presents nutritional indicators for women by various background characteristics. At the national level, the mean height for women is 150.5 centimeters, with 16 percent of women falling below the cutoff of 145 centimeters. Variation by most background characteristics is minimal. Urban women and women in Barisal and Khulna divisions are less likely to be short than other women. Education and wealth show a negative relationship to women being short. For example, 20 percent of the poorest women and 19 percent of uneducated women are below 145 centimeters, compared with only 11 percent of women in the wealthiest households and 6 percent of women who have completed secondary or higher education. The mean BMI for women age 10-49 is 20.2. Only 57 percent are normal or have a BMI between 18.5 and 24.9. Nine percent are overweight or obese (BMI ≥ 25). Thus, 34 percent of women are thin (BMI < 18.5). Analysis by background characteristics shows that although the proportion of women with 4 The 2004 BDHS measured nutritional status of ever-married women age 10-49, whereas the 1999-2000 BDHS included only mothers age 15-49 who had children under five years. A comparable analysis of 2004 data (Table 11.9) shows that the proportion of mothers age 15-49 who are less than 145 centimeters in height is almost the same, 16.0 percent; however, there was a substantial decrease (from 45 to 38 percent) in the proportion of women with a BMI below 18.5. Infant Feeding and Nutritional Status of Children and Women │ 183 a normal BMI is almost the same in urban and rural areas, women not in the normal range of BMI differ dramatically by residence. The proportion considered thin in rural areas is 37 percent—50 percent higher than in urban areas (25 percent). On the other hand, urban women are more than three times as likely to be overweight or obese as rural women. Among divisions, Sylhet has the highest proportion of women who are thin (48 percent), and Khulna has the least (29 percent). Differentials by education and wealth index for BMI are similar to differentials by these variables for women’s height. The proportion of overweight or obese women is low among women under 30 and varies little among older women (11 to 13 percent). Overweight and obese women are much more likely to be in urban areas, among those highly educated, and among those in the highest quintile of the wealth index. The 2004 BDHS included anthropometric measurements of all ever-married women under age 50, while in the previous two BDHS surveys, only women who had children under five years of age were selected for anthropometric measurements. To compare changes in women’s nutritional status over time, the 2004 BDHS data are reestimated based on 4,737 women who had a living child under five years of age. Figure 11.8 and Table 11.9 present the comparative data. The mean height of Bangladeshi mothers with children under five has not changed since the 1996-1997 BDHS. Although the proportion of women with height under 145 cm decreased between the 1996-1997 BDHS and the 1999-2000 BDHS, the proportion of mothers who were short in the 2004 BDHS is the same as in the 1999-2000 BDHS. However, the data indicate a substantial improvement in mother’s nutritional status as measured by the BMI. Since 1996-1997, the mean BMI has increased steadily, from 18.8 to 19.7 in 2004; consequently, the proportion of mothers below the BMI cutoff point of 18.5 has continued to drop, from 52 percent in 1996-97 to 38 percent in 2004—a decline of 27 percent in less than ten years. 184 │ Infant Feeding and Nutritional Status of Children and Women Table 11.9 Nutritional status of women by background characteristics Among ever-married women age 15-49, mean height, percentage under 145 centimeters, mean body mass index (BMI), and percentage with specific BMI levels, by background charac- teristics, Bangladesh 2004 Height BMI1 (kg/m2) Background Characteristic Mean height in centi- meters Per- cent- age below 145 cm Num- ber of women Mean BMI 18.5- 24.9 (nor- mal) <18.5 (thin) ≥25.0 (over- weight or obese) Num- ber of ever- married women Age 10-14 149.1 17.2 148 19.0 60.2 39.8 0.0 122 15-19 150.4 15.8 1,573 19.2 58.6 39.6 1.8 1,303 20-24 150.4 16.1 2,187 19.8 58.2 36.1 5.7 1,923 25-29 150.9 13.9 1,999 20.3 60.6 30.9 8.5 1,819 30-34 150.4 16.4 1,771 20.5 57.4 31.3 11.2 1,671 35-39 150.7 14.1 1,443 20.7 56.5 30.1 13.3 1,405 40-44 150.3 16.6 1,144 20.5 52.8 34.4 12.8 1,140 45-49 150.0 17.5 1,051 20.1 48.6 40.1 11.3 1,048 Residence Urban 150.7 13.4 2,552 21.5 55.4 25.0 19.5 2,374 Rural 150.4 16.3 8,765 19.8 57.2 37.1 5.8 8,057 Division Barisal 150.6 13.0 711 19.9 55.2 37.8 7.0 657 Chittagong 150.4 15.2 2,007 20.2 57.3 32.9 9.7 1,825 Dhaka 150.3 16.3 3,536 20.4 54.8 34.0 11.3 3,266 Khulna 151.1 12.9 1,391 20.5 60.6 29.2 10.3 1,293 Rajshahi 150.5 16.9 2,969 19.9 60.1 34.2 5.7 2,759 Sylhet 150.3 16.6 704 19.3 45.3 47.6 7.1 632 Education No education 149.9 18.7 4,645 19.5 55.2 40.1 4.8 4,409 Primary incomplete 150.2 17.0 2,321 19.9 56.6 36.2 7.2 2,130 Primary complete 150.6 13.6 1,002 20.4 58.6 31.7 9.7 908 Secondary incomplete 151.1 12.6 2,530 20.8 59.7 27.9 12.4 2,248 Secondary complete or higher 152.5 6.3 818 22.4 55.9 17.3 26.8 737 Wealth index Lowest 149.7 20.3 2,244 18.9 50.8 47.1 2.1 2,074 Second 150.4 16.5 2,255 19.3 56.6 40.5 2.9 2,077 Middle 150.3 15.8 2,251 19.7 59.4 35.6 5.0 2,057 Fourth 150.6 14.5 2,293 20.4 59.2 31.3 9.5 2,128 Highest 151.3 11.2 2,274 22.3 58.0 17.2 24.8 2,096 Total all women 150.5 15.6 11,316 20.2 56.8 34.3 8.9 10,431 WOMEN WHO HAVE CHILDREN UNDER 5 Total 2004 BDHS 150.5 16.0 5,192 19.7 56.3 37.9 5.8 4,737 Total 1999-2000 BDHS 150.4 15.9 5,154 19.3 na 45.4 na 4,483 Total 1996-1997 BDHS 150.2 17.3 4,457 18.8 na 52.0 na 3,921 Note: BMI is weight in kilograms divided by height in meters squared (kg/m2) 1 Excludes pregnant women and women with a birth in the preceding two months na = Not applicable Knowledge of HIV/AIDS and other STIs │ 185 KNOWLEDGE, ATTITUDES, AND BEHAVIOR RELATED TO HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS 12 Acquired immunodeficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV), which weakens the immune system and makes the body susceptible to and unable to recover from other opportunistic diseases, which lead to death if not adequately treated. The virus is generally transmitted through sexual contact, from infected mother to child during delivery or breastfeeding, or through contaminated needles (injections) or blood. In Bangladesh, there have been various efforts to prevent HIV transmission, such as public health education through the media and program activities of both government and nongovernmental organizations, particularly with groups that are considered to be at high risk for the transmission of HIV/AIDS. The 2004 BDHS included a section of questions on HIV/AIDS in order to assess knowledge and attitudes about the transmission and prevention of HIV/AIDS. The survey also included questions on sexually transmitted infections (STIs) to assess the level of knowledge about STIs and the proportion of respondents who reported having an STI or a symptom of an STI. 12.1 KNOWLEDGE OF HIV/AIDS Table 12.1.1 and Table 12.1.2 show the percentage of ever-married women and all men (ever-married and never-married), respectively, who have heard of HIV/AIDS, by background characteristics. Six in ten women and more than eight in ten men in Bangladesh have heard of HIV/AIDS. The level of knowledge has been increasing significantly since 1996-1997 (Figure 12.1). Knowledge of HIV/AIDS for ever-married women has increased from 19 percent in 1996-97 to 31 percent in 1999-2000, and then almost doubled by 2004 to 60 percent. The corresponding increase in knowledge among currently married men age 15-54 has been from 34 percent in 1996-97 to 51 percent in 1999-2000 and 78 percent in 2004.1 Generally, younger men and women are more likely to have knowledge of HIV/AIDS. Urban residents have a substantially higher level of knowledge about HIV/AIDS than rural residents, especially women (Figure 12.2). Eighty-two percent of women and 93 percent of men in urban areas have heard of HIV/AIDS, compared with 54 percent of women and 78 percent of men in rural areas. Awareness of HIV/AIDS is lower in Sylhet and Rajshahi, compared with the other divisions. Education is positively associated with knowledge of HIV/AIDS. The level of HIV/AIDS knowledge is low among uneducated women (37 percent), increases to 71 percent among women who have completed primary school only, and increases again to virtually all women (98 percent) with completed secondary education. A similar pattern exists for men. Awareness about HIV/AIDS is also positively associated with household economic status. For example, three in ten women in the lowest wealth quintile have heard about HIV/AIDS, compared with nine in ten women in the highest wealth quintile. For men, a similar pattern is observed, except that the difference in knowledge between the highest and lowest quintiles is not as large as that for women. 1 Direct comparison of the 1996-1997 and 1999-2000 BDHS surveys with the 2004 BDHS survey cannot be made for men because earlier surveys included married men age 15-64 years and 15-59 years, respectively. In comparing the results of the three surveys, statistics for currently married men for earlier surveys have been recalculated for men age 15- 54. The results published in the 1996-1997 and 1999-2000 BDHS reports for currently married men age 15-64 and 15-59 years, respectively, are lower than those calculated for men age 15-54. 186 │ Knowledge of HIV/AIDS and other STIs As part of the AIDS prevention program, the mass media are playing a major role in creating awareness among the general public. Tables 12.1.1 and 12.1.2 show the percentage of respondents who have heard of AIDS from specific sources and the mean number of sources for such information. Television is by far Table 12.1.1 Knowledge of HIV/AIDS and sources of AIDS information: women Percentage of ever-married women who have ever heard of HIV/AIDS, percentage who have received information about HIV/AIDS from specific sources, and mean number of sources of information about HIV/AIDS, by background characteristics, Bangladesh 2004 Source of HIV/AIDS information Background characteristic Ever heard of HIV/AIDS Radio TV News- papers Pam- phlets Health workers Mosques/ churches School Com- munity meetings Friend/ relative Work- place Bill- board Other Number of ever- married women Mean number of sources1 Age 10-14 61.9 29.7 49.1 3.5 1.8 2.8 0.0 0.0 1.1 21.1 0.0 2.5 0.0 150 1.8 15-19 70.9 32.9 56.6 4.3 3.5 6.1 0.1 0.9 0.3 24.8 0.6 1.9 0.5 1,598 1.9 20-24 69.5 30.3 55.8 4.1 3.0 7.2 0.0 0.9 0.8 26.9 0.3 2.9 0.5 2,202 1.9 25-29 62.1 21.8 47.1 4.6 2.4 6.0 0.0 0.4 1.2 25.5 0.4 2.9 0.6 2,013 1.8 30-39 55.6 17.1 39.4 3.1 1.5 6.4 0.1 0.2 1.1 23.3 0.7 2.3 0.4 3,251 1.7 40-49 47.1 13.0 31.6 3.0 0.9 4.2 0.1 0.1 1.0 20.5 0.4 1.4 0.9 2,227 1.6 15-24 70.1 31.4 56.1 4.2 3.2 6.7 0.0 0.9 0.6 26.0 0.5 2.5 0.5 3,800 1.9 Marital status Currently married 61.0 22.7 45.8 3.8 2.3 6.1 0.0 0.5 0.9 24.4 0.5 2.4 0.5 10,582 1.8 Divorced/separated/ widowed 47.8 13.3 33.7 2.2 0.7 4.1 0.0 0.3 0.6 19.1 0.6 1.3 0.9 858 1.6 Residence Urban 81.7 21.3 72.7 8.1 3.8 8.4 0.0 0.8 0.9 30.0 0.7 4.8 0.5 2,586 1.9 Rural 53.7 22.3 36.8 2.4 1.7 5.3 0.1 0.4 0.9 22.3 0.4 1.6 0.6 8,854 1.8 Division Barisal 60.2 29.3 37.7 2.6 2.6 7.5 0.0 0.5 0.6 26.1 0.4 2.6 0.2 719 1.8 Chittagong 59.1 21.5 46.1 4.1 1.6 5.7 0.0 0.2 0.4 21.1 0.3 1.6 0.5 2,041 1.7 Dhaka 66.9 21.8 52.6 4.4 2.5 6.0 0.1 0.5 1.2 26.9 0.8 3.0 0.5 3,570 1.8 Khulna 72.6 28.9 52.6 3.6 2.1 7.3 0.0 1.0 1.2 32.1 0.3 2.9 0.9 1,397 1.8 Rajshahi 49.9 19.9 36.0 2.7 2.2 5.2 0.0 0.3 0.9 19.5 0.4 1.6 0.4 2,994 1.8 Sylhet 45.4 12.8 32.8 4.0 1.5 5.1 0.1 0.3 0.9 19.1 0.4 2.6 1.3 719 1.8 Education No education 37.1 10.0 23.4 0.0 0.1 3.7 0.0 0.1 0.8 16.3 0.3 0.2 0.4 4,713 1.5 Primary incomplete 59.0 18.9 41.4 0.5 0.5 6.1 0.0 0.1 0.9 24.9 0.4 0.6 0.8 2,348 1.6 Primary complete 71.4 25.9 53.2 2.0 0.7 6.8 0.0 0.6 1.4 28.9 0.4 1.5 0.6 1,011 1.7 Secondary incomplete 86.3 38.3 70.1 5.8 4.1 8.3 0.1 0.7 1.0 33.3 0.4 4.0 0.6 2,541 1.9 Secondary complete or higher 98.4 44.6 90.1 29.1 13.9 10.5 0.0 2.7 1.0 31.3 2.3 14.5 0.6 827 2.4 Wealth index Lowest 28.9 8.3 14.3 0.1 0.2 3.4 0.0 0.0 0.7 13.5 0.3 0.3 0.3 2,279 1.4 Second 44.6 16.2 26.6 1.0 0.8 4.2 0.0 0.0 1.0 21.3 0.5 0.5 0.7 2,290 1.6 Middle 58.7 24.2 38.5 1.6 1.7 6.2 0.0 0.5 1.0 24.7 0.2 1.8 0.4 2,267 1.7 Fourth 75.0 31.5 59.7 3.4 2.2 6.9 0.2 0.8 1.0 28.9 0.5 2.7 0.7 2,307 1.8 Highest 92.4 29.9 85.0 12.2 5.8 9.2 0.0 1.0 0.8 31.6 0.9 6.2 0.7 2,297 2.0 Total 60.0 22.0 44.9 3.7 2.1 6.0 0.0 0.5 0.9 24.0 0.5 2.3 0.6 11,440 1.8 1 Mean number of sources is based on women who have heard of HIV/AIDS. the most important source of information about HIV/AIDS: 45 percent of women and 68 percent of men report television as a source of their information about HIV/AIDS. Other significant sources for both men and women are the radio and friends and relatives. For men, newspapers are an important source of information about HIV/AIDS (one in five men mentioned them as a source), while very few women (4 percent) were aware of HIV/AIDS through newspapers. Knowledge of HIV/AIDS and other STIs │ 187 Table 12.1.2 Knowledge of HIV/AIDS and sources of AIDS information: men Percentage of men who have ever heard of HIV/AIDS, percentage who have received information about HIV/AIDS from specific sources, and mean number of sources of information about HIV/AIDS, by background characteristics, Bangladesh 2004 Source of HIV/AIDS information Background characteristic Ever heard of HIV/AIDS Radio TV News- papers Pam- phlets Health workers Mosques/ churches School Com- munity meetings Friend/ relative Work- place Bill- board Other Number of men Mean number of sources1 Age 15-19 86.4 40.5 75.0 15.9 10.9 9.8 0.1 4.4 1.5 25.3 0.4 12.0 2.2 822 2.3 20-24 90.9 48.2 83.1 23.1 9.9 12.6 0.0 1.2 2.5 30.3 0.5 13.5 3.9 660 2.5 25-29 87.6 42.1 73.1 24.6 5.4 18.9 0.1 0.9 1.2 30.7 1.5 12.8 6.0 589 2.5 30-39 81.0 36.7 66.8 16.9 3.1 16.4 0.2 1.0 1.7 27.5 1.5 10.4 2.2 1,026 2.3 40-49 72.6 34.1 56.7 16.9 2.5 13.9 0.1 0.3 2.2 26.4 1.0 7.8 2.4 957 2.3 50-54 68.0 30.4 46.2 17.4 4.8 15.3 0.0 0.0 2.8 25.9 1.4 5.6 2.2 242 2.2 15-24 88.4 43.9 78.6 19.1 10.5 11.0 0.1 2.9 1.9 27.5 0.5 12.7 2.9 1,482 2.4 Marital status Never married 89.3 42.8 79.7 22.9 11.1 10.7 0.1 3.0 1.7 26.6 0.9 15.1 3.5 1,474 2.4 Currently married 78.0 37.4 62.5 16.9 3.3 16.1 0.1 0.5 2.0 28.4 1.1 8.4 2.7 2,780 2.3 Divorced/separated/ widowed (71.6) (7.4) (52.1) (90.0) (0.0) (18.0) (0.0) (7.0) (0.0) (10.2) (0.0) (3.8) (4.6) 43 1.4 Residence Urban 93.0 34.5 84.9 29.2 9.8 12.3 0.1 0.9 2.4 32.3 1.7 20.3 3.7 1,042 2.5 Rural 78.3 40.5 63.0 15.4 4.7 14.9 0.1 1.6 1.7 26.1 0.8 7.6 2.8 3,255 2.3 Division Barisal 82.3 53.3 64.1 19.1 6.9 11.9 0.0 1.3 1.4 19.8 0.5 12.3 3.7 225 2.4 Chittagong 81.4 29.6 72.7 18.7 5.2 11.6 0.1 1.2 0.4 25.2 0.2 9.2 2.6 739 2.2 Dhaka 84.6 39.8 69.9 19.4 6.3 15.1 0.1 1.1 2.4 31.0 1.1 13.6 2.7 1,342 2.4 Khulna 91.7 47.3 76.9 21.2 9.9 15.3 0.1 2.7 2.4 33.2 2.3 14.4 3.8 573 2.5 Rajshahi 75.2 40.2 62.4 17.2 3.8 16.1 0.0 1.5 2.5 25.3 0.8 6.3 3.5 1,114 2.4 Sylhet 76.3 27.8 59.2 16.9 5.9 9.9 0.3 1.1 0.5 22.5 1.9 8.7 2.0 304 2.1 Education No education 61.2 26.8 42.4 0.5 0.6 9.0 0.1 0.2 1.8 26.6 0.8 0.8 2.3 1,057 1.8 Primary incomplete 76.2 34.6 60.5 6.1 1.6 12.0 0.0 0.4 2.0 30.4 1.0 3.5 2.2 1,152 2.0 Primary complete 89.4 41.5 75.2 14.3 2.9 20.1 0.0 1.2 1.7 27.5 0.2 11.5 1.4 345 2.2 Secondary incomplete 95.1 43.8 85.2 25.9 11.1 18.0 0.2 2.8 1.7 28.4 1.3 15.3 3.6 1,045 2.5 Secondary complete or higher 98.9 56.4 91.8 58.8 14.9 17.5 0.2 3.2 2.1 23.4 1.4 30.0 5.3 698 3.1 Wealth index Lowest 61.1 28.4 42.0 3.8 1.1 11.5 0.0 0.3 0.8 23.5 0.3 3.5 2.5 717 1.9 Second 71.1 33.5 53.4 7.9 3.5 11.7 0.0 1.3 1.4 24.5 0.6 3.9 1.9 869 2.0 Middle 82.6 42.2 67.2 16.6 4.2 17.7 0.0 0.7 2.3 28.3 0.9 7.7 3.4 846 2.3 Fourth 90.5 46.9 80.4 23.1 6.9 16.1 0.2 2.0 2.5 30.5 1.4 11.4 3.5 892 2.5 Highest 98.2 41.7 90.9 37.4 12.3 13.9 0.4 2.4 2.1 30.2 1.8 23.9 3.7 973 2.7 Total 81.9 39.0 68.3 18.7 5.9 14.3 0.1 1.4 1.9 27.6 1.0 10.7 3.0 4,297 2.3 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Mean number of sources is based on men who have heard of HIV/AIDS. 188 │ Knowledge of HIV/AIDS and other STIs 12.2 KNOWLEDGE OF WAYS TO AVOID HIV/AIDS Tables 12.2.1 and 12.2.2 show the percentage of ever-married women and all men, respectively. who have heard of HIV/AIDS by knowledge of ways to avoid contracting the disease. To ascertain knowledge about modes of HIV/AIDS transmission, respondents were asked general questions as to whether there is anything a person can do to avoid getting AIDS or the virus that causes AIDS and, if so, what can be done. Six percent of women who have heard of HIV/AIDS reported that there is no way to avoid getting AIDS or the virus that causes AIDS and 18 percent do not know if AIDS can be avoided. These knowledge gaps are much smaller among men. The proportions of ever-married women and currently married men who said that there is no way to avoid AIDS and who do not know if AIDS can be avoided has declined sharply since 1999- 2000. Knowledge of HIV/AIDS and other STIs │ 189 Table 12.2.1 Knowledge of ways to avoid HIV/AIDS: women Among ever-married women who know of HIV/AIDS, percentage who know of ways to avoid contracting the disease, by background characteristics, Bangladesh 2004 Correct ways to avoid HIV/AIDS Incorrect ways to avoid HIV/AIDS Background characteristic Does not know if AIDS can be avoided Believes no way to avoid AIDS Does not know specific way Abstain from sex Use con- doms Limit sex to one partner/ stay faithful to one partner Avoid sex with prosti- tutes Avoid sex with persons who have many part- ners Avoid sex with homo- sexuals Avoid sex with persons who inject drugs intra- venously Avoid blood trans- fusions Avoid injections Avoid sharing razors/ blades Avoid kissing Avoid mos- quito bites Seek pro- tection from tradi- tional healer Other Number of ever- married women who know of HIV/AIDS Age 15-19 17.5 2.0 2.5 8.6 39.8 35.3 21.1 16.0 2.8 6.2 10.6 22.2 0.0 0.0 0.0 2.1 1.6 93 20-24 17.3 5.9 4.6 9.7 40.4 33.9 14.4 15.7 0.5 1.1 12.6 27.8 0.5 0.1 0.2 0.9 1.1 1,133 25-29 13.1 5.4 4.3 13.1 44.9 34.4 17.6 18.8 0.5 1.7 13.2 27.5 0.7 0.2 0.4 0.9 0.9 1,530 30-39 18.5 5.8 5.1 11.3 39.6 31.3 17.1 19.1 0.5 1.2 13.2 24.2 2.0 0.4 0.2 0.9 1.2 1,251 40-49 20.1 6.7 7.0 10.8 31.3 27.4 17.7 18.4 0.5 1.1 10.1 20.9 0.5 0.2 0.1 1.5 1.4 1,808 50-54 24.2 8.1 8.5 10.1 24.6 22.8 15.1 15.9 0.3 0.4 8.1 17.3 0.4 0.0 0.6 1.9 1.3 1,049 15-24 14.9 5.7 4.4 11.6 43.0 34.2 16.2 17.5 0.5 1.4 13.0 27.6 0.6 0.1 0.3 0.9 1.0 2,664 Marital status Currently married 17.9 6.2 5.8 11.2 37.3 30.5 16.8 17.9 0.5 1.2 11.8 24.0 0.8 0.2 0.3 1.1 1.2 6,454 Divorced/separated/ widowed 25.9 7.3 6.4 8.7 23.0 24.7 14.9 15.2 0.1 0.7 7.1 16.9 0.8 0.2 0.0 2.4 0.5 410 Residence Urban 10.7 4.2 5.1 11.7 46.0 33.4 21.3 22.5 0.7 1.5 17.6 32.3 1.0 0.3 0.2 0.5 1.1 2,113 Rural 21.8 7.2 6.1 10.8 32.2 28.7 14.6 15.7 0.4 1.1 8.7 19.7 0.7 0.1 0.3 1.5 1.2 4,751 Division Barisal 22.0 4.4 9.5 13.1 28.5 26.6 11.5 17.1 0.2 0.8 7.2 21.6 0.3 0.2 0.8 2.2 0.9 433 Chittagong 17.0 8.1 4.9 10.3 37.4 30.4 18.7 12.0 0.4 0.5 10.7 23.6 0.5 0.5 0.0 1.4 0.7 1,207 Dhaka 17.6 5.4 5.8 11.5 36.9 29.5 16.8 20.6 0.6 1.5 12.4 25.3 1.0 0.2 0.3 1.1 1.2 2,388 Khulna 19.9 6.5 5.7 12.1 35.3 27.2 20.5 19.4 1.3 2.4 13.2 26.1 0.9 0.0 0.2 0.3 0.5 1,014 Rajshahi 17.1 5.7 5.9 7.8 40.1 36.9 13.3 18.0 0.1 0.9 11.6 21.9 0.7 0.0 0.3 1.6 1.6 1,495 Sylhet 25.7 10.8 3.8 19.4 27.4 16.0 18.3 13.0 0.0 0.3 7.3 13.0 1.1 0.0 0.7 1.1 3.1 327 Education No education 29.2 9.1 8.5 7.6 22.0 23.2 14.0 14.1 0.3 0.5 5.7 10.9 0.5 0.1 0.1 1.3 0.8 1,749 Primary incomplete 22.8 7.7 6.7 10.4 27.9 29.1 13.0 16.4 0.1 0.9 6.3 16.0 0.4 0.2 0.2 1.5 1.2 1,385 Primary complete 19.2 6.3 4.8 12.9 36.4 28.2 15.3 17.4 0.5 0.9 8.7 18.3 0.8 0.0 0.1 1.2 1.9 722 Secondary incomplete 12.5 5.0 4.9 11.6 43.2 33.8 17.8 19.6 0.7 1.4 13.8 28.8 0.9 0.1 0.4 1.3 1.1 2,194 Secondary complete or higher 2.7 1.2 1.7 16.7 63.9 38.7 26.9 23.2 1.1 3.1 28.7 54.3 1.6 0.5 0.8 0.3 1.5 814 Wealth index Lowest 34.6 9.0 7.0 5.6 20.8 21.7 10.1 11.7 0.3 0.2 2.6 9.2 0.0 0.2 0.2 1.8 0.9 659 Second 26.8 10.8 8.1 8.1 24.2 24.7 12.4 13.9 0.4 1.1 6.1 12.6 0.2 0.0 0.1 1.0 1.3 1,021 Middle 21.2 7.8 6.1 10.3 30.2 31.2 13.2 15.8 0.5 1.2 7.7 16.5 0.5 0.2 0.2 2.0 1.3 1,332 Fourth 16.9 5.4 6.3 11.4 36.1 30.7 15.5 18.2 0.2 1.0 11.2 25.1 1.3 0.1 0.4 1.2 0.9 1,730 Highest 8.8 3.0 3.8 14.4 51.4 34.2 23.9 22.4 0.9 1.8 19.4 36.5 1.0 0.3 0.4 0.7 1.3 2,123 Total 18.4 6.3 5.8 11.1 36.5 30.1 16.7 17.8 0.5 1.2 11.5 23.6 0.8 0.2 0.3 1.2 1.2 6,864 The most frequently cited way to avoid contracting HIV/AIDS by both women and men is condom use, cited by 37 percent of women and 50 percent of men. Knowledge of condom use as a way to avoid HIV/AIDS has increased significantly in the past four years. In the 1999-2000 BDHS, only 16 percent of the ever-married women under age 50 and 18 percent of currently married men age 15-54 cited condom use as a way to avoid HIV/AIDS. Men are less likely than women to cite limiting the number of sexual partners as a way to avoid AIDS. Almost one in three currently married women and only one in eight men (and one in eight currently married men) said that limiting the number of sexual partners can prevent HIV/AIDS. The proportion of women and men who reported that abstinence from sex can help prevent the spread of the disease is almost the same (11 and 12 percent, respectively). Awareness that HIV/AIDS can be transmitted through shared needles seems to have increased noticeably among both men and women in the past four years. 190 │ Knowledge of HIV/AIDS and other STIs Table 12.2.2 Knowledge of ways to avoid HIV/AIDS: men Among men who know of HIV/AIDS, percentage who know of ways to avoid contracting the disease, by background characteristics, Bangladesh 2004 Correct ways to avoid HIV/AIDS Incorrect ways to avoid HIV/AIDS Background Characteristic Does not know if AIDS can be avoided Believes no way to avoid AIDS Does not know specific way Abstain from sex Use con- doms Limit sex to one partner/ stay faithful to one partner Avoid sex with prosti- tutes Avoid sex with persons who have many part- ners Avoid sex with homo- sexuals Avoid sex with persons who inject drugs intra- venously Avoid blood trans- fusions Avoid injections Avoid sharing razors/ blades Avoid kissing Avoid mos- quito bites Seek pro- tection from tradi- tional healer Other Number of men who know of HIV/AIDS Age 15-19 8.8 3.3 8.1 15.4 52.8 10.3 13.5 1.5 1.5 1.6 15.9 29.9 1.8 0.2 0.4 1.9 2.3 710 20-24 3.0 1.3 5.6 13.6 55.9 13.0 18.7 0.5 1.9 3.7 16.9 31.0 3.4 0.3 0.2 1.8 0.6 600 25-29 3.5 1.1 7.0 12.6 60.7 11.3 19.7 1.9 1.2 1.9 11.5 19.0 4.3 0.0 0.0 1.3 1.4 516 30-39 5.9 2.4 8.7 10.7 47.2 13.1 17.6 2.1 1.5 2.3 8.2 16.0 2.6 0.5 0.0 3.3 2.5 831 40-49 6.6 2.6 10.9 8.7 39.5 9.8 18.1 1.4 0.4 0.9 4.8 14.9 2.3 0.0 0.6 3.1 3.6 695 50-54 9.4 3.3 9.6 7.1 34.3 15.5 20.2 0.9 1.2 1.1 8.6 17.4 0.8 0.0 0.0 1.9 2.0 165 15-24 6.2 2.4 7.0 14.6 54.3 11.5 15.9 1.0 1.7 2.5 16.4 30.4 2.5 0.2 0.3 1.8 1.6 1,311 Marital status Never married 5.5 2.0 6.8 15.2 57.2 10.6 16.8 1.6 2.0 3.0 17.3 31.9 3.3 0.2 0.3 2.1 1.6 1,317 Currently married 6.2 2.5 9.2 9.7 45.3 12.4 18.1 1.3 0.9 1.4 7.4 15.6 2.3 0.2 0.2 2.4 2.6 2,170 Divorced/separated/ widowed (6.4) (0.0) (7.0) (21.7) (35.6) (12.8) (5.1) (10.9) (0.0) (0.0) (0.0) (5.8) (0.0) (0.0) (0.0) (9.8) (0.0) 31 Residence Urban 3.7 1.3 5.4 13.4 59.1 11.7 24.2 1.7 1.8 2.0 13.4 26.5 4.8 0.4 0.0 1.0 2.6 968 Rural 6.8 2.7 9.4 11.3 46.1 11.7 14.9 1.4 1.1 2.0 10.2 19.8 1.9 0.1 0.3 2.9 2.0 2,549 Division Barisal 1.7 4.2 8.2 18.5 49.9 12.9 17.1 3.2 0.2 0.1 6.6 20.2 4.0 0.9 0.0 0.0 2.9 185 Chittagong 5.7 0.8 12.3 10.6 45.2 7.7 18.2 0.9 1.8 0.7 8.0 24.8 1.8 0.3 0.6 2.5 1.9 602 Dhaka 8.5 2.2 4.9 13.5 49.1 13.7 17.0 1.3 1.5 2.3 12.6 23.2 2.4 0.2 0.0 2.3 2.9 1,135 Khulna 3.9 1.9 6.4 13.3 58.2 12.8 18.0 2.0 0.5 3.4 14.8 24.5 3.8 0.0 0.5 2.8 1.9 525 Rajshahi 4.2 2.7 9.5 8.4 51.2 10.5 16.3 1.2 0.9 1.9 11.1 19.1 2.8 0.0 0.2 2.6 1.4 838 Sylhet 8.4 4.4 14.4 11.3 39.3 13.1 21.6 2.5 3.1 2.5 6.6 9.9 2.4 0.1 0.0 2.4 2.5 232 Education No education 10.3 6.4 13.6 5.2 28.2 8.5 13.4 1.2 0.8 0.2 2.2 6.1 0.3 0.0 0.2 2.8 1.6 647 Primary incomplete 8.6 3.0 12.7 9.4 40.1 10.8 16.7 0.5 0.7 1.4 4.0 8.9 1.2 0.0 0.4 3.6 1.9 878 Primary complete 4.4 0.9 7.1 11.4 49.7 12.4 14.1 0.4 1.1 2.0 6.1 17.6 2.5 0.7 0.0 1.3 1.8 308 Secondary incomplete 4.4 1.0 5.3 12.8 58.6 11.7 17.4 2.5 1.8 2.1 15.3 29.0 2.4 0.1 0.3 2.4 2.5 994 Secondary complete or higher 1.4 0.0 2.5 20.0 69.2 15.5 23.9 2.1 1.9 4.3 24.6 43.6 7.2 0.5 0.0 0.8 3.0 691 Wealth index Lowest 12.5 6.5 15.3 8.3 33.4 8.0 11.6 0.7 0.7 0.5 2.5 6.5 0.4 0.0 0.0 2.7 1.0 438 Second 9.1 3.2 12.2 10.3 38.2 9.7 14.4 1.5 1.3 1.7 6.4 12.1 1.7 0.0 0.0 2.9 2.0 617 Middle 6.1 2.6 9.4 11.7 45.6 13.3 15.2 1.2 0.7 0.9 8.4 16.9 0.9 0.4 0.3 4.0 2.4 699 Fourth 4.9 1.4 6.4 13.6 53.2 12.9 17.0 1.3 1.2 3.4 15.0 27.5 3.0 0.0 0.6 1.9 2.3 807 Highest 1.7 0.3 3.3 13.1 64.6 12.4 24.3 2.3 2.0 2.5 16.7 33.3 5.4 0.4 0.1 1.0 2.6 956 Total 5.9 2.3 8.3 11.9 49.7 11.7 17.5 1.5 1.3 2.0 11.1 21.7 2.7 0.2 0.2 2.4 2.2 3,517 Note: Figures in parentheses are based on 25-49 unweighted cases. The proportion of women and men reporting each of the correct2 ways to avoid contracting AIDS is lower among rural than among urban respondents; however, the urban-rural gap in correct knowledge is wider for women than for men. The level of education and the wealth index are positively associated with knowledge of correct ways to avoid HIV/AIDS. 2 The following are considered correct ways: abstain from sex, use condom, limit sex with persons who have many partners, avoid sex with homosexuals, avoid sex with persons who inject drugs intravenously, avoid blood transfusions, and avoid injections. Knowledge of HIV/AIDS and other STIs │ 191 Table 12.3.1 shows the percent distribution of ever-married women with knowledge of correct ways to avoid HIV/AIDS. Six in ten women do not know any way to avoid HIV/AIDS. In the 2004 BDHS, about 30 percent of ever-married women were able to mention two or more correct ways to avoid getting HIV/AIDS. As far as specific ways to avoid HIV/AIDS, one-fifth of ever-married women mentioned condoms, and a slightly lower proportion mentioned limiting the number of sexual partners, limiting sex to one partner, and/or staying faithful to one partner. Table 12.3.1 Knowledge of HIV/AIDS and its prevention: women Percent distribution of ever-married women by knowledge of correct ways to avoid HIV/AIDS, and percentage of women who know of two specific ways to avoid HIV/AIDS, according to background characteristics, Bangladesh 2004 Knows no correct way to avoid HIV/AIDS Knowledge of specific ways to avoid HIV/AIDS Knows one or more correct ways to avoid HIV/AIDS Background characteristic Does not know of HIV/AIDS Knows of HIV/AIDS but does not know any correct ways One way Two or more ways Total Use condoms Limit number of sexual partners1 Number of ever- married women Age 10-14 38.1 14.9 12.3 34.8 100.0 24.7 21.9 150 15-19 29.1 20.4 13.5 37.0 100.0 28.6 24.0 1,598 20-24 30.5 16.4 13.8 39.3 100.0 31.2 23.9 2,202 25-29 37.9 18.9 11.4 31.8 100.0 24.6 19.4 2,013 30-39 44.4 19.7 11.0 24.9 100.0 17.4 15.2 3,251 40-49 52.9 20.3 9.4 17.4 100.0 11.6 10.7 2,227 Marital status Currently married 39.0 19.0 11.7 30.3 100.0 22.8 18.6 10,582 Divorced/separated/widowed 52.2 19.8 11.1 16.8 100.0 11.0 11.8 858 Residence Urban 18.3 17.0 15.2 49.6 100.0 37.6 27.3 2,586 Rural 46.3 19.7 10.7 23.3 100.0 17.3 15.4 8,854 Division Barisal 39.8 23.1 12.3 24.8 100.0 17.2 16.0 719 Chittagong 40.9 18.6 12.1 28.4 100.0 22.1 18.0 2,041 Dhaka 33.1 20.0 13.4 33.5 100.0 24.7 19.8 3,570 Khulna 27.4 23.7 11.1 37.9 100.0 25.6 19.8 1,397 Rajshahi 50.1 15.2 10.0 24.8 100.0 20.0 18.4 2,994 Sylhet 54.6 19.2 9.4 16.9 100.0 12.4 7.3 719 Education No education 62.9 17.9 7.2 12.0 100.0 8.2 8.6 4,713 Primary incomplete 41.0 22.7 12.3 24.0 100.0 16.5 17.1 2,348 Primary complete 28.6 22.9 15.9 32.7 100.0 26.0 20.2 1,011 Secondary incomplete 13.7 20.6 17.4 48.3 100.0 37.3 29.2 2,541 Secondary complete or higher 1.6 6.1 12.5 79.8 100.0 62.9 38.1 827 Wealth index Lowest 71.1 15.2 5.9 7.8 100.0 6.0 6.3 2,279 Second 55.4 20.8 8.7 15.1 100.0 10.8 11.0 2,290 Middle 41.3 21.9 12.9 24.0 100.0 17.7 18.3 2,267 Fourth 25.0 22.3 15.3 37.3 100.0 27.1 23.0 2,307 Highest 7.6 15.2 15.5 61.7 100.0 47.5 31.6 2,297 Total 40.0 19.1 11.7 29.2 100.0 21.9 18.1 11,440 Note: See top of Table 12.2.1 correct ways to avoid HIV/AIDS. 1Refers to limiting number of sexual partners, limiting sex to one partner, or staying faithful to one partner 192 │ Knowledge of HIV/AIDS and other STIs Table 12.3.2 shows similar data for all men. Forty-two percent of men do not know of any way to avoid HIV/AIDS. One-third of men know two or more correct ways to avoid the disease. Knowledge of ways to avoid the disease is much lower among married men than among never-married men. One-fourth of currently married men and 44 percent of never-married men know two or more correct ways to avoid HIV/AIDS. Table 12.3.2 Knowledge of HIV/AIDS and its prevention: men Percent distribution of men by knowledge of correct ways to avoid HIV/AIDS, and percentage of men who know of two specific ways to avoid HIV/AIDS, according to background characteristics, Bangladesh 2004 Knows no correct way to avoid HIV/AIDS Knowledge of specific ways to avoid HIV/AIDS Knows one or more correct ways to avoid HIV/AIDS Background characteristic Does not know of HIV/AIDS Knows of HIV/AIDS but does not know any correct ways One way Two or more ways Total Use condoms Limit number of sexual partners1 Number of men Age 10-14 13.6 25.2 21.2 40.1 100.0 45.7 8.9 822 15-19 9.1 17.9 28.2 44.8 100.0 50.9 11.8 660 20-24 12.4 19.2 31.6 36.8 100.0 53.2 9.9 589 25-29 19.0 24.9 28.4 27.6 100.0 38.2 10.6 1,026 30-39 27.4 28.6 24.2 19.8 100.0 28.7 7.1 957 40-49 32.0 26.6 20.4 21.0 100.0 23.3 10.5 242 Marital status Never married 10.7 20.2 25.4 43.8 100.0 51.1 9.4 1,474 Currently married 22.0 26.1 26.3 25.6 100.0 35.4 9.6 2,780 Divorced/separated/widowed (8.4) (21.6) (31.6) (18.4) 100.0 (25.5) (9.1) 43 Residence Urban 7.0 18.4 30.7 43.9 100.0 54.9 10.9 1,042 Rural 21.7 25.8 24.6 27.9 100.0 36.1 9.2 3,255 Division Barisal 17.7 20.8 29.1 32.4 100.0 41.0 10.7 225 Chittagong 18.6 25.7 25.8 29.9 100.0 36.8 6.3 739 Dhaka 15.4 24.3 26.2 34.1 100.0 41.5 11.6 1,342 Khulna 8.3 21.8 26.7 43.1 100.0 53.4 11.7 573 Rajshahi 24.8 23.7 25.0 26.5 100.0 38.5 7.9 1,114 Sylhet 23.7 26.2 26.5 23.6 100.0 30.0 10.0 304 Education No education 38.8 31.5 20.5 9.2 100.0 17.2 5.2 1,057 Primary incomplete 23.8 30.1 26.5 19.6 100.0 30.5 8.2 1,152 Primary complete 10.6 24.5 35.3 29.6 100.0 44.4 11.1 345 Secondary incomplete 4.9 19.1 29.9 46.1 100.0 55.8 11.1 1,045 Secondary complete or higher 1.1 9.8 23.4 65.8 100.0 68.4 15.3 698 Wealth index Lowest 38.9 30.4 19.3 11.4 100.0 20.4 4.9 717 Second 28.9 29.9 21.3 19.8 100.0 27.2 6.9 869 Middle 17.4 27.2 28.1 27.3 100.0 37.7 11.0 846 Fourth 9.5 21.5 27.7 41.3 100.0 48.1 11.7 892 Highest 1.8 13.7 31.9 52.7 100.0 63.4 12.2 973 Total 18.1 24.0 26.0 31.8 100.0 40.7 9.6 4,297 Note: See top of Table 12.2.2 for correct ways to avoid HIV/AIDS. Figures in parentheses are based on 25-49 unweighted cases. 1Refers to limiting number of sexual partners, limiting sex to one partner, or staying faithful to one partner Knowledge of HIV/AIDS and other STIs │ 193 Since 1999-2000, the unprompted knowledge of at least two correct ways to avoid HIV/AIDS has increased substantially among ever-married women, from 7 to 29 percent, and only moderately among currently married men age 15-54, from 19 to 26 percent (Figure 12.3). Although awareness of HIV/AIDS is much higher among currently married men (Figure 12.1), Figure 12.3 shows that the gender gap in knowledge of two or more correct ways to avoid HIV/AIDS has been completely eliminated since the 1999-2000 BDHS. 12.3 KNOWLEDGE OF HIV/AIDS-RELATED ISSUES AND COMMUNICATION WITH SPOUSES Ever-married women and all men who know of HIV/AIDS were asked whether they think that a healthy-looking person can have the AIDS virus and whether they think that HIV/AIDS can be transmitted from a mother to a child. The results of the responses are shown in Table 12.4. Among respondents who know of HIV/AIDS, seven in ten women and more than eight in ten men say that a healthy-looking person can have the AIDS virus. Women and men living in Barisal division and men in Khulna division have the highest awareness that a healthy-looking person can be infected with HIV. Since 1999-2000, the proportion of currently married men who know that a healthy-looking person can have the AIDS virus has increased substantially—from 66 to 85 percent. Table 12.4 also shows that 91 percent of ever-married women and all men who have heard of HIV/AIDS know that it can be transmitted from a mother to her child. Differentials in knowledge of mother- to-child transmission by background variables show a pattern similar to that observed for the knowledge that a healthy-looking person can have AIDS. 194 │ Knowledge of HIV/AIDS and other STIs Table 12.4 Perceptions of HIV/AIDS-related issues Percentage of ever-married women and all men who have heard of HIV/AIDS by perception of AIDS related issues, according to background characteristics, Bangladesh 2004 Percentage of ever-married women who think: Percentage of men who think: Background characteristic A healthy- looking person can have the AIDS virus HIV/AIDS can be transmitted from a mother to a child Number of ever-married women A healthy- looking person can have the AIDS virus HIV/AIDS can be transmitted from a mother to a child Number of men Age 10-14 65.7 88.5 150 na na na 15-19 69.2 90.8 1,598 78.7 88.9 710 20-24 70.5 92.2 2,202 84.0 93.6 600 25-29 70.9 91.9 2,013 84.7 90.2 516 30-39 71.3 90.5 3,251 85.3 91.9 831 40-49 69.5 90.3 2,227 85.5 88.7 695 50-54 na na na 87.4 94.3 165 15-24 69.9 91.6 2,664 81.1 91.0 1,311 Marital status Never married na na na 82.7 90.1 1,317 Currently married 70.7 91.3 6,454 84.6 91.3 2,170 Divorced/separated/ widowed 65.0 87.6 410 (70.9) (90.4) 31 Residence Urban 72.0 92.9 2,113 87.8 93.6 968 Rural 69.6 90.3 4,751 82.3 89.7 2,549 Division Barisal 83.7 93.3 433 89.4 93.7 185 Chittagong 65.4 89.4 1,207 83.8 92.0 602 Dhaka 68.1 92.3 2,388 79.8 89.4 1,135 Khulna 74.0 89.5 1,014 89.7 90.4 525 Rajshahi 71.9 91.4 1,495 85.3 92.4 838 Sylhet 69.1 89.9 327 80.1 87.2 232 Education No education 64.1 88.4 1,749 76.7 86.4 647 Primary incomplete 67.1 89.0 1,385 79.4 88.2 878 Primary complete 70.1 91.2 722 85.2 87.9 308 Secondary incomplete 73.5 92.7 2,194 84.5 93.0 994 Secondary complete or higher 81.2 96.4 814 94.2 96.4 691 Wealth index Lowest 67.2 87.4 659 74.4 87.2 438 Second 64.0 86.5 1,021 78.8 84.8 617 Middle 69.7 89.5 1,332 83.3 90.1 699 Fourth 70.4 92.5 1,730 84.5 93.4 807 Highest 74.8 94.4 2,123 91.0 94.7 956 Total 70.4 91.1 6,864 83.8 90.8 3,517 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable The 2004 BDHS respondents who are currently married were asked whether they ever discussed HIV/AIDS prevention with their spouse. It seems that only a few currently married men (24 percent) and Knowledge of HIV/AIDS and other STIs │ 195 fewer women (14 percent) discussed HIV/AIDS prevention with their spouse (Table 12.5). Urban residents, those with higher education, and those who come from the wealthiest households are most likely to have discussed HIV/AIDS prevention methods with their spouse. It may appear that since the 1999-2000 BDHS, spousal discussion of HIV/AIDS prevention methods has decreased for both currently married women and men; however, the results are not directly comparable because Table 12.5 is based on all currently married respondents while the corresponding tables in the 1999-2000 BDHS were based on currently married women and currently married men who had knowledge of HIV/AIDS. The adjusted 2004 BDHS results for knowledge of HIV/AIDS indicate that since 1999-2000, spousal discussion has remained virtually unchanged for currently married women and has increased by more than 40 percent for currently married men.3 Table 12.5 Discussion of HIV/AIDS with spouse Percent distribution of women and men who are currently married by whether they ever discussed HIV/AIDS prevention methods with their spouse, according to background characteristics, Bangladesh 2004 Women Men Background characteristic Ever discussed HIV/AIDS prevention methods Never discussed HIV/AIDS prevention methods Has not heard of AIDS Number of currently married women Ever discussed HIV/AIDS prevention methods Never discussed HIV/AIDS prevention methods Has not heard of AIDS Number of currently married men Age 10-14 7.2 53.8 38.9 145 na na na na 15-19 16.5 54.8 28.7 1,536 (38.8) (49.2) (12.1) 28 20-24 18.5 51.1 30.4 2,121 20.0 68.1 11.9 221 25-29 15.9 46.5 37.6 1,935 29.7 54.6 15.7 401 30-39 13.2 43.5 43.4 2,992 25.8 54.8 19.5 939 40-49 8.7 39.5 51.9 1,852 21.9 50.9 27.2 952 50-54 na na na na 16.8 51.3 31.8 240 15-24 17.7 52.6 29.7 3,657 22.1 66.0 11.9 249 Residence Urban 21.7 61.2 17.1 2,372 30.5 60.6 8.9 655 Rural 12.2 42.4 45.3 8,210 21.9 52.1 26.0 2,125 Division Barisal 14.9 45.9 39.1 674 27.4 50.3 22.3 146 Chittagong 10.0 50.2 39.8 1,877 20.4 58.0 21.7 422 Dhaka 16.0 51.5 32.5 3,315 26.0 55.6 18.5 866 Khulna 17.5 56.9 25.6 1,296 26.8 64.0 9.2 384 Rajshahi 13.9 37.0 49.1 2,782 21.4 48.5 30.0 805 Sylhet 13.6 33.0 53.4 638 24.7 44.0 31.3 157 Education No education 5.9 31.3 62.8 4,187 12.8 47.9 39.3 866 Primary incomplete 10.0 49.7 40.3 2,176 16.8 58.1 25.1 831 Primary complete 15.4 56.0 28.7 958 32.5 59.3 8.2 209 Secondary incomplete 23.5 62.9 13.5 2,457 32.4 59.7 7.9 504 Secondary complete or higher 41.1 57.4 1.5 804 49.5 49.1 1.4 370 Wealth index Lowest 4.5 24.4 71.1 2,042 11.7 46.1 42.2 552 Second 8.1 36.7 55.2 2,112 14.9 52.9 32.2 599 Middle 11.9 48.1 40.0 2,112 23.9 56.2 19.9 555 Fourth 19.1 56.6 24.4 2,168 30.4 57.9 11.6 520 Highest 27.6 66.0 6.4 2,148 39.7 57.7 2.5 554 Total 14.4 46.6 39.0 10,582 23.9 54.1 22.0 2,780 Note: Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 3 The adjusted percentages of currently married women and currently married men with knowledge of HIV/AIDS who had communication about HIV/AIDS with their spouse are 23.6 and 30.6, respectively. 196 │ Knowledge of HIV/AIDS and other STIs 12.4 AWARENESS, PREVALENCE, AND TREATMENT OF SEXUALLY TRANSMITTED INFECTIONS Tables 12.6.1 and 12.6.2 show the percentage of ever-married women and all men, respectively, who know of the signs and symptoms of sexually transmitted infections (STIs) other than HIV/AIDS, according to background characteristics. Knowledge of STI symptoms among ever-married women and currently married men has not changed much since 1999-2000. Ninety-four percent of women and 78 percent of currently married men do not have any knowledge of STIs. Ignorance about the symptoms of STI is higher among never-married men than among formerly and currently married men. Knowledge of STIs is highest among men and women who have completed secondary education (38 and 19 percent, respectively). Table 12.6.1 Knowledge of signs and symptoms of STIs: women Percent distribution of ever-married women by knowledge of signs and symptoms associated with sexually transmitted infections (STIs) other than HIV/AIDS, according to background characteristics, Bangladesh 2004 Knowledge of symptoms of STIs in a man Knowledge of symptoms of STIs in a woman Background characteristic No knowledge of STIs No symptoms One symptom Two or more symptoms No symptoms One symptom Two or more symptoms Number of ever- married women Age 10-14 94.3 4.3 0.0 1.4 4.3 0.2 1.2 150 15-19 96.4 2.4 0.5 0.7 2.4 0.3 0.9 1,598 20-24 93.6 3.7 1.1 1.6 3.5 1.4 1.5 2,202 25-29 92.7 4.0 0.9 2.3 3.7 1.0 2.6 2,013 30-39 93.4 3.0 1.3 2.3 2.9 1.0 2.7 3,251 40-49 92.3 3.9 1.2 2.6 3.9 1.2 2.6 2,227 15-24 94.8 3.1 0.9 1.2 3.0 1.0 1.2 3,800 Marital status Currently married 93.5 3.4 1.1 2.0 3.3 1.0 2.1 10,582 Divorced/separated/widowed 93.8 3.0 1.1 2.1 3.0 0.8 2.4 858 Residence Urban 90.3 5.0 1.3 3.4 4.9 1.4 3.4 2,586 Rural 94.5 2.9 1.0 1.6 2.8 0.9 1.8 8,854 Division Barisal 89.3 5.3 1.5 3.9 4.7 1.7 4.3 719 Chittagong 94.6 3.4 0.8 1.2 3.1 0.7 1.6 2,041 Dhaka 92.2 4.4 1.3 2.1 4.1 1.3 2.4 3,570 Khulna 92.8 3.8 0.8 2.6 4.1 0.9 2.3 1,397 Rajshahi 95.9 1.8 1.0 1.3 1.9 0.9 1.3 2,994 Sylhet 93.0 2.6 1.1 3.2 2.7 0.7 3.6 719 Education No education 96.7 1.4 0.6 1.2 1.5 0.5 1.3 4,713 Primary incomplete 95.1 2.4 0.9 1.5 2.6 0.8 1.5 2,348 Primary complete 92.1 4.3 1.1 2.5 4.2 1.0 2.8 1,011 Secondary incomplete 90.8 5.6 1.2 2.4 5.3 1.3 2.6 2,541 Secondary complete or higher 81.1 9.6 3.5 5.8 8.1 3.8 6.9 827 Wealth index Lowest 97.4 1.2 0.7 0.7 1.2 0.5 0.8 2,279 Second 96.9 1.6 0.6 1.0 1.7 0.3 1.1 2,290 Middle 93.8 3.2 1.1 2.0 3.0 1.1 2.2 2,267 Fourth 91.5 4.3 1.2 3.0 4.3 1.3 2.9 2,307 Highest 88.2 6.7 1.7 3.4 6.3 1.8 3.7 2,297 Total 93.5 3.4 1.1 2.0 3.3 1.0 2.1 11,440 Knowledge of HIV/AIDS and other STIs │ 197 Table 12.6.2 Knowledge of signs and symptoms of STIs: men Percent distribution of men by knowledge of signs and symptoms associated with sexually transmitted infections (STIs) other than HIV/AIDS, according to background characteristics, Bangladesh 2004 Knowledge of symptoms of STIs in a man Knowledge of symptoms of STIs in a woman Background characteristic No knowledge of STIs No symptoms One symptom Two or more symptoms No symptoms One symptom Two or more symptoms Number of men Age 10-14 92.3 4.3 1.2 2.1 6.0 0.7 0.9 822 15-19 87.9 4.2 2.7 5.2 8.2 1.7 2.3 660 20-24 79.2 7.1 3.4 10.3 12.8 2.6 5.3 589 25-29 76.0 6.8 5.0 12.2 13.8 3.7 6.5 1,026 30-39 77.0 7.1 3.5 12.4 12.7 3.5 6.8 957 40-49 79.7 4.6 4.6 11.2 10.5 3.6 6.2 242 15-24 90.3 4.3 1.9 3.5 7.0 1.1 1.5 1,482 Marital status Never married 88.1 4.8 2.1 5.0 8.6 1.3 1.9 1,474 Currently married 78.4 6.5 4.0 11.1 12.2 3.2 6.1 2,780 Divorced/separated/widowed (87.0) (2.6) (7.8) (2.6) (2.6) (7.8) (2.6) 43 Residence Urban 72.0 8.8 4.7 14.5 17.8 3.3 6.9 1,042 Rural 85.0 5.0 2.9 7.1 8.7 2.4 3.9 3,255 Division Barisal 75.5 7.5 3.8 13.2 15.6 3.8 5.1 225 Chittagong 82.6 7.3 2.5 7.6 12.6 1.6 3.1 739 Dhaka 80.0 5.2 4.8 10.0 11.8 3.2 5.0 1,342 Khulna 79.4 7.5 2.1 11.0 10.7 3.0 6.9 573 Rajshahi 84.5 5.4 3.3 6.8 8.6 2.3 4.5 1,114 Sylhet 87.3 3.7 1.4 7.7 7.7 1.9 3.0 304 Education No education 89.8 4.1 2.2 3.8 6.8 1.0 2.4 1,057 Primary incomplete 86.7 3.8 3.1 6.5 8.3 1.8 3.1 1,152 Primary complete 84.5 5.5 2.0 8.0 8.9 2.9 3.7 345 Secondary incomplete 80.9 6.4 3.9 8.8 12.2 2.9 4.0 1,045 Secondary complete or higher 61.7 11.6 5.5 21.2 20.4 5.9 12.1 698 Wealth index Lowest 90.0 3.2 2.0 4.8 5.5 1.6 3.0 717 Second 88.4 4.7 2.4 4.5 8.1 1.0 2.5 869 Middle 84.3 5.8 4.6 5.4 10.8 2.3 2.7 846 Fourth 80.2 5.9 2.8 11.2 10.9 3.4 5.6 892 Highest 69.3 9.1 4.7 16.8 17.4 4.5 8.7 973 Total 81.8 5.9 3.4 8.9 10.9 2.6 4.7 4,297 Note: Figures in parentheses are based on 25-49 unweighted cases. Information about the incidence of STIs is not only useful as a marker of unprotected sexual intercourse, but also as a cofactor for HIV transmission. The 2004 BDHS asked women for information on specific gynecological health problems that they had during the six months preceding the survey. Men were asked whether they had an STI in the 12 months preceding the survey or whether they had some specific symptoms related to an STI. Since information on health problems is based on self-reports rather than clinical tests or examinations, the results should be interpreted with caution. 198 │ Knowledge of HIV/AIDS and other STIs Table 12.7 shows the prevalence of gynecological health problems experienced by currently married women, according to their background characteristics. The prevalence is estimated from the self-reported experience with each of the following problems in the past six months: itching or irritation on/around genitals, genital sore, bad odor with discharge, abdominal pain with discharge (not related to menstruation), vaginal discharge accompanied by fever, pain and burning while urinating or frequent or difficult urination, painful intercourse, and bleeding after intercourse. One in five currently married women reported having had each of Table 12.7 Gynecological health problems Percentage of currently married women self-reporting gynecological health problems during the six months preceding the survey, by specific problem and background characteristics, Bangladesh 2004 Percentage of women with: Background characteristic Itching or irritation on/around genitals Genital sore/ulcer Bad odor with discharge Abdominal pain with discharge Vaginal discharge with fever Urinating problem Pain during intercourse Bleeding after intercourse Other problem Any problem Number of currently married women Age 10-14 13.5 2.7 3.3 17.6 3.4 12.2 24.2 4.2 1.3 42.1 145 15-19 18.2 6.1 4.7 16.4 6.2 16.6 17.6 1.3 2.3 41.0 1,536 20-24 20.0 6.1 3.7 17.9 7.2 17.5 15.0 1.0 3.1 41.2 2,121 25-29 21.4 6.8 3.8 20.3 8.3 20.8 15.3 0.6 3.2 42.7 1,935 30-39 20.8 7.5 5.2 20.7 9.2 22.8 13.3 1.3 4.0 43.1 2,992 40-49 18.8 6.0 4.2 17.4 6.7 21.7 10.0 0.9 3.0 38.9 1,852 15-24 19.3 6.1 4.2 17.2 6.8 17.1 16.1 1.1 2.8 41.1 3,657 Residence Urban 19.8 5.7 3.9 18.2 6.4 18.2 13.7 1.3 4.4 40.7 2,372 Rural 19.9 6.8 4.5 19.0 8.0 20.7 14.4 1.0 2.9 41.8 8,210 Division Barisal 26.7 13.2 10.0 25.1 10.0 24.9 17.6 0.7 3.0 48.5 674 Chittagong 24.0 8.5 3.8 22.8 9.7 23.8 16.7 1.0 3.7 46.0 1,877 Dhaka 20.0 5.9 3.7 18.1 7.0 20.9 13.6 1.1 3.7 42.0 3,315 Khulna 18.9 6.0 4.3 20.0 6.3 18.2 17.0 1.3 3.5 43.1 1,296 Rajshahi 15.7 4.4 4.1 14.2 6.8 17.2 11.3 1.3 2.7 35.7 2,782 Sylhet 20.6 7.5 5.2 21.8 9.7 16.9 13.5 0.8 1.6 41.1 638 Education No education 19.2 6.4 4.6 19.5 8.6 21.8 12.2 1.1 3.2 41.0 4,187 Primary incomplete 21.5 8.2 5.2 20.6 9.7 23.3 16.6 1.5 3.9 45.1 2,176 Primary complete 18.2 5.4 3.9 19.0 6.7 17.4 13.7 0.7 2.5 37.8 958 Secondary incomplete 20.8 6.4 4.2 17.5 6.0 17.2 16.0 1.1 2.8 42.2 2,457 Secondary complete or higher 18.7 4.9 2.7 14.3 3.8 14.6 13.0 0.3 3.4 37.9 804 Wealth index Lowest 21.2 8.4 5.8 20.2 9.9 22.4 15.3 1.3 2.4 42.8 2,042 Second 19.9 6.5 4.4 19.0 8.3 21.1 13.8 1.3 2.8 42.0 2,112 Middle 19.6 7.3 4.9 19.5 8.5 21.6 15.8 1.0 3.8 42.7 2,112 Fourth 20.4 5.4 3.8 19.0 7.3 19.6 13.7 1.1 3.2 41.7 2,168 Highest 18.5 5.2 3.2 16.4 4.5 16.1 12.5 0.9 3.8 38.7 2,148 Total 19.9 6.5 4.4 18.8 7.7 20.1 14.2 1.1 3.2 41.6 10,582 Knowledge of HIV/AIDS and other STIs │ 199 the following three problems: itching or irritation on/around genitals, urinating problem, and abdominal pain with discharge in the six months preceding the survey. Eight percent reported vaginal discharge with fever. Reproductive health problems are somewhat less common: 14 percent of women reported having pain during intercourse, and 7 percent reported genital sores or ulcers. Overall, four out of ten women reported having one or more gynecological health problems in the six months preceding the survey. Differentials in the proportion who reported having a gynecological health problem or reproductive health problem are muted, with only slightly higher levels among women living in Barisal and Chittagong divisions. Women who had at least one gynecological health problem were asked, “Have you seen anyone for advice or treatment to help you with (this/these) problem(s)?” Among women who reported a gynecological health problem, six in ten did not see anyone for advice or treatment (Table 12.8). Women seeking advice or treatment are practically the same proportion in urban areas and rural areas—around four in ten women. The main sources for advice or treatment were health facilities or trained providers (22 percent), followed by traditional doctors (11 percent). Urban women were more likely than rural women to seek advice from a health facility or a medically trained provider. Table 12.8 Women seeking treatment for gynecological health problems Among currently married women reporting gynecological health problems in the six months preceding the survey, the percentage who sought advice or treatment by source, according to residence, Bangladesh 2004 Residence Source of advice or treatment Urban Rural Total No one 56.8 60.5 59.7 Facility/trained provider 29.5 19.6 21.8 Traditional doctor 6.7 12.2 11.0 Pharmacy 4.8 4.5 4.5 Other 3.7 5.5 5.1 Total 964 3,434 4,398 Although only 2 percent of the men who ever had sex reported that they had an STI in the 12 months preceding the survey, almost one in five men had one of the following signs of STI—discharge from penis, sore or ulcer on penis, or pain or burning during urination. Almost one in eleven men had an STI or discharge from the penis or a sore or ulcer on the penis (Table 12.9). The proportion of men who reported having an STI or any of the symptoms of a probable STI decreases steadily with age. By marital status, the highest infection rates are reported by never-married men who ever had sex and the lowest by those who are currently married. One in three never-married men who ever had sex had an STI or related symptoms in the 12 months preceding the survey; the most commonly reported problems were pain during urination (27 percent) and sore or ulcer on penis (20 percent). Rural residents, compared with urban residents, and those living in Barisal, compared with those living in other divisions, are more likely to report having had an STI or a related symptom. By education, the highest infection rates are reported by men who have no education or have not completed primary education. The proportion of men who reported having had an STI or a related symptom is almost double among men in the lowest wealth quintile (24 percent), compared with men in the highest quintile of the wealth index (13 percent). 200 │ Knowledge of HIV/AIDS and other STIs Table 12.9 Self-reporting (men) of sexually transmitted infections (STIs) and STI symptoms Among men who have ever had sex, percentage self-reporting having an STI and/or symptoms of an STI in the 12 months preceding the survey, by background characteristics, Bangladesh 2004 Percentage of men who had: Background characteristic STI Discharge from penis Sore or ulcer on penis Pain or burning sensation during urination Had STI or discharge from penis or sore or ulcer on penis Had STI or any symptoms Number of men who ever had sex Age 15-19 4.2 10.2 23.9 28.9 29.7 40.0 135 20-24 3.7 3.1 11.6 23.9 13.9 26.1 320 25-29 2.2 2.7 6.4 19.0 8.7 21.8 487 30-39 1.9 2.4 5.2 13.7 7.3 16.3 980 40-49 2.1 1.7 4.0 13.2 6.4 15.9 956 50-54 0.8 0.8 2.7 10.2 3.6 12.0 242 15-24 3.9 5.2 15.3 25.4 18.6 30.2 454 Marital status Never married 4.9 7.1 19.5 27.3 22.9 33.1 297 Currently married 1.9 2.0 4.9 14.5 7.1 17.1 2,780 Divorced/separated/widowed (2.2) (3.7) (6.8) (23.8) (24.8) (24.8) 43 Residence Urban 1.6 2.1 4.7 12.0 6.7 14.2 732 Rural 2.4 2.6 6.8 17.0 9.2 20.1 2,388 Division Barisal 6.2 4.1 11.7 20.1 15.7 26.1 166 Chittagong 1.6 3.6 9.9 18.2 13.1 21.0 477 Dhaka 2.1 2.4 5.3 14.3 7.4 17.7 970 Khulna 1.9 1.3 5.3 15.6 6.8 18.6 431 Rajshahi 1.7 1.7 4.9 14.8 6.7 16.6 875 Sylhet 3.2 4.9 6.6 19.0 10.1 21.6 200 Education No education 1.4 2.8 5.9 16.7 8.0 20.0 912 Primary incomplete 3.4 3.3 8.0 18.9 11.0 21.9 916 Primary complete 2.0 2.0 6.9 9.2 10.1 13.2 241 Secondary incomplete 1.3 1.8 5.3 16.3 7.4 18.1 607 Secondary complete or higher 2.6 1.4 4.6 10.7 5.8 13.5 444 Wealth index Lowest 2.9 3.5 8.0 19.9 11.2 24.1 588 Second 1.7 3.2 7.3 17.3 8.0 20.1 657 Middle 1.9 1.9 6.2 15.8 9.6 18.1 629 Fourth 3.5 2.8 6.5 16.2 9.4 19.2 590 Highest 1.1 1.2 3.7 10.5 5.1 12.9 655 Total 2.2 2.5 6.3 15.8 8.6 18.7 3,120 Note: Figures in parentheses are based on 25-49 unweighted cases. Men who reported having an STI or any of the three symptoms of STIs were asked if they sought advice or treatment from each of the following health care providers: health worker, traditional healer, pharmacy, or homeopath. In addition, they were asked if they had asked for advice from friends or relatives. Knowledge of HIV/AIDS and other STIs │ 201 Table 12.10 shows the percentage of men seeking advice or treatment for STIs or symptoms of an STI, by residence. Forty-four percent of men who reported having had an STI or STI-related symptoms sought neither advice nor treatment. Men were most likely to seek advice from a health worker in urban areas (32 percent) and from a traditional healer and/or pharmacy (26 percent) in rural areas. About one in four men in both urban and rural areas sought advice or treatment from a pharmacy. Table 12.10 Men seeking treatment for sexually transmitted infections (STIs) Among men reporting an STI or symptoms of an STI in the 12 months preceding the survey, the percentage who sought advice or treatment from specific sources, by residence, Bangladesh 2004 Residence Source of advice or treatment Urban Rural Total No one 46.4 43.0 43.6 Health worker 31.6 20.4 22.4 Traditional healer 14.0 26.0 23.8 Pharmacy 24.9 25.7 25.6 Homeopath 15.7 14.7 14.9 Friends/relatives 11.4 14.3 13.8 Total 104 481 584 Community Characteristics │ 203 COMMUNITY CHARACTERISTICS 13 This chapter includes the findings from a Service Availability survey conducted by a separate team of interviewers as part of the 2004 Bangladesh DHS survey. The Service Availability survey, which was implemented prior to the main survey, was carried out in each of the sample points (communities) selected for the main survey. Data in the Service Availability survey were collected on characteristics of the selected sample points (e.g., distance to upazila headquarters, school, post office, etc.) as well as on the accessibility of health and family planning services that are available either within or near the sample point. The other reasons for conducting the Service Availability survey were to generate a list of facilities available in the sample area and a list of health and family planning fieldworkers who cover the area, including identification of affiliation (government versus non-government). These lists were later supplied to the interviewing teams for the main survey to help identify the specific source of services used by respondents. Data about a sample point were collected by administering a community questionnaire to a group of residents in the sample point. The informants mostly included the chairman or members of the union council, the ward commissioner, village/mahallah heads, male teachers, imams, and female opinion leaders. Distance to facilities was measured from the center of each sample point; all interviewed women in the sample point were assumed to be the same distance from the facility. Table 13.1 presents the distribution of ever-married women by distance to various services. About 90 percent of rural women have geographical access to a daily market, weekly market, post office, and telephone service within 5 kilometers of their residence. Accessibility to these services is slightly higher for urban women. More than 90 percent of women live in a village/mahallah where there is a primary school, and almost all have access to a primary school within 5 kilometers (Table 13.2). Access to a high school is more limited; however, about 95 percent of women have access to at least a coeducational high school within 5 kilometers. Religious schools are also widespread in Bangladesh. About 58 percent of the women live in a mahallah/village that has a madrasha. Urban women are more likely to have a high school or madrasha nearby, compared with rural women. Table 13.3 shows the availability of various income-generating organizations such as BRAC, ASHA, the Grameen Bank, and PROSHIKA, by residence. Non-governmental organizations (NGOs) are widespread in Bangladesh; more than three-fourths of women live in areas that have BRAC income- generating activities, followed by Grameen Bank (60 percent), ASHA (51 percent), other NGOs (48 percent), and PROSHIKA (36 percent). Forty-one percent of women live in areas where a cooperative society is functioning. Very few women live in areas with cottage industries. More rural than urban women have access to BRAC and Grameen Bank, while the reverse is true for ASHA, voluntary organizations, mother’s clubs or ladies’ associations, cooperative societies, cottage industries, and PROSHIKA. 204 │ Community Characteristics Table 13.1 Distance to nearest general services Percent distribution of ever-married women by distance to nearest specified service, according to type of service, Bangladesh 2004 Type of service Residence and distance to nearest service Upazila headquarters District headquarters Daily market Weekly market Telephone service Post office Cinema hall Urban Less than one km or mile na 4.1 61.9 na 6.5 41.3 17.3 <5 km na 26.1 35.8 na 93.5 51.7 59.0 5-9 km na 12.8 1.0 na 0.0 7.0 12.9 ≥10 km na 53.3 0.8 na 0.0 0.0 7.2 Don't know/missing na 3.7 0.5 na 0.0 0.0 3.6 Total na 100.0 100.0 na 100.0 100.0 100.0 Number of women na 2,586 2,586 na 2,586 2,586 2,586 Median distance na 14.4 u na 1.6 2.3 3.3 Rural Less than one km or mile 0.3 0.0 42.2 32.9 8.0 29.6 2.0 <5 km 14.0 2.0 46.3 52.7 84.3 62.1 21.4 5-9 km 25.7 3.2 6.4 9.1 5.3 6.1 28.6 ≥10 km 50.1 88.0 3.3 2.8 1.1 0.9 41.9 Don't know/missing 9.9 6.8 1.9 2.5 1.4 1.4 6.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 8,854 8,854 8,854 8,854 8,854 8,854 8,854 Median distance 11.0 35.3 2.2 2.6 2.9 2.6 8.9 Total Less than one km or mile na 0.9 46.6 na 7.6 32.2 5.4 <5 km na 7.5 43.9 na 86.4 59.7 29.9 5-9 km na 5.4 5.2 na 4.1 6.3 25.1 ≥ 10 km na 80.1 2.7 na 0.9 0.7 34.1 Don't know/missing na 6.1 1.6 na 1.1 1.1 5.5 Total na 100.0 100.0 na 100.0 100.0 100.0 Number of women na 11,440 11,440 na 11,440 11,440 11,440 Median distance na 32.3 1.6 na 2.8 2.6 8.2 na = Not applicable u = Unknown; median distance cannot be calculated because more than 50 percent of cases are in the category “less than one km or mile.” Community Characteristics │ 205 Table 13.2 Distance to nearest education facilities Percent distribution of ever-married women by distance to the nearest education facility, according to type of facility, Bangladesh 2004 Education facility Residence and distance to the nearest education facility Madrasha1 Primary school Boys high school Girls high school Coeduca- tional high school Urban Within mahallah 64.1 88.5 28.1 31.5 57.9 <5 km 34.2 11.5 52.3 54.3 37.6 5-9 km 1.7 0.0 4.7 6.7 4.5 ≥10 km 0.0 0.0 9.0 4.2 0.0 Don't know/missing 0.0 0.0 5.9 3.3 0.0 Total 100.0 100.0 100.0 100.0 100.0 Number of women 2,586 2,586 2,586 2,586 2,586 Median distance u u 2.9 2.8 u Rural Within village 56.1 91.9 3.1 9.7 41.3 <5 km 36.9 7.7 18.0 35.0 51.9 5-9 km 5.5 0.0 17.8 23.5 6.2 ≥10 km 1.2 0.0 53.9 27.2 0.0 Don't know/missing 0.3 0.4 7.3 4.5 0.5 Total 100.0 100.0 100.0 100.0 100.0 Number of women 8,854 8,854 8,854 8,854 8,854 Median distance u u 11.8 6.6 2.2 Total Within village or mahallah 57.9 91.2 8.8 14.7 45.1 <5 km 36.3 8.5 25.7 39.4 48.7 5-9 km 4.6 0.0 14.8 19.7 5.8 ≥10 km 0.9 0.0 43.7 22.0 0.0 Don't know/missing 0.2 0.3 6.9 4.2 0.4 Total 100.0 100.0 100.0 100.0 100.0 Number of women 11,440 11,440 11,440 11,440 11,440 Median distance u u 10.0 5.6 2.1 1 Religious school u = Unknown; median distance cannot be calculated because more than 50 percent of cases are in the categories “within village” and “within mahallah.” Table 13.3 Availability of income-generating organizations Percentage of ever-married women who have access to specific income-generating organizations, by residence, Bangladesh 2004 Residence Income-generating organization Urban Rural Total Mother's club or ladies' association 27.8 9.6 13.8 Grameen Bank 46.9 63.3 59.6 Voluntary organization 34.4 11.2 16.5 BRAC income-generating activities 70.2 77.3 75.7 PROSHIKA 49.0 31.8 35.7 ASHA 64.4 46.7 50.7 Cottage industries of BSIC 16.2 3.6 6.5 Cooperative society 44.6 39.6 40.7 Other NGO income-generating activities 47.4 47.5 47.5 Number of women 2,586 8,854 11,440 BSIC = Bangladesh Small Industries Corporation 206 │ Community Characteristics Health and family planning services are available to a majority of women in Bangladesh. Table 13.4 provides information on the presence of family planning depot holders, shops that sell family planning methods, and satellite clinics, by residence. Almost 90 percent of the women live in villages/mahallahs where satellite clinics are held. Among these women, 83 percent live in villages/mahallahs with clinics that provide oral pills, 73 percent have access to clinics that distribute condoms, and 56 percent of women have access to clinics that provide injectables as a family planning method. Only 11 percent of these women have access to clinics that provides IUD insertion. Compared with 1999-2000, availability of injectables and IUDs through satellite clinics seems to have declined in 2004. In areas covered by satellite clinics, almost all women can get child immunization services and vitamin A supplies. Almost two-thirds of the women have access to pharmacies or shops that sell family planning methods in the village/mahallah where they live. Urban women are much more likely to have a pharmacy or shop nearby, compared with rural women. About one in eight women live in areas where there is a depot holder selling family planning methods. Table 13.4 Availability of family planning and health services Percentage of ever-married women who have access to specific family planning (FP) and health services, by residence, Bangladesh 2004 Residence Family planning or health service Urban Rural Total Depot holder who sells FP methods 17.9 11.9 13.3 Shop that sells FP methods 77.8 58.5 62.8 Satellite clinic 91.9 85.5 87.0 Number of women 2,586 8,854 11,440 Of those with satellite clinic, percentage with clinic supplying Family planning education 75.8 75.1 75.3 Pills 81.3 83.6 83.0 IUD insertion 10.3 11.2 10.9 Injectables 61.3 53.9 55.7 Condoms 74.6 72.8 73.3 Menstrual regulation 9.6 6.0 6.9 Antenatal care 68.2 58.1 60.5 Delivery care 18.0 7.2 9.8 Postpartum care 41.4 36.1 37.4 Child immunization 96.7 99.0 98.5 Growth monitoring 48.8 38.7 41.1 Treatment of sick children 47.7 35.1 38.1 Oral rehydration therapy 69.3 63.3 64.8 Health education 77.1 67.4 69.7 Vitamin A 99.4 97.6 98.1 National immunization day (NID) 97.5 95.1 95.7 Number of women with access to satellite clinic 2,378 7,571 9,949 As Table 13.5 shows, 92 percent of ever-married women live in areas where child immunization is available within one kilometer, while 76 percent of women can get an ORS packet within one kilometer. Not all family planning methods are equally available. Supplies of methods such as Community Characteristics │ 207 contraceptive pills and condoms are more readily available than are clinical methods such as injectables, IUDs, and sterilization. Eighty-four percent of women live in villages/mahallahs where both pills and condoms are available within one kilometer. Other methods are less readily available to women: injectables (49 percent), IUD (18 percent), tubectomy (7 percent), and vasectomy (6 percent). Urban women are more likely to have health and family planning services available nearby, compared with rural women. Table 13.5 Distance to nearest health and family planning services Percent distribution of ever-married women by distance to nearest health services and family planning services that offer specific services or supplies, Bangladesh 2004 Health services Family planning services and supplies Residence and distance to nearest service Child immun- ization ORS packets Condoms Pills Inject- ables IUD Vasec- tomy Tubec- tomy Urban Less than one kilometer or mile 95.7 83.0 90.3 89.3 65.9 37.0 21.7 23.2 <5 km 4.3 12.6 8.8 8.8 27.6 52.3 58.9 57.4 5-9 km 0.0 3.4 1.0 1.9 3.8 6.7 9.8 9.8 ≥10 km 0.0 0.0 0.0 0.0 1.7 3.0 7.5 6.7 Don't know/missing 0.0 1.0 0.0 0.0 1.0 1.0 2.0 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 2,586 2,586 2,586 2,586 2,586 2,586 2,586 2,586 Median distance u u u u u 2.4 3.0 3.0 Rural Less than one kilometer or mile 91.4 74.1 82.4 81.9 43.8 12.4 1.9 1.9 <5 km 7.1 19.2 13.7 13.7 26.1 33.1 21.9 23.3 5-9 km 1.5 3.4 2.6 3.1 9.7 18.1 22.0 22.0 ≥10 km 0.0 1.8 0.9 0.9 14.2 27.7 44.4 43.7 Don't know/missing 0.0 1.4 0.4 0.4 6.3 8.7 9.8 9.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 8,854 8,854 8,854 8,854 8,854 8,854 8,854 8,854 Median distance u u u u 2.4 6.3 10.4 10.3 Total Less than one kilometer or mile 92.4 76.1 84.2 83.6 48.8 18.0 6.4 6.7 <5 km 6.5 17.7 12.6 12.6 26.4 37.5 30.3 31.0 5-9 km 1.2 3.4 2.2 2.8 8.3 15.5 19.2 19.2 ≥ 10 km 0.0 1.4 0.7 0.7 11.4 22.1 36.1 35.3 Don't know/missing 0.0 1.3 0.3 0.3 5.1 7.0 8.0 7.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 11,440 11,440 11,440 11,440 11,440 11,440 11,440 11,440 Median distance u u u u 1.5 5.4 8.2 8.1 u = Unknown; median distance cannot be calculated because more than 50 percent of cases are in the category “less than one kilometer or mile.” Policy Implications of the 2004 BDHS │ 209 POLICY IMPLICATIONS OF THE 2004 BDHS 14 Peter Kim Streatfield, Shams El Arifeen ,and Ahmed Al-Sabir 14.1 NATIONAL POLICY ENVIRONMENT This discussion of the policy implications of the 2004 Bangladesh Demographic and Health Survey (BDHS) will be more relevant if set in the context of the very substantial changes that have occurred in Bangladesh since 1998 in the ways health services are expected to be delivered. The following discussion is restricted to policy and sectoral changes that are likely to have affected the indicators discussed in this report. The late 1980s and early 1990s saw considerable progress in Bangladesh in areas of rising contraceptive prevalence, declining fertility rates, improving child survival, and indications of declining maternal mortality. However, during the Fourth Five Year Plan (Family Planning and Health Program - FPHP, 1990-1995), progress in immunization coverage, antenatal care, and control of diarrhea with oral rehydration therapy slowed, and child malnutrition remained widespread. Reviews of FPHP indicated that despite encouraging progress, poverty-related diseases, maternal mortality and morbidity, and substantial unmet need for family planning, remained as challenges for the next five-year plan. (HPSP Annual Programme Review 2005: 11). In response to these issues, the following five-year Health and Population Sector Programme (HPSP),1 1998-2003 was designed with a sector-wide approach where: • In terms of policy and strategy, the HPSP was intended to look at the sector as a whole, whether the services were run by the Government, the private sector, NGOs, or by other agencies such as community groups; • Equally, in a sector-wide way, it was intended to consider all sources of funding, and cover a range of services (e.g., health, family planning) in an integrated way; • Planning was intended to embrace all relevant programs as a single entity rather than have separate plans for individual projects; • The major focus was to be on an Essential Services Package (ESP) that would benefit vulnerable groups, particularly poor women and children, and which would be delivered from facilities close to the population affected; • The review of performance for the sector would be carried out collectively and annually. There were some other differences as well, but the key points resulting from this major shift in the way of doing business were that: 1 FPHP was extended until mid-1998 210 │ Policy Implications of the 2004 BDHS • Procurement of drugs, vaccines, equipment, etc., was centralized; although some time passed before the procurement agency was adequately strengthened to deal with the very large increase in business, especially international procurement, under new procurement procedures; • Procurement of training was centralized, rather than being project-based; although flexibility to expand capacity was limited, especially for training in ESP services; • The formerly separate Health and Family Planning Management Information Systems (MIS) were merged, and some of the existing functioning components were stopped before the new system was operational; • It was planned that Community Clinics (CC) would be constructed with community participation, including land donation, for every 6,000 population. They would be staffed by one female Family Welfare Assistant, and one Health Assistant (usually male), and would offer selected ESP services from the CC, with occasional outreach activities; • It was planned to unify the Directorate of Health and the Directorate of Family Planning, from the field level on up (though not initially at the top levels), with various functions such as Behavior Change Communication (BCC), logistics, and Management Information Systems, being merged; • The former projects were grouped together under a small number of Line Directors. Financial authority was transferred from the former Project Directors to the Line Directors. There was a variety of consequences of these changes in the functioning of the health system. The consequences relevant to this discussion are that drug supplies were sometimes erratic, new training capacity took time to develop, outreach services were disrupted by changes to service delivery, and information was less than adequate for program managers to make decisions. Given this unsettled environment, it is encouraging that most of the survey indicators presented in this report show virtually no deterioration during HPSP. Several have picked up subsequently, such as antenatal care, family planning, and child immunization. In the following section, the individual indicators for Bangladesh will be reviewed, with reference to other countries where appropriate, and with suggestions for future action. 14.2 FERTILITY In October 2004, the MOHFW formulated the Bangladesh Population Policy, the finalization of efforts that began with the Population Policy Outline of 1976. Since that time, the focus on managing rapid population growth has been reflected in all successive five-year plans and programs. The current target is to reach replacement-level fertility by 2010 so as to stabilize the population at 210 million around the year 2060. This projection differs from other population projections, which estimate that the population will continue growing for another century to around 260 million (Bos et al., 1994). After almost a decade of a fertility plateau at 3.3 children, the current survey shows a decline (borderline statistically significant) to 3.0. The question is, does it signal the resumption of the decline of the 1980s, or is it a minor drop to a new plateau. Global comparison. At the end of the last century (1995-2000), the average TFR for the world’s less developed regions had declined to 3.1 children per woman, so Bangladesh is far from alone with this fertility level. Out of 50 Asian countries, 24 had a TFR of 3 or less, and of those, 14 countries were below replacement-level fertility. But many countries have also experienced fertility declines that have slowed down, “often when fertility levels approach 3 children per women” (United Nations, 2004a: 29). India’s Policy Implications of the 2004 BDHS │ 211 TFR decline stalled at a level similar to Bangladesh (3.3) at the end of the 1990s, as did Malaysia and Myanmar (3.3 to 3.5) during the 1990s. So, is Bangladesh resuming a decline in fertility towards replacement level? Most countries that have achieved such low levels have undergone a shift in the pattern of childbearing to older ages, due to postponement of marriage and first birth, and lengthening of the birth intervals. Bangladesh appears to have undergone a steady rise in the average age at birth for second and higher birth orders. This pattern resulted when many couples adopted family planning after the first birth—the so-called “tempo effect” (Bongaarts and Feeney, 1998). But, the country has not experienced any substantial rise in age at marriage for women, nor in age at first birth (Streatfield et al., 2005). As a result, women under age 30 account for three out of four births—a higher proportion than generally found in the developing world. This pattern of fertility in Bangladesh is due to the extremely high level of adolescent fertility, which has failed to decline over the past decade. At present, because of the young age structure of the Bangladesh population, 30 percent of all births are to teenage mothers. The adolescent fertility rate is 133 births per 1,000 women. By comparison, more than half of the Asian countries have adolescent fertility rates below 50 per 1,000 women. This extraordinarily high level of teenage fertility is related to the pattern of early marriage in Bangladesh. The proportion of women age 15-19 who have ever been married remains about one-half (Figure 14.1). This level is the highest in Asia, and, with the exception of two African countries, is the highest among the 70 countries covered by the DHS program. Recent data suggest that the downward trend in the proportion of young women (age 20-24) who have married before age 18—the legal minimum age for girls to marry—has reversed, rising above two- thirds again. Anecdotal information suggests that due to various types of insecurity there may be a greater urgency for parents to marry their young daughters off in the belief that marriage can provide some protection. This resistance of adolescent fertility to change is surprising considering the major inputs over the past decade to female education (Figure 14.2), and increased urban employment opportunities for young 212 │ Policy Implications of the 2004 BDHS females. Even so, only about 6 percent of women 15-19 are in cash employment, a minimal level that is not showing any positive impact from increasing educational attainment. The following graph shows the extraordinarily rapid growth in secondary school enrollment for girls in Bangladesh—more than a twelvefold increase in a decade. While there are concerns about classroom crowding, quality of teaching, low school completion rates, etc., the fact remains that there are as many girls enrolled in secondary school, as boys—a very different situation from a decade earlier. Examples of interventions that are needed to address this highly undesirable pattern of early marriage and early initiation of childbearing are: • Communities are being encouraged to proceed with marriages without any requirements or demands for dowry; • Community meetings are being organized to discuss the disadvantages of dowry marriages, and early marriages, in the context of increased education opportunities for girls; • Efforts are underway to convince “matchmakers” and unofficial marriage registrars to cease endorsing early marriage (below the legal minimum age) and producing marriage certificates with falsely reported age of bride; • Enforcement of the legal minimum age at marriage for girls is urgently needed, and would delay two out of three marriages. In addition to increasing education opportunities, there needs to be greater effort put toward the creation of employment opportunities in rural areas for single women after they leave school. At this time, most of such employment opportunities are in urban areas, and require young women to leave their families and migrate to the cities—a process regarded as dangerous and undesirable by many families. While large-scale employment generation in rural areas is a major challenge in most countries, and will require central Government intervention offering tax breaks and subsidized transport to manufacturers, there are other options. Policy Implications of the 2004 BDHS │ 213 One such option is broadening of the widespread microcredit facilities offered to married women in rural areas for employment or income generation. Indeed, some NGOs are now offering such facilities to single women, including one of the biggest, BRAC, with its BRAC Junior credit scheme. In addition to efforts to delay early marriage, there are options within marriage to delay the first birth. Figure 14.3 shows that while age at marriage has risen slightly (less than 1 year) over the past decade, age at first birth has not changed; rather, the average interval between marriage and first birth has shrunk from 3.0 years to 2.4 years. This is often the pattern when age at marriage starts to rise. This decrease is also in a context of slowly rising proportions of couples using family planning before first birth (23 percent in 2004), though these are often adopting male controlled short-term methods. There is also anecdotal evidence that many couples consciously avoid hormonal contraception before their first birth. This decline in marriage-first birth interval is the reverse of the pattern amongst second and higher births, where birth intervals have increased substantially over the past decade, largely due to adoption of family planning, which will be discussed in more detail below. 14.3 FAMILY PLANNING Over the past several decades, the contraceptive prevalence rate (CPR) in Bangladesh has been rising at a rate similar to that of many other Asian countries—about 1.5 to 1.8 percent per year, slightly less in recent years. In only a few Asian countries have contraceptive prevalence rates risen faster: Iran, Vietnam, and Pakistan, at over 2 percent per year in recent years. Contraceptive method mix in Bangladesh shares one similarity with many other countries, namely a reliance on oral contraceptives, although elsewhere, female sterilization and IUDs account for many more users than pills. In Bangladesh, female sterilization accounts for one in twenty users, although it Key Messages • Early marriage is still a major obstacle to fertility decline in Bang- ladesh. As a result, one in three births are to teenage mothers. Greater efforts are needed to delay early marriage, and delay first births within marriage. This must include greater investment in secondary schooling and employment for single women in rural areas. 214 │ Policy Implications of the 2004 BDHS is falling, and IUD use is negligible. Use of methods requiring male participation (condom or male sterilization) or cooperation (rhythm or withdrawal) in Bangladesh (11 percent of users) is about half the average in developing countries. The low and declining level of female sterilization in Bangladesh—half the level of the early 1990s—is of concern. The age pattern of sterilized women reflects high acceptance rates in the 1980s, at an average age of 27 years, and these women are now in their 40s, and are not being replaced by new acceptors in any significant numbers. In developing countries, the IUD ranks as the second most popular contraceptive method. But in Bangladesh, because of a tendency for women to avoid clinical methods, this is not the case. The current IUD level of 0.6 percent for couples is about the same as when the family planning program began three decades ago. Indeed, even Norplant, which is used by less than 1 percent of couples, now exceeds the IUD in prevalence, even though it is a type of clinical method. It is encouraging that recent efforts to increase acceptance of long-term clinical methods appear to be succeeding. The Ministry of Health and Family Welfare devised a strategy, with the assistance of EngenderHealth, to provide training, upgrading of facilities, and motivation at individual and community level, including religious leaders, and numbers of acceptors of both male and female sterilization have been increasing impressively to more than 6,000 monthly. This is one of the first signs of a reversal of the disturbing declines of the past decade. However, with 22 million couples of reproductive age, a 1 percent increase in CPR requires over 200,000 additional users. Efforts to increase use of Norplant and injectables should be promoted, as both are less invasive and less susceptible to access barriers than sterilization. One of the major controversial aspects of HPSP was the proposed transition from outreach or domiciliary family planning services to static community clinics (CCs). In the confusion surrounding this issue, the public sector lost a substantial share of family planning service provision, very little of which was picked up by the CCs. Household visits for family planning by GOB fieldworkers have fallen dramatically since the mid-1990s. However, CPR has not fallen, suggesting that demand for family planning is no longer fragile in Bangladesh. In the reduction in household visits by GOB workers, many couples switched to private outlets (especially pharmacies), and less so to NGOs. There are still ‘low-performing’ areas of the country where a proportion of GOB fieldworker posts remain vacant long-term. The Government needs to recognize difficulties in recruitment and retention in these areas, and consider alternative approaches to provision of services. For example, contracting out family planning service provision at the community level is being piloted by the MOHFW. Further involvement of the NGO and private sectors should be considered to bring these areas in the north and east of the country up to the levels of the rest of the country. This experience suggests a reassessment of the role of GOB fieldworkers who were formerly responsible for carrying out household visits. It could be that they would be more effectively utilized for BCC activities, for motivation of pregnant women to make ANC visits, for nutrition activities, for Key Messages • Longer-term and clinical family planning methods are almost nonexistent now. Global experience indicates sus- tainable and high CPR must have substantial reliance on long-term, clinical methods. • The role of family planning fieldworkers changed away from doorstep delivery recently, but CPR continued to rise. It is time to reassess the role of FWAs regarding motivation and referral for long-term and clinical methods, rather than delivering pills and condoms. The FWAs can potentially play an important role in motivating couples for sound safe mother-hood practices, such as using antenatal care, facility delivery, and postnatal care. They can also convey behavior change communi-cation for other reproductive health programs. Policy Implications of the 2004 BDHS │ 215 awareness rising about HIV/AIDS, and other related health education activities. It needs to be remembered that targeted visits can only be made if there is some way that the fieldworkers can identify the target group. If the fieldworkers are no longer making outreach visits, then community-level or village-level informants, such as depot holders, need to be made responsible for identifying family planning dropouts, EPI dropouts, newly weds, etc., and notifying the fieldworkers. 14.4 CHILDHOOD HEALTH AND MORTALITY Is Bangladesh on target for achieving the millennium development goals for child mortality? The United Nations has recently assessed that of the 10 developing country regions, only 3 (North Africa, South East Asia, and Latin America/Caribbean were on track to achieve MDG 4 (United Nations, 2004). The target for Bangladesh is to reduce under-five mortality from 151 deaths/1000 live births in 1990 to 50 in 2015. From 1991 to 2001 (mid-years of the BDHS 1993-94 and 2004), under-five mortality in Bangladesh declined by a third, i.e., about 4.1 percent per year, which compares well with the required annual decline of 4.3 percent needed to achieve the MDG of a two-third reduction in under-five mortality by 2015 from 1990 levels. However, if this estimate is disaggregated, between 1991 and 1997 the decline was more than 5.6 percent annually; but from 1997 till 2001, the decline has only been 1.6 percent per annum. The reduction in mortality appears to have slowed down and it is obvious that if the rate of reduction is not revived, Bangladesh will not achieve MDG 4 (Table 14.1). Table 14.1 Percent reduction in mortality per year, among children under five, Bangladesh 1991-2001 Percent reduction in mortality Infant and child mortality 1991 to 1994 1994 to 1997 1997 to 2001 Child mortality (age 1-4 years) -10.0 -6.6 -8.2 Postneonatal mortality -1.3 -10.4 -0.4 Neonatal mortality -2.6 -4.6 -0.8 What needs to be done to achieve MDG 4 in Bangladesh? The answers to this lie to some extent on the knowledge about when and why these children die. Recent global reviews indicate that almost 60 percent of under-five deaths can be prevented by taking known/existing interventions to scale and high coverage (Jones, 2003). The 2004 BDHS shows that while neonatal deaths were 39 percent of all under- five deaths in 1991, they constituted almost half of under-five deaths in 2001. Birth asphyxia is responsible for a fifth of the neonatal deaths, while infections (sepsis, ARI and diarrhea) kill 45 percent of the neonates. Almost two-fifths of the neonatal deaths are associated with prematurity/low birth weight. In postneonates, the single biggest killer is ARI followed by other infections which together account for about 72 percent of these deaths. In older children (1-4 years), a similar pattern of a large contribution by ARI and infections is observed. However, a fifth of these deaths are due to injuries (particularly drowning). Among all under-five children, prematurity/low birth weight and malnutrition together contribute to about 45 percent of all deaths. The age and cause of death pattern indicate certain interventions that need to be scaled up rapidly to reach high coverage, if one still hopes to achieve the MDG for under-five Key Messages • Bangladesh is faltering in its effort to achieve MDG 4 of reducing under-five mortality by two-thirds. Strengthening and implementing pro- grams to reduce neonatal deaths and deaths due to ARI is critical. • Exclusive breastfeeding rates are not improving at all. Large-scale programs are needed that provide appropriate counseling and sup- port to pregnant and lactating women • There have been significant im- provements in child immunization rates and these need to be sustained. 216 │ Policy Implications of the 2004 BDHS mortality. These include skilled attendance at delivery, postnatal care for the child and prevention and management of infections. Skilled attendance and postnatal care is important because of their critical role in preventing neonatal deaths. Progress in ensuring skilled attendance at delivery has been very limited in Bangladesh, increasing from about 9 percent in 1993-1994 to 13 percent in 2004. Only 12 percent of the newborns in the 2004 survey received care from a trained provider within 2 days of birth, and 83 percent received no care within 42 days post partum. It is inconceivable that one can achieve substantial declines in neonatal mortality if rates of skilled delivery assistance and post-partum care are not increased. It is reported that achieving national coverage with skilled birth attendant (SBA) may require at least 15-20 years, and even then, uncertainties remain as to whether the newly trained SBA cadre can reach effective coverage. Recent reviews on neonatal health (Darmstadt, 2005) as well as experiences from India, Nepal and Bangladesh suggest that other community-based interventions such as health education to improve neonatal care practices and care-seeking for illness, and creating demand for skilled care can be used to improve neonatal survival. A policy dialogue and decisions on such interventions seem essential and urgent. Poor quality of care, misperceptions regarding need for care, and other social barriers underlie the low level of care-seeking for childhood illness in Bangladesh. However, there is also evidence that with appropriate training and sustained support, the quality of care from government first-level facilities can be improved substantially and maintained (Arifeen, 2004). It has also been shown that such improvements in care quality along with targeting families and communities with well designed messages and counseling can improve utilization of these facilities—by at least threefold. There are important lessons here that can be scaled up to contribute to a reduction in under-five mortality. A key lesson here is that good quality and sustained supervision and support are indispensable. While various projects in the past have been successful in ensuring adequate supervision and monitoring, this has not been translated into sector-wide systems that function effectively. Many of these successes in the past came when programs created semi-independent or external supervisory and monitoring systems that did not depend only on managers at different levels who usually are too busy with routine work to be effective supervisors and monitors. Examples are the current EPI program and the Polio Eradication program that have successfully used an independent network of monitors. This kind of monitoring requires additional finance, the lack of which is also a barrier. The second key lesson is the need to reach families and communities with targeted messages and information. Families and parents require information to make the right decision regarding care for their children. They often need support to change deeply ingrained practices. The very large government community-based work force (HAs and FWAs) would seem ideal for reaching the community with such information. However, structural problems, e.g., many of these workers being nonresidents in their work areas, and an overwhelming emphasis on providing “hard” services such as immunizations, contraceptives, etc. are barriers to their assuming this role effectively. Under the current system, they have little incentive to spend their time on communication, even if we were able to provide them with appropriately designed training on communication, tools and messages. Case management of ARI remains the primary tool for reducing ARI deaths in this country. Unfortunately, the percentage of children with ARI taken to a facility or health worker has declined from 33 percent in 1996-1997 to 20 percent in 2004. This trend highlights lack of progress and the serious challenges that impede the achievement of high coverage of ARI case management. This is in sharp contrast to consistently increasing use of ORS for the management of diarrhea, up from 50 percent in 1993-1994 to 67 percent in 2004. Policy Implications of the 2004 BDHS │ 217 The 2003 Lancet series on child survival identifies four interventions of established efficacy in preventing ARI deaths (Jones, 2005). These include breastfeeding, complementary feeding, Hemophilus influenza (Hib) vaccine and zinc. Among these, the Hib vaccine is not available in Bangladesh through the public health system while no policy decision has been taken on introducing zinc in the country. The government does have the opportunity to introduce Hib vaccine in the country, if it wished to, using Global Alliance for Vaccines and Immunization (GAVI) funds. The last four BDHS surveys show that the percent of newborn started on breast milk within 1 hour of birth has increased from 9 percent in 1993 to 24 percent in 2004. However, the median duration of breastfeeding has remained unchanged at about 32 months, and there has been absolutely no change in rates of exclusive breastfeeding. The consistent and very similar patterns of exclusive breastfeeding over 10 years show that the various efforts at improving the practice of exclusive breastfeeding including Baby Friendly Initiatives, BCC, etc has had minimal impact, if any. A critical review of the situation and programs is essential. There is considerable evidence that with appropriate counseling and support more women are able to breast-feed exclusively. These include antenatal education, showing and helping mothers how to breast- feed, and continuing support. As coverage of antenatal care increases, the opportunities now exist with reaching a large proportion of pregnant women with messages on exclusive breastfeeding. However, low skilled birth attendance and post partum care present barriers to providing further support and guidance to the newly delivered woman. Even though studies in Bangladesh and elsewhere have demonstrated the value of community-based peer counselors in breastfeeding promotion, these interventions have not been widely implemented (Haider, 2000). Using existing government community-based workers is a possibility, but problems associated with this have already been discussed above. Nutritional status was first assessed in the 1996-1997 BDHS. Significant improvement in child nutritional status was observed between the 1996-1997 BDHS and the 1999-2000 BDHS. Since then, children’s nutritional status has not improved. It is obvious that the initial gains in reducing childhood malnutrition have been difficult to sustain. Although the National Nutrition Project still covers only 22 percent of the subdistricts, it remains the only program being implemented at scale in Bangladesh aimed at improving childhood nutrition. However, questions have been raised recently as to the effectiveness of this project (Hossain, 2005). Though this particular analysis had various limitations and was not definitive, it does raise the need to review NNP program strategies, emphasis (in terms of funds allocated), and expansion plans. BDHS 2004 shows that in many areas of child health, Bangladesh has made sustained and remarkable progress. A remarkable achievement has been in the percentage of 12-23 month old children who have received all vaccines. In urban areas, it is 81 percent (an increase of 16 percent from 1999- 2000) and in the rural areas it is 71 percent (a 22 percent increase from 1999-2000). The goal of immunizing at least 80 percent of children with all vaccines (particularly measles) has not been achieved yet, but recent improvements suggest that it is achievable. Much has been written about the experience and successes in Bangladesh in taking oral rehydration therapy for diarrhea to scale (Chowdhury, 1998). The evidence from four BDHS confirms this achievement. The use of ORS for the management of diarrhea has been consistently increasing from 50 percent in 1993-1994 to 67 percent in 2004. Vitamin A coverage among children age 9-59 months has been consistently increasing in every BDHS since the first survey in 1993-4. Much of this achievement can be attributed to linking vitamin A supplementation to national immunization days (NID) for polio vaccination. The first NID was held in Bangladesh in 1994. This success demonstrates the advantages of using a campaign-based strategy to deliver interventions that need only be delivered intermittently. With the last NID implemented in early 2004, it remains to be seen if this coverage can be sustained. 218 │ Policy Implications of the 2004 BDHS 14.5 MATERNAL CARE The National Strategy for Maternal Health was released in October 2001, well into the HPSP. The strategy adopted the three delays approach, based on the now widely accepted view that all pregnant women are at risk of developing life-threatening complications, and that most of these complications can neither be predicted accurately nor prevented. Once a woman develops any of these complications, she needs prompt access to emergency obstetric care (EOC) services (MOHFW, 2001: 5). The dominant approach during the 1990s has been to build or renovate existing facilities to provide EOC services across the country, at a target level of one comprehensive EOC and four basic EOC facilities per 500,000 population. By the end of the HPSP in mid-2003, C-EOC was available in all 59 District Hospitals, some 60 MCWCs, and 45 selected Upazila Health Complexes, still some way below the target. To complement the provision of facilities, efforts have been made to strengthen the referral system to those facilities by building capacity of Female Welfare Assistants (FWA) and female Health Assistants (HA) as Skilled Birth Attendants (SBA). 14.5.1 Use of Antenatal Care Antenatal Care (ANC) has been rising in recent years, but is still too low with just over half of all women receiving any ANC during their most recent pregnancy. It is encouraging that in the 2004 BDHS, among users of ANC, the number of visits finally jumped from less than two towards the recommended number of three. While this increase is positive, it remains a source of concern that among ANC users, only one in three make their first visit in the first trimester, as recommended. It should be kept in mind that if all pregnant women made all the recommended ANC visits, it would amount to some 12-15 million annually, more than double the current number of 5.5 million or so. There is a question of the capacity of the health system to deal with such numbers, even if all the planned upgrading of institutions to provide safe motherhood services takes place. Among ANC users, the source, in almost all cases, remains a medically skilled provider, as it has been for a decade. Since the previous BDHS, there has also been an encouraging increase in the useful content of the ANC visits. In 2004, one in three women say they had received information on the danger signs of pregnancy, although this and other content is highly skewed towards the well educated and economically better off. 14.5.2 Place of Delivery and Delivery Attendant One proxy indicator that remains resistant to change is place of delivery. A decade ago, 19 out of 20 deliveries were at home. In 2004, it is 18 out of 20, with the private sector accounting for one-third of facility deliveries. This is despite a very substantial effort to construct and renovate a large number of MOHFW facilities. The major shift in attendance over the past decade has been from relatives/family members, who previously accounted for one quarter or more, but have now declined to less than one in ten. The disturbing aspect of this shift though, is that it is not to highly trained providers like doctors and nurse/midwives, but largely to birth attendants who now do 77 percent of deliveries compared with 60 percent a decade ago. Even today, less than one in five of these TBAs are trained, and the evidence from Key Messages • Almost half of all pregnant women do not get ANC, and two of three ANC users start late. FWAs need to identify newly preg- nant women and motivate them to make an ANC visit in each trimester. ANC needs to be promoted as part of a total care package through pregnancy, delivery and the post-natal period. Policy Implications of the 2004 BDHS │ 219 1980s is that even those who have received training do not necessarily absorb or retain those skills, due to infrequent practice, and other reasons. At the least, TBAs need to receive training in how to recognize complications, to know when and where to refer patients with complications, and they need close supportive supervision. As mentioned above, to provide community-level, safe delivery services, two schemes to train higher-level female staff have been implemented. At the Union level, Family Welfare Visitors attached to UHFWCs have been receiving six months training in batches of 100 for several years. More recently, Family Welfare Assistants and female Health Assistants have started to receive six months training on safe delivery. Some 900 have now received training, with the expectation that they would participate in normal deliveries, and actively refer cases experiencing complications. At the reported rate of only a few deliveries a month by these Skilled Birth Attendants, this approach will take some time before having a major impact on the national childbirth scene (DGHS, 2005). Evidence from the Bangladesh TBA Training Program of the 1980s, and from other countries, is that SBAs need to conduct 8-16 deliveries monthly to retain their skills. It is not yet clear that families will rely on workers with limited training to provide delivery services at the home. Even if large numbers of families decide to use these workers, the families need to understand that lower level workers, however well trained, cannot be expected to perform all necessary procedures at household level. Under emergency circumstances, the TBAs will have to refer cases with complications to higher-level facilities. With some of the new approaches being developed, such as oral oxytocics (e.g., Misoprostol), they may also need training in how to administer such home-based measures to minimize hemorrhage. The recent focus for upgrading has been at district level (59 District Hospitals and 60 MCWCs), and Upazila level (80 or so Upazila Health Centers). The district and Upazila headquarters are 35 km and 11 km, respectively, from the average home. These lengthy distances may be an obstacle for many people to utilize such EOC facilities. An alternative might be to consider upgrading Union level facilities (Union Health and Family Welfare Centres where there is already a plan to post two Family Welfare Visitors, who could work in shifts to ensure round the clock service. Many of these facilities have residential accommodation for staff, although at present only one in three FWVs posted there actually live on the premises. The average Union has about 700 deliveries annually (two per day), many of which are conducted at higher level facilities, especially those referred with complications. Other deliveries will continue to take place at home for some time to come, so a UHFWC could cope with expected numbers of deliveries under these circumstances. This possibility could be explored using an Operations Research approach for a small number of UHFWCs that are functioning well. Key Messages • Skilled Birth Attendants (SBA) training requires substantial hands-on practice, and thus training suf-ficient numbers will take a long time. This suggests that the TBAs will continue to play a role in delivery for a considerable time to come. Thus they need to be oriented to avoid bad practices, and to refer for complica-tions. • The EOC facility approach and the skilled birth attendant approach are not sufficiently linked for refer-rals of complicated cases to be effective. The investments in training SBAs must be linked through referrals of compli-cated cases to EOC facilities. • Even with widespread invest-ments in EOC facilities, at least at the district level, little improvement in facility delivery is being seen. It is worthwhile to consider testing models of normal delivery at Union level, linked with referral to higher levels if complications arise. 220 │ Policy Implications of the 2004 BDHS The use of medically trained attendants is among the most highly inequitable health services, with the least poor quintile being ten or more times more likely than the poorest quintile to use a doctor or nurse/midwife. This skewed use of services is showing no signs of becoming more equitable. 14.5.3 Postnatal Care Information on PNC has been limited, but it appears that a small proportion of mothers who deliver at home are accessing PNC. Mothers need to be made aware that postnatal care is a natural part of the process of childbirth, and an integral not optional part of the “package.” This will require BCC to explain when maternal deaths and neonatal deaths occur. A large proportion of the latter occur within three days of delivery, and neonatal deaths account for half of all deaths to children under five years, so proper care in this period around delivery has great potential to reduce not only maternal but infant deaths and morbidity. 14.6 KNOWLEDGE OF HIV/AIDS AND WAYS TO AVOID HIV/AIDS The National Policy on HIV/AIDS and sexually transmitted disease-related issues was issued in late 1996. It concentrated mainly on surveillance, testing policy, management and counseling of patients, and safe blood. The focus was generally on high-risk groups. In terms of interventions, there was very little said about awareness raising or behavior change—half page on information, education, and communication (IEC) in 90 pages. A new program HAPP (2000-2005) was formed with the MOHFW and development partners, but working closely with NGOs and the private sector for implementation. Although “by mid-2003, [HAPP] program implementation had been very slow” (HPSP Annual Program Review, 2005: 44), the proportion of men and women who have knowledge of HIV/AIDS has risen dramatically since the mid-1990s. In the 1996-1997 BDHS, less than one in five women, and one in three men, had ever heard of HIV/AIDS. In the 2004 BDHS, it was three out of five women and four out of five men. The source of this information has consistently been TV, followed by radio, for both men and women. Newspapers are also an important third source for men, though not for women. While it can be argued that having heard of HIV/AIDS does not necessarily mean the respondent understands the routes of transmission, or the incurable and fatal nature of the disease. In the 1996/97 BDHS, some two-thirds of those respondents who had heard of HIV/AIDS did report that it is almost always fatal. But only a small proportion knew ways of preventing it. Since then, knowledge that condoms can prevent the disease has risen from 1 to 37 percent among women, and from 6 to 50 percent among men. These levels are much higher than knowledge of two or more symptoms of sexually transmitted infections for both men and women. The protective effect of having only one partner has also become more widely known among women (30 percent), though reportedly less so for men (12 percent). Among all male and female respondents, it is encouraging that 30 percent of women and 50 percent of men correctly know two or more ways of avoiding HIV. It is disturbing though, that around Key Messages • Among mothers who experienced complications around delivery, only one of three sought assistance from trained providers. Another one in three went to unqualified providers, and one in three did nothing. As awareness of dangers is raised, families must be motivated to make use of medically trained providers for these complications. • Postnatal care is currently seen as an option, and used by very few mothers. Many maternal deaths due to hemorrhage occur at this time, also many neonatal deaths. ANC, safe delivery, and postnatal checkups must be promoted as a total ‘package’ of maternity care. Policy Implications of the 2004 BDHS │ 221 half of women (47 percent) and men (54 percent) have never discussed HIV/AIDS prevention methods with their spouse. There have been a variety of approaches to raising awareness of HIV/AIDS. Social Marketing Company (SMC) is using eight mobile film units, which move around the country conducting up to 18 film sessions each per month for audiences of around 1,000 per night, thereby addressing large numbers of the rural population. Education packages containing information and advocacy materials (but no services), are being offered at the community level, and also targeting factory workers, transport workers, and young people in and out of school—the latter through youth clubs. Outreach educational activities are targeting registered brothels, areas with heavy industries where a large proportion of males live away from families, and border crossings with truck waiting areas. Increasingly, since 2000, the visual media has become a more important source, with short films with popular themes such as overseas employment, being used as vehicles for messages about risk, symptoms of STIs and HIV, and treatment. Recently, the Ministry of Information has approved the showing of condoms for disease prevention on television. The GOB Censorship Board still blocks certain messages, but satellite TV falls outside their purview, and is increasingly being used to broadcast such messages. They do control Bangladesh TV (BTV), which recently banned advertisements showing condoms. 14.7 ARSENIC IN HOUSEHOLD DRINKING WATER Awareness of arsenic, in terms of having heard of it, is common for five out of six people, although substantial numbers who rely on tubewells for drinking water seem not to have heard of it. There is considerable geographic variation in knowledge, just as there is in prevalence of the problem. A couple of important points emerge from the DHS. A modest number of tubewells, labeled red (contaminated) in the past, tested clear (green) in this survey. One explanation might be that their arsenic concentration can vary between testings, or the testing procedure differs in important ways. A substantial number of people are still drawing their drinking water from tubewells marked contaminated (red). This may be because they have no choice, or it could reflect a lack of understanding of the significance of the markings. Or it could be that they do not perceive any serious danger from doing so. The latter could be explained by the observation that relatively few people with long exposure to arsenic show any external physical symptoms. For example, two-thirds of the 16,000 tubewells in the ICDDR,B Matlab field site are contaminated, yet only 3 in 1,000 people show skin changes as a result of this exposure. This is puzzling, and points to the need for research into the sequence of damage due to arsenicosis. For example, do the external skin changes appear before, after, or simultaneous with internal organ damage? Can switching to noncontaminated water reverse organ damage? Are certain individuals protected from the negative effects by a more effective capacity to convert (methylate) arsenic into a non- toxic form? The national program, BAMWSP, has focused mainly on testing tube wells (almost 5 million so far), and providing alternative sources of drinking water, through sinking deep tubewells (11,000 plus) Key Messages • There are encouraging signs of growing awareness of HIV/AIDS among the general public, including knowledge of ways to avoid infection, less so for STIs. Greater effort is needed to explain STIs and their link with susceptibility to HIV/AIDS. • Between spouses, there is still little communication about HIV/AIDS and ways to prevent it. More spousal communication is needed, along with greater capacity of wives to negotiate sex when their spouse has an STI. 222 │ Policy Implications of the 2004 BDHS and providing dug wells (1,100) where needed. There has been awareness raising, but it would be useful for the national program to increase its awareness raising efforts on the dangers of consuming arsenic contaminated water in future activities. 14.8 DISPARITIES Bangladesh has achieved impressive equity in the use of certain health and family planning services, where the poorest 20 percent (quintile) of the population has levels of use around three quarters of the level of the best off 20 percent. These tend to be services like EPI and family planning, which have traditionally relied for delivery on fieldworkers. Other vital services, such as safe motherhood, remain disturbingly inequitable, with delivery by a medically trained attendant, and delivery in a health institution, show levels for the poorest quintile around 10 percent of levels for the best off. 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Appendix A | 229 SAMPLE IMPLEMENTATION APPENDIX A Table A.1.1 Sample implementation: women Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall response rates, according to urban-rural residence and Division, Bangladesh 2004 Division Residence Result Barisal Chittagong Dhaka Khulna Rajshahi Sylhet Urban Rural Total Selected households Completed (C) 96.5 96.7 96.8 97.3 98.3 96.5 96.4 97.5 97.1 Household present but no competent respondent at home (HP) 0.4 0.1 0.1 0.0 0.0 0.4 0.2 0.1 0.1 Refused (R) 0.0 0.0 0.1 0.1 0.0 0.0 0.1 0.0 0.0 Dwelling not found (DNF) 0.0 0.0 0.0 0.1 0.0 0.2 0.0 0.1 0.0 Household absent (HA) 1.2 1.6 0.8 1.4 0.7 1.5 1.3 1.1 1.1 Dwelling vacant/address not a dwelling (DV) 1.6 1.1 1.7 0.9 0.6 1.0 1.6 0.9 1.2 Dwelling destroy (DD) 0.2 0.2 0.2 0.1 0.1 0.1 0.2 0.1 0.1 Other (O) 0.2 0.3 0.3 0.0 0.3 0.4 0.3 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 1,274 1,920 2,547 1,620 2,400 1,050 3,646 7,165 10,811 Household response rate (HRR) 99.6 99.9 99.8 99.8 99.9 99.4 99.7 99.8 99.8 Eligible women Completed (EWC) 98.2 98.5 98.6 99.0 99.3 97.5 98.3 98.8 98.6 Not at home (EWNH) 1.6 0.9 1.1 0.8 0.5 1.5 1.2 0.9 1.0 Refused (EWR) 0.0 0.1 0.0 0.1 0.0 0.0 0.1 0.0 0.0 Incapacitated (EWI) 0.2 0.5 0.2 0.1 0.2 0.6 0.3 0.3 0.3 Other (EWO) 0.0 0.0 0.1 0.0 0.0 0.3 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,385 2,101 2,627 1,726 2,583 1,179 3,973 7,628 11,601 Eligible women response rate (EWRR) 98.2 98.5 98.6 99.0 99.3 97.5 98.3 98.8 98.6 Overall response rate (ORR) 97.8 98.4 98.4 98.8 99.2 97.0 98.0 98.6 98.4 Note: The household response rate is calculated for completed households as a proportion of completed, no competent respondent, refused, and dwelling not found. The eligible woman response rate is calculated for completed interviews as proportion of completed, not at home, postponed, refused, partially completed, incapacitated and “other.” The overall response rate is the product of the household and eligible woman response rates divided by 100. 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C C + HP + P + R + DNF 2 Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as: 100 * EWC EWC + EWNH + EWP + EWR + EWPC + EWI + EWO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EWRR/100 230 | Appendix A Table A.1.2 Sample implementation: men Percent distribution of households and eligible men by results of the household and individual interviews, and household, eligible men and overall response rates, according to urban-rural residence and Division Bangladesh 2004 Division Residence Result Barisal Chittagong Dhaka Khulna Rajshahi Sylhet Urban Rural Total Selected households Completed (C) 97.1 96.7 96.5 96.9 98.4 97.0 96.2 97.6 97.1 Household present but no competent respondent at home (HP) 0.3 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.1 Refused (R) 0.0 0.0 0.1 0.0 0.1 0.0 0.1 0.0 0.0 Dwelling not found (DNF) 0.0 0.0 0.0 0.2 0.0 0.4 0.0 0.1 0.1 Household absent (HA) 1.0 1.5 0.9 1.4 0.7 1.6 1.2 1.1 1.1 Dwelling vacant/address not a dwelling (DV) 1.2 1.3 2.2 1.4 0.6 0.5 2.0 0.9 1.3 Dwelling destroy (DD) 0.3 0.4 0.1 0.1 0.1 0.2 0.3 0.1 0.2 Other (O) 0.1 0.1 0.1 0.0 0.1 0.4 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 679 1,024 1,358 864 1,280 560 1,944 3,821 5,765 Household response rate (HRR) 99.7 99.9 99.9 99.8 99.9 99.6 99.8 99.8 99.8 Eligible men Completed (EMC) 94.0 94.8 95.0 98.2 96.8 94.2 95.6 95.7 95.7 Not at home (EMNH) 4.6 4.7 4.4 1.5 2.8 5.8 3.5 3.9 3.8 Postponed (EMP) 0.4 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 Refused (EMR) 0.4 0.1 0.3 0.1 0.0 0.0 0.4 0.0 0.2 Partly completed (EMPC) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Incapacitated (EMI) 0.4 0.4 0.3 0.1 0.3 0.0 0.4 0.2 0.3 Other (EMO) 0.2 0.0 0.0 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 of men 481 749 1,065 711 1,032 452 1,583 2,907 4,490 Eligible men response rate (EMRR) 94.0 94.8 95.0 98.2 96.8 94.2 95.6 95.7 95.7 Overall response rate (ORR) 93.7 94.7 95.0 97.9 96.7 93.9 95.5 95.6 95.5 Note: The household response rate is calculated for completed households as a proportion of completed, no competent respondent, refused, and dwelling not found. The eligible man response rate is calculated for completed interviews as proportion of completed, not at home, postponed, refused, partially completed, incapacitated and “other.” The overall response rate is the product of the household and eligible man response rates divided by 100. 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C C + HP + P + R + DNF 2 Using the number of eligible men falling into specific response categories, the eligible man response rate (EMRR) is calculated as: 100 * EWC EMC + EMNH + EMP + EMR + EMPC + EMI + EMO 3 The overall response rate (ORR) is calculated as: ORR = HRR * EMRR/100 Appendix A | 231 Figure A.1 Urban Sampling Points, Bangladesh 232 | Appendix A Figure A.1 Rural Sampling Points, Bangladesh Appendix B | 233 ESTIMATES OF SAMPLING ERRORS APPENDIX B The estimates from a sample survey are affected by two types of errors: (1) nonsampling errors, and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2004 Bangladesh Demographic and Health Survey (BDHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2004 BDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2004 BDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the 2004 BDHS is the ISSA Sampling Error Module. This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ∑ ∑ = =− ⎥⎥⎦ ⎤ ⎢⎢⎣ ⎡ ⎟⎟⎠ ⎞ ⎜⎜⎝ ⎛ −−== H h h h m i hi h h m z z m m x frvarrSE h 1 2 1 2 1 2 2 1)()( in which hihihi rxyz −= , and hhh rxyz −= 234 | Appendix B where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one clusters in the calculation of the estimates. Pseudo- independent replications are thus created. In the 2004 BDHS, there were 361 non-empty clusters. Hence, 361 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )= = − −=∑ in which )()1( ii rkkrr −−= where r is the estimate computed from the full sample of 361 clusters, r(i) is the estimate computed from the reduced sample of 360 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, ISSA computes the design effect (DEFT) for each estimate, which is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. ISSA also computes the relative error and confidence limits for the estimates. Sampling errors for the 2004 BDHS are calculated for selected variables considered to be of primary interest for woman’s survey and for man’s surveys, respectively. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the 6 divisions of the country. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 to B.10 present the value of the statistic (R), its standard error (SE), the number of unweighted (N-UNWE) and weighted (N-WEIG) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The DEFT is considered undefined when the standard error considering simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to child-bearing. The confidence interval (e.g., as calculated for children ever born to women aged 40-49) can be interpreted as follows: the overall average from the national sample is 5.118 and its standard error is 0.072. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 5.118±2×0.072. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 4.974 and 5.261. Appendix B | 235 Sampling errors are analyzed for the national woman sample and for two separate groups of estimates: (1) means and proportions, and (2) complex demographic rates. The relative standard errors (SE/R) for the means and proportions range between 0.3 percent and 14.3 percent with an average of 3.5 percent; the highest relative standard errors are for estimates of very low values (e.g., currently using female sterilization). If estimates of very low values (less than 10 percent) were removed, then the average drops to 2.4 percent. So in general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. The relative standard error for the total fertility rate is small, 2.2 percent. However, for the mortality rates, the average relative standard error is much higher, 7.2 percent. There are differentials in the relative standard error for the estimates of sub-populations. For example, for the variable want no more children, the relative standard errors as a percent of the estimated mean for the whole country, and for the urban areas are 0.9 percent and 1.9 percent, respectively. For the total sample, the value of the design effect (DEFT), averaged over all variables, is 1.44 which means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.44 over that in an equivalent simple random sample. 236 | Appendix B Table B.1 List of selected variables for sampling errors, BDHS 2004 Variable Estimate Base population WOMEN Urban residence Proportion Ever-married women 10-49 No education Proportion Ever-married women 10-49 Secondary education or higher Proportion Ever-married women 10-49 Currently married Proportion Ever-married women 10-49 Currently pregnant Proportion Women aged 15-49 Children ever born Mean Currently married women 10-49 Children surviving Mean Currently married women 10-49 Children ever born to women over 40 Mean Women aged 40-49 Ever used any contraceptive method Proportion Currently married women 10-49 Currently using any method Proportion Currently married women 10-49 Currently using a modern method Proportion Currently married women 10-49 Currently using pill Proportion Currently married women 10-49 Currently using IUD Proportion Currently married women 10-49 Currently using injectables Proportion Currently married women 10-49 Currently using Norplant Proportion Currently married women 10-49 Currently using female sterilization Proportion Currently married women 10-49 Currently using periodic abstinence Proportion Currently married women 10-49 Currently using withdrawal Proportion Currently married women 10-49 Using public sector source Proportion Current users of modern method Want no more children Proportion Currently married women 10-49 Want to delay at least 2 years Proportion Currently married women 10-49 Ideal number of children Mean Ever married women 10-49 Mother received ANC (trained provider) Proportion Births in the five years before survey Mothers received tetanus injection in the last birth Proportion Women with at least one live birth in five years before survey Mothers received medical care at birth Proportion Births occurring 1-59 months before survey Had diarrhea in the last 2 weeks Proportion Children under 5 Treated with ORS packets Proportion Children under 5 with diarrhea in last 2 weeks Sought medical treatment Proportion Children under 5 with diarrhea in last 2 weeks Child having health card Proportion Children 12-23 months Received BCG vaccination Proportion Children 12-23 months Received DPT vaccination (3 doses) Proportion Children 12-23 months Received polio vaccination (3 doses) Proportion Children 12-23 months Received measles vaccination Proportion Children 12-23 months Received all vaccinations Proportion Children 12-23 months Height-for-age (<-2SD) Proportion Children under 5 who are measured Weight-for-height (<-2SD) Proportion Children under 5 who are measured Weight-for-age (<-2SD) Proportion Children under 5 who are measured BMI < 18.5 Proportion Ever-married women 10-49 Has heard of HIV/AIDS Proportion Ever-married women 10-49 Knows about condoms to prevent AIDS Proportion Ever-married women 10-49 Knows about limiting partners to prevent AIDS Proportion Ever-married women 10-49 Total fertility rate (3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate¹ Rate Births in 5 (10) years before survey Postneonatal mortality rate¹ Rate Births in 5 (10) years before survey Infant mortality rate¹ Rate Births in 5 (10) years before survey Child mortality rate¹ Rate Births in 5 (10) years before survey surviving to age one Under five mortality rate¹ Rate Births in 5 (10) years before survey MEN Urban residence Proportion All men 15-54 No education Proportion All men 15-54 With secondary education or higher Proportion All men 15-54 Never married Proportion All men 15-54 Currently married Proportion All men 15-54 Ideal number of children Mean Currently married men 15-54 Has heard of HIV/AIDS Proportion All men 15-54 Knows about condoms to prevent AIDS Proportion All men 15-54 Knows about limiting partners to prevent AIDS Proportion All men 15-54 ¹ The mortality rates are calculated for 10 years except at the national level, which are for five years. Appendix B | 237 Table B.2 Sampling errors: Total sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.226 0.006 11,440 11,440 1.557 0.027 0.214 0.238 No education 0.412 0.008 11,440 11,440 1.780 0.020 0.396 0.428 With secondary education or higher 0.294 0.008 11,440 11,440 1.787 0.026 0.279 0.310 Currently married 0.925 0.003 11,440 11,440 1.102 0.003 0.920 0.930 Currently pregnant 0.051 0.002 13,543 13,542 1.122 0.041 0.047 0.056 Children ever born 2.998 0.028 10,417 10,436 1.300 0.009 2.941 3.054 Children surviving 2.591 0.022 10,417 10,436 1.240 0.009 2.547 2.635 Children ever born to women 40-49 5.118 0.072 2,263 2,230 1.415 0.014 4.974 5.261 Ever used any contraceptive method 0.828 0.006 10,553 10,582 1.705 0.008 0.815 0.840 Currently using any contraceptive method 0.581 0.007 10,553 10,582 1.433 0.012 0.567 0.594 Currently using a modern method 0.473 0.007 10,553 10,582 1.451 0.015 0.459 0.487 Currently using pill 0.262 0.006 10,553 10,582 1.352 0.022 0.251 0.274 Currently using IUD 0.006 0.001 10,553 10,582 1.154 0.143 0.004 0.008 Currently using condom 0.042 0.003 10,553 10,582 1.346 0.063 0.037 0.047 Currently using injectables 0.097 0.005 10,553 10,582 1.819 0.054 0.086 0.107 Currently using female sterilization 0.052 0.004 10,553 10,582 1.741 0.072 0.044 0.060 Currently using periodic abstinence 0.065 0.003 10,553 10,582 1.290 0.048 0.059 0.071 Currently using withdrawal 0.036 0.002 10,553 10,582 1.178 0.059 0.032 0.040 Currently using Norplant 0.008 0.001 10,553 10,582 1.251 0.137 0.006 0.010 Obtained method from public sector source 0.573 0.011 4,994 5,053 1.602 0.020 0.550 0.595 Want no more children 0.628 0.006 10,553 10,582 1.188 0.009 0.617 0.640 Want to delay birth at least 2 years 0.212 0.004 10,553 10,582 1.096 0.021 0.203 0.220 Ideal number of children 2.420 0.013 11,012 11,017 1.840 0.006 2.393 2.446 Mothers received ANC (trained provider) 0.487 0.13 5,366 5,416 1.936 0.027 0.460 0.513 Mothers received tetanus injection (last birth) 0.848 0.009 5,366 5,416 1.837 0.011 0.830 0.866 Mothers received medical care at delivery 0.132 0.006 6,908 7,002 1.447 0.049 0.119 0.145 Child had diarrhea in the last 2 weeks 0.075 0.004 6,424 6,498 1.064 0.048 0.068 0.082 Treated with ORS packets 0.672 0.026 485 486 1.193 0.039 0.619 0.724 Sought medical treatment 0.157 0.018 485 486 1.085 0.117 0.120 0.193 Child having health card, seen 0.494 0.017 1,247 1,265 1.199 0.034 0.460 0.528 Child received BCG vaccination 0.934 0.012 1,247 1,265 1.671 0.013 0.911 0.958 Child received DPT vaccination (3 doses) 0.810 0.017 1,247 1,265 1.576 0.022 0.775 0.845 Child received polio vaccination (3 doses) 0.823 0.017 1,247 1,265 1.554 0.020 0.789 0.856 Child received measles vaccination 0.757 0.019 1,247 1,265 1.600 0.026 0.718 0.795 Child fully immunized 0.731 0.020 1,247 1,265 1.563 0.027 0.692 0.770 Height-for-age (-2SD) 0.430 0.009 6,012 6,005 1.421 0.022 0.411 0.449 Weight-for-height (-2SD) 0.128 0.005 6,012 6,005 1.105 0.038 0.119 0.138 Weight-for-age (-2SD) 0.475 0.010 6,012 6,005 1.534 0.022 0.454 0.496 BMI < 18.5 0.343 0.006 10,448 10,431 1.373 0.019 0.330 0.356 Has heard of HIV/AIDS 0.600 0.011 11,440 11,440 2.407 0.018 0.578 0.622 Knows about condoms 0.219 0.008 11,440 11,440 1.987 0.035 0.203 0.234 Knows about limiting partners 0.181 0.007 11,440 11,440 1.953 0.039 0.167 0.195 Total fertility rate (last 3 years) 3.028 0.067 na 38,850 1.497 0.022 2.894 3.161 Neonatal mortality (last 5 years) 41.373 2.861 6,967 7,056 1.149 0.069 35.652 47.095 Post-neonatal mortality (last 5 years) 23.822 2.048 6,978 7,065 1.133 0.086 19.725 27.918 Infant mortality (last 5 years) 65.195 3.604 6,980 7,068 1.181 0.055 57.986 72.403 Child mortality (last 5 years) 23.936 2.434 7,038 7,133 1.282 0.102 19.068 28.805 Under-five mortality (last 5 years) 87.571 4.327 7,053 7,148 1.239 0.049 78.917 96.224 MEN Urban residence 0.242 0.008 4,297 4,297 1.220 0.033 0.226 0.258 No education 0.246 0.011 4,297 4,297 1.642 0.044 0.224 0.268 With secondary education or higher 0.406 0.011 4,297 4,297 1.532 0.028 0.383 0.429 Never married 0.343 0.011 4,297 4,297 1.506 0.032 0.321 0.365 Currently married 0.647 0.011 4,297 4,297 1.511 0.017 0.625 0.669 Ideal number of children 2.314 0.021 2,993 2,653 1.513 0.009 2.272 2.356 Has heard of HIV/AIDS 0.819 0.009 4,297 4,297 1.480 0.011 0.801 0.836 Knows about condoms 0.407 0.012 4,297 4,297 1.537 0.028 0.384 0.430 Knows about limiting partners 0.096 0.007 4,297 4,297 1.498 0.070 0.082 0.109 na = Not applicable 238 | Appendix B Table B.3 Sampling errors: Urban sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 1.000 0.000 3,904 2,586 na 0.000 1.000 1.000 No education 0.330 0.017 3,904 2,586 2.221 0.051 0.297 0.363 With secondary education or higher 0.402 0.019 3,904 2,586 2.478 0.048 0.363 0.441 Currently married 0.917 0.006 3,904 2,586 1.305 0.006 0.905 0.928 Currently pregnant 0.049 0.004 4,846 3,196 1.429 0.089 0.040 0.058 Children ever born 2.695 0.048 3,534 2,336 1.428 0.018 2.600 2.791 Children surviving 2.364 0.038 3,534 2,336 1.380 0.016 2.288 2.441 Children ever born to women 40-49 4.441 0.164 780 505 1.966 0.037 4.113 4.769 Ever used any contraceptive method 0.878 0.010 3,578 2,372 1.790 0.011 0.858 0.897 Currently using any contraceptive method 0.629 0.012 3,578 2,372 1.546 0.020 0.604 0.654 Currently using a modern method 0.516 0.014 3,578 2,372 1.700 0.028 0.488 0.545 Currently using pill 0.269 0.010 3,578 2,372 1.368 0.038 0.249 0.289 Currently using IUD 0.005 0.001 3,578 2,372 1.233 0.284 0.002 0.008 Currently using condom 0.083 0.009 3,578 2,372 1.915 0.106 0.066 0.101 Currently using injectables 0.091 0.007 3,578 2,372 1.417 0.075 0.078 0.105 Currently using female sterilization 0.053 0.004 3,578 2,372 1.089 0.077 0.045 0.061 Currently using periodic abstinence 0.065 0.005 3,578 2,372 1.328 0.084 0.054 0.076 Currently using withdrawal 0.041 0.003 3,578 2,372 1.037 0.084 0.034 0.048 Currently using Norplant 0.010 0.002 3,578 2,372 1.196 0.204 0.006 0.013 Obtained method from public sector source 0.376 0.019 1,895 1,238 1.685 0.050 0.339 0.414 Want no more children 0.627 0.012 3,578 2,372 1.452 0.019 0.603 0.650 Want to delay birth at least 2 years 0.204 0.008 3,578 2,372 1.226 0.041 0.187 0.220 Ideal number of children 2.306 0.018 3,825 2,531 1.580 0.008 2.271 2.341 Mothers received ANC (trained provider) 0.708 0.024 1,684 1,123 2.131 0.033 0.661 0.755 Mothers received tetanus injection (last birth) 0.878 0.014 1,684 1,123 1.801 0.016 0.850 0.907 Mothers received medical care at delivery 0.295 0.021 2,073 1,392 1.907 0.072 0.252 0.337 Child had diarrhea in the last 2 weeks 0.067 0.006 1,930 1,284 1.089 0.095 0.054 0.080 Treated with ORS packets 0.771 0.047 136 86 1.269 0.061 0.676 0.866 Sought medical treatment 0.314 0.054 136 86 1.332 0.173 0.205 0.422 Child having health card, seen 0.581 0.027 377 251 1.044 0.046 0.527 0.635 Child received BCG vaccination 0.942 0.026 377 251 2.011 0.027 0.891 0.993 Child received DPT vaccination (3 doses) 0.857 0.035 377 251 1.912 0.041 0.786 0.927 Child received polio vaccination (3 doses) 0.858 0.035 377 251 1.905 0.041 0.787 0.928 Child received measles vaccination 0.828 0.037 377 251 1.862 0.045 0.754 0.901 Child fully immunized 0.809 0.037 377 251 1.780 0.045 0.736 0.883 Height-for-age (-2SD) 0.376 0.024 1,795 1,174 1.971 0.063 0.329 0.424 Weight-for-height (-2SD) 0.115 0.008 1,795 1,174 1.021 0.068 0.099 0.131 Weight-for-age (-2SD) 0.422 0.022 1,795 1,174 1.816 0.052 0.378 0.466 BMI < 18.5 0.250 0.014 3,599 2,374 1.986 0.057 0.221 0.279 Has heard of HIV/AIDS 0.817 0.018 3,904 2,586 2.853 0.022 0.782 0.852 Knows about condoms 0.376 0.019 3,904 2,586 2.394 0.049 0.339 0.413 Knows about limiting partners 0.273 0.015 3,904 2,586 2.137 0.056 0.242 0.303 Total fertility rate (last 3 years) 2.511 0.096 na 8,767 1.429 0.038 2.319 2.703 Neonatal mortality (last 10 years) 43.853 4.135 4,308 2,889 1.265 0.094 35.583 52.123 Post-neonatal mortality (last 10 years) 28.440 3.447 4,312 2,892 1.379 0.121 21.546 35.334 Infant mortality (last 10 years) 72.293 4.959 4,312 2,892 1.227 0.069 62.375 82.211 Child mortality (last 10 years) 21.435 3.222 4,326 2,899 1.412 0.150 14.990 27.879 Under-five mortality (last 10 years) 92.178 6.422 4,330 2,902 1.451 0.070 79.333 105.023 MEN Urban residence 1.000 0.000 1,514 1,042 na 0.000 1.000 1.000 No education 0.185 0.017 1,514 1,042 1.752 0.095 0.150 0.220 With secondary education or higher 0.518 0.026 1,514 1,042 2.016 0.050 0.466 0.569 Never married 0.369 0.023 1,514 1,042 1.816 0.061 0.324 0.414 Currently married 0.629 0.023 1,514 1,042 1.821 0.036 0.584 0.675 Ideal number of children 2.202 0.041 1,064 630 1.895 0.019 2.121 2.284 Has heard of HIV/AIDS 0.930 0.010 1,514 1,042 1.488 0.011 0.910 0.949 Knows about condoms 0.549 0.026 1,514 1,042 2.063 0.048 0.496 0.602 Knows about limiting partners 0.109 0.013 1,514 1,042 1.623 0.119 0.083 0.135 na = Not applicable Appendix B | 239 Table B.4 Sampling errors: Rural sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.000 0.000 7,536 8,854 na na 0.000 0.000 No education 0.436 0.010 7,536 8,854 1.677 0.022 0.417 0.455 With secondary education or higher 0.263 0.008 7,536 8,854 1.614 0.031 0.247 0.279 Currently married 0.927 0.003 7,536 8,854 1.026 0.003 0.921 0.933 Currently pregnant 0.052 0.002 8,838 10,355 1.024 0.046 0.047 0.057 Children ever born 3.085 0.034 6,883 8,100 1.244 0.011 3.017 3.153 Children surviving 2.657 0.027 6,883 8,100 1.181 0.010 2.604 2.710 Children ever born to women 40-49 5.305 0.078 1,488 1,729 1.257 0.015 5.149 5.462 Ever used any contraceptive method 0.813 0.008 6,975 8,210 1.635 0.009 0.798 0.828 Currently using any contraceptive method 0.567 0.008 6,975 8,210 1.381 0.014 0.550 0.583 Currently using a modern method 0.460 0.008 6,975 8,210 1.373 0.018 0.444 0.477 Currently using pill 0.260 0.007 6,975 8,210 1.306 0.026 0.247 0.274 Currently using IUD 0.006 0.001 6,975 8,210 1.096 0.164 0.004 0.008 Currently using condom 0.030 0.002 6,975 8,210 1.109 0.076 0.025 0.034 Currently using injectables 0.098 0.006 6,975 8,210 1.809 0.066 0.085 0.111 Currently using female sterilization 0.052 0.005 6,975 8,210 1.774 0.091 0.042 0.061 Currently using periodic abstinence 0.065 0.004 6,975 8,210 1.241 0.056 0.058 0.073 Currently using withdrawal 0.035 0.003 6,975 8,210 1.174 0.074 0.030 0.040 Currently using Norplant 0.007 0.001 6,975 8,210 1.235 0.172 0.005 0.010 Obtained method from public sector source 0.636 0.013 3,099 3,816 1.526 0.021 0.610 0.663 Want no more children 0.629 0.006 6,975 8,210 1.098 0.010 0.616 0.642 Want to delay birth at least 2 years 0.214 0.005 6,975 8,210 1.036 0.024 0.204 0.224 Ideal number of children 2.454 0.017 7,187 8,486 1.808 0.007 2.420 2.487 Mothers received ANC (trained provider) 0.429 0.016 3,682 4,293 1.909 0.036 0.397 0.460 Mothers received tetanus injection (last birth) 0.840 0.011 3,682 4,293 1.761 0.013 0.819 0.862 Mothers received medical care at delivery 0.092 0.006 4,835 5,610 1.394 0.069 0.079 0.104 Child had diarrhea in the last 2 weeks 0.077 0.004 4,494 5,215 1.013 0.054 0.068 0.085 Treated with ORS packets 0.651 0.030 349 400 1.129 0.046 0.590 0.711 Sought medical treatment 0.123 0.018 349 400 0.988 0.146 0.087 0.159 Child having health card, seen 0.473 0.020 870 1,014 1.182 0.043 0.433 0.513 Child received BCG vaccination 0.932 0.013 870 1,014 1.551 0.014 0.906 0.959 Child received DPT vaccination (3 doses) 0.798 0.020 870 1,014 1.468 0.025 0.758 0.838 Child received polio vaccination (3 doses) 0.814 0.019 870 1,014 1.443 0.023 0.776 0.852 Child received measles vaccination 0.739 0.023 870 1,014 1.509 0.030 0.694 0.784 Child fully immunized 0.711 0.023 870 1,014 1.481 0.032 0.666 0.757 Height-for-age (-2SD) 0.443 0.010 4,217 4,832 1.286 0.023 0.422 0.464 Weight-for-height (-2SD) 0.132 0.006 4,217 4,832 1.068 0.044 0.120 0.143 Weight-for-age (-2SD) 0.488 0.012 4,217 4,832 1.434 0.024 0.464 0.512 BMI < 18.5 0.371 0.007 6,849 8,057 1.251 0.020 0.356 0.385 Has heard of HIV/AIDS 0.537 0.014 7,536 8,854 2.369 0.025 0.509 0.564 Knows about condoms 0.173 0.008 7,536 8,854 1.898 0.048 0.156 0.189 Knows about limiting partners 0.154 0.008 7,536 8,854 1.923 0.052 0.138 0.170 Total fertility rate (last 3 years) 3.187 0.082 na 28,462 1.434 0.026 3.023 3.352 Neonatal mortality (last 10 years) 46.793 2.577 9,834 11,429 1.109 0.055 41.639 51.947 Post-neonatal mortality (last 10 years) 25.684 1.730 9,846 11,443 1.041 0.067 22.224 29.144 Infant mortality (last 10 years) 72.477 3.284 9,848 11,446 1.162 0.045 65.908 79.046 Child mortality (last 10 years) 27.225 2.148 9,893 11,493 1.130 0.079 22.929 31.521 Under-five mortality (last 10 years) 97.729 3.953 9,909 11,513 1.197 0.040 89.824 105.634 MEN Urban residence 0.000 0.000 2,783 3,255 na na 0.000 0.000 No education 0.266 0.013 2,783 3,255 1.586 0.050 0.239 0.292 With secondary education or higher 0.370 0.013 2,783 3,255 1.421 0.035 0.344 0.396 Never married 0.335 0.012 2,783 3,255 1.393 0.037 0.310 0.360 Currently married 0.653 0.013 2,783 3,255 1.397 0.019 0.627 0.678 Ideal number of children 2.349 0.024 1,929 2,023 1.387 0.010 2.301 2.398 Has heard of HIV/AIDS 0.783 0.011 2,783 3,255 1.438 0.014 0.760 0.805 Knows about condoms 0.361 0.013 2,783 3,255 1.414 0.036 0.335 0.387 Knows about limiting partners 0.092 0.008 2,783 3,255 1.443 0.086 0.076 0.107 na = Not applicable 240 | Appendix B Table B.5 Sampling errors: Barisal sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.146 0.033 1,360 719 3.405 0.223 0.081 0.212 No education 0.253 0.027 1,360 719 2.325 0.108 0.198 0.308 With secondary education or higher 0.340 0.023 1,360 719 1.826 0.069 0.293 0.387 Currently married 0.936 0.007 1,360 719 1.054 0.007 0.922 0.950 Currently pregnant 0.047 0.005 1,598 851 0.916 0.102 0.037 0.056 Children ever born 3.226 0.120 1,254 665 1.755 0.037 2.986 3.467 Children surviving 2.768 0.104 1,254 665 1.880 0.038 2.559 2.977 Children ever born to women 40-49 5.543 0.187 296 159 1.291 0.034 5.169 5.918 Ever used any contraceptive method 0.839 0.016 1,271 674 1.526 0.019 0.808 0.871 Currently using any contraceptive method 0.542 0.014 1,271 674 1.028 0.027 0.513 0.571 Currently using a modern method 0.427 0.020 1,271 674 1.441 0.047 0.387 0.467 Currently using pill 0.225 0.017 1,271 674 1.414 0.074 0.192 0.259 Currently using IUD 0.006 0.003 1,271 674 1.164 0.423 0.001 0.011 Currently using condom 0.019 0.005 1,271 674 1.193 0.238 0.010 0.029 Currently using injectables 0.128 0.010 1,271 674 1.055 0.077 0.108 0.148 Currently using female sterilization 0.038 0.006 1,271 674 1.168 0.164 0.026 0.051 Currently using periodic abstinence 0.073 0.007 1,271 674 1.013 0.101 0.058 0.088 Currently using withdrawal 0.034 0.007 1,271 674 1.452 0.217 0.019 0.049 Currently using Norplant 0.004 0.002 1,271 674 1.233 0.537 0.000 0.009 Obtained method from public sector source 0.562 0.043 569 291 2.058 0.076 0.476 0.648 Want no more children 0.641 0.015 1,271 674 1.132 0.024 0.611 0.672 Want to delay birth at least 2 years 0.215 0.012 1,271 674 1.025 0.055 0.191 0.238 Ideal number of children 2.431 0.029 1,318 693 1.414 0.012 2.372 2.489 Mothers received ANC (trained provider) 0.395 0.034 615 333 1.747 0.086 0.327 0.463 Mothers received tetanus injection (last birth) 0.861 0.024 615 333 1.757 0.028 0.813 0.910 Mothers received medical care at delivery 0.111 0.022 752 410 1.788 0.199 0.067 0.155 Child had diarrhea in the last 2 weeks 0.092 0.014 709 386 1.233 0.148 0.065 0.120 Treated with ORS packets 0.523 0.080 66 36 1.264 0.153 0.363 0.684 Sought medical treatment 0.069 0.028 66 36 0.936 0.413 0.012 0.125 Child having health card, seen 0.496 0.057 135 75 1.352 0.115 0.382 0.610 Child received BCG vaccination 0.962 0.025 135 75 1.536 0.026 0.912 1.000 Child received DPT vaccination (3 doses) 0.815 0.053 135 75 1.639 0.066 0.708 0.922 Child received polio vaccination (3 doses) 0.846 0.052 135 75 1.720 0.062 0.742 0.950 Child received measles vaccination 0.773 0.036 135 75 1.017 0.046 0.701 0.845 Child fully immunized 0.725 0.043 135 75 1.142 0.059 0.639 0.811 Height-for-age (-2SD) 0.489 0.024 658 354 1.248 0.049 0.440 0.537 Weight-for-height (-2SD) 0.072 0.011 658 354 1.136 0.158 0.049 0.095 Weight-for-age (-2SD) 0.463 0.026 658 354 1.327 0.057 0.411 0.516 BMI < 18.5 0.378 0.019 1,247 657 1.368 0.050 0.340 0.416 Has heard of HIV/AIDS 0.602 0.039 1,360 719 2.901 0.064 0.525 0.679 Knows about condoms 0.172 0.022 1,360 719 2.136 0.127 0.128 0.215 Knows about limiting partners 0.160 0.016 1,360 719 1.586 0.099 0.128 0.191 Total fertility rate (last 3 years) 2.879 0.186 na 2,319 1.576 0.064 2.508 3.250 Neonatal mortality (last 10 years) 31.995 5.345 1,646 899 1.203 0.167 21.305 42.685 Post-neonatal mortality (last 10 years) 29.443 5.708 1,649 901 1.329 0.194 18.026 40.859 Infant mortality (last 10 years) 61.438 8.108 1,649 901 1.300 0.132 45.222 77.653 Child mortality (last 10 years) 32.162 4.629 1,660 907 1.028 0.144 22.904 41.420 Under-five mortality (last 10 years) 91.623 9.363 1,663 909 1.286 0.102 72.897 110.350 MEN Urban residence 0.168 0.040 452 225 2.251 0.236 0.089 0.247 No education 0.132 0.029 452 225 1.830 0.221 0.074 0.190 With secondary education or higher 0.497 0.048 452 225 2.053 0.097 0.400 0.594 Never married 0.340 0.043 452 225 1.929 0.126 0.254 0.426 Currently married 0.648 0.040 452 225 1.766 0.061 0.568 0.727 Ideal number of children 2.296 0.056 308 139 1.363 0.024 2.184 2.408 Has heard of HIV/AIDS 0.823 0.028 452 225 1.558 0.034 0.767 0.879 Knows about condoms 0.410 0.036 452 225 1.534 0.087 0.339 0.481 Knows about limiting partners 0.107 0.016 452 225 1.124 0.153 0.074 0.139 na = Not applicable Appendix B | 241 Table B.6 Sampling errors: Chittagong sample, Bangladesh 2004 Number of cases Variable Confidence limits Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.260 0.010 2,069 2,041 1.034 0.038 0.240 0.280 No education 0.404 0.024 2,069 2,041 2.219 0.059 0.356 0.452 With secondary education or higher 0.325 0.022 2,069 2,041 2.155 0.068 0.281 0.369 Currently married 0.920 0.006 2,069 2,041 1.022 0.007 0.907 0.932 Currently pregnant 0.060 0.005 2,602 2,561 1.120 0.086 0.049 0.070 Children ever born 3.260 0.064 1,883 1,862 1.162 0.019 3.133 3.387 Children surviving 2.858 0.048 1,883 1,862 1.047 0.017 2.761 2.954 Children ever born to women 40-49 5.637 0.137 395 394 1.168 0.024 5.363 5.910 Ever used any contraceptive method 0.744 0.020 1,898 1,877 2.040 0.027 0.703 0.785 Currently using any contraceptive method 0.471 0.018 1,898 1,877 1.542 0.037 0.436 0.507 Currently using a modern method 0.374 0.017 1,898 1,877 1.544 0.046 0.340 0.409 Currently using pill 0.194 0.013 1,898 1,877 1.386 0.065 0.169 0.220 Currently using IUD 0.006 0.002 1,898 1,877 1.204 0.353 0.002 0.010 Currently using condom 0.048 0.007 1,898 1,877 1.447 0.148 0.034 0.062 Currently using injectables 0.083 0.009 1,898 1,877 1.393 0.106 0.066 0.101 Currently using female sterilization 0.036 0.005 1,898 1,877 1.158 0.138 0.026 0.046 Currently using periodic abstinence 0.057 0.005 1,898 1,877 1.033 0.097 0.046 0.068 Currently using withdrawal 0.031 0.005 1,898 1,877 1.127 0.144 0.022 0.040 Currently using Norplant 0.005 0.002 1,898 1,877 0.997 0.314 0.002 0.009 Obtained method from public sector source 0.512 0.026 750 708 1.425 0.051 0.460 0.564 Want no more children 0.589 0.013 1,898 1,877 1.176 0.023 0.562 0.616 Want to delay birth at least 2 years 0.221 0.012 1,898 1,877 1.261 0.054 0.197 0.245 Ideal number of children 2.685 0.040 1,970 1,934 2.047 0.015 2.604 2.765 Mothers received ANC (trained provider) 0.471 0.031 1,109 1,115 2.067 0.065 0.409 0.532 Mothers received tetanus injection (last birth) 0.831 0.019 1,109 1,115 1.746 0.023 0.792 0.870 Mothers received medical care at delivery 0.115 0.014 1,503 1,527 1.526 0.120 0.088 0.143 Child had diarrhea in the last 2 weeks 0.082 0.008 1,400 1,424 1.050 0.098 0.066 0.098 Treated with ORS packets 0.789 0.044 113 116 1.120 0.056 0.700 0.877 Sought medical treatment 0.135 0.035 113 116 1.017 0.260 0.065 0.206 Child having health card, seen 0.489 0.037 261 268 1.224 0.077 0.414 0.564 Child received BCG vaccination 0.931 0.025 261 268 1.525 0.026 0.882 0.980 Child received DPT vaccination (3 doses) 0.843 0.035 261 268 1.569 0.042 0.772 0.914 Child received polio vaccination (3 doses) 0.844 0.036 261 268 1.578 0.042 0.773 0.915 Child received measles vaccination 0.771 0.042 261 268 1.624 0.055 0.687 0.855 Child fully immunized 0.751 0.042 261 268 1.571 0.056 0.668 0.835 Height-for-age (-2SD) 0.462 0.018 1,316 1,320 1.303 0.040 0.425 0.499 Weight-for-height (-2SD) 0.141 0.012 1,316 1,320 1.160 0.083 0.118 0.164 Weight-for-age (-2SD) 0.499 0.018 1,316 1,320 1.206 0.035 0.464 0.534 BMI < 18.5 0.329 0.012 1,857 1,825 1.104 0.037 0.305 0.353 Has heard of HIV/AIDS 0.591 0.032 2,069 2,041 2.957 0.054 0.527 0.655 Knows about condoms 0.221 0.017 2,069 2,041 1.871 0.077 0.187 0.255 Knows about limiting partners 0.180 0.015 2,069 2,041 1.823 0.086 0.149 0.211 Total fertility rate (last 3 years) 3.709 0.175 na 6,903 1.493 0.047 3.359 4.058 Neonatal mortality (last 10 years) 40.551 4.038 2,985 3,010 1.054 0.100 32.476 48.627 Post-neonatal mortality (last 10 years) 27.011 3.078 2,991 3,016 1.048 0.114 20.855 33.167 Infant mortality (last 10 years) 67.563 4.349 2,991 3,016 0.948 0.064 58.865 76.260 Child mortality (last 10 years) 38.509 4.598 3,007 3,033 1.189 0.119 29.313 47.706 Under-five mortality (last 10 years) 103.470 5.797 3,013 3,039 0.992 0.056 91.876 115.065 MEN Urban residence 0.306 0.016 710 739 0.916 0.052 0.274 0.338 No education 0.252 0.026 710 739 1.621 0.105 0.199 0.305 With secondary education or higher 0.406 0.029 710 739 1.575 0.072 0.347 0.464 Never married 0.423 0.025 710 739 1.332 0.058 0.374 0.473 Currently married 0.572 0.025 710 739 1.335 0.043 0.522 0.621 Ideal number of children 2.663 0.087 437 390 1.768 0.033 2.490 2.836 Has heard of HIV/AIDS 0.814 0.019 710 739 1.335 0.024 0.775 0.853 Knows about condoms 0.368 0.026 710 739 1.445 0.071 0.316 0.420 Knows about limiting partners 0.063 0.014 710 739 1.510 0.219 0.035 0.090 na = Not applicable 242 | Appendix B Table B.7 Sampling errors: Dhaka sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.321 0.014 2,589 3,570 1.490 0.043 0.294 0.348 No education 0.421 0.016 2,589 3,570 1.616 0.037 0.390 0.453 With secondary education or higher 0.291 0.016 2,589 3,570 1.793 0.055 0.259 0.323 Currently married 0.929 0.006 2,589 3,570 1.102 0.006 0.917 0.940 Currently pregnant 0.049 0.005 3,067 4,237 1.194 0.093 0.040 0.059 Children ever born 2.981 0.048 2,364 3,266 1.097 0.016 2.886 3.076 Children surviving 2.559 0.037 2,364 3,266 1.050 0.015 2.484 2.634 Children ever born to women 40-49 4.931 0.157 492 669 1.492 0.032 4.617 5.245 Ever used any contraceptive method 0.862 0.011 2,399 3,315 1.540 0.013 0.840 0.883 Currently using any contraceptive method 0.593 0.013 2,399 3,315 1.275 0.022 0.567 0.619 Currently using a modern method 0.485 0.014 2,399 3,315 1.350 0.028 0.457 0.512 Currently using pill 0.273 0.010 2,399 3,315 1.147 0.038 0.252 0.294 Currently using IUD 0.005 0.002 2,399 3,315 1.068 0.303 0.002 0.008 Currently using condom 0.049 0.005 2,399 3,315 1.215 0.109 0.039 0.060 Currently using injectables 0.080 0.011 2,399 3,315 1.975 0.137 0.058 0.102 Currently using female sterilization 0.062 0.010 2,399 3,315 1.963 0.156 0.042 0.081 Currently using periodic abstinence 0.067 0.007 2,399 3,315 1.353 0.103 0.053 0.081 Currently using withdrawal 0.034 0.004 2,399 3,315 1.120 0.121 0.026 0.043 Currently using Norplant 0.012 0.002 2,399 3,315 1.094 0.206 0.007 0.016 Obtained method from public sector source 0.534 0.019 1,193 1,623 1.282 0.035 0.497 0.572 Want no more children 0.633 0.011 2,399 3,315 1.155 0.018 0.611 0.656 Want to delay birth at least 2 years 0.198 0.008 2,399 3,315 1.041 0.043 0.181 0.215 Ideal number of children 2.401 0.024 2,510 3,453 1.654 0.010 2.353 2.450 Mothers received ANC (trained provider) 0.485 0.025 1,192 1,677 1.717 0.051 0.436 0.535 Mothers received tetanus injection (last birth) 0.867 0.017 1,192 1,677 1.726 0.019 0.833 0.901 Mothers received medical care at delivery 0.148 0.013 1,531 2,175 1.323 0.089 0.122 0.174 Child had diarrhea in the last 2 weeks 0.066 0.006 1,409 2,005 0.888 0.090 0.054 0.078 Treated with ORS packets 0.637 0.057 91 132 1.113 0.089 0.523 0.750 Sought medical treatment 0.157 0.042 91 132 1.140 0.266 0.073 0.240 Child having health card, seen 0.430 0.031 266 375 1.017 0.072 0.368 0.492 Child received BCG vaccination 0.955 0.015 266 375 1.170 0.015 0.926 0.985 Child received DPT vaccination (3 doses) 0.781 0.034 266 375 1.363 0.044 0.713 0.849 Child received polio vaccination (3 doses) 0.795 0.032 266 375 1.321 0.041 0.730 0.859 Child received measles vaccination 0.720 0.040 266 375 1.479 0.056 0.640 0.801 Child fully immunized 0.688 0.040 266 375 1.437 0.059 0.608 0.769 Height-for-age (-2SD) 0.447 0.020 1,309 1,837 1.444 0.045 0.407 0.488 Weight-for-height (-2SD) 0.117 0.008 1,309 1,837 0.917 0.069 0.101 0.133 Weight-for-age (-2SD) 0.476 0.024 1,309 1,837 1.659 0.051 0.427 0.524 BMI < 18.5 0.340 0.014 2,372 3,266 1.449 0.042 0.311 0.368 Has heard of HIV/AIDS 0.669 0.019 2,589 3,570 2.102 0.029 0.630 0.708 Knows about condoms 0.247 0.015 2,589 3,570 1.765 0.061 0.217 0.277 Knows about limiting partners 0.198 0.013 2,589 3,570 1.648 0.065 0.172 0.223 Total fertility rate (last 3 years) 2.898 0.111 na 11,731 1.309 0.038 2.676 3.120 Neonatal mortality (last 10 years) 46.649 4.370 3,187 4,530 1.107 0.094 37.909 55.388 Post-neonatal mortality (last 10 years) 27.940 2.933 3,191 4,535 1.006 0.105 22.074 33.806 Infant mortality (last 10 years) 74.589 5.842 3,191 4,535 1.175 0.078 62.906 86.272 Child mortality (last 10 years) 26.527 3.766 3,202 4,551 1.184 0.142 18.995 34.060 Under-five mortality (last 10 years) 99.138 7.214 3,206 4,557 1.268 0.073 84.709 113.566 MEN Urban residence 0.340 0.019 1,012 1,342 1.287 0.056 0.302 0.379 No education 0.272 0.023 1,012 1,342 1.619 0.083 0.226 0.317 With secondary education or higher 0.404 0.023 1,012 1,342 1.514 0.058 0.357 0.451 Never married 0.344 0.023 1,012 1,342 1.523 0.066 0.299 0.390 Currently married 0.645 0.023 1,012 1,342 1.509 0.035 0.600 0.691 Ideal number of children 2.330 0.038 715 833 1.473 0.016 2.254 2.407 Has heard of HIV/AIDS 0.846 0.014 1,012 1,342 1.255 0.017 0.817 0.874 Knows about condoms 0.415 0.024 1,012 1,342 1.547 0.058 0.367 0.463 Knows about limiting partners 0.116 0.014 1,012 1,342 1.439 0.125 0.087 0.145 na = Not applicable Appendix B | 243 Table B.8 Sampling errors: Khulna sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN 0.217 0.013 1,708 1,397 1.325 0.061 0.191 0.243 No education 0.329 0.018 1,708 1,397 1.540 0.053 0.294 0.364 With secondary education or higher 0.356 0.019 1,708 1,397 1.598 0.052 0.319 0.393 Currently married 0.928 0.007 1,708 1,397 1.077 0.007 0.915 0.941 Currently pregnant 0.048 0.005 1,935 1,583 0.974 0.098 0.038 0.057 Children ever born 2.663 0.071 1,563 1,274 1.447 0.027 2.520 2.806 Children surviving 2.352 0.055 1,563 1,274 1.328 0.024 2.241 2.462 Children ever born to women 40-49 4.510 0.169 333 276 1.398 0.037 4.173 4.847 Ever used any contraceptive method 0.890 0.010 1,587 1,296 1.305 0.012 0.869 0.910 Currently using any contraceptive method 0.638 0.018 1,587 1,296 1.487 0.028 0.602 0.674 Currently using a modern method 0.507 0.015 1,587 1,296 1.186 0.029 0.478 0.537 Currently using pill 0.286 0.013 1,587 1,296 1.134 0.045 0.260 0.312 Currently using IUD 0.007 0.002 1,587 1,296 0.891 0.260 0.004 0.011 Currently using condom 0.049 0.008 1,587 1,296 1.413 0.156 0.034 0.064 Currently using injectables 0.115 0.012 1,587 1,296 1.440 0.101 0.091 0.138 Currently using female sterilization 0.036 0.006 1,587 1,296 1.272 0.165 0.024 0.048 Currently using periodic abstinence 0.068 0.008 1,587 1,296 1.184 0.110 0.053 0.083 Currently using withdrawal 0.056 0.006 1,587 1,296 0.996 0.103 0.044 0.067 Currently using Norplant 0.004 0.002 1,587 1,296 1.079 0.436 0.000 0.007 Obtained method from public sector source 0.561 0.025 818 664 1.447 0.045 0.510 0.611 Want no more children 0.637 0.011 1,587 1,296 0.930 0.018 0.615 0.659 Want to delay birth at least 2 years 0.218 0.009 1,587 1,296 0.858 0.041 0.200 0.236 Ideal number of children 2.227 0.030 1,669 1,363 1.891 0.013 2.167 2.286 Mothers received ANC (trained provider) 0.548 0.027 728 607 1.474 0.049 0.495 0.602 Mothers received tetanus injection (last birth) 0.860 0.019 728 607 1.475 0.022 0.822 0.897 Mothers received medical care at delivery 0.205 0.022 866 731 1.476 0.105 0.162 0.248 Child had diarrhea in the last 2 weeks 0.080 0.012 825 694 1.266 0.150 0.056 0.104 Treated with ORS packets 0.712 0.073 62 55 1.344 0.103 0.565 0.859 Sought medical treatment 0.172 0.044 62 55 0.922 0.256 0.084 0.261 Child having health card, seen 0.582 0.055 156 130 1.411 0.095 0.472 0.693 Child received BCG vaccination 0.969 0.015 156 130 1.101 0.016 0.939 0.999 Child received DPT vaccination (3 doses) 0.876 0.039 156 130 1.474 0.044 0.799 0.953 Child received polio vaccination (3 doses) 0.902 0.032 156 130 1.353 0.035 0.839 0.966 Child received measles vaccination 0.866 0.038 156 130 1.422 0.044 0.789 0.943 Child fully immunized 0.828 0.047 156 130 1.554 0.056 0.735 0.921 Height-for-age (-2SD) 0.317 0.026 794 662 1.556 0.083 0.265 0.370 Weight-for-height (-2SD) 0.142 0.013 794 662 1.047 0.092 0.115 0.168 Weight-for-age (-2SD) 0.403 0.028 794 662 1.600 0.070 0.347 0.459 BMI < 18.5 0.292 0.012 1,581 1,293 1.048 0.041 0.268 0.316 Has heard of HIV/AIDS 0.726 0.019 1,708 1,397 1.790 0.027 0.688 0.765 Knows about condoms 0.256 0.020 1,708 1,397 1.914 0.079 0.216 0.297 Knows about limiting partners 0.198 0.018 1,708 1,397 1.898 0.093 0.161 0.234 Total fertility rate (last 3 years) 2.777 0.131 na 4,366 1.141 0.047 2.516 3.038 Neonatal mortality (last 10 years) 46.883 6.427 1,748 1,457 1.305 0.137 34.029 59.736 Post-neonatal mortality (last 10 years) 19.070 5.008 1,748 1,457 1.493 0.263 9.055 29.086 Infant mortality (last 10 years) 65.953 7.116 1,748 1,457 1.213 0.108 51.722 80.184 Child mortality (last 10 years) 12.779 2.591 1,753 1,461 0.871 0.203 7.596 17.962 Under-five mortality (last 10 years) 77.889 7.697 1,753 1,461 1.204 0.099 62.495 93.283 MEN Urban residence 0.218 0.016 698 573 1.023 0.073 0.186 0.250 No education 0.188 0.021 698 573 1.400 0.110 0.147 0.230 With secondary education or higher 0.440 0.024 698 573 1.302 0.056 0.391 0.489 Never married 0.322 0.025 698 573 1.420 0.078 0.271 0.372 Currently married 0.671 0.025 698 573 1.431 0.038 0.620 0.722 Ideal number of children 2.134 0.047 507 374 1.577 0.022 2.041 2.228 Has heard of HIV/AIDS 0.917 0.014 698 573 1.379 0.016 0.888 0.945 Knows about condoms 0.534 0.027 698 573 1.436 0.051 0.479 0.588 Knows about limiting partners 0.117 0.021 698 573 1.686 0.175 0.076 0.159 na = Not applicable 244 | Appendix B Table B.9 Sampling errors: Rajshahi sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.131 0.007 2,564 2,994 0.990 0.050 0.117 0.144 No education 0.454 0.014 2,564 2,994 1.463 0.032 0.425 0.483 With secondary education or higher 0.268 0.011 2,564 2,994 1.288 0.042 0.246 0.291 Currently married 0.929 0.005 2,564 2,994 0.993 0.005 0.919 0.939 Currently pregnant 0.048 0.003 2,863 3,348 0.869 0.071 0.042 0.055 Children ever born 2.838 0.063 2,335 2,735 1.444 0.022 2.711 2.964 Children surviving 2.452 0.049 2,335 2,735 1.373 0.020 2.353 2.550 Children ever born to women 40-49 4.948 0.146 523 594 1.368 0.030 4.656 5.241 Ever used any contraceptive method 0.881 0.010 2,376 2,782 1.555 0.012 0.861 0.902 Currently using any contraceptive method 0.683 0.013 2,376 2,782 1.340 0.019 0.657 0.708 Currently using a modern method 0.578 0.014 2,376 2,782 1.339 0.023 0.551 0.605 Currently using pill 0.331 0.014 2,376 2,782 1.419 0.041 0.304 0.359 Currently using IUD 0.006 0.002 2,376 2,782 1.249 0.326 0.002 0.010 Currently using condom 0.034 0.005 2,376 2,782 1.211 0.132 0.025 0.043 Currently using injectables 0.122 0.012 2,376 2,782 1.801 0.099 0.098 0.146 Currently using female sterilization 0.065 0.007 2,376 2,782 1.316 0.102 0.052 0.079 Currently using periodic abstinence 0.063 0.006 2,376 2,782 1.215 0.096 0.051 0.075 Currently using withdrawal 0.037 0.005 2,376 2,782 1.172 0.123 0.028 0.046 Currently using Norplant 0.007 0.002 2,376 2,782 1.296 0.319 0.002 0.011 Obtained method from public sector source 0.646 0.023 1,403 1,626 1.831 0.036 0.599 0.692 Want no more children 0.654 0.011 2,376 2,782 1.143 0.017 0.631 0.676 Want to delay birth at least 2 years 0.223 0.009 2,376 2,782 1.001 0.038 0.206 0.240 Ideal number of children 2.286 0.026 2,534 2,952 2.029 0.011 2.234 2.338 Mothers received ANC (trained provider) 0.511 0.031 1,085 1,285 2.024 0.061 0.450 0.572 Mothers received tetanus injection (last birth) 0.864 0.022 1,085 1,285 2.102 0.025 0.821 0.908 Mothers received medical care at delivery 0.106 0.013 1,312 1,560 1.429 0.121 0.080 0.131 Child had diarrhea in the last 2 weeks 0.074 0.007 1,223 1,449 0.978 0.098 0.059 0.088 Treated with ORS packets 0.607 0.056 89 107 1.088 0.092 0.496 0.718 Sought medical treatment 0.198 0.044 89 107 1.064 0.224 0.109 0.287 Child having health card, seen 0.534 0.037 261 313 1.222 0.070 0.460 0.609 Child received BCG vaccination 0.911 0.036 261 313 2.076 0.040 0.839 0.983 Child received DPT vaccination (3 doses) 0.829 0.042 261 313 1.837 0.051 0.745 0.914 Child received polio vaccination (3 doses) 0.842 0.041 261 313 1.857 0.049 0.759 0.925 Child received measles vaccination 0.770 0.045 261 313 1.751 0.058 0.680 0.860 Child fully immunized 0.764 0.045 261 313 1.732 0.059 0.674 0.854 Height-for-age (-2SD) 0.403 0.020 1,148 1,349 1.352 0.050 0.363 0.444 Weight-for-height (-2SD) 0.142 0.012 1,148 1,349 1.167 0.085 0.118 0.166 Weight-for-age (-2SD) 0.481 0.021 1,148 1,349 1.398 0.044 0.438 0.524 BMI < 18.5 0.342 0.012 2,374 2,759 1.215 0.035 0.318 0.365 Has heard of HIV/AIDS 0.499 0.023 2,564 2,994 2.300 0.046 0.454 0.545 Knows about condoms 0.200 0.016 2,564 2,994 2.066 0.082 0.167 0.233 Knows about limiting partners 0.184 0.016 2,564 2,994 2.150 0.089 0.151 0.217 Total fertility rate (last 3 years) 2.570 0.109 na 9,269 1.138 0.042 2.353 2.788 Neonatal mortality (last 10 years) 48.231 5.346 2,732 3,256 1.163 0.111 37.540 58.923 Post-neonatal mortality (last 10 years) 21.903 3.283 2,733 3,258 1.139 0.150 15.337 28.470 Infant mortality (last 10 years) 70.135 6.413 2,735 3,261 1.221 0.091 57.308 82.962 Child mortality (last 10 years) 17.340 2.727 2,741 3,266 0.944 0.157 11.886 22.795 Under-five mortality (last 10 years) 86.259 7.395 2,746 3,273 1.279 0.086 71.469 101.049 MEN Urban residence 0.136 0.006 999 1,114 0.577 0.046 0.123 0.148 No education 0.276 0.022 999 1,114 1.536 0.079 0.232 0.319 With secondary education or higher 0.385 0.020 999 1,114 1.293 0.052 0.345 0.425 Never married 0.265 0.021 999 1,114 1.495 0.079 0.223 0.306 Currently married 0.722 0.022 999 1,114 1.539 0.030 0.678 0.766 Ideal number of children 2.160 0.028 775 777 1.304 0.013 2.105 2.215 Has heard of HIV/AIDS 0.752 0.021 999 1,114 1.504 0.027 0.711 0.793 Knows about condoms 0.385 0.022 999 1,114 1.460 0.058 0.340 0.430 Knows about limiting partners 0.079 0.012 999 1,114 1.438 0.155 0.054 0.104 na = Not applicable Appendix B | 245 Table B.10 Sampling errors: Sylhet sample, Bangladesh 2004 Number of cases Confidence limits Variable Value (R) Standard error (SE) Un- weighted (N) Weight- ed (WN) Design effect (DEFT) Relative error (SE/R) R-2SE R+2SE WOMEN Urban residence 0.152 0.025 1,150 719 2.316 0.161 0.103 0.201 No education 0.530 0.032 1,150 719 2.150 0.060 0.467 0.594 With secondary education or higher 0.170 0.017 1,150 719 1.554 0.101 0.135 0.204 Currently married 0.887 0.012 1,150 719 1.303 0.014 0.863 0.911 Currently pregnant 0.059 0.006 1,559 970 1.086 0.108 0.047 0.072 Children ever born 3.436 0.071 1,018 636 0.875 0.021 3.294 3.579 Children surviving 2.869 0.061 1,018 636 0.921 0.021 2.747 2.991 Children ever born to women 40-49 5.777 0.175 230 143 0.970 0.030 5.426 6.127 Ever used any contraceptive method 0.524 0.023 1,022 638 1.493 0.045 0.477 0.571 Currently using any contraceptive method 0.318 0.019 1,022 638 1.293 0.059 0.280 0.356 Currently using a modern method 0.220 0.019 1,022 638 1.431 0.084 0.183 0.258 Currently using pill 0.096 0.012 1,022 638 1.277 0.122 0.073 0.120 Currently using IUD 0.009 0.002 1,022 638 0.855 0.287 0.004 0.014 Currently using condom 0.025 0.004 1,022 638 0.803 0.158 0.017 0.033 Currently using injectables 0.041 0.009 1,022 638 1.518 0.231 0.022 0.059 Currently using female sterilization 0.037 0.009 1,022 638 1.435 0.228 0.020 0.054 Currently using periodic abstinence 0.076 0.010 1,022 638 1.254 0.137 0.055 0.097 Currently using withdrawal 0.018 0.005 1,022 638 1.156 0.268 0.008 0.028 Currently using Norplant 0.012 0.006 1,022 638 1.611 0.452 0.001 0.023 Obtained method from public sector source 0.551 0.047 261 141 1.535 0.086 0.456 0.646 Want no more children 0.578 0.018 1,022 638 1.196 0.032 0.541 0.615 Want to delay birth at least 2 years 0.188 0.011 1,022 638 0.913 0.059 0.166 0.210 Ideal number of children 2.741 0.047 1,011 624 1.587 0.017 2.648 2.834 Mothers received ANC (trained provider) 0.438 0.038 637 400 1.914 0.086 0.363 0.513 Mothers received tetanus injection (last birth) 0.739 0.026 637 400 1.522 0.036 0.686 0.791 Mothers received medical care at delivery 0.111 0.014 944 599 1.176 0.127 0.083 0.139 Child had diarrhea in the last 2 weeks 0.073 0.014 858 540 1.520 0.196 0.045 0.102 Treated with ORS packets 0.699 0.068 64 40 1.082 0.097 0.564 0.835 Sought medical treatment 0.167 0.048 64 40 1.001 0.285 0.072 0.263 Child having health card, seen 0.509 0.038 168 105 0.994 0.075 0.433 0.586 Child received BCG vaccination 0.871 0.030 168 105 1.172 0.035 0.811 0.932 Child received DPT vaccination (3 doses) 0.683 0.034 168 105 0.955 0.050 0.615 0.752 Child received polio vaccination (3 doses) 0.695 0.029 168 105 0.818 0.042 0.637 0.753 Child received measles vaccination 0.663 0.041 168 105 1.129 0.062 0.581 0.746 Child fully immunized 0.615 0.036 168 105 0.962 0.059 0.542 0.687 Height-for-age (-2SD) 0.462 0.022 787 485 1.125 0.047 0.419 0.505 Weight-for-height (-2SD) 0.122 0.014 787 485 1.153 0.111 0.095 0.149 Weight-for-age (-2SD) 0.498 0.029 787 485 1.470 0.058 0.440 0.555 BMI < 18.5 0.476 0.030 1,017 632 1.917 0.063 0.416 0.537 Has heard of HIV/AIDS 0.454 0.030 1,150 719 2.027 0.066 0.395 0.514 Knows about condoms 0.124 0.020 1,150 719 2.003 0.157 0.085 0.163 Knows about limiting partners 0.073 0.012 1,150 719 1.546 0.163 0.049 0.096 Total fertility rate (last 3 years) 4.152 0.238 na 2,645 1.367 0.057 3.677 4.627 Neonatal mortality (last 10 years) 63.455 6.345 1,844 1,167 1.036 0.100 50.764 76.146 Post-neonatal mortality (last 10 years) 36.501 5.131 1,846 1,169 1.111 0.141 26.239 46.763 Infant mortality (last 10 years) 99.956 10.027 1,846 1,169 1.310 0.100 79.901 120.011 Child mortality (last 10 years) 29.117 6.358 1,856 1,174 1.378 0.218 16.401 41.833 Under-five mortality (last 10 years) 126.163 12.462 1,858 1,176 1.433 0.099 101.238 151.088 MEN Urban residence 0.147 0.029 426 304 1.694 0.198 0.089 0.205 No education 0.204 0.026 426 304 1.352 0.129 0.151 0.257 With secondary education or higher 0.356 0.044 426 304 1.894 0.124 0.268 0.444 Never married 0.472 0.035 426 304 1.434 0.074 0.403 0.542 Currently married 0.518 0.035 426 304 1.458 0.068 0.447 0.589 Ideal number of children 2.598 0.057 251 140 1.010 0.022 2.485 2.712 Has heard of HIV/AIDS 0.763 0.041 426 304 1.984 0.054 0.681 0.845 Knows about condoms 0.300 0.028 426 304 1.245 0.092 0.245 0.355 Knows about limiting partners 0.100 0.018 426 304 1.248 0.182 0.063 0.136 na = Not applicable Appendix C | 247 SAMPLE DESIGN APPENDIX C Table C.1 Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Bangladesh 2004 Male Female Male Female Age Number Percentage Number Percentage Age Number Percentage Number Percentage 0 670 2.7 636 2.4 36 210 0.8 289 1.1 1 587 2.3 659 2.5 37 151 0.6 260 1.0 2 677 2.7 658 2.5 38 325 1.3 296 1.1 3 689 2.7 662 2.5 39 119 0.5 280 1.1 4 692 2.8 630 2.4 40 817 3.3 345 1.3 5 625 2.5 660 2.5 41 128 0.5 209 0.8 6 635 2.5 607 2.3 42 247 1.0 209 0.8 7 747 3.0 722 2.8 43 193 0.8 217 0.8 8 706 2.8 631 2.4 44 60 0.2 179 0.7 9 639 2.5 613 2.3 45 661 2.6 282 1.1 10 748 3.0 753 2.9 46 123 0.5 230 0.9 11 533 2.1 525 2.0 47 89 0.4 189 0.7 12 790 3.1 698 2.7 48 199 0.8 207 0.8 13 573 2.3 637 2.4 49 63 0.3 188 0.7 14 549 2.2 632 2.4 50 493 2.0 85 0.3 15 567 2.3 802 3.1 51 87 0.3 148 0.6 16 578 2.3 729 2.8 52 135 0.5 160 0.6 17 442 1.8 606 2.3 53 104 0.4 163 0.6 18 602 2.4 643 2.5 54 58 0.2 128 0.5 19 260 1.0 542 2.1 55 235 0.9 177 0.7 20 607 2.4 666 2.5 56 83 0.3 153 0.6 21 282 1.1 497 1.9 57 66 0.3 119 0.5 22 431 1.7 582 2.2 58 138 0.5 136 0.5 23 252 1.0 411 1.6 59 43 0.2 91 0.3 24 286 1.1 470 1.8 60 428 1.7 225 0.9 25 634 2.5 495 1.9 61 40 0.2 96 0.4 26 333 1.3 433 1.7 62 88 0.4 90 0.3 27 267 1.1 391 1.5 63 59 0.2 77 0.3 28 328 1.3 450 1.7 64 36 0.1 59 0.2 29 140 0.6 360 1.4 65 287 1.1 160 0.6 30 705 2.8 375 1.4 66 32 0.1 40 0.2 31 165 0.7 314 1.2 67 36 0.1 40 0.2 32 315 1.3 367 1.4 68 38 0.2 44 0.2 33 316 1.3 399 1.5 69 22 0.1 30 0.1 34 211 0.8 339 1.3 70+ 889 3.5 602 2.3 35 729 2.9 355 1.4 Don't know/ missing 8 0.0 7 0.0 Total 25,099 100.0 26,156 100.0 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. 248 | Appendix C Table C.2.1 Age distribution of eligible and interviewed women De facto household population of women age 5-54, interviewed women age 10-49, and percentage of eligible women who were interviewed (weighted), by five-year age groups, Bangladesh 2004 Household population of women age 5-54 Total Ever-married Women age 10-49 interviewed Age group Number Percentage Number Percentage Number Percentage Percentage of eligible women age 10-49 interviewed (weighted) 5-9 3,233 15.6 na na na na na 10-14 3,245 15.6 134 1.1 133 1.2 99.2 15-19 3,321 16.0 1,565 12.9 1,549 13.7 99.0 20-24 2,625 12.6 2,221 18.3 2,200 19.5 99.1 25-29 2,129 10.3 2,039 16.8 2,013 17.8 98.7 30-34 1,795 8.6 1,772 14.6 1,756 15.5 99.1 25-39 1,479 7.1 1,471 12.1 1,448 12.8 98.5 40-44 1,159 5.6 1,152 9.5 1,133 10.0 98.3 45-49 1,095 5.3 1,095 9.0 1,077 9.5 98.4 50-54 684 3.3 684 5.6 na na na 10-49 16,848 11,449 11,309 100.0 98.8 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household schedule. na = Not applicable Table C.2.2 Age distribution of eligible and interviewed men De facto household population of men age 10-59, men eligible to be interviewed age 15-54, interviewed men age 15-54, and percentage of eligible men who were interviewed (weighted), Bangladesh 2004 Household population of men age 10-59 Men eligible for interview age 15-54 Interviewed men age 15-54 Age group Number Percentage Number Percentage Number Percentage Percentage of eligible men age 15-54 interviewed (weighted) 5-9 1,710 19.8 na na na na na 10-14 1,248 14.5 622 14.0 607 14.2 97.7 15-19 952 11.0 522 11.7 502 11.8 96.3 20-24 890 10.3 614 13.8 587 13.7 95.6 25-29 932 10.8 737 16.5 691 16.2 93.8 30-34 798 9.2 654 14.7 630 14.8 96.4 25-39 725 8.4 578 13.0 548 12.8 94.9 40-44 613 7.1 433 9.7 425 10.0 98.2 45-49 488 5.7 295 6.6 279 6.5 94.9 50-54 276 3.2 na na na na na 10-49 6,646 4,453 100.0 4,270 100.0 95.9 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household schedule. na = Not applicable Appendix C | 249 Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Bangladesh 2004 Subject Reference group Percentage with missing information Number of cases Birth date Births in the 15 years preceding the survey Month only 0.16 21,022 Month and year 0.00 21,022 Age at death Deceased children born in the 15 years preceding the survey 0.00 2,226. Age/date at first marriage1 Ever-married women age 15-49 0.12 11,440 Respondent's education All women age 15-49 0.00 11,440 Diarrhea in last two weeks Living children age 0-59 months 0.61 6,498 Anthropometry Height Living children age 0-59 months (from the household questionnaire) 5.40 6,529 Weight 3.52 6,529 Height or weight 5.63 6,529 1 Both year and age missing Table C.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living ,dead, and total children (weighted), Bangladesh 2004 Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Calendar year Living Dead Total Living Dead Total Living Dead Total Living Dead Total 2004 271 13 284 100.0 100.0 100.0 123.4 189.9 125.7 na na na 2003 1,329 76 1,404 100.0 100.0 100.0 103.2 90.0 102.4 na na na 2002 1,283 89 1,372 100.0 99.3 99.9 87.7 133.6 90.1 96.3 87.9 95.7 2001 1,338 127 1,464 100.0 100.0 100.0 104.7 107.7 104.9 103.2 122.6 104.6 2000 1,309 118 1,426 100.0 100.0 100.0 109.8 106.1 109.5 99.9 97.1 99.7 1999 1,281 116 1,397 100.0 100.0 100.0 102.4 132.5 104.6 98.3 97.0 98.2 1998 1,297 121 1,418 100.0 100.0 100.0 99.6 108.7 100.4 99.0 80.7 97.2 1997 1,338 184 1,522 99.8 98.0 99.6 103.5 105.6 103.8 100.8 149.3 105.0 1996 1,356 126 1,482 99.8 100.0 99.8 95.7 123.0 97.7 102.3 70.1 98.5 1995 1,313 174 1,488 99.9 99.4 99.9 115.9 143.6 118.8 101.9 118.8 103.6 2000-2004 5,529 421 5,950 100.0 99.8 100.0 102.1 110.4 102.7 na na na 1995-1999 6,586 722 7,307 99.9 99.3 99.8 103.2 121.6 104.8 na na na 1990-1994 5,943 914 6,857 99.8 99.6 99.7 103.1 116.6 104.8 na na na 1985-1989 5,048 984 6,032 99.9 99.7 99.9 101.0 112.2 102.7 na na na < 1985 5,967 1,759 7,726 99.8 99.5 99.7 106.5 105.6 106.3 na na na All 29,073 4,800 33,873 99.9 99.5 99.8 103.2 111.7 104.4 na na na na = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, r espectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x 250 | Appendix C Table C.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Bangladesh 2004 Number of years preceding the survey Age at death (days) 0-4 5-9 10-14 15-19 Total 0-19 <1 92 104 98 82 375 1 45 48 43 56 192 2 13 14 19 12 58 3 29 43 44 39 155 4 10 16 21 17 63 5 7 19 20 26 73 6 11 5 18 15 48 7 10 24 31 31 96 8 5 13 16 10 44 9 1 3 4 6 13 10 3 9 6 8 26 11 3 3 8 13 27 12 1 5 5 12 23 13 5 5 7 3 19 14 4 7 11 10 33 15 8 8 6 7 29 16 5 1 4 3 13 17 5 8 7 3 22 18 5 1 2 1 9 19 5 3 1 2 11 20 2 7 5 1 15 21 8 4 4 4 20 22 5 3 5 6 19 23 1 0 2 1 4 24 0 1 3 1 5 25 0 3 1 2 6 26 1 0 0 2 3 27 2 3 5 0 10 28 1 2 2 3 8 29 0 1 4 2 7 30 0 1 0 1 2 Percent early neonatal1 72.2 68.6 65.1 64.7 67.3 Total 0-30 285 365 401 381 1,432 1 Percent early neonatal = (0-6 days /0-30 days) * 100 Appendix C | 251 Table C.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to occur at age under one month, for five-year periods of birth preceding the survey, Bangladesh 2004 Number of years preceding the survey Age at death (months) 0-4 5-9 10-14 15-19 Total 0-19 <1a 285 365 401 381 1,432 1 39 50 54 64 206 2 20 28 26 26 100 3 12 27 42 27 108 4 12 18 26 17 73 5 16 12 16 21 65 6 16 17 36 21 89 7 12 7 21 10 49 8 7 17 13 13 50 9 6 8 9 15 38 10 4 7 14 8 33 11 6 4 10 7 28 12 12 8 21 20 60 13 5 5 9 12 31 14 0 3 4 1 9 15 5 8 3 3 18 16 4 6 4 9 24 17 2 4 0 4 10 18 4 20 41 30 95 19 7 4 1 3 15 20 4 4 3 1 12 21 1 2 3 1 8 22 1 1 2 1 5 23 3 1 1 1 6 1 Year 0 0 0 2 2 Percent neonatal 1 65.6 65.2 60.1 62.4 63.0 Total 0-11 435 559 668 609 2,272 a <1 includes deaths under one month reported in days 1 Percent neonatal = (under one month/under one year) * 100 Appendix D │253 D PERSONS INVOLVED IN THE 2004 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY APPENDIX Technical Review Committee (TRC) Mr. Lokman Hakim, Director General, NIPORT Chairman Mr. Md. Abdur Rashid Sikder, Deputy Director General, Bangladesh Bureau of Statistics (BBS) Member Dr. Jahiruddin Ahmed, Director (Planning & MIS), Directorate of Family Planning Member Director (Planning and Research), Directorate of Health Services Member Dr. Jafar Ahmed Hakim, Line Director (ESP-RH), Directorate of Family Planning Member Deputy Secretary (Program), Ministry of Health and Family Welfare Member Deputy Chief (Health), Planning Cell, Ministry of Health and Family Welfare Member Deputy Chief (Family Welfare), Planning Cell, Ministry of Health and Family Welfare Member Deputy Chief, Population Planning Wing, Planning Commission Member Prof. M. Kabir, Department of Statistics, Jahangeernagar University Member Prof. Sekandar Hayat Khan, Institute of Statistical Research and Training, Dhaka University Member Dr. Abbas Bhuiya, Head, Social and Behavioral Sciences Unit, ICDDR,B Member Prof. A.K.M. Nurun Nabi, Department of Population Sciences, Dhaka University Member Dr. Mizanur Rahman, NGO Service Delivery Program (NSDP), Pathfinder International Member Dr. Peter Kim Streatfield, Head, Population Program and HDS Program, ICDDR,B Member Representative, WHO, Dhaka Member Deputy Representative, UNFPA, Dhaka Member Health Manager, DFID, British High Commission, Dhaka Member Senior HNP Specialist, World Bank, Dhaka Member Representative, HRD-GTZ, Dhaka Member Dr. Kanta Jamil, Program Coordinator for Research, Population, Health and Nutrition Team USAID, Dhaka Member Dr. Yasmin Ali Haque, Project Officer, Health and Nutrition Section, UNICEF, Dhaka Member Dr. Yuriko Egami, Chief Advisor, HRDRH Project, JICA, Dhaka Member Representative, ORC-Macro, USA Member Mr. Toslim Uddin Khan, Manager, Market Research, Social Marketing Company (SMC) Member Mr. S.N. Mitra, Executive Director, Mitra and Associates Member Dr. Ahmed Al-Sabir, Director (Research), NIPORT Member-Secretary Technical Task Force (TTF) Dr. Ahmed Al-Sabir, Director (Research), NIPORT Chairman Dr. Abbas Bhuiya, Head, Social and Behavioral Sciences Unit, ICDDR,B Member Dr. Peter Kim Streatfield, Head, Population Program and HDS Program, ICDDR,B Member Dr. Kanta Jamil, Program Coordinator for Research, Population, Health and Nutrition Team USAID, Dhaka Member Dr. Mizanur Rahman, NGO Service Delivery Program (NSDP), Pathfinder International Member Representative ORC-Macro, USA Member Mr. S.N. Mitra, Executive Director, Mitra and Associates 254 │ Appendix D COUNTRY COORDINATOR Dr. Ahmed Al-Sabir ASSOCIATE COORDINATORS Mr. Subrata K. Bhadra Ms. Shahin Sultana PROJECT DIRECTOR Mr. S. N. Mitra DEPUTY PROJECT DIRECTOR Mr. Shahidul Islam ASSISTANT PROJECT DIRECTORS PROJECT MANAGERS Mr. Md. A. B. Siddique Mozumder Mr. Md. Jahangir Hossain Sharif Mr. Nripendra Chandra Barman Ms. Nargis Akhter ORC MACRO STAFF Sushil Kumar Anne R. Cross Alexander Izmukhambetov Sidney Moore Kiersten Johnson Alfredo Aliaga Ren Ruilin Justine Faulkenburg Daniel Vadnais Kaye Mitchell John Chang FAMILY WELFARE VISITORS TRAINING INSTITUTES/RTC STAFF Dr. Harichand Shil, Faridpur Dr. Kamal Uddin Ahmed, Comilla Mr. Abdus Samad Talukder, Dinajpur Mr. AKM Abdullah, Dhaka Mr. Faridul Huq, Rajshahi Mr. Giyas Uddin Ahmed, Rangamati Mr. GM Arifeen, Sylhet Mr. Humayun Kabir, Gaila Mr. Md. Anwarul Islam, Gangni Mr. Md. Asaduzzaman, Ghatail Mr. Md. Rejaul Kabir, Khulna Mr. Mobarak Hossain, Methapukur Appendix D │255 FIELD STAFF QUALITY CONTROL OFFICERS Mr. Md. Najim Uddin Mr. Sankar Chandra Banik Mr. Sanjoy Bhowmik Ms. Dulena Begum Ms. Jesmin Akter Ms. Latifa Khatun Ms. Minara Mahbub Mr. Abu Md. Hossain Manik HOUSEHOLD LISTING SUPERVISORS Mr. Md. Masud Karim Reza Mr. Md. Najim Uddin Mr. Sankar Chandra Banik Mr. Sanjoy Bhowmik Mr. Abu Md. Hossain Manik Mr. Abdul Kadir Khan LISTERS Mr. Nurul Islam Mr. Hayat Alam Munshi Mr. Pingkon Chandra Das Mr. Nazrul Islam Mr. Abdul Aziz Mr. Azgar Hossain Mr. Nibir Kanti Roy Mr. Mizanur Rahman Mr. Mokbul Hossain Sharif Mr. Swapan Chandra Sutradhar Mr. Monsur Ali Sarker Mr. Sheikh Moniruzzaman Mr. Shaikh Nashiruzzaman Mr. Abul Kalam Azad Mr. Ziaur Rahman Mr. Abdur Rahim Mr. Almas Sikder Mr. Jontu Kumer Sil Mr. Yacin Akond Mr. Rejaul Karim Mr. Prodip Biswas Mr. Robiul Islam Chowdhary. Mr. Ohiduzzaman Mr. Rezaun Nabi Mr. Hossain Imam Mr. Binoy Chowdhury Mr. Golam Rabbani Mr. Ahasan Rashid Mr. Billal Hossain Mr. Arman Mr. Golam Sarowar Mr. Elyus Kabir Mr. Mohd. Ratan Sikder Mr. Sajedul Hoque 256 │ Appendix D HOUSEHOLDSURVEY/WOMEN’SSURVEY/MEN’SSURVEY MALE SUPERVISORS Mr. Golam Ahemed Siddique Mr. Saiful Islam Mukul Mr. Akram Hossain Mr. Akteruzzaman Mr. Abdus Salam Miah Mr. Prodip Ch. Das Mr. Abu Yousuf Mozumder Mr. Mahadi Hasan Mr. Jamal Uddin Mr. Moshiur Rahman Mr. Dilip Kumer Halder Mr. Almas Uddin FEMALE SUPERVISORS Ms. Joytsna Akter (Juthie) Ms. Mahbuba Lotus Ms. Tahera Khatun Ms. Aparna Rani Mondal Ms. Sirajum Monira Ms. Shahinur Pervin Ms. Rehana Akter Ms. Faizunnessa Hoque Ms. Afroza Khatun Sheuly Ms. Yesmin Begum Ms. Parven Akter Ms. Selina Akter MALE INTERVIEWERS Mr. D.M. Saiful Islam Mr. Rafiqul Alam Mr. Nasir Ahmed Mr. Mizanur Rahman (1) Mr. Mofiz Uddin Mr. Rezaun Nabi Mr. Nibir Kanti Roy Mr. Sirajul Islam Mr. Sontosh Kumer Banik Mr. Amar Ch. Mozumder Mr. Salam Khan Mr. Abdur Rahim Mr. Hayat Alam Munshi Mr. Mizanur Rahman (2) Mr. Ranjit Kumer Barman Mr. Arifur Rahman Mr. Kamrul Islam Mr. Kamruzzaman Mr. Sontosh Kumer Mondol Mr. Sonjoy Kumer Biswas Mr. Mizanur Rahman(2) Mr. Mokbul Hossain Sharif Mr. Rezaul Karim Mr. Abdur Rahman Mr. Johurul Islam Mr. Khairul Motin Mr. Sajedul Hoque Mr. Monir Ahemed Mr. Shamsuzzaman Mr. Monsur Ali Sarker Mr. Binoy Chowdhury Mr. Ohiduzzaman Appendix D │257 FEMALE INTERVIEWERS Ms. Farida Rahman Ms. Kanchon Mala Ms. Salma Sultana Ms. Ilora Sharf Khan Ms. Joly Haque Ms. Nazma Khanom Ms. Khadiza Akter Ms. Popy Akter Ms. Rabeya Khantun (Old) Ms. Morzina Begum Ms. Suraiya Pervin Trishna Ms. Mehenaz Pervin Ms. Hira Anindita Ghagra Ms. Rina Akter Ms. Lutfun Nahar (Rekha) Ms. Nasrin Sultana (Old) Ms. Rozina Khatun Ms. Pala Halder Ms. Nazmun Nahar Ms. Sayeda Masuda Akter (Moni) Ms. Rajia Sultana Ms. Taibatun Nahar Ms. Jinnat Rehana Ms. Nasrin Akter Ms. Nahida Akter Ms. Ismat Jahan Ms. Salma Pervin Joly Ms. Sabina Akter Ms. Mousumi Akter Ms. Sharmina Pervin Ms. Nazmun Sultana Ms. Shamima Pervin Ms. Yeasmin Akter Ms. Shirin Akter Ms. Mahinur Begum (Akhi) Ms. Umme Rafia Ms. Taslima Islam Ms. Rumana Akter Ms. Umme Kulsum Ms. Masuma Begum Ms. Rozina Khatun (Khuku) Ms. Kaniz Fatema Ms. Rebeka Sultana (Moli) Ms. Jhunu Talukder Ms. Habiba Hawa Ms. Mahmuda Akter Ms. Selina Akter Seli Ms. Jannatul Ferdaus Shefali Ms. Shelly Sultana Ms. Ayesha Begum Ms. Momeza Khatun Ms. Farida Yeasmin Ms. Roksana Yeasmin Ms. Shalina Khanam Ms. Sultana Rajia Ms. Sushoma Halder Ms. Shamsun Naher Lipi Ms. Rabeya Khatun Ms. Chandana Falguni Ms. Hamida Begum Ms. Salina Begum Ms. Liza Sultana Ms. Rowshon Ara Begum Ms. Nahid Ferdous Ms. Rokeya Akter Ms. Irin Pervin Ms. Lilima Akter Banu Ms. Halima Hawa Ms. Dilara Begum (Koli) Ms. Pervin Sultan Ruma Ms. Shalina Ali Lima COMPUTER PROGRAMMERS Mr. Shishir Paul Mr. Haradhan Kumar Sen DATA ENTRY OPERATORS Ms. Jharna Rani Dev Mr. Sujan Sen Mr. Anowar Hossain Mr. Eskander Ali Mr. Khairul Islam Mr. Ashraful Alam Mr. Wahidur Rahman (Shakil) 258 │ Appendix D VALIDATORS/OFFICE EDITORS Mr. Murshidul Islam Ms. Jesmin Sultana Ms. Sakina Begum Ms. Kamrun Nahar Ms. Majeda Begum Ms. Rabeya Khatun (2) ADMINISTRATIVE STAFF Mr. S. Fuad Pasha DPD-Admin. Mr. Md. Joynal Abdin Secretary Mr. Bimal Chandra Datta Accounts Officer Appendix E | 259 QUESTIONNAIRES APPENDIX E BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2004 HOUSEHOLD QUESTIONNAIRE IDENTIFICATION DIVISION _______________________________________________________________________ DISTRICT ______________________________________________________________________ UPAZILA _______________________________________________________________________ UNION/WARD ___________________________________________________________________ VILLAGE/MOHALLA/BLOCK ________________________________________________________ CLUSTER NUMBER. HOUSEHOLD NUMBER. RURAL = 1, MUNICIPALITY = 2, OTHER URBAN = 3, SMA = 4 . IS HOUSEHOLD IN A SLUM? (YES = 1, NO = 2) ________________________________________ NAME OF THE SLUM _____________________________________________________________ NAME OF HOUSEHOLD HEAD _____________________________________________________ IS HOUSEHOLD SELECTED FOR MEN’S SURVEY? (YES = 1, NO = 2) _____________________ INTERVIEWER VISITS 1 2 3 FINAL VISIT DAY MONTH YEAR INTV. CODE RESULT* DATE INTERVIEWER’S NAME RESULT* NEXT VISIT: DATE TIME TOTAL NO. OF VISITS TOTAL PERSONS IN HOUSEHOLD TOTAL ELIGIBLE WOMEN TOTAL ELIGIBLE MEN *RESULT CODES: 1 COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 4 POSTPONED 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER (SPECIFY) LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY NAME NAME DATE DATE HOUSEHOLD SCHEDULE Now we would like some information about the people who usually live in your household or who are staying with you now. LINE NO. USUAL RESIDENTS AND VISITORS RELATION SHIP TO HEAD OF HOUSEHO LD SEX RESIDENCE AGE MARITAL STATUS ELIGIBILITY EDUCATION IF AGE 5 YEARS OR OLDER EMPLOYMENT IF AGE 8 YEARS OR OLDER Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household? * Is (NAME) male or female? Does (NAME) usually live here? Did (NAME ) stay here last night? How old is (NAME)? IF AGE IS LESS THAN 1 YEAR, WRITE ‘00’ FOR ALL AGED 10 OR ABOVE What is the current marital status of (NAME)?** Currently married=1 Formerly married=2 Never married=3 CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN (Q8=1 OR 2) AGE 10-49 IF HOUSE- HOLD CHOSEN FOR MEN’S SURVEY, CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 CIRCLE LINE NUMBER OF ALL CHIL- DREN UNDER 6 Record mother’s line no. Of all children under 6 (RECORD ‘00’ IF MOTHER OF CHILDREN NOT LISTED IN HOUSEHO LD) Has (NAME) ever attended school? What is the level of schooling (NAME) has last attended?*** What is the highest class (NAME) completed at that schooling?*** IF AGED LESS THAN 25 YEARS Is (NAME) currently attending school? Is (NAME) currently working? Does (NAME) receive wages or income in cash or kind? CASH .1 KIND.2 BOTH .3 NONE .4 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (16) (17) (18) (19) (20) 01 M F 1 2 YES NO 1 2 YES NO 1 2 IN YEARS CM FM NM 1 2 3 01 01 01 YES .1 NO .2 GO TO 19 LEVEL GRADE YES NO 1 2 YES NO 1 2 NEXT LINE 1 2 3 4 02 1 2 1 2 1 2 1 2 3 02 02 02 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 03 1 2 1 2 1 2 1 2 3 03 03 03 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 04 1 2 1 2 1 2 1 2 3 04 04 04 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 05 1 2 1 2 1 2 1 2 3 05 05 05 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 06 1 2 1 2 1 2 1 2 3 06 06 06 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 07 1 2 1 2 1 2 1 2 3 07 07 07 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 08 1 2 1 2 1 2 1 2 3 08 08 08 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 HOUSEHOLD CONTINUED LINE NO. USUAL RESIDENTS AND VISITORS RELATION SHIP TO HEAD OF HOUSEHO LD SEX RESIDENCE AGE MARITAL STATUS ELIGIBILITY EDUCATION IF AGE 5 YEARS OR OLDER EMPLOYMENT IF AGE 8 YEARS OR OLDER Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. What is the relationship of (NAME) to the head of the household? * Is (NAME) male or female? Does (NAME) usually live here? Did (NAME ) stay here last night? How old is (NAME)? IF AGE IS LESS THAN 1 YEAR, WRITE ‘00’ FOR ALL AGED 10 OR ABOVE What is the current marital status of (NAME)?** Currently married=1 Formerly married=2 Never married=3 CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN (Q8=1 OR 2) AGE 10-49 IF HOUSE- HOLD CHOSEN FOR MEN’S SURVEY, CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 CIRCLE LINE NUMBER OF ALL CHIL- DREN UNDER 6 Record mother’s line no. Of all children under 6 (RECORD ‘00’ IF MOTHER OF CHILDREN NOT LISTED IN HOUSEHO LD) Has (NAME) ever attended school? What is the level of schooling (NAME) has last attended?*** What is the highest class (NAME) completed at that schooling?*** IF AGED LESS THAN 25 YEARS Is (NAME) currently attending school? Is (NAME) currently working? Does (NAME) receive wages or income in cash or kind? CASH .1 KIND.2 BOTH .3 NONE .4 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (16) (17) (18) (19) (20) 09 M F 1 2 YES NO 1 2 YES NO 1 2 IN YEARS CM FM NM 1 2 3 09 09 09 YES .1 NO .2 GO TO 19 LEVEL GRADE YES NO 1 2 YES NO 1 2 NEXT LINE 1 2 3 4 10 1 2 1 2 1 2 1 2 3 10 10 10 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 11 1 2 1 2 1 2 1 2 3 11 11 11 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 12 1 2 1 2 1 2 1 2 3 12 12 12 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 13 1 2 1 2 1 2 1 2 3 13 13 13 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 14 1 2 1 2 1 2 1 2 3 14 14 14 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 15 1 2 1 2 1 2 1 2 3 15 15 15 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 16 1 2 1 2 1 2 1 2 3 16 16 16 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 HOUSEHOLD CONTINUED (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (16) (17) (18) (19) (20) 17 M F 1 2 YES NO 1 2 YES NO 1 2 IN YEARS CM FM NM 1 2 3 17 17 17 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 18 1 2 1 2 1 2 1 2 3 18 18 18 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 19 1 2 1 2 1 2 1 2 3 19 19 19 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 20 1 2 1 2 1 2 1 2 3 20 20 20 YES .1 NO .2 GO TO 19 LEVEL GRADE 1 2 1 2 NEXT LINE 1 2 3 4 TICK HERE IF CONTINUATION SHEET USED ┌──┐ └──┘ Just to make sure that I have a complete listing: 1) Are there any other persons such as small children or infants that we have not listed? YES ENTER EACH IN TABLE NO 2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here? YES ENTER EACH IN TABLE NO 3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed? YES ENTER EACH IN TABLE NO * CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD: 01 = HEAD 02 = WIFE OR HUSBAND 03 = SON OR DAUGHTER 04 = SON-IN-LAW OR DAUGHTER-IN-LAW 05 = GRANDCHILD 06=PARENT 07 = PARENT-IN-LAW 08 = BROTHER OR SISTER 10 = OTHER RELATIVE 11 = ADOPTED/FOSTER/STEPCHILD 12 = NOT RELATED 98 = DON’T KNOW ** CODE FOR Q.8 MARITAL STATUS: 1 = CURRENTLY MARRIED 2 = FORMERLY MARRIED (DIVORCED/WIDOWED/SEPARATED/DESERTED) 3 = NEVER MARRIED ***CODES FOR Q17 EDUCATION LEVEL SCHOOL 1 = PRIMARY 2 = SECONDARY 3 = COLLEGE AND HIGHER GRADE: 00 = LESS THAN 1 YEAR COMPLETED 98 = DON’T KNOW NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 21 What is the main source of water your household used for dishwashing? (PROBE IF TUBEWELL IS MENTIONED) PIPED WATER PIPED INSIDE DWELLING.11 PIPED OUTSIDE DWELLING .12 WELL WATER TUBEWELL .21 SHALLOW TUBEWELL.22 DEEP TUBEWELL .23 SURFACE WELL/OTHER WELL .24 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP SURFACE WATER POND/TANK/LAKE .31 RIVER/STREAM.32 RAINWATER .41 OTHER 96 (SPECIFY) 22 What is the main source of drinking water for members of your household? (PROBE IF TUBEWELL IS MENTIONED) PIPED WATER PIPED INSIDE DWELLING.11 PIPED OUTSIDE DWELLING .12 WELL WATER TUBEWELL .21 SHALLOW TUBEWELL.22 DEEP TUBEWELL .23 SURFACE WELL/OTHER WELL .24 SURFACE WATER POND/TANK/LAKE .31 RIVER/STREAM.32 RAINWATER .41 OTHER 96 (SPECIFY) WILL YOU PLEASE GIVE ME SOME DRINKING WATER. INTERVIEWER: PLEASE PRESERVES THE DRINKING WATER FOR ARSENIC TEST. 23 What is the source of this drinking water? (PROBE IF TUBEWELL IS MENTIONED) PIPED WATER PIPED INSIDE DWELLING.11 PIPED OUTSIDE DWELLING .12 WELL WATER TUBEWELL .21 SHALLOW TUBEWELL.22 DEEP TUBEWELL .23 SURFACE WELL/OTHER WELL .24 SURFACE WATER POND/TANK/LAKE .31 RIVER/STREAM.32 RAINWATER .41 OTHER 96 (SPECIFY) 24 How long have you been using this source for drinking water? YEARS. 25 Have you heard of arsenic? YES .1 NO.2 26 CHECK Q23: CIRCLED ‘21’ OR ‘22’ OR ‘23’ YES: NO 29 27 Is the tube well marked red or green color from where you obtained this water for drinking? RED.1 GREEN .2 UNMARKED .3 DK .8 28B 29 28A Do you know the meaning of red color in the tube well? ARSENIC IN THE WATER. A NOT SAFE TO DRINK. B OTHER___________________________X (SPECIFY) DK .Z 29 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 28B Do you know the meaning of green color in the tube well? NOT ARSENIC IN THE WATER. A SAFE TO DRINK . B OTHER___________________________X (SPECIFY) DK .Z 29 What kind of toilet facility does your household have? SEPTIC TANK/MODERN TOILET .11 PIT TOILET/LATRINE WATER SEALED/SLAB LATRINE .21 PIT LATRINE.22 OPEN LATRINE .23 HANGING LATRINE.24 NO FACILITY/BUSH/FIELD .31 OTHER 96 (SPECIFY) 31 Does your household (or any member of your household) have: Electricity? Almirah or wardrobe? A table? A chair or bench? A watch or clock? A cot or bed? A radio that is working? A television that is working? A bicycle? A Motorcycle? A Sewing machine? Telephone or mobile phone? YES NO ELECTRICITY. 1 2 ALMIRAH. 1 2 TABLE. 1 2 CHAIR/BENCH. 1 2 WATCH/CLOCK. 1 2 COT/BED . 1 2 RADIO. 1 2 TELEVISION. 1 2 BICYCLE. 1 2 MOTORCYCLE. 1 2 SEWING MACHINE . 1 2 TELEPHONE/MOBILE . 1 2 32 MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION. NATURAL ROOF KATCHA (BAMBOO/THATCH).11 RUDIMENTARY ROOF TIN .21 FINISHED ROOF (PUKKA) CEMENT/CONCRETE/TILED.31 OTHER 96 (SPECIFY) 33 MAIN MATERIAL OF THE WALLS. RECORD OBSERVATION. NATURAL WALLS JUTE/BAMBOO/MUD (KATCHA) .11 RUDIMENTARY WALLS WOOD .21 FINISHED WALLS BRICK/CEMENT .31 TIN .32 OTHER 96 (SPECIFY) 34 MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION. NATURAL FLOOR EARTH/BAMBOO (KATCHA) .11 RUDIMENTARY FLOOR WOOD .21 FINISHED FLOOR (PUKKA) CEMENT/CONCRETE.31 OTHER 96 (SPECIFY) 35 Besides bathroom, how many rooms are there in your household? ROOMS . 36 How many rooms do you have for sleeping? SLEEPING ROOMS . NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 38 What type of fuel does your household mainly use for cooking? WOOD .01 CROP RESIDUE/GRASS.02 DUNG CAKES.03 COAL/COKE/LIGNITE.04 CHARCOAL.05 KEROSENE.06 ELECTRICITY.07 LIQUID GAS/GAS.08 BIO-GAS .09 OTHER _________________________ 96 (SPECIFY) 39 What type of cooking stove is mainly used in your house? KEROSINE STOVE.1 GAS STOVE .2 OPEN FIRE.3 OPEN FIRE OR STOVE WITH CHIMNEY OR HOOD.4 CLOSED STOVE WITH CHIMNEY .5 OTHER __________________________ 6 (SPECIFY) 40 Where is cooking usually done? IN A ROOM USED FOR LIVING OR SLEEPING .1 IN A SEPARATE ROOM IN SAME BUILDING USED AS KITCHEN.2 IN A SEPARATE BUILDING USED AS KITCHEN .3 OUTDOORS .4 OTHER __________________________ 6 (SPECIFY) 41 Does your household own any homestead? IF ‘NO’, PROBE: Does your household own homestead any other places? YES .1 NO.2 42 Does your household own any land (other than the homestead land)? YES .1 NO.2 44 43 How much land does your household own (other than the homestead land)? AMOUNT __________________ SPECIFY UNIT_______________ AMOUNT ACRES DECIMALS 44 In terms of household food consumption, how do you classify your household: deficit in whole year; sometimes deficit; neither deficit nor surplus; surplus. DEFICIT IN WHOLE YEAR.1 SOMETIMES DEFICIT .2 NEITHER DEFICIT NOT SURPLUS.3 SURPLUS.4 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 44A USE ARSENIC TEST KIT TO TEST DRINKING WATER AND CIRCLED APPROPRIATE CODE. 0 .01 10 .02 10-25.03 25 .04 25-50.05 50 .06 50-100.07 100 .08 100-250.09 250 .10 250-500.11 500-1500.12 1500-4000.13 OTHERS ________________________ 96 (SPECIFY) 44B IS THERE ANY SMELL OF ROTTEN EGG IN THE DRINKING WATER THAT WAS COLLECTED FOR TESTING? YES .1 NO.2 HEIGHT AND WEIGHT MEASUREMENT CHECK COLUMNS (9) AND (11): RECORD THE LINE NUMBER, NAME AND AGE OF ALL EVER MARRIED WOMEN AGE 10-49 AND ALL CHILDREN UNDER 6 YEARS. WOMEN 10-49 WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 10-49 LINE NO. FROM COL.(9) NAME FROM COL.(2) AGE FROM COL.(7) What is (NAME)’s date of birth? WEIGHT (KILOGRAMS) HEIGHT (CENTIMETERS) MEASURED LYING DOWN OR STANDING UP RESULT 1 MEASURED 2 NOT PRESENT 3 REFUSED 6 OTHER (45) (46) (47) (48) (49) (50) (51) (52) YEARS ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ ┌──┐ │░░│ └──┘ CHILDREN UNDER 6 YEARS [FROM FOL.(7)] WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN UNDER 6 YEARS LINE NO. FROM COL.(11) NAME FROM COL.(2) AGE FROM COL.(7) What is (NAME)’s date of birth?* WEIGHT (KILOGRAMS) HEIGHT (CENTIMETERS) MEASURED LYING DOWN OR STANDING UP RESULT 1 MEASURED 2 NOT PRESENT 3 REFUSED 6 OTHER ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ DAY MONTH YEAR ┌──┬──┐┌──┬──┐┌──┬──┬──┬──┐ │░░│░░││░░│░░││░░│░░│░░│░░│ └──┴──┘└──┴──┘└──┴──┴──┴──┘ ┌──┬──┬──┐ ┌──┐ │░0│░░│░░│ │░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ LYING STAND. 1 2 ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐┌──┬──┐┌──┬──┬──┬──┐ │░░│░░││░░│░░││░░│░░│░░│░░│ └──┴──┘└──┴──┘└──┴──┴──┴──┘ ┌──┬──┬──┐ ┌──┐ │░0│░░│░░│ │░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ 1 2 ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐┌──┬──┐┌──┬──┬──┬──┐ │░░│░░││░░│░░││░░│░░│░░│░░│ └──┴──┘└──┴──┘└──┴──┴──┴──┘ ┌──┬──┬──┐ ┌──┐ │░0│░░│░░│ │░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ 1 2 ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐┌──┬──┐┌──┬──┬──┬──┐ │░░│░░││░░│░░││░░│░░│░░│░░│ └──┴──┘└──┴──┘└──┴──┴──┴──┘ ┌──┬──┬──┐ ┌──┐ │░0│░░│░░│ │░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ 1 2 ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐┌──┬──┐┌──┬──┬──┬──┐ │░░│░░││░░│░░││░░│░░│░░│░░│ └──┴──┘└──┴──┘└──┴──┴──┴──┘ ┌──┬──┬──┐ ┌──┐ │░0│░░│░░│ │░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ 1 2 ┌──┐ │░░│ └──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐ │░░│░░│ └──┴──┘ ┌──┬──┐┌──┬──┐┌──┬──┬──┬──┐ │░░│░░││░░│░░││░░│░░│░░│░░│ └──┴──┘└──┴──┘└──┴──┴──┴──┘ ┌──┬──┬──┐ ┌──┐ │░0│░░│░░│ │░░│ └──┴──┴──┘.└──┘ ┌──┬──┬──┐┌──┐ │░░│░░│░░││░░│ └──┴──┴──┘.└──┘ 1 2 ┌──┐ │░░│ └──┘ TICK HERE IF CONTINUATION SHEET USED ┌──┐ └──┘ BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2004 WOMAN’S QUESTIONNAIRE IDENTIFICATION DIVISION ______________________________________________________________________ DISTRICT______________________________________________________________________ UPAZILA ______________________________________________________________________ UNION/WARD __________________________________________________________________ VILLAGE/MOHALLA/BLOCK_______________________________________________________ CLUSTER NUMBER. HOUSEHOLD NUMBER. RURAL = 1, MUNICIPALITY = 2, OTHER URBAN = 3, SMA = 4 . NAME OF HOUSEHOLD HEAD ____________________________________________________ NAME AND LINE NUMBER OF ELIGIBLE WOMAN ____________________________________ INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE INTERVIEWERS NAME RESULT** DAY MONTH* YEAR CODE RESULT NEXT VISIT: DATE TIME TOTAL NO. OF VISITS **RESULT CODES: 1 COMPLETED 4 REFUSED 7 OTHER_____________________ 2 NOT AT HOME 5 PARTLY COMPLETED (SPECIFY) 3 POSTPONED 6 RESPONDENT INCAPACITATED *MONTH CODES 01. JANUARY 04. APRIL 07. JULY 10. OCTOBER 02. FEBRUARY 05. MAY 08. AUGUST 11. NOVEMBER 03. MARCH 06. JUNE 09. SEPTEMBER 12. DECEMBER SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY NAME NAME DATE DATE SECTION 1. RESPONDENT’S BACKGROUND INTRODUCTION AND CONSENT INFORMED CONSENT Hello. My name is . We came from the Mitra and Associates, a private research organization, is located at Dhaka. To assist in the implementation of socio-development programs in the country, we conduct different types of surveys. We are now conducting a national survey about the health of women and children under the authority of NIPORT of Ministry of Health and Family Welfare. We would very much appreciate your participation in this survey. I would like to ask you about your health (and the health of your children). This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer: Date: RESPONDENT AGREES TO BE INTERVIEWED. 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED .2 END NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 RECORD THE TIME STARTED. HOUR . MINUTES. 102 First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a city, in a town, or in the countryside? DHAKA/CHITTAGONG/ KHULNA/RAJSHAHI .1 SMALL CITY .2 TOWN .3 VILLAGE .4 103 How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)? NUMBER OF YEARS. ALWAYS.95 VISITOR.96 105 104 Just before you moved here, did you live in a city, a town, or in the countryside? DHAKA/CHITTAGONG/ KHULNA/RAJSHAHI .1 SMALL CITY .2 TOWN .3 VILLAGE .4 105 In what month and year were you born? MONTH. DON’T KNOW MONTH.98 YEAR . DON’T KNOW YEAR.9998 106 How old are you at your last birthday? COMPARE AND CORRECT 105 AND /OR 106 IF INCONSISTENT AGE IN COMPLETED YEARS. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 106A Are you now married, separated, deserted, widowed, or divorced? CURRENTLY MARRIED . 1 SEPARATED . 2 DESERTED. 3 DIVORCED . 4 WIDOWED. 5 NEVER MARRIED . 6 END 106B Do you have a marriage certificate/marriage registration? YES.1 NO.2 107 Have you ever attended school or madrasha? YES, SCHOOL.1 YES, MADRASHA.2 YES, BOTH.3 NO.4 108B 111 108A What type of schooling (NAME) have you last attended? SCHOOL.1 MADRASHA.2 108B What level of schooling (NAME) have you last attended? What is the highest grade (NAME) completed at that schooling? LEVEL. GRADE . 109 CHECK 108B: GRADE IS LESS THAN 6 GRADE IS 6 OR MORE THAN 6 112 111 Can you read and write a letter in any language easily, with difficulty, or not at all? EASILY. 1 WITH DIFFICULTY. 2 NOT AT ALL . 3 113 112 Do you usually read a newspaper or magazine? YES . 1 NO. 2 113 112A How often do you read newspaper or magazine: every day, at least once a week, or less than once a week? EVERY DAY . 1 AT LEAST ONCE A WEEK . 2 LESS THAN ONCE A WEEK. 3 113 Do you listen to the radio? YES . 1 NO. 2 114 113A How often do you listen to the radio: every day, at least once a week, less than once a week? EVERY DAY . 1 AT LEAST ONCE A WEEK . 2 LESS THAN ONCE A WEEK. 3 114 Do you watch television? YES . 1 NO. 2 115 114A How often do you watch television: every day, at least once a week, less than once a week? EVERY DAY . 1 AT LEAST ONCE A WEEK . 2 LESS THAN ONCE A WEEK. 3 115 What is your religion? ISLAM. 1 HINDUISM. 2 BUDDHISM. 3 CHRISTIANITY. 4 OTHER __________________________ 6 (SPECIFY) 118 Do you belong to any of the following organizations? Grameen Bank? BRAC? BRDB? Mother’s Club? Any other organization (such as micro credit)? YES NO GRAMEEN BANK. 1 2 BRAC . 1 2 BRDB . 1 2 MOTHER’S CLUB. 1 2 OTHER ____________________ 1 2 (SPECIFY) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 119 CHECK Q. 5 IN THE HOUSEHOLD SECTION: THE WOMAN INTERVIEWED IS NOT A USUAL RESIDENT THE WOMAN INTERVIEWED IS A USUSAL RESIDENT 201 120 Now I would like to ask about the place in which you usually live. Do you usually live in a city, in a town, or in a village? IF CITY: In which city do you live? DHAKA/CHITTAGONG/ KHULNA/RAJSHAHI .1 SMALL CITY .2 TOWN.3 VILLAGE .4 122 121 In which division is that located? RAJSHAHI .1 DHAKA.2 CHITTAGONG .3 KHULNA.4 BARISAL.5 SYLHET .6 122 Now I would like to ask you some questions about your household where you usually live. What is the main source of water your household uses for dishwashing? (IF TUBEWELL, PROBE) PIPED WATER PIPED INSIDE DWELLING.11 PIPED OUTSIDE DWELLING .12 WELL WATER TUBEWELL.21 SHALLOW TUBEWELL .22 DEEP TUBEWELL .23 SURFACE WELL/OTHER WELL .24 SURFACE WATER POND/TANK/LAKE .31 RIVER/STREAM .32 RAINWATER.41 OTHER _________________________ 96 (SPECIFY) 123 What is the main source of drinking water for members of your household? (IF TUBEWELL, PROBE) PIPED WATER PIPED INSIDE DWELLING.11 PIPED OUTSIDE DWELLING .12 WELL WATER TUBEWELL.21 SHALLOW TUBEWELL .22 DEEP TUBEWELL .23 SURFACE WELL/OTHER WELL .24 SURFACE WATER POND/TANK/LAKE .31 RIVER/STREAM .32 RAINWATER.41 OTHER _________________________ 96 (SPECIFY) 124 What kind of toilet facility does your household have? SEPTIC TANK/MODERN TOILET . 11 PIT TOILET/LATRINE WATER SEALED/SLAB LATRINE. 21 PIT LATRINE . 22 OPEN LATRINE. 23 HANGING LATRINE . 24 NO FACILITY/BUSH/FIELD. 31 OTHER 96 (SPECIFY) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 126 Does your household (or any member of your household) have: Electricity? Almirah or wardrobe? A table? A chair or bench? A watch or clock? A cot or bed? A radio that is working? A television that is working? A bicycle? A Motorcycle? A Sewing machine? Telephone or mobile phone? YES NO ELECTRICITY . 1 2 ALMIRAH. 1 2 TABLE . 1 2 CHAIR/BENCH . 1 2 WATCH/CLOCK . 1 2 COT/BED. 1 2 RADIO . 1 2 TELEVISION. 1 2 BICYCLE . 1 2 MOTORCYCLE. 1 2 SEWING MACHINE. 1 2 TELEPHONE/MOBILE. 1 2 127 What is the main material of the roof of your house? NATURAL ROOF KATCHA (BAMBOO/THATCH) . 11 RUDIMENTARY ROOF TIN. 21 FINISHED ROOF (PUKKA) CEMENT/CONCRETE/TILED. 31 OTHER _________________________ 96 (SPECIFY) 128 What is the main material of the walls of your house? NATURAL WALLS JUTE/BAMBOO/MUD (KATCHA). 11 RUDIMENTARY WALLS WOOD. 21 FINISHED WALLS BRICK/CEMENT. 31 TIN. 32 OTHER _________________________ 96 (SPECIFY) 129 What is the main material of the floor of your house? NATURAL FLOOR EARTH/BAMBOO (KATCHA) . 11 RUDIMENTARY FLOOR WOOD. 21 FINISHED FLOOR (PUKKA) CEMENT/CONCRETE. 31 OTHER _________________________ 96 (SPECIFY) 130 Does your household own any homestead? IF ‘NO’, PROBE: Does your household own homestead any other places? YES . 1 NO . 2 130A Does your household own any land (other than the homestead land)? YES . 1 NO . 2 132 131 How much land does your household own (other than the homestead land)? AMOUNT __________________ SPECIFY UNIT_______________ AMOUNT ACRES DECIMALS 132 In terms of household food consumption, how do you classify your household: deficit in whole year; sometimes deficit; neither deficit nor surplus; surplus. DEFICIT IN WHOLE YEAR . 1 SOMETIMES DEFICIT . 2 NEITHER DEFICIT NOT SURPLUS . 3 SURPLUS. 4 SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 Now I would like to ask about all the births you have had during your life. Have you ever given birth? YES . 1 NO . 2 206 202 Do you have any sons or daughters to whom you have given birth who are now living with you? YES . 1 NO . 2 204 203 How many sons live with you? And how many daughters live with you? IF NONE, RECORD ‘00'. SONS AT HOME. DAUGHTERS AT HOME . 204 Do you have any sons or daughters to whom you have given birth who are alive but do not live with you? YES . 1 NO . 2 206 205 How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? IF NONE, RECORD ‘00'. SONS ELSEWHERE . DAUGHTERS ELSEWHERE . 206 Have you ever given birth to a boy or girl who was born alive but later died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive? YES . 1 NO . 2 208 207 How many boys have died? And how many girls have died? IF NONE, RECORD ‘00'. BOYS DEAD. GIRLS DEAD . 208 SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD ‘00'. TOTAL . 209 CHECK 208: Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct? PROBE AND YES NO CORRECT 201-208 AS  NECESSARY. 210 CHECK 208 ONE OR MORE BIRTHS NO BIRTHS 226 211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. IF NO NAME WAS GIVEN, RECORD ‘NO NAME’ IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. 212 213 214 215 216 217 IF ALIVE: 218 IF ALIVE: 219 IF ALIVE: 220 IF DEAD: 221 221A IF DEAD: What name was given to your (first /next) baby? (NAME) Were any of these births twins? Is (NAME) a boy or a girls? In what month and year was (NAME) born? Is (NAME) still alive? How old was (NAME) at his/her last birthday? RECORD AGE IN COMPLE- TED YEARS. Is (NAME) living with you? RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD) How old was (NAME) when he/she died? IF '1 YR.', PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)? RECORD LINE NUMBER OF CHILD AS IN Q212 IF CHILD WAS BORN SINCE JUNE 1998 01 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER NEXT BIRTH DAYS . 1 MONTHS. 2 YEARS. 3 LINE NUMBER (NEXT BIRTH) 02 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 03 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 04 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 05 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 06 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212 . IF NO NAME WAS GIVEN, RECORD ‘NO NAME’ IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. 212 213 214 215 216 217 IF ALIVE: 218 IF ALIVE: 219 IF ALIVE: 220 IF DEAD: 221 221A IF DEAD: What name was given to your (first /next) baby? (NAME) Were any of these births twins? Is (NAME) a boy or a girls? In what month and year was (NAME) born? Is (NAME) still alive? How old was (NAME) at his/her last birthday? RECORD AGE IN COMPLE- TED YEARS. Is (NAME) living with you? RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD) How old was (NAME) when he/she died? IF '1 YR.', PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)? RECORD LINE NUMBER OF CHILD AS IN Q212 IF CHILD WAS BORN SINCE JUNE 1998 07 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 LINE NUMBER (NEXT BIRTH) 08 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 09 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 10 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 11 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) 12 SING. 1 MULT. 2 BOY.1 GIRL.2 MONTH YEAR YES. 1 NO.2 220 AGE IN YEARS YES . 1 NO. 2 LINE NUMBER 221 DAYS . 1 MONTHS. 2 YEARS. 3 YES.1 NO.2 LINE NUMBER (NEXT BIRTH) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 222 Have you had any pregnancy outcome since the birth of (NAME OF LAST BIRTH)? YES .1 NO .2 223 COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK: NUMBERS NUMBERS ARE ARE SAME DIFFERENT (PROBE AND RECONCILE) CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED. FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED. FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED. FOR AGE AT DEATH 12 MONTHS OR 1 YR.: PROBE TO DETERMINE EXACT NUMBER OF MONTHS 224 CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JUNE 1998. IF NONE, RECORD ‘0'. 224A CHECK 221A AND ENTER THE NUMBER OF BIRTH SINCE JUNE 1998 AND DEATHS OCCURED SINCE JUNE 1998 FOR VERBAL AUTOPSY. IF NONE, RECORD ‘0'. 225 FOR EACH BIRTH SINCE JUNE 1998, ENTER ’B’ IN THE MONTH OF BIRTH IN COLUMN 1 OF THE CALENDAR. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD ‘P’ IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF ’P’s MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.) WRITE THE NAME OF THE CHILD TO THE LEFT OF THE ‘B’ CODE. 226 Are you pregnant now? YES . 1 NO. 2 UNSURE . 8 229 227 How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS. ENTER ‘P’s IN COLUMN 1 OF CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS. MONTHS. 228 At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all? THEN. 1 LATER. 2 NOT AT ALL. 3 229 Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth or had a menstrual regulation? YES . 1 NO. 2 236 230 When did the last such pregnancy end? MONTH . YEAR. 231 CHECK 230: LAST PREGNANCY LAST PREGNANCY ENDED ENDED SINCE JUNE1998 BEFORE JUNE1998 235 231A Was that a stillbirth, a miscarriage, a menstrual regulation, or an abortion? STILLBIRTH. 1 MISCARRIAGE . 2 MENSTRUAL REGULATION . 3 ABORTION . 4 232 How many months pregnant were you when the last such pregnancy ended? RECORD NUMBER OF COMPLETED MONTHS. ENTER ‘T’ IN COLUMN 1 OF CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND ‘P’ FOR THE REMAINING NUMBER OF COMPLETED MONTHS. MONTHS. 233 Have you ever had any other pregnancies which did not result in a live birth? YES.1 NO.2 235 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 234 ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JUNE 1998. ENTER ‘T’ IN COLUMN 1 OF CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND ‘P’ FOR THE REMAINING NUMBER OF COMPLETED MONTHS. 235 IN THE BOXES AT THE BOTTOM OF THE CALENDAR, FILL IN THE MONTH AND YEAR OF TERMINATION OF THE LAST NON-LIVE BIRTH PREGNANCY PRIOR TO JUNE 1998. 236 When did your last menstrual period start? _________________________________ (DATE, IF GIVEN) DAYS AGO . 1 WEEKS AGO . 2 MONTHS AGO. 3 YEARS AGO . 4 IN MENOPAUSE/ HAS HAD HYSTERECTOMY.994 BEFORE LAST BIRTH.995 NEVER MENSTRUATED.996 SECTION 3. CONTRACEPTION Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED IN 302. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301 OR 302, ASK 303. 302 Have you ever heard of (METHOD)? PROBED 301 Which ways or methods have you heard about? SPONTAN EOUS YES YES NO 303 Have you ever used (METHOD)? 01 FEMALE STERILIZATION: Women can have an operation to avoid having any more children. 1 2 3 Have you ever had an operation to avoid having any more children? YES . 1 NO . 2 02 MALE STERILIZATION (VASECTOMY): Men can have an operation to avoid having any more children. 1 2 3 Has your husband ever had an operation to avoid having any more children? YES . 1 NO . 2 03 PILL: Women can take a pill every day 1 2 3 YES . 1 NO . 2 04 IUD: Women can have a loop or coil placed inside them by a doctor or a nurse. 1 2 3 YES . 1 NO . 2 05 INJECTIONS: Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months. 1 2 3 YES . 1 NO . 2 06 IMPLANTS/NORPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years. 1 2 3 YES . 1 NO . 2 07 CONDOM: Men can put a rubber sheath on their penis before sexual intercourse. 1 2 3 YES . 1 NO . 2 08 SAFE PERIOD (COUNTING DAYS, CALENDAR, RHYTHM METHOD: Couples can avoid having sexual intercourse on certain days of the month when the woman is more likely to get pregnant. 1 2 3 YES . 1 NO . 2 09 WITHDRAWAL: Men can be careful and pull out before climax. 1 2 3 YES . 1 NO . 2 1 2 3 10 Have you heard of any other ways or methods that women or men can use to avoid pregnancy? (SPECIFY) (SPECIFY) YES . 1 NO . 2 YES . 1 NO . 2 NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 303A CHECK 301: OTHER METHOD MR NOT MENTIONED MR MENTIONED 303D 303B Have you ever heard of MR (Menstrual Regulation) (MR means when a woman’s menstrual period does not come on time, she can go to a health centre or to the FWV/to another provider and have a tube put in her for a short while to regularize her periods.) YES.1 NO.2 303D 303C Have you ever used MR (Menstrual regulation) YES.1 NO.2 303D CHECK 303: NOTA SINGLE ‘YES’ AT LEAST ONE ‘YES’ (NEVER USED) (EVER USED) 306A 304 Have you ever used anything or tried in any way to delay or avoid getting pregnant? YES. 1 NO. 2 306 305 ENTER ‘0' IN COLUMN 1 OF CALENDAR IN EACH BLANK MONTH. 328 306 What have you used or done? CORRECT 302 AND 303 (AND 301 IF NECESSARY). 306A Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant. What was the first method that you ever used? FEMALE STERILIZATION . 01 MALE STERILIZATION. 02 PILL. 03 IUD. 04 INJECTIONS. 05 IMPLANTS . 06 CONDOM. 07 PERIODIC ABSTINENCE . 08 WITHDRAWAL . 09 OTHER METHOD__________________10 (SPECIFY) 307 How many living children did you have at that time, if any? IF NONE, RECORD ‘00'. NUMBER OF CHILDREN. 308 CHECK 303 (01): WOMAN NOT WOMAN STERILIZED STERILIZED 311A 308A CHECK 106A: CURRENTLY SEPARATED/ DESERTED MARRIED DIVORCED/ WIDOWED 319 309 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 319 310 Are you currently doing something or using any method to delay or avoid getting pregnant? YES. 1 NO. 2 319 311 311A Which method are you using? CIRCLE ‘01' FOR FEMALE STERILIZATION. FEMALE STERILIZATION . 01 MALE STERILIZATION. 02 PILL. 03 IUD. 04 INJECTIONS. 05 IMPLANTS . 06 CONDOM. 07 PERIODIC ABSTINENCE . 08 WITHDRAWAL . 09 OTHER __________________________ 10 (SPECIFY) 313 318 312C 318 NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 312A May I see the package of pills that you are using now? RECORD NAME OF BRAND IF PACKAGE IS SEEN PACKAGE SEEN . 1 BRAND NAME . PACKAGE NOT SEEN. 2 318 312B SHOW BRAND CHART FOR PILLS Please tell me which of these is the brand of pills that you are using. BRAND NAME . DOES NOT KNOW . 98 318 312C May I see the package of condoms that you are using now? RECORD NAME OF BRAND IF PACKAGE IS SEEN PACKAGE SEEN . 1 BRAND NAME . PACKAGE NOT SEEN. 2 318 312D SHOW BRAND CHART FOR CONDOMS Please tell me which of these is the brand of condoms that you are using. BRAND NAME . DOES NOT KNOW . 98 318 313 Where did the sterilization take place? (NAME OF PLACE) PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE . 11 FAMILY WELFARE CENTRE (FWC). 12 THANA HEALTH COMPLEX. 13 SATELLITE CLINIC/ EPI OUTREACH SITE . 14 MATERNAL AND CHILD WELFARE CENTER (MCWC) . 15 NGO SECTOR NGO STATIC CLINIC. 21 NGO SATELLITE CLINIC . 22 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC. 31 QUALIFIED DOCTOR. 32 OTHER 96 (SPECIFY) DON’T KNOW . 98 314 CHECK 311: CODE ‘1’ CIRCLED Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation? CODE ‘2’ CIRCLED Before the sterilization operation, was your husband told that he would not be able to have any (more) children because of the operation? YES. 1 NO. 2 CANNOT REMEMBER/DON’T KNOW. 8 315A Do you regret that (you/your husband) had the operation not to have any more children? YES. 1 NO. 2 316 315B Why do you regret it? RESPONDENT WANTS ANOTHER CHILD . 1 PARTNER WANTS ANOTHER CHILD . 2 SIDE EFFECTS . 3 CHILD DIED. 4 OTHER REASON __________________6 (SPEC IFY) 316 In what month and year was the sterilization operation performed? MONTH. YEAR . NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 318 CHECK 311: IN CURRENT MONTH IN COLUMN 1 OF CALENDAR, ENTER CALENDAR METHOD CODE SHOWN TO THE LEFT OF THE CALENDAR FOR THE HIGHEST METHOD CIRCLED IN 311. THEN DETERMINE WHEN SHE STARTED USING METHOD THIS TIME. ENTER METHOD CODE IN EACH MONTH OF USE. IF CURRENT METHOD STARTED IN JUNE 1998 OR LATER, ENTER METHOD SOURCE CODE IN COLUMN 2 OF CALENDAR IN THE SAME MONTH THAT USE OF CURRENT METHOD BEGAN. ILLUSTRATIVE QUESTIONS:  When did you start using this method continuously?  How long have you been using this method continuously?  When you started using this method, where did you obtain it? 319 I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years. USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JUNE 1998. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS. IN COLUMN 1, ENTER METHOD USE CODE OR ‘0' FOR NONUSE IN EACH BLANK MONTH. ILLUSTRATIVE QUESTIONS: COLUMN 1:  When was the last time you used a method? Which method was that?  When did you start using that method? How long after the birth of (NAME)?  How long did you use the method then? IN COLUMN 2, ENTER METHOD SOURCE CODE IN FIRST MONTH OF EACH USE. ILLUSTRATIVE QUESTIONS: COLUMN 2:  Where did you obtain the method when you started using it?  Where did you get advice on how to use the method [for rhythm or withdrawal]? IN COLUMN 3, ENTER CODES FOR DISCONTINUATION NEXT TO LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 3 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1. ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT. ILLUSTRATIVE QUESTIONS: COLUMN 3:  Why did you stop using the (METHOD)?  Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason? IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK:  How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER ‘0' IN EACH SUCH MONTH IN COLUMN 1. 320 CHECK 311/311A: CIRCLE METHOD CODE: NO CODE CIRCLED. 00 FEMALE STERILIZATION . 01 MALE STERILIZATION. 02 PILL. 03 IUD. 04 INJECTIONS. 05 IMPLANTS . 06 CONDOM. 07 PERIODIC ABSTINENCE . 08 WITHDRAWAL . 09 OTHER METHOD . 10 328 325A 325A 321 CHECK COLUMN 1 OF CALENDAR FOR MONTH STARTED USING CURRENT METHOD: STARTED USING SINCE STARTED USING JUNE 1998 BEFORE JUNE 1998 326 322 You first obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM CALENDAR) in (DATE). At that time, were you told about side effects or problems you might have with the method? YES. 1 NO. 2 DON’T KNOW . 8 325 325 NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 323 Were you told what to do if you experienced side effects or problems? YES. 1 NO. 2 325 CHECK 320: ANY CODE ‘01’ TO ‘06' CIRCLED At that time, were you told about other methods of family planning which you could use? YES. 1 NO. 2 325A You had told me that you are currently using family planning. Would you say that using family planning is mainly your decision, mainly your husband’s decision or did you both decide together? MAINLY RESPONDENT . 1 MAINLY HUSBAND. 2 JOINT DECISION. 3 OTHER __________________________ 6 (SPECIFY) 326 CHECK 311/311A: CIRCLE METHOD CODE: FEMALE STERILIZATION . 01 MALE STERILIZATION. 02 PILL. 03 IUD. 04 INJECTIONS. 05 IMPLANTS . 06 CONDOM. 07 PERIODIC ABSTINENCE . 08 WITHDRAWAL . 09 OTHER METHOD _________________10 (SPECIFY) 327C 330 328 327 Where did you obtain (CURRENT METHOD) the last time? (NAME OF PLACE) PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE . 11 FAMILY WELFARE CENTRE . 12 UPAZILA HEALTH COMPLEX. 13 SATELLITE CLINIC/ EPI OUTREACH SITE . 14 MATERNAL CHILD WELFARE CENTER (MCWC) . 15 GOVT. FIELD WORKER (FWA) . 16 COMMUNITY CLINIC. 17 NGO SECTOR NGO STATIC CLINIC. 21 NGO SATELLITE CLINIC . 22 NGO DEPOT HOLDER. 23 NGO FIELDWORKER. 24 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC. 31 QUALIFIED DOCTOR. 32 TRADITIONAL DOCTOR . 33 PHARMACY. 34 OTHER PRIVATE SECTOR SHOP. 41 FRIEND/RELATIVES . 42 OTHER _________________________96 (SPECIFY) DON’T KNOW . 98 327A CHECK 311/311A: USING PILL OR CONDOMS USING ANOTHER METHOD  327C 327B Who obtained the (pills/condoms) the last time you got them? RESPONDENT . 1 HUSBAND. 2 SON/DAUGHTER . 3 OTHER RELATIVE . 4 OTHER___________________________6 (SPECIFY) 327C Are you having any problems in using (CURRENT METHOD)? YES. 1 NO. 2 330 NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 327D What problems are you having with using (CURRENT METHOD)? WEIGHT GAIN.A WEIGHT LOSS .B TOO MUCH BLEEDING.C HYPERTENSION.D HEADACHE .E NAUSEA . F NO MENSTRUATION . G WEAK/TIRED.H DIZZINESS . I HUSBAND DISAPPROVES . J OTHER RELATIVE DISAPPROVES .K RELIGION DISAPPROVES. L ACCESS/AVAILABILITY . M COSTS TOO MUCH.N INCONVENIENT TO USE . O STERILIZED, WANTS CHILDREN.P ABDOMINAL PAIN. Q OTHER X (SPECIFY) DOES NOT KNOW . Z 330 328 Do you know of a place where you can obtain a method of family planning? YES. 1 NO. 2 330 329 Where is that? (NAME OF PLACE) IF WOMAN SAYS MORE THAN ONE PLACE, ASK FOR THE PLACE SHE WOULD MOST LIKELY USE. PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE . 11 FAMILY WELFARE CENTRE. 12 UPZILA HEALTH COMPLEX. 13 SATELLITE CLINIC/ EPI OUTREACH SITE. 14 MATERNAL CHILD WELFARE CENTER (MCWC). 15 GOVT. FIELD WORKER (FWA). 16 COMMUNITY CLINIC. 17 NGO SECTOR NGO STATIC CLINIC. 21 NGO SATELLITE CLINIC. 22 NGO DEPOT HOLDER . 23 NGO FIELDWORKER. 24 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC. 31 QUALIFIED DOCTOR . 32 TRADITIONAL DOCTOR . 33 PHARMACY . 34 OTHER PRIVATE SECTOR SHOP. 41 FRIEND/RELATIVES . 42 OTHER _________________________96 (SPECIFY) DON’T KNOW . 98 330 CHECK 327 AND 329: SATELLITE/EPI OUTREACH SATELLITE /EPI OUTREACH NOT MENTIONED MENTIONED  332 331 In some places, there is a clinic set up for a day or part of a day in someone’s house or in a school. During the past 3 months, was there any such clinic in this village or mohalla? YES. 1 NO. 2 DOES NOT KNOW . 8 334A 332 Did you visit such a temporary health clinic in the last 3 months? YES. 1 NO. 2 334A NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 333 What services did you receive? CIRCLED ALL MENTIONED FAMILY PLANNING METHODS. A IMMUNIZATION . B CHILD GROWTH MONITORING . C T.T. FOR PREGNANT WOMEN. D ANTENATAL CARE . E TT VACCINE FOR WOMEN AGE BETWEEN 15-45 YEARS.F VITAMIN ‘A’ FOR CHILDREN. G OTHER __________________________ X (SPECIFY) DOES NOT KNOW .Z 334A During the last six months has anyone visited you in your house to talk to you about family planning or to give you any family planning method? IF YES, Who came? ________________________ NAME Anyone else? ________________________ NAME WRITE THE NAME OF THE FIELD WORKER. GOVT. FP WORKER . A GOVT. HEALTH WORKER. B NGO WORKER. C NO ONE. Y 335A 334B How many times did a worker /workers visit you for the family planning in the last six months? TIMES . DOES NOT KNOW .98 334C When was the last visit? IF MORE THAN ONE WORKER VISITED: When did the last worker visit you? IF LESS THAN ONE MONTH AGO, WRITE ‘0’. MONTHS AGO. DOES NOT KNOW .8 335A During the last six months has anyone visited you in your house to talk to you about your health or your child health or to give you any medicine such as vitamin A, ORS? IF YES, Who came? ________________________ NAME Anyone else? ________________________ NAME WRITE THE NAME OF THE FIELD WORKER. GOVT. FP WORKER . A GOVT. HEALTH WORKER. B NGO WORKER. C NO ONE. Y 336 335B How many times did a worker visit you for the health services in the last six months? TIMES . DOES NOT KNOW .98 335C When was the last visit? IF MORE THAN ONE WORKER VISITED (SEE 335A): When did the last worker visit you? IF LESS THAN ONE MONTH AGO, WRITE ‘0’. MONTHS AGO. DOES NOT KNOW .8 336 CHECK 334A AND 335A: BOTH FP AND HEALTH WORKER OTHER RESPONSE i.e., ‘Y’s ARE NOTCIRCLED 401 337 Is he/she is the same person who talked to you about family planning or gave you family planning method and talked to you about health or provided health services? SAME.1 DIFFERENT .2 DOES NOT KNOW .8 SECTION 4A. PREGNANCY, POSTNATAL CARE AND BREASTFEEDING NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 401 ASK QUESTIONS SEPARATELY FOR PREGNANCY, DELIVERY AND AFTER DELIVERY BUT RECORD RESPONSES IN SAME CODING CATEGORY. What are the problems at the time of pregnancy that may cause death to the mother? Any other? What are the problems at the time of delivery that may cause death to the mother? Any other? What are the problems after the delivery that may cause death to the mother? Any other? SEVERE HEADACHE .A BLURRY VISION.B HIGH BLOOD PRESSURE.C PRE-ECLAMSIA.D CONVULSION/ECLAMSIA .E EXCESSIVE VAGINAL BLEEDING. F FOUL-SMELLING DISCHARGE WITH HIGH FEVER . G JAUNDICE .H TETANUS. I BABY'S HAND OR FEET COME/ BABY IN BAD POSITION . J PROLONG LABOR.K OBSTRUCTED LABOR. L RETAINED PLACENTA. M TORNED UTEROUS .N OTHER ___________________________X (SPECIFY) DON'T KNOW .Y 402A CHECK 215: ONE OR MORE BIRTHS SINCE NO BIRTHS JUNE 1998 SINCE JUNE 1998 501 402B ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JUNE 1998. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES). Now I would like to ask you some questions about the health of all your children born in the last five years. (We will talk about one child at a time.) 403 LINE NUMBER FROM 212 LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 404 FROM 212 AND 216 NAME ALIVE DEAD NAME ALIVE DEAD 405 At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, did you want not want to have any (more) children at all? THEN .1 (SKIP TO 407) LATER .2 NO/NO MORE.3 (SKIP TO 407) THEN .1 (SKIP TO 417) LATER .2 NO/NO MORE.3 (SKIP TO 417) 406 How much longer would you like to have waited? MONTHS.1 YEARS.2 DON’T KNOW .998 MONTHS.1 YEARS.2 DON’T KNOW .998 407 When you were pregnant with (NAME), Did you see anyone for a medical checkup i.e., antenatal care for this pregnancy? IF YES: Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN. HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT (HA) . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA . H UNQUALIFIED DOCTOR .I OTHER ________________________ X (SPECIFY) (SKIP TO 407B) NO ONE. Y LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 407A Why did you not see anyone? Any other reason? RECORD ALL MENTIONED. TOO FAR . A INCONVENIENT SERVICE HOUR . B UNPLEASANT STAFF BEHAVIOUR . C LACK OF PROVIDER EXPERTISE . D LACK OF PRIVACY . E INADEQUATE DRUG SUPPLY.F LONG WAITING TIME .G SERVICE TOO EXPENSIVE. H RELIGIOUS REASONS .I NOT BENEFICIAL/NEEDED .J DID NOT KNOW OF NEED FOR SERVICE . K WAS UNABLE /NOT PERMITTED TO GO OUT OF THE HOUSE.L DID NOT KNOW OF EXISTENCE .M OTHER ________________________ X (SPECIFY) (SKIP TO 412A) 407B When you were pregnant with (NAME), the first time you go for antenatal care because just to check everything was fine or you had a problem? BECAUSE OF PROBLEM. 1 TO CHECK ONLY . 2 408 How many months pregnant were you when you first received medical checkup i.e., antenatal care for this pregnancy? MONTHS. DON’T KNOW .98 409 How many times did you receive medical checkup during this pregnancy? NO. OF TIMES. DON’T KNOW .98 410 CHECK 409: NUMBER OF TIMES RECEIVED MEDICAL CHECKUP (ANTENATAL CARE) ONCE MORE THAN ONCE OR DK (SKIP TO 412A) 411 How many months pregnant were you the last time your received medical checkup i.e., antenatal care? MONTHS. DON’T KNOW .98 412A During this pregnancy, were you weighed at least once? YES.1 NO.2 DON’T KNOW .8 412B During this pregnancy, was your height measured? YES.1 NO.2 DON’T KNOW .8 412C During this pregnancy, did anyone take your blood pressure (put a cuff on your arm and pump air into it)? YES.1 NO.2 DON’T KNOW .8 412D When you were pregnant with (NAME), did anyone take your urine for testing? YES.1 NO.2 DON’T KNOW .8 412E When you were pregnant with (NAME), did anyone take your blood for testing? YES.1 NO.2 DON’T KNOW .8 412F When you were pregnant with (NAME), did anyone check/exam your eye for anemia? YES.1 NO.2 DON’T KNOW .8 412G When you were pregnant with (NAME), did you have an ultrasonography test? YES.1 NO.2 DON’T KNOW .8 LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 413 When you were pregnant with (NAME) were you told about the signs of pregnancy complications? YES .1 NO.2 (SKIP TO 415) DON’T KNOW .8 414 Were you told where to go if you had these complications? YES.1 NO.2 DON’T KNOW .8 415 During this pregnancy, were you given a TT Injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth? YES.1 NO.2 (SKIP TO 416) DON’T KNOW .8 415A During this pregnancy, how many times did you get this injection? TIMES . DON’T KNOW .8 416 Did you take any iron tablet or iron syrup during this pregnancy? SHOW TABLET/SYRUP. YES .1 NO.2 DON’T KNOW .8 417 Around the time of the birth (NAME), did you have any of the following problems: Long labor, that is, did your regular contractions last more than 12 hours? Excessive bleeding that was so much that you feared it was life threatening? A high fever with bad smelling vaginal discharge? Convulsions? Baby’s hands and feet came first during delivery? YES NO DK LONG LABOR. 1 2 8 EXCESSIVE BLEEDING. 1 2 8 HIGH FEVER . 1 2 8 CONVULSIONS . 1 2 8 HANDS AND FEET . 1 2 8 YES NO DK LONG LABOR. 1 2 8 EXCESSIVE BLEEDING. 1 2 8 HIGH FEVER . 1 2 8 CONVULSIONS . 1 2 8 HANDS AND FEET . 1 2 8 418 CHECK 417: AT LEAST NOT A SINGLE ONE ‘YES’ ‘YES’ (SKIP TO 420) AT LEAST NOT A SINGLE ONE ‘YES’ ‘YES’ (SKIP TO 425) 419 Did you see seek any assistance for this complication? IF YES, Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN. HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA (DAI) . H UNQUALIFIED DOCTOR.I RELATIVES.J NEIGHBOURS/FRIENDS. K OTHER ________________________ X (SPECIFY) NO ONE. Z HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA (DAI) . H UNQUALIFIED DOCTOR.I RELATIVES.J NEIGHBOURS/FRIENDS. K OTHER_________________________ X (SPECIFY) NO ONE. Z 420 During this pregnancy, did you suffer from night blindness (ratkana)? YES.1 NO.2 DON’T KNOW .8 LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 421 During this pregnancy, did you have difficulty with your vision during the daylight? YES.1 NO.2 DON’T KNOW .8 425 Who assisted with the delivery of (NAME)? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING. HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA (DAI) . H UNQUALIFIED DOCTOR.I RELATIVES.J NEIGHBOURS/FRIENDS. K OTHER ________________________ X (SPECIFY) NO ONE. Z HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA (DAI) . H UNQUALIFIED DOCTOR.I RELATIVES.J NEIGHBOURS/FRIENDS. K OTHER_________________________ X (SPECIFY) NO ONE. Z 426 Where did you give birth to (NAME)? HOME OWN HOME .11 OTHER HOME.12 (SKIP TO 428) PUBLIC SECTOR GOVT. HOSPITAL .21 UPAZILA HEALTH COMPLEX.22 MATERNAL AND CHILD WELFARE CENTER (MCWC) .23 NGO SECTOR NGO STATIC CLINIC.31 PRIVATE SECTOR PVT. HOSPITAL/CLINIC.41 OTHER _______________________ 96 (SPECIFY) (SKIP TO 428) HOME OWN HOME .11 OTHER HOME.12 (SKIP TO 434) PUBLIC SECTOR GOVT. HOSPITAL .21 THANA HEALTH COMPLEX.22 MATERNAL AND CHILD WELFARE CENTER (MCWC) .23 NGO SECTOR NGO STATIC CLINIC.31 PRIVATE SECTOR PVT. HOSPITAL/CLINIC.41 OTHER _______________________ 96 (SPECIFY) (SKIP TO 434) 427 Was (NAME) delivered by caesarian section? YES.1 (SKIP TO 432) NO.2 YES.1 (SKIP TO 434) NO.2 428 After (NAME) was born, did any medical persons check on your health? YES.1 NO.2 (SKIP TO 432) 429 How many days or weeks after the delivery did the first check take place? RECORD ‘00’ DAYS IF SAME DAY DAYS AFTER DEL.1 WEEKS AFTER DEL .2 DON’T KNOW .998 LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 430 Who checked on your health at that time? PROBE FOR THE MOST QUALIFIED PERSON. HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA (DAI) . H UNQUALIFIED DOCTOR .I OTHER ________________________ X (SPECIFY) NO ONE. Z 431 Where did this first check take place? HOME OWN HOME . 01 OTHER HOME.02 PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE.11 FAMILY WELFARE CENTRE .12 THANA HEALTH COMPLEX.13 SATELLITE CLINIC/ EPI OUTREACH SITE .14 MATERNAL AND CHILD WELFARE CENTER (MCWC) .15 COMMUNITY CLINIC .16 NGO SECTOR NGO STATIC CLINIC.21 NGO SATELLITE CLINIC .22 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL /CLINIC .31 QUALIFIED DOCTOR.32 TRADITIONAL DOCTOR .33 PHARMACY.34 OTHER________________________ 96 (SPECIFY) 432 In the first two months after delivery, did you take a Vitamin A capsule like this? SHOW CAPSULE YES.1 NO.2 432A After (NAME) was born did any medical persons check on your baby’s health? YES.1 NO.2 (SKIP TO 433) 432B How many days or weeks after the delivery did the first check takes place? RECORD ‘00’ DAYS IF SAME DAY DAYS AFTER DELIVERY .1 WEEKS AFTER DELIVERY.2 DON’T KNOW .998 432C Who checked on your baby’s health at that time? HEALTH PROFESSIONAL QUALIFIED DOCTOR. A NURSE/MIDWIFE/PARAMEDIC . B FAMILY WELFARE VISITOR. C MA/SACMO. D HEALTH ASSISTANT . E FAMILY WELFARE ASST (FWA) . F OTHER PERSON TRAINED TRADITIONAL BIRTH ATTENDANT (TTBA) .G UNTRAINED TBA (DAI) . H UNQUALIFIED DOCTOR.I OTHER ________________________ X (SPECIFY) LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 432D Where did this first check take place? HOME OWN HOME . 01 OTHER HOME.02 PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE.11 FAMILY WELFARE CENTRE .12 UPAZILA HEALTH COMPLEX.13 SATELLITE CLINIC/ EPI OUTREACH SITE .14 MATERNAL AND CHILD WELFARE CENTER (MCWC) .15 COMMUNITY CLINIC .16 NGO SECTOR NGO STATIC CLINIC.21 NGO SATELLITE CLINIC .22 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL /CLINIC .31 QUALIFIED DOCTOR.32 TRADITIONAL DOCTOR .33 PHARMACY.34 OTHER________________________ 96 (SPECIFY) 433 Has your period returned since the birth of (NAME)? YES.1 (SKIP to 435) NO.2 (SKIP TO 436) 434 Did your period return between the birth of (NAME) and your next pregnancy? YES.1 NO.2 (SKIP TO 438) 435 For how many months after the birth of (NAME) did you not have your period? MONTHS. DON’T KNOW .98 MONTHS. DON’T KNOW .98 436 CHECK 226: RESPONDENT PREGNANT? NOT PREGNANT PREG- NANT OR UNSURE (SKIP TO 438) 437 Have you resumed sexual relations since the birth of (NAME)? YES.1 NO.2 (SKIP TO 439) 438 For how many months after the birth of (NAME) did you not have sexual relations? MONTHS. DON’T KNOW .98 MONTHS. DON’T KNOW .98 439 Did you ever breastfeed (NAME)? YES.1 NO.2 (SKIP TO 444) YES.1 NO.2 (SKIP TO 444) 440 How long after birth did you first put (NAME) to the breast? IF LESS THAN 1 HOUR, RECORD “00” HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS. IMMEDIATELY.000 HOURS .1 DAYS .2 IMMEDIATELY.000 HOURS .1 DAYS .2 440A Was (NAME) given colostrum immediately after his/her birth? YES.1 NO.2 YES.1 NO.2 441 CHECK 404: CHILD ALIVE? ALIVE DEAD (SKIP TO 443) ALIVE DEAD (SKIP TO 443) LAST BIRTH LINE NUMBER ___________________ NEXT-TO-LAST BIRTH LINE NUMBER____________________ 442 Are you still breastfeeding (NAME)? YES.1 (SKIP TO 447) NO.2 YES.1 (SKIP TO 447) NO.2 443 For how many months did you breastfeed (NAME)? MONTHS. DON’T KNOW .98 MONTHS. DON’T KNOW .98 444 CHECK 404: ALIVE (SKIP TO 447) DEAD (GO BACK TO 405 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 451) ALIVE (SKIP TO 447) DEAD (GO BACK TO 405 AND USE LAST COLUMN OF ADDITIONAL SHEET, IF NO MORE BIRTHS, GO TO 451) 447 Did (NAME) drink anything from a bottle with a nipple last 24 hours? YES.1 NO.2 DON’T KNOW .8 YES.1 NO.2 DON’T KNOW .8 447A Do you give (NAME) anything else to eat solid/semi-solid beside breakstmilk? YES.1 NO.2 (GO TO 449) YES.1 NO.2 (GO TO 449) 448 How many times did (NAME) eat solid, semi-solid, or soft foods other than liquids in last 24 hours? IF 7 OR MORE TIMES, RECORD ‘7’ NUMBER OF LAST 24 HOURS . NUMBER OF LAST 24 HOURS . ANY TIME IN 7 DAYS YESTER DAY ANY TIME IN 7 DAYS YESTER DAY At any time in 7 days was (NAME) given any of the following: At any time yesterday (last 24 hours) was (NAME) given any of the following: YES NO YES NO YES NO YES NO Plain water? PLAIN WATER 1 2 1 2 PLAIN WATER 1 2 1 2 Sugar water/ honey/juice? SUGAR WATER 1 2 1 2 SUGAR WATER 1 2 1 2 Baby or infant formula? BABY FORMULA 1 2 1 2 BABY FORMULA 1 2 1 2 Cow's or goat’s milk? COW’S/GOAT MILK 1 2 1 2 COW’S/GOAT MILK 1 2 1 2 Other liquids? OTHER LIQUIDS 1 2 1 2 OTHER LIQUIDS 1 2 1 2 Banana/papaya/mango? BANANA/PAPAYA 1 2 1 2 BANANA/PAPAYA 1 2 1 2 Green leafy vegetables? GREEN VEGETABLE 1 2 1 2 GREEN VEGETABLE 1 2 1 2 Rice, wheat, porridge? RICE, WHEAT 1 2 1 2 RICE, WHEAT 1 2 1 2 Meat/fish/eggs? MEAT/FISH 1 2 1 2 MEAT/FISH 1 2 1 2 Dal? DAL 1 2 1 2 DAL 1 2 1 2 449 Other _____________? (SPECIFY) OTHER 1 2 1 2 OTHER 1 2 1 2 450 GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 451. GO BACK TO 405 AND USE LAST COLUMN OF ADDITIONAL SHEET, IF NO MORE BIRTHS, GO TO 451 SECTION 4B. IMMUNIZATION AND HEALTH 451 ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE JUNE 1998 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL FORM). 452 LINE NUMBER FROM 212 LAST BIRTH LINE NUMBER _____________ NEXT-TO-LAST BIRTH LINE NUMBER ____________ NAME ___________________________ NAME ___________________________453 FROM 212 AND 216 ALIVE DEAD (GO TO 453 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501) ALIVE DEAD (GO TO 453 AND USE LAST COLUMN OF ADDITIONAL SHEET; OR, IF NO MORE BIRTHS, GO TO 501) 454 Did (NAME) receive a Vitamin A dose like this during the last 6 months? SHOW CAPSULE YES . 1 NO . 2 DON’T KNOW. 8 YES.1 NO .2 DON’T KNOW .8 455 Do you have a card where (NAME’S) vaccinations are written down? IF YES, May I see it please? YES, SEEN. 1 (SKIP TO 457) YES, NOT SEEN . 2 (SKIP TO 459) NO CARD . 3 YES, SEEN.1 (SKIP TO 457) YES, NOT SEEN.2 (SKIP TO 459) NO CARD.3 456 Did you ever have a vaccination card for (NAME)? YES . 1 (SKIP TO 459) NO . 2 YES.1 (SKIP TO 459) NO .2 (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. (2) WRITE “44” IN “DAY” COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED DAY MON YEAR DAY MON YEAR 457 BCG POLIO 0 (POLIO GIVEN AT BIRTH) POLIO1 POLIO 2 POLIO 3 DPT 1 DPT 2 DPT 3 MEASLES VITAMIN A (MOST RECENT) BCG . P0 . P1 . P2 . P3 . D1. D2. D3. MEA. VIT. A BCG . P0. P1. P2 . P3 . D1 . D2 . D3 . MEA. VIT. A 457A Did your child (NAME) receive any polio vaccine from National Immunization Day (NID)? IF YES, How many times did you receive from NID campaign? RECORD '0' IF NOT RECEIVED TIMES. TIMES. LAST BIRTH LINE NUMBER ____________________ NEXT-TO-LAST BIRTH LINE NUMBER ____________________ 458 Has (NAME) received any vaccinations that were not recorded on this card? RECORD “YES” ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR MEASLES VACCINE(S) YES . 1 (PROBE FOR VACCINATIONS AND WRITE “66” IN THE CORRESPONDING DAY COLUMN IN 457) NO . 2 DON’T KNOW. 8 (SKIP TO 463) YES.1 (PROBE FOR VACCINATIONS AND WRITE “66” IN THE CORRESPONDING DAY COLUMN IN 457) NO .2 DON’T KNOW .8 (SKIP TO 463) 459 Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases? YES . 1 NO . 2 (SKIP TO 463) DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 463) DON’T KNOW .8 460 460A Please tell me if (NAME) received any of the following vaccinations: A BCG vaccination against tuberculosis, that is, an injection in the left shoulder that caused a scar? YES . 1 NO . 2 YES.1 NO .2 460B Polio vaccine that is, drops in the mouth? YES . 1 NO . 2 (SKIP TO 460E) DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 460E) DON’T KNOW .8 460C How many times did (NAME) receive polio vaccine: From clinic? From NID? TIMES FROM CLINIC. TIMES FROM NID . TIMES FROM CLINIC . TIMES FROM NID. 460D When was the first polio vaccine received, just after birth or later? JUST AFTER BIRTH. 1 LATER . 2 JUST AFTER BIRTH.1 LATER .2 460E DPT vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops? YES . 1 NO . 2 (SKIP TO 460G) DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 460G) DON’T KNOW .8 460F How many times? NUMBER OF TIMES. NUMBER OF TIMES. 460G An injection to prevent measles? YES . 1 NO . 2 DON’T KNOW. 8 YES.1 NO .2 DON’T KNOW .8 463 Has (NAME) been ill with a fever at any time in the last two weeks? YES . 1 NO . 2 DON’T KNOW. 8 YES.1 NO .2 DON’T KNOW .8 464 Has (NAME) been ill with a cough at any time in the last 2 weeks? YES . 1 NO . 2 (SKIP TO 466) DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 466) DON’T KNOW .8 465 In the last 2 weeks, did (NAME) had: Rapid breathing? Difficulty in breathing? Chest in drawing? YES NO RAPID BREATHING . 1 2 DIFFICULTY IN BREATHING . 1 2 CHEST IN DRAWING. 1 2 YES NO RAPID BREATHING . 1 2 DIFFICULTY IN BREATHING . 1 2 CHEST IN DRAWING . 1 2 LAST BIRTH LINE NUMBER ____________________ NEXT-TO-LAST BIRTH LINE NUMBER ____________________ 466 CHECK 463 AND 464: FEVER OR COUGHS? “YES” IN 463 OR 464 OTHER (SKIP TO 472) “YES” IN 463 OR 464 OTHER (SKIP TO 472) 467 Did you seek advice or treatment for (NAME) for the illness? YES . 1 NO . 2 (SKIP TO 472) YES.1 NO .2 (SKIP TO 472) 468 Where did you seek advice or treatment? Anywhere else? RECORD ALL MENTIONED. PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE.A FAMILY WELFARE CENTRE/FWV .B UPAZILA HEALTH COMPLEX. C SATELLITE CLINIC/ EPI OUTREACH SITE . D MATERNAL AND CHILD WELFARE CENTER (MCWC) .E GOVT. FIELD WORKER (FWA) .F COMMUNITY CLINIC . G NGO SECTOR NGO STATIC CLINIC . H NGO SATELLITE CLINIC . I NGO FIELDWORKER . J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC .K QUALIFIED DOCTOR. L TRADITIONAL DOCTOR. M PHARMACY . N OTHER _________________________X (SPECIFY) PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE. A FAMILY WELFARE CENTRE/FWV . B UPAZILA HEALTH COMPLEX. C SATELLITE CLINIC/ EPI OUTREACH SITE . D MATERNAL AND CHILD WELFARE CENTER (MCWC) . E GOVT. FIELD WORKER (FWA) .F COMMUNITY CLINIC . G NGO SECTOR NGO STATIC CLINIC . H NGO SATELLITE CLINIC .I NGO FIELDWORKER. J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . K QUALIFIED DOCTOR.L TRADITIONAL DOCTOR .M PHARMACY. N OTHER _________________________X (SPECIFY) 472 Has (NAME) had diarrhea in the last 2 weeks? YES . 1 NO . 2 (SKIP TO 480) DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 480) DON’T KNOW .8 473 When (NAME) had diarrhea, was he/she offered the same amount to drink, more than usual to drink, or less than usual to drink? SAME. 1 MORE . 2 LESS. 3 DON’T KNOW. 8 SAME.1 MORE .2 LESS.3 DON’T KNOW .8 474 Was he/she offered the same amount to eat, more than usual to eat or less than usual to eat? SAME. 1 MORE . 2 LESS. 3 DON’T KNOW. 8 SAME.1 MORE .2 LESS.3 DON’T KNOW .8 475 When (NAME) had diarrhea, was he/she given any of the following to drink: A fluid made from a special saline packet? Homemade sugar-salt-water solution (laban gur)? Water? Any other liquids? YES NO DK FLUID FROM PACKET. 1 2 8 LABON GUR. 1 2 8 WATER. 1 2 8 OTHER LIQUID. 1 2 8 YES NO DK FLUID FROM PACKET .1 2 8 LABON GUR.1 2 8 WATER.1 2 8 OTHER LIQUID.1 2 8 476 Was anything (else) given to treat the diarrhea? YES . 1 NO . 2 (SKIP TO 478) DON’T KNOW. 8 YES.1 NO .2 (SKIP TO 478) DON’T KNOW .8 LAST BIRTH LINE NUMBER ____________________ NEXT-TO-LAST BIRTH LINE NUMBER ____________________ 477 What was given to treat the diarrhea? Anything else? RECORD ALL MENTIONED. PILL /CAPSULE OR SYRUP .A INJECTION.B (I.V.) INTRAVENOUS . C HOME REMEDIES/ HERBAL MEDICINES. D OTHER _______________________ X (SPECIFY) PILL /CAPSULE OR SYRUP. A INJECTION . B (I.V.) INTRAVENOUS. C HOME REMEDIES/ HERBAL MEDICINES . D OTHER ________________________ X (SPECIFY) 478 Did you seek advice or treatment for the diarrhea? YES . 1 NO . 2 (SKIP TO 480) YES.1 NO .2 (SKIP TO 480) 479 Where did you seek advice or treatment? Anywhere else? RECORD ALL MENTIONED. PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE.A FAMILY WELFARE CENTRE/FWV .B UPAZILA HEALTH COMPLEX. C SATELLITE CLINIC/ EPI OUTREACH SITE . D MATERNAL AND CHILD WELFARE CENTER (MCWC) .E GOVT. FIELD WORKER (FWA) .F COMMUNITY CLINIC . G NGO SECTOR NGO STATIC CLINIC . H NGO SATELLITE CLINIC . I NGO FIELDWORKER . J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC .K QUALIFIED DOCTOR. L TRADITIONAL DOCTOR. M PHARMACY . N OTHER _________________________X (SPECIFY) PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE. A FAMILY WELFARE CENTRE/FWV . B UPAZILA HEALTH COMPLEX. C SATELLITE CLINIC/ EPI OUTREACH SITE . D MATERNAL AND CHILD WELFARE CENTER (MCWC) . E GOVT. FIELD WORKER (FWA) .F COMMUNITY CLINIC . G NGO SECTOR NGO STATIC CLINIC . H NGO SATELLITE CLINIC .I NGO FIELDWORKER. J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . K QUALIFIED DOCTOR.L TRADITIONAL DOCTOR .M PHARMACY. N OTHER _________________________X (SPECIFY) 480 GO BACK TO 453 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501 GO BACK TO 453 AND USE LAST COLUMN OF ADDITIONAL SHHET; OR IF NO MORE BIRTHS, GO TO 501 SECTION 5. MARRIAGE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 501 PRESENCE OF OTHERS AT THIS POINT. YES NO CHILDREN UNDER 10. 1 2 HUSBAND . 1 2 OTHER MALES . 1 2 OTHER FEMALES . 1 2 501A CHECK 106A: CURRENTLY MARRIED NOT CURRENTLY MARRIED (WIDOWED, DIVORCED, DESERTED OR SEPARATED) 507 505 Is your husband staying with you now or is he staying elsewhere? STAYING WITH HER . 1 STAYING ELSEWHERE . 2 506 505A How long he is not staying with you? MONTHS . 506 RECORD THE HUSBAND’S NAME AND LINENUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD ‘00’ NAM E_____________________________ LINE NO. . 507 Have you been married or lived with a man only once, or more than once? ONCE . 1 MORE THAN ONCE . 2 508 CHECK 507: MARRIED ONLY ONCE In what month and year did you start living with your husband? MARRIED MORE THAN ONCE Now we will talk about your first husband. In what month and year did you start living with him? MONTH . DON’T KNOW MONTH. 98 . YEAR . DON’T KNOW YEAR.9998 510 509 How old were you when you started living with him? AGE. 510 How old was your husband when you started living with him? AGE. 512 DETERMINE MONTHS MARRIED SINCE JUNE 1998. ENTER “X” IN COLUMN 4 OF CALENDAR FOR EACH MONTH MARRIED AND ENTER “0” FOR EACH MONTH NOT MARRIED, SINCE JUNE 1998. FOR WOMEN WITH MORE THAN ONE MARRIAGE: PROBE FOR STARTING AND TERMINATION DATES OF ANY PREVIOUS UNIONS. FOR WOMEN NOT CURRENTLY MARRIED: PROBE FOR DATE WHEN LAST MARRIAGE STARTED AND FOR TERMINATION DATE AND, IF APPROPRIATE, FOR THE STARTING AND TERMINATION DATES OF ANY PREVIOUS MARRIAGES. SECTION 6. FERTILITY PREFERENCES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 601A CHECK 106A: CURRENTLY NOT CURRENTLY MARRIED MARRIED (WIDOWED, DIVORCED, DESERTED OR SEPARATED) 614 601B CHECK 106A: NEITHER HE OR SHE STERILIZED STERILIZED 614 602 CHECK 226: NOT PREGNANT OR UNSURE Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children? PREGNANT Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children? HAVE (A/ANOTHER) CHILD. 1 NO MORE/NONE. 2 SAYS SHE CAN’T GET PREGNANT. 3 UNDECIDED/DON’T KNOW . 8 604 609 609 603 CHECK 226: NOT PREGNANT OR UNSURE How long would you like to wait from now before the birth of (a/another) child? PREGNANT After the birth of the child you are expecting now, how long would you like to wait before the birth of another child? MONTHS . 1 YEARS. 2 SOON/NOW.993 SAYS SHE CAN’T GET PREGNANT.994 OTHER ______________________ 996 (SPECIFY) DON’T KNOW .998 609 604 CHECK 226: NOT PREGNANT OR UNSURE PREGNANT 610 605 CHECK 310: USING A METHOD? NOT ASKED PREGNANT NOT CURRENTLY USING CURRENTLY USING 614 606 CHECK 603: NOT ASKED 24 OR MORE MONTHS 00-23 MONTHS OR 02 OR MORE YEARS OR 00-01 YEAR 610 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 607 CHECK 602: WANTS A/ANOTHER CHILDREN You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy. Can you tell me why? RECORD ALL MENTIONED CHECK 602: WANTS NO MORE CHILDREN You have said that you do not want any (more) children, but you are not using any method to avoid pregnancy. Can you tell me why? FERTILITY-RELATED REASONS NOT HAVING SEX. A INFREQUENT SEX. B MENOPAUSAL/HYSTERECTOMY. C SUBFECUND/INFECUND . D POSTPARTUM AMENORRHEIC. E FATALISTIC .F OPPOSITION TO USE RESPONDENT OPPOSED.G HUSBAND OPPOSED. H OTHERS OPPOSED .I RELIGIOUS PROHIBITION .J LACK OF KNOWLEDGE KNOWS NO METHOD. K KNOWS NO SOURCE.L METHOD-RELATED REASONS HEALTH CONCERNS.M FEAR OF SIDE EFFECTS. N LACK OF ACCESS/TOO FAR .O COST TOO MUCH. P INCONVENIENT TO USE.Q INTERFERES WITH BODY’S NORMAL PROCESSES. R OTHER _________________________ X (SPECIFY) DON’T KNOW .Z 609 CHECK 310: USING A METHOD? NOT ASKED NOT CURRENTLY CURRENTLY USING USING 614 610 Do you think you will use a method to delay or avoid pregnancy at any time in the future? YES.1 NO.2 DON’T KNOW .8 612 611 Which method would you prefer to use? FEMALE STERILIZATION . 01 MALE STERILIZATION . 02 PILL. 03 IUD. 04 INJECTIONS. 05 IMPLANTS . 06 CONDOM. 07 PERIODIC ABSTINENCE . 08 WITHDRAWAL. 09 OTHER METHOD_________________10 (SPECIFY) UNSURE . 98 614 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 612 What is the main reason that you think you will not use a method at any time in the future? FERTILITY-RELATED REASONS NOT HAVING SEX.11 INFREQUENT SEX.12 MENOPAUSAL/HYSTERECTOMY.13 SUBFECUND/INFECUND .14 POSTPARTUM AMENORRHEIC.15 FATALISTIC .16 OPPOSITION TO USE RESPONDENT OPPOSED.21 HUSBAND OPPOSED.22 OTHERS OPPOSED .23 RELIGIOUS PROHIBITION .24 LACK OF KNOWLEDGE KNOWS NO METHOD.31 KNOWS NO SOURCE.32 METHOD-RELATED REASONS HEALTH CONCERNS.41 FEAR OF SIDE EFFECTS.42 LACK OF ACCESS/TOO FAR .43 COST TOO MUCH.45 INCONVENIENT TO USE.46 INTERFERES WITH BODY’S NORMAL PROCESSES.47 OTHER ________________________ 96 (SPECIFY) DON’T KNOW .98 614 CHECK 216: HAS LIVING CHILDREN NO LIVING CHILDREN If you could go back to the time you If you could choose exactly the you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be? the number of children to have in your whole life, how many would that be? PROBE FOR A NUMERIC RESPONSE. NUMBER. OTHER 96 (SPECIFY) 619 615 How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter? NUMBER BOYS . GIRLS . EITHER. OTHER ________________________96 (SPECIFY) 619 In the last month have you heard about family planning: On the radio? On the television? In a newspaper or magazine? From a poster or billboard or leaflet? From a community event? SOME- OFTEN TIMES NEVER RADIO.1 2 3 TELEVISION .1 2 3 NEWSPAPER .1 2 3 POSTER/BILLBOARD.1 2 3 COMMUNITY EVENT .1 2 3 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP CHECK 106A: CURRENTLY MARRIED NOT CURRENTLY MARRIED 619A 701 621 How often have you talked to your husband about family planning in the last three months? NEVER.1 ONCE OR TWICE.2 MORE OFTEN .8 622 Do you think your husband wants the same number of children that you want, or does he want more or fewer than you want? SAME NUMBER.1 MORE CHILDREN .2 FEWER CHILDREN .3 DON’T KNOW .8 SECTION 7: AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 701 Now I would like to talk about something else. Have you ever heard of an illness called AIDS? YES .1 NO.2 709A 702 From which sources of information have you learned most about AIDS? Any other sources? RECORD ALL MENTIONED. RADIO. A TV. B NEWSPAPER/MAGAZINES. C PAMPHLETS/POSTERS. D HEALTH WORKERS. E MOSQUES/TEMPLES/CHURCES . F SCHOOLS/TEACHERS.G COMMUNITY MEETINGS . H FRIENDS/RELATIVES .I WORK PLACE .J BILL BOARD/SIGN BOARD . K OTHER___________________________X (SPECIFY) 703 Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS? YES .1 NO.2 DONT KNOW .8 705 704 What can a person do? Anything else? RECORD ALL MENTIONED. ABSTAIN FROM SEX. A USE CONDOMS. B LIMIT SEX WITHIN MARRIAGE. C LIMIT SEX WITH TRUSTED PARTNER . D AVOID SEX WITH PROSTITUTES . E AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS. F AVOID SEX WITH HOMOSEXUALS.G AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY . H AVOID UNSAFE BLOOD TRANSFUSIONS .I AVOID UNSTERILIZED NEEDLE/SYRING .J AVOID KISSING. K AVOID MOSQUITO BITES.L SEEK PROTECTION FROM TRADITIONAL HEALER .M AVOID SHARING RAZORS/BLADES . N OTHER _________________________ W (SPECIFY) OTHER _________________________ X (SPECIFY) DON’T KNOW . Z 705 Is it possible for a healthy-looking person to have the AIDS virus? YES .1 NO.2 DON’T KNOW .8 706 Can the virus that causes AIDS be transmitted from a mother to a child? YES .1 NO.2 DON’T KNOW .8 707 CHECK 106A: CURRENTLY MARRIED NOT CURRENTLY MARRIED 709A 708 Have you ever talked about ways to prevent getting the virus that causes AIDS with your husband? YES .1 NO.2 709A (Apart from AIDS), have you heard about (other) infection/disease that can be transmitted through sexual contact? YES .1 NO.2 710 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 709B Have you heard about -----------------------? a. Syphilis b. Gonorrhea YES NO 1 2 1 2 709C CHECK 709B: AT LEAST ONE “YES” NOT A SINGLE “YES” 712 710 In a man, what signs and symptoms would lead you to think that he has such a disease? Any others? RECORD ALL MENTIONED. LOWER ABDOMINAL PAIN . A DISCHARGE FROM PENIS/DRIPPING . B FOUL SMELLING DISCHARGE . C BURNING PAIN ON URINATION . D REDNESS/INFLAMMATION IN GENITAL AREA . E SWELLING IN GENITAL AREA . F GENITAL SORES/ULCERS .G GENITAL WARTS . H BLOOD IN URINE .I LOSS OF WEIGHT .J IMPOTENCE . K NO SYMPTOMS.L OTHER _________________________ W (SPECIFY) OTHER _________________________ X (SPECIFY) DONT KNOW . Z 711 In a woman, what signs and symptoms would lead you to think that she has such a disease? Any others? RECORD ALL MENTIONED. LOWER ABDOMINAL PAIN . A GENITAL DISCHARGE . B FOUL SMELLING DISCHARGE . C BURNING PAIN ON URINATION . D REDNESS/INFLAMMATION IN GENITAL AREA . E SWELLING IN GENITAL AREA . F GENITAL SORES/ULCERS .G GENITAL WARTS . H BLOOD IN URINE .I LOSS OF WEIGHT .J INABILITY TO GIVE BIRTH . K NO SYMPTOMS.L OTHER _________________________ W (SPECIFY) OTHER _________________________ X (SPECIFY) DONT KNOW . Z NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 712 Now I would like to ask you about some health symptoms you yourself may have. During the past 6 months, have you had any of the following problems: 1. Any itching or irritation in vaginal area with a discharge? 2. A genital sore or ulcer? 3. A bad odour along with a discharge? 4. Severe lower abdominal pain with a discharge, not related with menstruation? 5. A fever along with a discharge? 6. Problem with pain or burning while urinating or more frequent or difficult urination? CHECK Q106A: IF NOT CURRENTLY MARRIED THEN SKIP TO ITEM 9 7. Pain in abdomen or vagina during intercourse? 8. Blood after having sex when you are not menstruating? 9. Any other problem with a discharge?________________________ (SPECIFY) YES NO ITCHING/IRRITATION .1 2 GENITAL SORE.1 2 BAD ODOUR.1 2 ABDOMINAL PAIN.1 2 FEVER .1 2 URINATING PROBLEM .1 2 PAIN INTERCOURSE.1 2 BLOOD AFTER SEX.1 2 OTHER PROBLEM .1 2 713 CHECK 712: AT LEAST ONE “YES” NOT A SINGLE “YES” 801 714 Have you seen anyone for advice or treatment to help you with (this/these) problem (s)? IF YES, ASK: Whom did you see? Anyone else? RECORD ALL MENTIONED PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE.A FAMILY WELFARE CENTRE/FWV .B THANA HEALTH COMPLEX.C SATELLITE CLINIC/ EPI OUTREACH SITE .D MATERNAL AND CHILD WELFARE CENTER (MCWC) .E GOVT. FIELD WORKER (FWA) . F COMMUNITY CLINIC. G NGO SECTOR NGO STATIC CLINIC.H NGO SATELLITE CLINIC . I NGO FIELDWORKER. J PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC.K QUALIFIED DOCTOR. L TRADITIONAL DOCTOR . M PHARMACY.N OTHER X (SPECIFY) NO ONE . Z SECTION 8. HUSBAND'S BACKGROUND, WOMAN'S WORK NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 801 CHECK 106A: CURRENTLY WIDOWED/ MARRIED DIVORCED/ DESERTED/ SEPARATED 803 802 How old was your husband/partner on his last birthday? AGE. 803 Have you husband ever attended school or madrasha? YES, SCHOOL . 1 YES, MADRASHA . 2 YES, BOTH . 3 NO. 4 805 805 806 804 What type of schooling (NAME) has he last attended? SCHOOL . 1 MADRASHA . 2 805 What level of schooling has he last attended? What is the highest grade he completed at that schooling? LEVEL . GRADE. 806 What kind of work does did) your (last) husband mainly do? _______________________ _________________________________ __________________________________ 807 Now I would like to ask you some questions about your work. Aside from your own housework, are you currently working? YES . 1 NO. 2 809 808 As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. Are you currently doing any of these things or any other work? YES . 1 NO. 2 812 809 What is your occupation, that is, what kind of work do (did) you mainly do? _______________________ _________________________________ __________________________________ 810 Do you usually work throughout the year, or do you work seasonally, or only once in a while? THROUGHOUT THE YEAR . 1 SEASONALLY/PART OF THE YEAR. 2 ONCE IN A WHILE. 3 811A Are you paid in cash or kind for this work or are you not paid? CASH ONLY. 1 KIND ONLY . 2 CASH AND KIND . 3 NOT PAID. 4 812 812 811B Who mainly decides how the money you earn will be used? RESPONDENT. 1 HUSBAND . 2 RESPONDENT AND HUSBAND JOINTLY. 3 SOMEONE ELSE . 4 RESPONDENT AND SOMEONE ELSE JOINTLY. 5 812 Who in you family usually has the final say on the following decisions: Your own health care? Child health care? Making large household purchases? Making household purchases for daily needs? Visits to family, friends, or relatives? What food should be cooked each day? RESPONDENT=1, HUSBAND=2, RESPONDENT & HUSBAND JOINTLY=3, SOMEONE ELSE=4, RESPONDENT & SOMEONE ELSE JOINTLY =5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 813 How frequently do you go shopping/marketing? ONCE A MONTH OR MORE . 1 SEVERAL TIMES A YEAR . 2 ONCE A YEAR OR LESS. 3 NEVER . 4 815 814 Do you usually go by yourself or do you go with children or your husband or other relatives? BY HERSELF . 1 WITH CHILDREN . 2 WITH HUSBAND. 3 WITH RELATIVES. 4 815 Do you go outside the village/town/city alone (or with your young children)? YES, ALONE . 1 YES, WITH CHILDREN . 2 NO. 3 OTHER. 6 (SPECIFY) 817 817 816 Can you go outside the village/town/city alone (or with your young children)? YES, ALONE . 1 YES, WITH CHILDREN . 2 NO. 3 OTHER. 6 (SPECIFY) 818 817 How frequently do you go outside this village/town/city? ONCE A MONTH OR MORE . 1 SEVERAL TIMES A YEAR . 2 ONCE A YEAR OR LESS. 3 NEVER . 4 818 Do you go to a health center or hospital alone (or with your young children)? YES, ALONE . 1 YES, WITH CHILDREN . 2 YES, WITH HUSBAND. 3 NO. 4 OTHER___________________________ 6 (SPECIFY) 820 820 819 Can you go to a health center or hospital alone (or with your young children)? YES, ALONE . 1 YES, WITH CHILDREN . 2 YES, WITH HUSBAND. 3 NO. 4 OTHER___________________________ 6 (SPECIFY) 820 RECORD THE TIME. HOUR. MINUTES . 1 4 COL. 1 COL. 2 COL. 3 COL. 4 1 02 JAISTHA 01 01 05 MAY 2 1 01 BAISHAK 02 02 04 APR 0 12 CHOITRA 03 03 03 MAR 0 11 FALGUN 04 04 02 FEB 4 10 MAGH 05 05 01 JAN 09 POUSH 06 06 12 DEC 08 AGRAHAYAN 07 07 11 NOV 1 07 KARTIK 08 08 10 OCT 2 4 06 ASHWIN 09 09 09 SEP 0 1 05 BADHRA 10 10 08 AUG 0 0 04 SRABAN 11 11 07 JUL 3 03 ASHAR 12 12 06 JUN 02 JAISTHA 13 13 05 MAY 01 BAISHAK 14 14 04 APR 12 CHOITRA 15 15 03 MAR 11 FALGUN 16 16 02 FEB 10 MAGH 17 17 01 JAN 09 POUSH 18 18 12 DEC 08 AGRAHAYAN 19 19 11 NOV 1 07 KARTIK 20 20 10 OCT 2 4 06 ASHWIN 21 21 09 SEP 0 0 05 BADHRA 22 22 08 AUG 0 9 04 SRABAN 23 23 07 JUL 2 03 ASHAR 24 24 06 JUN 02 JAISTHA 25 25 05 MAY 01 BAISHAK 26 26 04 APR 12 CHOITRA 27 27 03 MAR 11 FALGUN 28 28 02 FEB 10 MAGH 29 29 01 JAN 09 POUSH 30 30 12 DEC 08 AGRAHAYAN 31 31 11 NOV 1 07 KARTIK 32 32 10 OCT 2 4 06 ASHWIN 33 33 09 SEP 0 0 05 BADHRA 34 34 08 AUG 0 8 04 SRABAN 35 35 07 JUL 1 03 ASHAR 36 36 06 JUN 02 JAISTHA 37 37 05 MAY 01 BAISHAK 38 38 04 APR 12 CHOITRA 39 39 03 MAR 11 FALGUN 40 40 02 FEB 10 MAGH 41 41 01 JAN 09 POUSH 42 42 12 DEC 08 AGRAHAYAN 43 43 11 NOV 1 07 KARTIK 44 44 10 OCT 2 4 06 ASHWIN 45 45 09 SEP 0 0 05 BADHRA 46 46 08 AUG 0 7 04 SRABAN 47 47 07 JUL 0 03 ASHAR 48 48 06 JUN 02 JAISTHA 49 49 05 MAY 01 BAISHAK 50 50 04 APR 12 CHOITRA 51 51 03 MAR 11 FALGUN 52 52 02 FEB 10 MAGH 53 53 01 JAN 09 POUSH 54 54 12 DEC 08 AGRAHAYAN 55 55 11 NOV 1 07 KARTIK 56 56 10 OCT 1 4 06 ASHWIN 57 57 09 SEP 9 0 05 BADHRA 58 58 08 AUG 9 6 04 SRABAN 59 59 07 JUL 9 03 ASHAR 60 60 06 JUN 02 JAISTHA 61 61 05 MAY 01 BAISHAK 62 62 04 APR 12 CHOITRA 63 63 03 MAR 11 FALGUN 64 64 02 FEB 10 MAGH 65 65 01 JAN 09 POUSH 66 66 12 DEC 08 AGRAHAYAN 67 67 11 NOV 1 07 KARTIK 68 68 10 OCT 1 4 06 ASHWIN 69 69 09 SEP 9 0 05 BADHRA 70 70 08 AUG 9 5 04 SRABAN 71 71 07 JUL 8 03 ASHAR 72 72 06 JUN INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX. FOR COLUMNS 1, 3, AND 4, ALL MONTHS SHOULD BE FILLED IN. INFORMATION TO BE CODED FOR EACH COLUMN COL.1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE B BIRTHS P PREGNANCIES H HYSTERECTOMY T TERMINATIONS 0 NO METHOD 1 FEMALE STERILIZATION 2 MALE STERLIZATION 3 PILL 4 IUD 5 INJECTIONS 6 IMPLANTS 7 CONDOM A PERIODIC ABSTINENCE W WITHDRAWAL X OTHER ____________________ (SPECIFY) COL 2: SOURCE OF CONTRACEPTION 1 HOSPITAL/MEDICAL COLLEGE 2 FAMILY WELFARE CENTER 3 THANA HEALTH COMPLEX 4 SATELLITE/EPI CLINIC 5 COMMUNITY CLINIC 6 PVT. CLINIC/DOCTOR 7 TRADITIONAL DOCTOR 8 PHARMACY 9 SHOP A FRIENDS/RELATIVES B FIELDWORKER/FWA C NGO CLINIC X OTHER_____________________ (SPECIFY) COL.3: DISCONTINUATION OF CONTRACEPTIVE USE 0 INFREQUENT SEX/HUSBAND AWAY 1 BECAME PREGNANT WHILE USING 2 WANTED TO BECOME PREGNANT 3 HUSBAND DISAPPROVED 4 WANTED MORE EFFECTIVE METHOD 5 HEALTH CONCERNS 6 SIDE EFFECTS 7 LACK OF ACCESS/TOO FAR 8 COST TOO MUCH 9 INCONVENIENT TO USE F FATALISTIC A DIFFICULT TO GET PREGNANT/MENOPAUSE D MARITAL DISSOLUTION/SEPARATION X OTHER ________________________ (SPECIFY) Z DON’T KNOW COL.4: MARRIAGE/UNION X IN UNION (MARRIED OR LIVING TOGETHER) 0 NOT IN UNION TERMINATION OF LAST PREGNANCY PRIOR TO JUNE 1998 IF NO PREVIOUS PREGNANCY, RECORD ‘00' FOR MONTH AND ‘0000' FOR YEAR MONTH . YEAR . INTERVIEWER’S OBSERVATIONS (To be filled in after completing interview) Comments About Respondent: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Comments on Specific Questions: _________________________________________________________ _________________________________________________________ _________________________________________________________ Any Other Comments: _________________________________________________________ _________________________________________________________ SUPERVISOR’S OBSERVATIONS ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ____________________________________________________________ NAME OF SUPERVISOR:______________________________________ DATE:_________________________ EDITOR’S OBSERVATIONS _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ NAME OF EDITOR:______________________________________ DATE:_________________________ BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2004 MAN'S QUESTIONNAIRE IDENTIFICATION DIVISION____________________________________________________________________ DISTRICT ___________________________________________________________________ UPAZILA ____________________________________________________________________ UNION OR WARD_____________________________________________________________ VILLAGE OR MOHALLA OR BLOCK ______________________________________________ CLUSTER NUMBER. HOUSEHOLD NUMBER. RURAL=1, MUNICIPALITY=2, OTHER URBAN=3, SMA=4 . NAME OF THE HOUSEHOLD HEAD ______________________________________________ NAME AND LINE NUMBER OF MAN ______________________________________________ INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE INTERVIEWERS NAME RESULT** DAY MONTH* YEAR CODE RESULT** NEXT VISIT: DATE TIME TOTAL NO. OF VISITS **RESULT CODES: 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 RESPONDENT INCAPACITATED 7 OTHER (SPECIFY) *MONTH CODES 01 JANUARY 04 APRIL 07 JULY 10 OCTOBER 02 FEBRUARY 05 MAY 08 AUGUST 11 NOVEMBER 03 MARCH 06 JUNE 09 SEPTEMBER 12 DECEMBER SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY NAME NAME DATE DATE SECTION 1. RESPONDENT’S BACKGROUND INTRODUCTION AND CONSENT INFORMED CONSENT Hello. My name is . We came from the Mitra and Associates, a private research organization, is located at Dhaka. To assist in the implementation of socio-development programs in the country, we conduct different types of surveys. We are now conducting a national survey about man and the health of women and children under the authority of NIPORT of Ministry of Health and Family Welfare. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin the interview now? Signature of interviewer: Date: RESPONDENT AGREES TO BE INTERVIEWED 1  RESPONDENT DOES NOT AGREE TO BE INTERVIEWED.2 END NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 RECORD THE TIME STARTED. HOUR. MINUTES . 102 First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a city, in a town, or in the countryside? DHAKA/CHITTAGONG/ KHULNA/RAJSHAHI. 1 SMALL CITY . 2 TOWN . 3 VILLAGE . 4 103A Do you usually live in (THE CURRENT PLACE OF RESIDENCE)? YES. 1 NO . 2 106 103B How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD ‘00’ YEAR. NUMBER OF YEARS . ALWAYS . 95 VISITOR . 96 105 104 Just before you moved here, did you live in a city, a town, or in the countryside? DHAKA/CHITTAGONG/ KHULNA/RAJSHAHI. 1 SMALL CITY . 2 TOWN . 3 VILLAGE . 4 105 In the last 1 year, have you ever lived away from your home community? YES. 1 NO . 2 108 106 In the last 1 year, on how many occasions have you lived away from your home community? NUMBER OF OCCASION . 107 How many days altogether (mentioned in 106) did you spend away from your home community? NUMBER OF TIMES. 108 In what month and year were you born? MONTH . DONT KNOW MONTH . 98 YEAR. DONT KNOW YEAR . 9998 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 109 How old were you at your last birthday? COMPARE AND CORRECT 108 AND /OR 109 IF INCONSISTENT AGE IN COMPLETED YEARS. IF AGE IN NOT BETWEEN 15 AND 59 END 110 Have you ever attended school or madrasha? YES, SCHOOL.1 YES, MADRASHA .2 YES, BOTH.3 NO.4 111B 113 111A What type of schooling did you last attend? SCHOOL.1 MADRASHA.2 111B What level of schooling have you last attended? What is the highest grade you completed at that schooling? LEVEL. CLASS . 112 CHECK 111B: CLASS IS LESS THAN 6 CLASS IS 6 OR MORE THAN 6 114 113 Can you read and write a letter in any language easily, with difficulty, or not at all? EASILY. 1 WITH DIFFICULTY. 2 NOT AT ALL. 3 115 114 Do you usually read a newspaper or magazine? YES . 1 NO . 2 115 114A How often do you read newspaper or magazine: every day, at least once a week, or less than once a week? EVERY DAY. 1 AT LEAST ONCE A WEEK . 2 LESS THAN ONCE A WEEK . 3 115 Do you listen to the radio? YES . 1 NO . 2 116 115A How often do you listen to the radio: every day, at least once a week, less than once a week? EVERY DAY. 1 AT LEAST ONCE A WEEK . 2 LESS THAN ONCE A WEEK . 3 116 Do you watch television? YES . 1 NO . 2 117 116A How often do you watch television: every day, at least once a week, less than once a week? EVERY DAY. 1 AT LEAST ONCE A WEEK . 2 LESS THAN ONCE A WEEK . 3 117 What is your religion? ISLAM . 1 HINDUISM . 2 BUDDHISM . 3 CHRISTIANITY . 4 OTHER ___________________________ 6 (SPECIFY) 119 Are you currently working? YES .1 NO.2 128 120 What is you occupation, that is, what kind of work do you mainly do? . . . 121 CHECK 120: WORKS IN AGRICULTURE WORKS IN OTHER SECTORS 123 122 Do you work mainly on your own land or on family land, or do you rent land or work on someone else's land? OWN LAND. 1 FAMILY LAND . 2 RENTED LAND . 3 SOMEONE ELSE'S LAND. 4 123 Do you do this work for a member of your family, for someone else, or are you self-employed? FOR FAMILY MEMBER . 1 FOR SOMEONE ELSE . 2 SELF-EMPLOYED . 3 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 124 Do you usually work throughout the year, or do you work seasonally, or only once in a while? THROUGHOUT THE YEAR . 1 SEASONALLY/PART OF THE YEAR . 2 ONCE IN A WHILE . 3 126 125 During the last 1 year, how many months did you work? NUMBER OF MONTHS. 126 Do you think that your earning is sufficient, moderately sufficient or not sufficient to provide for your familys basic needs? SUFFICIENT . 1 MODERATELY SUFFICIENT. 2 NOT SUFFICIENT . 3 201 128 Have you done any work in the last 1 year? YES . 1 NO . 2 201 129 What have you been doing over the last 1 year? GOING TO SCHOOL/STUDYING . 1 LOOKING FOR WORK. 2 INACTIVE. 3 COULD NOT WORK/HANDICAPPED. 4 OTHER ___________________________ 6 (SPECIFY) SECTION 2. HEALTH AND LIFE STYLE NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 At any time during the last 3 months, for any health problem(s) or injury, did you have difficulty in doing your normal work, or in doing regular activities? YES, ILLNESS .A YES, INJURY.B NONE.Y 207A 202 For how many days in the last 3 months were you unable to do your normal work or regular activities due to this (these) health problem(s) and/or injuries? NUMBER OF DAYS . 203 CHECK 201: CIRCLED ‘A’(ILLNESS) DID NOT CIRCLE ‘A’  207A 204 What type of illness prevents you from doing your work or other regular activities? TUBERCULOSIS.A ASTHMA .B DIABETES .C HIGH BLOOD PRESSURE .D HEART PROBLEM.E MALARIA/FEBER . F JAUNDICE/HEPATITIS . G OTHER _____________________________X (SPECIFY) 207A Do you smoke? Such as: 207B.In 24 hours usually how many times do you smoke/eat (NAME OF THE ITEM)? 207C. Have you ever smoked/eaten (NAME OF THE ITEM)? 1 Cigarette? Yes. 1 No . 2 SKIP 207C Times . GO TO NEXT ITEM Yes .1 No.2 2 Bidi? Yes. 1 No . 2 SKIP 207C Times . GO TO NEXT ITEM Yes .1 No.2 3 Hukka? Yes. 1 No . 2 SKIP 207C Times . GO TO NEXT ITEM Yes .1 No.2 4 Pipe? Yes. 1 No . 2 SKIP 207C Times . GO TO NEXT ITEM Yes .1 No.2 5 Anything else? __________________ (Specify) Yes . 1 No . 2 SKIP 207C Times . GO TO NEXT ITEM Yes .1 No.2 6 Do you currently eat tobacco leaves or sada pata or gul? Yes. 1 No . 2 SKIP 207C Times . GO TO NEXT ITEM Yes .1 No.2 7 Do you currently eat pan with tobacco or zarda? Yes. 1 No . 2 SKIP 207C Times . GO TO 301 Yes .1 No.2 SECTION 3. MARRIAGE AND SEXUAL ACTIVITY Now, I would like to ask you some questions about your marriage life. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 301 Are you currently married, widowed, divorced or separated? MARRIED . 1 WIDOWED . 2 DIVORCED. 3 SEPARATED. 4 NEVER MARRIED. 5 306 316A 305 Is your wife living with you now or is she staying elsewhere? LIVING WITH HIM. 1 STAYING ELSEWHERE. 2 306 Have you been married only once, or more than once? ONCE. 1 MORE THAN ONCE. 2 307A CHECK 301: CURRENTLY MARRIED NOT CURRENTLY MARRIED 308 307B RECORD THE WIFE’S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF SHE IS NOT LISTED IN THE HOUSEHOLD, RECORD ‘00'. IF THERE ARE TWO WIVES IN THE HOUSEHOLD, RECORD THE NAME AND LINE NUMBERS OF BOTH. NAME LINE NO. NAME LINE NO. 308 CHECK 306: MARRIED ONLY ONCE In what month and year did you start living with your wife? MARRIED MORE THAN ONCE Now, we will talk about your first wife. In what month and year did you start living with her? MONTH. DON’T KNOW MONTH. 98 YEAR . DON’T KNOW YEAR.9998 310 309 How old were you when you started living with her? AGE . 310 Did you have sex before (first) marriage? YES. 1 NO. 2 311 310A How old were you when you first had sexual intercourse? AGE IN YEARS . 311 Now I would like to talk about sexual relationship after marriage. Sometimes, a man may seek for sexual relationship with women other than his wife. After marriage, have you ever had sex with any woman other than your wife? YES. 1 NO. 2 317 312 Beside your wife, with whom did you have sexual relationship? Any other? GIRL FRIEND/FIANCEE .A OTHER FRIEND.B CASUAL ACQUAINTANCE .C COMMERCIAL SEX WORKER .D RELATIVE .E OTHER ___________________________ X (SPECIFY) 313A In the last 1 year, did you have sexual intercourse with any women other than your wife? YES. 1 NO. 2 317 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 313B Beside your wife, with whom did you have sexual intercourse? Any other? GIRL FRIEND/FIANCEE . A OTHER FRIEND . B CASUAL ACQUAINTANCE.C COMMERCIAL SEX WORKER.D RELATIVE . E OTHER ___________________________ X (SPECIFY) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 313C In the last 1 year, with how many women did you have sexual intercourse other than your wife? NUMBER. 313D CHECK 313B: MULTIPLE CODES CIRCLED ONLY ONE CODE CIRCLED  315 314A Beside your wife, with whom (among those mentioned in Q 313B) did you have last sexual intercourse? GIRL FRIEND/FIANCEE . 1 OTHER FRIEND . 2 CASUAL ACQUAINTANCE. 3 COMMERCIAL SEX WORKER. 4 RELATIVE . 5 OTHER ___________________________ 6 (SPECIFY) 314B The last time you had sexual intercourse with (mentioned 314A), did you use a condom? YES. 1 NO . 2 315A 315B 315 The last time you had sexual intercourse with (mentioned 313B), did you use a condom? YES. 1 NO . 2 315B 315A Why did you use condom? TO PREVENT STD . A TO PREVENT PREGNENCY . B OTHER ___________________________ X (SPECIFY) 315B CHECK 106: RESPONSE GIVEN DID NOT GIVE ANY ANSWER (Lived outside in last 1 year) (Did not live outside in last 1 year)  317 315C In the last 1 year, did you have sexual intercourse with any woman other than your wife while travelling outside your home community? YES. 1 NO . 2 317 315D Did you have this sexual intercourse inside Bangladesh or outside Bangladesh? INSIDE BANGLADESH. A OUTSIDE BANGLADESH . B 315E INTERVIWER: CHECK 315D IF CODE ‘A’ CIRCLED THEN ASK, OTHERWISE SKIP TO 315F In the last 1 year with whom did you have sexual intercourse other than your wife while travelling inside Bangladesh? Any other? GIRL FRIEND/FIANCEE . A OTHER FRIEND . B CASUAL ACQUAINTANCE.C COMMERCIAL SEX WORKER.D RELATIVE . E OTHER ___________________________ X (SPECIFY) 315EA Beside your wife, with how many women did you have sexual intercourse in the last 1 year? NUMBER. 315EB The last time you had sexual intercourse with (among those mentioned in 315EA), did you use a condom? YES. 1 NO . 2 315F 315EC Why did you use condom? TO PREVENT STD . A TO PREVENT PREGNENCY . B OTHER ___________________________ X (SPECIFY) NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 315F INTERVIWER: CHECK 315D IF CODE ‘B’ CIRCLED THEN ASK, OTHERWISE SKIP TO 317 In the last 1 year, with whom did you have sexual intercourse other than your wife while travelling outside Bangladesh? Any other? GIRL FRIEND/FIANCEE .A OTHER FRIEND.B CASUAL ACQUAINTANCE .C COMMERCIAL SEX WORKER .D RELATIVE .E OTHER ___________________________ X (SPECIFY) 315FA Beside your wife, with how many women did you have sexual intercourse in the last 1 year? NUMBER . 315FB The last time you had sexual intercourse with (among those mentioned in 315FA), did you use a condom? YES. 1 NO. 2 317 315FC Why did you use condom? TO PREVENT STD .A TO PREVENT PREGNENCY.B OTHER ___________________________ X (SPECIFY) 317 316A Some times men have sexual urge and have sex before marriage. Have you ever had sex with any woman? YES. 1 NO. 2 317 316B How old were you when you first had sexual intercourse? AGE IN YEARS . 316C With whom did you have sexual intercourse? Any other? GIRL FRIEND/FIANCEE .A OTHER FRIEND.B CASUAL ACQUAINTANCE .C COMMERCIAL SEX WORKER .D RELATIVE .E OTHER ___________________________ X (SPECIFY) 316D In the last 1 year, did you have sexual intercourse with any women? YES. 1 NO. 2 317 316E With whom did you have sexual intercourse? Any other? GIRL FRIEND/FIANCEE .A OTHER FRIEND.B CASUAL ACQUAINTANCE .C COMMERCIAL SEX WORKER .D RELATIVE .E OTHER ___________________________ X (SPECIFY) 316EA With how many women did you have sexual intercourse in the last 1 year? NUMBER . 316EB CHECK 316E : MULTIPLE CODES CIRCLED ONLY ONE CODE CIRCLED  316H 316F With whom (among those mentioned in Q 316E) did you have last sexual intercourse? GIRL FRIEND/FIANCEE . 1 OTHER FRIEND. 2 CASUAL ACQUAINTANCE . 3 COMMERCIAL SEX WORKER . 4 RELATIVE . 5 OTHER ___________________________ 7 (SPECIFY) 316G The last time you had sexual intercourse with (mentioned 316F), did you use a condom? YES. 1 NO. 2 316I 316IA 316H The last time you had sexual intercourse with (mentioned 316E), did you use a condom? YES. 1 NO. 2 316IA 316I Why did you use condom? TO PREVENT STD .A TO PREVENT PREGNANCY.B OTHER ___________________________ X (SPECIFY) 316IA CHECK 106: RESPONSE GIVEN DID NOT GIVE ANY RESPONSE (Lived outside in the last 1 year) (Did not live outside in the last 1 year)  317 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 316J In the last 1 year, did you have sexual intercourse with any women while travelling outside your home community? YES. 1 NO . 2 317 316K Was this sexual intercourse inside Bangladesh or outside Bangladesh? INSIDE BANGLADESH. A OUTSIDE BANGLADESH . B 316L INTERVIWER: CHECK 316K IF CODE ‘A’ CIRCLED THEN ASK, OTHERWISE SKIP TO 317. With whom did you have sexual intercourse? Any other? GIRL FRIEND/FIANCEE . A OTHER FRIEND . B CASUAL ACQUAINTANCE.C COMMERCIAL SEX WORKER.D RELATIVE . E OTHER X (SPECIFY) 316LA With how many women did you have sexual intercourse in the last i year? NUMBER. 316LB The last time you had sexual intercourse with (among those mentioned in 316LA), did you use a condom? YES. 1 NO . 2 316M 316LC Why did you use condom? TO PREVENT STD . A TO PREVENT PREGNANCY . B OTHER ___________________________ X (SPECIFY) 316M INTERVIWER: CHECK 316K IF CODE ‘B’ CIRCLED THEN ASK, OTHERWISE SKIP TO 317 With whom did you have sexual intercourse? Any other? GIRL FRIEND/FIANCEE . A OTHER FRIEND . B CASUAL ACQUAINTANCE.C COMMERCIAL SEX WORKER.D RELATIVE . E OTHER X (SPECIFY) 316MA With how many women did you have sexual intercourse in the last 1 year? NUMBER. 316MB The last time you had sexual intercourse with (among those mentioned in 316MA), did you use a condom? YES. 1 NO . 2 317 316MC Why did you use condom? TO PREVENT STD . A TO PREVENT PREGNANCY . B OTHER ___________________________ X (SPECIFY) 317 Sometimes, some men may desire sexual pleasure from persons other than women. Have you ever had sex with any boys/men or transgender (hizra)? YES, WITH A MAN/BOYS . 1 YES, WITH A TRANSGENDER . 2 YES, BOTH . 3 NONE . 4 321 318 In the last 1 year, did you have such sex? YES, WITH A MAN . 1 YES, WITH A TRANSGENDER . 2 YES, BOTH . 3 NONE . 4 319 The last time you had such sexual intercourse, did you or your partner use a condom? YES. 1 NO . 2 321 320 Why did you use condom? TO PREVENT STD . A OTHER____________________________X (SPECIFY) 321 Do you know of a place where you can obtain a condom? YES. 1 NO . 2 401 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 322 Where is that? (NAME OF PLACE) IF WOMAN SAYS MORE THAN ONE PLACE ASK FOR THE PLACE SHE WOULD MOST LIKELY USE PUBLIC SECTOR HOSPITAL/MEDICAL COLLEGE . 11 FAMILY WELFARE CENTRE. 12 UPAZILA HEALTH COMPLEX . 13 SATELLITE CLINIC/ EPI OUTREACH SITE . 14 MATERNAL CHILD WELFARE CENTER (MCWC) . 15 GOVT. FIELD WORKER (FWA). 16 COMMUNITY CLINIC . 17 NGO SECTOR NGO STATIC CLINIC . 21 NGO SATELLITE CLINIC . 22 NGO DEPOT HOLDER. 23 NGO FIELDWORKER . 24 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . 31 QUALIFIED DOCTOR. 32 TRADITIONAL DOCTOR. 33 PHARMACY. 34 OTHER PRIVATE SECTOR SHOP. 41 FRIEND/RELATIVES . 42 OTHER __________________________ 96 (SPECIFY) DON’T KNOW . 98 SECTION 4. PARTICIPATION IN HEALTH CARE Now, I would like to ask you some questions about the participation in healthcare. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 401 ASK QUESTIONS SEPARATELY FOR PREGNANCY, DELIVERY AND AFTER DELIVERY BUT RECORD RESPONSES IN SAME CODING CATEGORY. What are the problems at the time of pregnancy that may cause death to the mother? Any other? What are the problems at the time of delivery that may cause death to the mother? Any other? What are the problems after the delivery that may cause death to the mother? Any other? RECORD ALL MENTIONED SEVERE HEADACHE .A BLURRY VISION .B HIGH BLOOD PRESSURE . C PRE-ECLAMSIA . D CONVULSION/ECLAMSIA.E EXCESSIVE VAGINAL BLEEDING .F FOUL-SMELLING DISCHARGE WITH HIGH FEVER. G JAUNDICE . H TETANUS . I BABY'S HAND OR FEET COME/ BABY IN BAD POSITION . J PROLONG LABOR.K OBSTRUCTED LABOR. L RETAINED PLACENTA. M TORNED UTEROUS . N OTHER ___________________________ X (SPECIFY) DON'T KNOW.Y 402 Do you think that women should have a medical checkup when they are pregnant even if they are not sick? YES .1 NO.2 DON’T KNOW.8 404 403 At what months of pregnancy do you think that women should have first check up for pregnancy? MONTH . DON’T KNOW.98 404 During the pregnancy do you think women should eat more, same or less? MORE.1 SAME .2 LESS .3 DON’T KNOW.8 405A In what year was you last child born? PROBE YEAR. UNMARRIED/NO CHILDREN BORN .9996 419B 405B CHECK 405A : CHILD BORN 1998 OR LATER CHILD BORN 1997 OR EARLIER  418B 406 What is the name of your last born child? _________________________________ (NAME OF LAST CHILD) 407 Did your wife go to a health facility to receive antenatal care when she was pregnant with (NAME OF LAST BORN CHILD)? YES .1 NO.2 DONT KNOW.8 409 408 Did any health professional such as doctor, nurse, FWV or others come for your wife’s antenatal care when shewas pregnant with (NAME OF LAST BORN CHILD)? YES .1 NO.2 412 409 Were you present anytime during the antenatal care visit? YES .1 NO.2 410 At any time while she was pregnant with (NAME OF LAST BORN CHILD), did any health professional such as doctor, nurse, or FWV talk to you about this particular pregnancy? YES .1 NO.2 411 During this pregnancy, did you ever talk with your wife about what the health professional such as doctor, nurse, or FWV told her about her own health or the babys health? YES .1 NO.2 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 412 Where did your wife give birth to (NAME OF LAST BORN CHILD)? HOME OWN HOME.11 OTHER HOME.12 PUBLIC SECTOR GOVT. HOSPITAL .21 UPAZILA HEALTH COMPLEX.22 MATERNAL AND CHILD WELFARE CENTER (MCWC) .23 NGO SECTOR NGO STATIC CLINIC .31 PRIVATE SECTOR PVT. HOSPITAL/CLINIC .41 OTHER 96 (SPECIFY) 413 When she gave birth to (NAME OF LAST BORN CHILD), were you present (NAME OF THE PLACE IN 412) at that time? YES. 1 NO. 2 414 In the first two months after (NAME OF LAST BORN CHILD) was born, did your wife visit a health facility to have her own health or the childs health checked or did someone such as doctor, nurse or FWV from the health facility come to your place to check your wife’s or child’s health? YES, VISITED. 1 YES, CAME TO THEIR PLACE . 2 NO. 8 416 415 Were you present at that time? YES. 1 NO. 2 416 Where is your last child (alive or dead)? ALIVE. 1 DEAD. 2 418B 417 Did (NAME OF LAST BORN CHILD) ever receive any vaccinations to prevent him/her from getting diseases? YES. 1 NO. 2 DONT KNOW . 8 418B 418A When (NAME OF LAST BORN CHILD) was vaccinated in a health facility, did you take him/her anytime to the health facility? YES. 1 NO. 2 418B How many living children do you have? NUMBER . 419A CHECK 418B HAS LIVING CHILDREN If you could go back to the time you you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be? 419B NO LIVING CHILDREN If you could choose exactly the the number of children to have in your whole life, how many would that be? 419 PROBE FOR A NUMERIC RESPONSE. NUMBER . OTHER ___________________________ 96 (SPECIFY) 501 420 How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter? NUMBER BOYS. GIRLS . EITHER. OTHER __________________________ 96 (SPECIFY) SECTION 5: AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 501 Now I would like to talk about something else. Have you ever heard of an illness called AIDS? YES.1 NO .2 509A 502 From which sources of information have you learned most about AIDS? Any other sources? RECORD ALL MENTIONED. RADIO . A TV . B NEWSPAPER/MAGAZINES.C PAMPHLETS/POSTERS .D HEALTH WORKERS . E MOSQUES/TEMPLES/CHURCES. F SCHOOLS/TEACHERS.G COMMUNITY MEETINGS .H FRIENDS/RELATIVES.I WORK PLACE .J BILL BOARD/SIGN BOARD . K OTHER __________________________ X (SPECIFY) 503 Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS? YES.1 NO .2 DONT KNOW .8 505 504 What can a person do? Anything else? RECORD ALL MENTIONED. ABSTAIN FROM SEX. A USE CONDOMS . B LIMIT SEX WITHIN MARRIAGE .C LIMIT SEX WITH TRUSTED PARTNER.D AVOID SEX WITH PROSTITUTES. E AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS. F AVOID SEX WITH HOMOSEXUALS .G AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY .H AVOID UNSAFE BLOOD TRANSFUSIONS .I AVOID UNSTERILIZED NEEDLE/SYRING .J AVOID KISSING. K AVOID MOSQUITO BITES.L SEEK PROTECTION FROM TRADITIONAL HEALER.M AVOID SHARING RAZORS/BLADES.N AVOID SEX WITH OTHER WOMEN .O OTHER W (SPECIFY) OTHER X (SPECIFY) DON’T KNOW . Z 505 Is it possible for a healthy-looking person to have the AIDS virus? YES.1 NO .2 DON’T KNOW .8 506 Can the virus that causes AIDS be transmitted from a mother to a child? YES.1 NO .2 DON’T KNOW .8 507 CHECK 301: YES CURRENLY MARRIED NOT CURRENTLY MARRIED  509A 508 Have you ever talked with your wife about ways to prevent getting the virus that causes AIDS? YES.1 NO .2 509A (Apart from AIDS), have you heard about (other) infection or disease that can be transmitted through sexual contact? YES.1 NO .2 510 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 509B Have you heard about ___________? a. Syphilis? b. Gonorrhea? YES NO 1 2 1 2 509C CHECK 509B: AT LEAST ONE ‘YES’ NOT A SINGLE ‘YES’  ─ 514 510 In a man, what signs and symptoms would lead you to think that he has diseases such as STD or syphilis or gonorrhea? Any others? RECORD ALL MENTIONED. LOWER ABDOMINAL PAIN .A DISCHARGE FROM PENIS/DRIPPING.B FOUL SMELLING DISCHARGE . C BURNING PAIN ON URINATION . D REDNESS/INFLAMMATION IN GENITAL AREA.E SWELLING IN GENITAL AREA.F GENITAL SORES/ULCERS. G GENITAL WARTS . H BLOOD IN URINE . I LOSS OF WEIGHT . J IMPOTENCE.K NO SYMPTOMS. L OTHER W (SPECIFY) OTHER X (SPECIFY) DONT KNOW .Z 511 In a woman, what signs and symptoms would lead you to think that she has such a disease STD/syphilis/gonorrhea? Any others? RECORD ALL MENTIONED. LOWER ABDOMINAL PAIN .A GENITAL DISCHARGE.B FOUL SMELLING DISCHARGE . C BURNING PAIN ON URINATION . D REDNESS/INFLAMMATION IN GENITAL AREA.E SWELLING IN GENITAL AREA.F GENITAL SORES/ULCERS. G GENITAL WARTS . H BLOOD IN URINE . I LOSS OF WEIGHT . J INABILITY TO GIVE BIRTH .K NO SYMPTOMS. L OTHER W (SPECIFY) OTHER X (SPECIFY) DONT KNOW .Z 513 Now I would like to ask you some questions about your health in the last 1 year. During the last 1 year, have you had a sexually transmitted disease? YES. 1 NO. 2 DONT KNOW . 8 514 During the last 1 year, have you had a discharge from your penis? YES. 1 NO. 2 DONT KNOW . 8 515 Sometimes, men experience a sore or ulcer on or near their penis? During the last 1 year, have you had a sore or ulcer on or near your penis? YES. 1 NO. 2 DONT KNOW . 8 516 During the last 1 year, have you had pain or burning sensation during urination? YES. 1 NO. 2 DONT KNOW . 8 517 CHECK 513, 514, 515 OR 516: AT LEAST ONE ‘YES’ NOT A SINGLE ‘YES’  521 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 518 The last time you had (INFECTION/DISEASE FROM 513, 514, 515 OR 516), did you seek any kind of advice or treatment? YES. 1 NO . 2 520 519 The last time you had (INFECTION/DISEASE FROM 513, 514, 515 OR 516) did you do any of the following? Did you. Seek advice from a health professional such as doctor, nurse in a clinic or hospital? Seek advice or medicine from a traditional healer? Seek advice or buy medicines in a shop or pharmacy? Seek treatment from a homeopath doctor? Ask for advice from friends or relatives? YES NO HEALTH WORKER .1 2 TRADITIONAL HEALER.1 2 PHARMACY .1 2 HOMEOPATH .1 2 FRIENDS/RELATIVES.1 2 520 CHECK 301: CURRENTLY MARRIED CURRENTLY NOT MARRIED 520B 520A The last time when you had (INFECTION/DISEASE FROM 513, 514, 515 OR 516), did you inform your wife? YES. 1 NO . 2 SOME/NOT ALL. 3 520B The last time when you had (INFECTION/DISEASE FROM 513, 514, 515 OR 516), did you have sex with anyone? YES. 1 NO . 2 521 520C The last time when you had infection and had sexual intercourse with someone, did you use condom? YES. 1 NO . 2 521 520D As long as you had the infection, did you use condom every time you had sexual intercourse or did you use condom occasionally? AS LONG AS INFECTION . 1 OCCASIONALLY . 2 520E The last time why did you use condom? TO PREVENT STD .A TO PREVENT PREGNANCY .B OTHER____________________________X (SPECIFY) 601 521 If a woman’s husband has a sexually transmitted disease? Would it be acceptable for her to ask him to use a condom? YES. 1 NO . 2 DOES NOT KNOW . 8 521A If a woman’s husband has a sexually transmitted disease? Would it be acceptable for her to refuse to have sex with him? YES. 1 NO . 2 DOES NOT KNOW . 8 SECTION 6. ATTITUDES TOWARDS WOMEN AND DOMESTIC VIOLENCE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Now I would like to ask you a few questions regarding men and women in couples. People have many different opinions on this subject and we would like to know what it is that you think about it. 601 If the husband is making enough money, do you believe that it is acceptable for married women to work outside the home to earn an income? YES .1 NO.2 DK .8 602 If for some reason the husband cannot making enough money for the family, do you believe that it is acceptable for married women to work outside the home to earn an income? YES .1 NO.2 DK .8 603 CHECK 301: YES CURRENLY MARRIED NOT CURRENTLY MARRIED  612 606 Do youtake your wife’s opinion on: a. Large household expenses, that require a lot of money? b. Minor daily household expenses? C. When you wish visit family, friends or relatives? NO YES NO OPINION 1 2 8 1 2 8 1 2 8 606A Does your wife own cash in her work? YES .1 NO.2 607 606B Who mainly decides how to spend the money that your own wife earn? RESPONDENT.1 WIFE .2 HUSBAND AND WIFE TOGETHER .3 SOMEONE ELSE .4 RESPONDENT WITH SOMEONE ELSE .5 607 It is normal for couple to have quarrels and disagreements. During those quarrels some husbands occasionally severely reprimand or even beat their wives. In your opinion, do you think a man would be justified to beat his wife: If she neglects the children? If she argues with her husband? If she fails to provide food on time If she visit family or friend without her husband’s permission? NO YES NO OPINION 1 2 8 1 2 8 1 2 8 1 2 8 Anytime, were there any circumstances or family disagreement which caused you to do? In the last 1 year, were there any circumstances or family disagreement which caused you to do any of the following? YES NO YES NO A. Pushing or shaking your wife, or throwing something at her? 1 2 1 2 B. Slapping her or twisting her arm? 1 2 1 2 C. Punching her with your fist or with something that could hurt her? 1 2 1 2 D. Kicking her or dragging her? 1 2 1 2 E. Trying to strangle her or kill her or by burning her? 1 2 1 2 610 H. Physically forcing her to have sexual intercourse with her even when she did not want to? 1 2 1 2 612 Now I would now like to ask you a very personal question. Some people take such things as Ganja, Charas, Phensidle, Pethedine, Heroin, Morphine, etc. I would like to know if you have any such habits. The information you provide shall be kept confidential and be used only for research purposes like the other information. In the last 3 months, have you taken .? (In addition to this/these), have you taken any injectable drug in the last three months? YES NO GANJA . 1 2 CHARAS . 1 2 PHENSIDLE. 1 2 PETHEDINE. 1 2 HEROIN . 1 2 MORPHINE. 1 2 INJECTABLE DRUG. 1 OTHER ___________________ 1 2 (SPECIFY) 613 RECORD THE TIME HOUR. MINUTES . INTERVIEWER’S OBSERVATIONS (To be filled in after completing interview) Comments About Respondent: ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Comments on Specific Questions: ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Any Other Comments: ____________________________________________________________________ _____________________________________________________________________ SUPERVISOR’S OBSERVATIONS ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ NAME OF SUPERVISOR:______________________________________ DATE:_________________________ EDITOR’S OBSERVATIONS ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ NAME OF EDITOR:______________________________________ DATE:_________________________ Bangladesh Demographic and Health Survey 2003-04 COMMUNITY QUESTIONNAIRE DIVISION DISTRICT _______________________________________________________ THANA _________________________________________________________ UNION/WARD____________________________________________________ VILLAGE/MOHALLA/BLOCK________________________________________ PSU NUMBER ___________________________________________________ RESIDENCE: RURAL =1, MUNICIPALITY =3, OTHER URBAN =4, SMA =5 . GPS READING: LATITUDE. LONGITUDE . Degrees Minutes Thousandths Degrees Minutes Thousandths WAYPOINT . DATE OF VISIT_______________________________ RESULTS OF THE INTERVIEW: (COMPLETED =1, INCOMPLETE = 2, OTHER (SPECIFY) = 6) NAME OF INTERVIEWER______________________ DAY. MONTH . YEAR . RESULT . INTERVIEWER CODE. POSITION OF PERSON INTERVIEWED 1 _________________________________________ 2 _________________________________________ 3 _________________________________________ 4 _________________________________________ 5 _________________________________________ SEX (Male =1; Female =2) BEGINNING TIME: HOUR . MINUTES. E N 1. Community information AFTER ASSEMBLING THE INFORMANTS, READ THE FOLLOWING GREETING: Hello. I am representing the NIPORT of Ministry of Health and Family Welfare. We are carrying out a survey of communities to get a picture of services available to the communities and to understand when and why people use health services. I would like to ask you some questions about your community and about sources of health care in it and around it as a way of better understanding how to serve the population. Please be assured that this discussion is strictly confidential and you may choose to stop the interview at any time. May I continue? No. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 100 PERMISSION RECEIVED TO CONTINUE? YES.1 NO .2 Stop 100A CHECK: RURAL AREA URBAN AREA 104 101 How far is the Thana Health Center? IF LESS THAN ONE MILE/KILOMETER, RECORD “00”. RECORD “97”IF DISTANCE IS MORE THAN 97 MILES/KILOMETERS. MILE . 1 KILOMETER . 2 102 Which is the most common type of transportation i.e, most of the people use to go to the Thana Health Center? CAR/BUS/TEMPO .01 MOTORCYCLE.02 MOTOR LAUNCH .03 BICYCLE.04 ANIMAL CART.05 BOAT .06 PATH .07 RICKSHAW/RICKSHAW VAN.08 BABYTAXI/CNG.09 TRAIN.10 OTHER_______________________ 96 (SPECIFY) 103 How long does it take to go to the Thana Health Center using the transportation (MENTIONED IN Q 102)? MINUTES. 104 How far is the District Headquarters? IF LESS THAN ONE MILE/KILOMETER, RECORD “00”. RECORD “97” IF DISTANCE IS MORE THAN 97 MILES/KILOMETERS. MILE . 1 KILOMETER . 2 105 Which is the most common type of transportation i.e, most of the people use to go to the District Headquarters? CAR/BUS/TEMPO .01 MOTORCYCLE.02 MOTOR LAUNCH .03 BICYCLE.04 ANIMAL CART.05 BOAT .06 PATH .07 RICKSHAW/RICKSHAW VAN.08 BABYTAXI/CNG.09 TRAIN.10 OTHER_______________________ 96 (SPECIFY) 106 How long does it take to go to the District Headquarters using the transportation (MENTIONED IN Q 105)? MINUTES. No. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 107 What is the main access road to this community? ALL WEATHER ROAD.1 SEASONAL ROAD .2 WATERWAY.3 PATH .4 OTHER________________________ 6 (SPECIFY) 108 What type of work usually done by most people of this community i.e what is the main economic activities of this community? AGRICULTURE .01 LIVESTOCK .02 FISHING .03 COMMERCE .04 MANUFACTURING.05 LABOR.06 OTHER_______________________ 96 (SPECIFY) 109 How far is the nearest daily market from this village/mohalla? IF LESS THAN ONE MILE/KILOMETER, RECORD “00”. RECORD “97” IF DISTANCE IS MORE THAN 97 MILES/KILOMETERS. MILE . 1 KILOMETER . 2 109A CHECK: RURAL AREA URBAN AREA 111a 110 How far is the nearest weekly market from this village/mohalla? IF LESS THAN ONE MILE/KILOMETER, RECORD “00”. RECORD “97” IF DISTANCE IS MORE THAN 97 MILES/KILOMETERS. MILE . 1 KILOMETER . 2 111a Is there any telephone service in this area? YES.1 NO .2 112 111b How far is the nearest telephone service (government or private) from this village? IF LESS THAN ONE MILE/KILOMETER, RECORD “00”. RECORD “97” IF DISTANCE IS MORE THAN 97 MILES/KILOMETERS. MILE . 1 KILOMETER . 2 112 Is electricity available here? YES.1 NO .2 113 What is the primary source of drinking water for the majority of people in this village? PIPED WATER PIPED INSIDE DWELLING.11 PIPED OUTSIDE DWELLING .12 WELL WATER TUBEWELL.21 DEEP TUBEWELL .22 SURFACE WELL/OTHER WELL .23 SURFACE WATER POND/TANK/LAKE .31 RIVER/STREAM .32 RAINWATER .41 OTHER_______________________ 96 (SPECIFY) 116 116 114 Is there any arsenic problem in the drinking water in your area? YES.1 NO .2 114A Did you know whether the wells/tubewells in the water for arsenic? YES.1 NO .2 116 115 Is there a red marker, a green marker on the well? ALL RED MARK.1 ALL GREEN MARK.2 SOME RED AND SOME GREEN MARK.3 NO MARK .4 No. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 116 In this village/mohalla, are there any of the following : MOTHER'S CLUB OR LADIES ASSOCIATIONS? GRAMEEN BANK MEMBER? VOLUNTARY ORGANIZATION MEMBER? BRAC INCOME GENERATING ACTVITIES PROSHIKA ASHA COTTAGE INDUSTRIES OF BSIC COOPERATIVE SOCIETY OTHER NGO INCOME GENERATING ACTIVITIES YES NO MOTHERS CLUB.1 2 GRAMEEN BANK .1 2 V0 MEMBER.1 2 BRAC.1 2 PROSHIKA .1 2 ASHA.1 2 BSIC .1 2 COOPERATIVE SOCIETY.1 2 NGOS .1 2 121 In this village/mohalla, is there a television for the community? YES.1 NO .2 122 Please tell me if the following things are in this village/mohalla. IF LOCATED IN THE VILLAGE/MOHALLA, WRITE '00'. IF NO, ASK: How far is it? IF DO NOT KNOW, PUT '98'. A. How far is the madrasha from this village/mohalla? MILE 1 KILOMETER 2 B. How far is the primary school from this village/mohalla? MILE 1 KILOMETER 2 C. How far is the boy’s high school from this viilage/mohalla? MILE 1 KILOMETER 2 D. How far is the girl’s high school from this village/mohalla? MILE 1 KILOMETER 2 E. How far is the high school (co-education)? MILE 1 KILOMETER 2 F. How far is the post office from this village/mohalla? MILE 1 KILOMETER 2 G. Is there a cinema hall here? MILE 1 KILOMETER 2 123 Is there anyone in the village/mohalla who sells family planning methods from his or her house? YES.1 NO .2 124 Is there any shop in this village/mohalla, which sells family planning methods? YES.1 NO .2 125 In some places, there is a clinic, which is set up temporarily in someone’s house or a school on certain days to provide health and family planning services to mothers and children. It is called the satellite clinic. Is there a clinic like this held in this village/mohalla in the last 6 months? YES.1 NO .2 DOES NOT KNOW .8 127 126 Was there a clinic like this held nearby to this village/mohalla in the last 6 months? IF YES; How far away is the place where they had the clinic? YES.1 NO .2 DOES NOT KNOW .8 MILES. 1 KM . 2 128 No. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 127 Does this outreach program /satellite clinic provide: A. Family Planning Education/ Counseling? B. Family Planning Services? if YES I. Pill? II. IUD Insertion? III. Injections? IV. Condoms? C. Menstrual Regulation (MR)? D. Antenatal Care? E. Delivery Care? F. Postpartum Care? G. Child Immunization? H. Growth Monitoring? I. Treatment of sick children? J. Oral Rehydration Therapy? K. Health Education? L. Vitamin A M. National Immunization Day (NID) N. Other________________________ (Specify) YES NO FP EDUCATION/COUNSELING . 1 2 FAMILY PLANNING SERVICES . 1 2 PILL . 1 2 IUD INSERTION . 1 2 INJECTIONS. 1 2 CONDOMS . 1 2 MENSTRUAL REGULATION . 1 2 ANTENATAL CARE . 1 2 DELIVERY CARE . 1 2 POSTPARTUM CARE . 1 2 CHILD IMMUNIZATION . 1 2 GROWTH MONITORING. 1 2 TREATMENT OF SICK CHILD. 1 2 ORAL REHYDRATION . 1 2 HEALTH EDUCATION. 1 2 VITAMIN A. 1 2 NID . 1 2 OTHER . 1 2 127C 128 How far is it from here to the nearest place that provides: a) Child Immunization/EPI? b) ORS Packet? c) Condoms? d) Pill? e) Injectables? f) IUD? g) Vasectomy? h) Tubectomy? i) Other health service IF NEAREST PLACE IS IN VILLAGE/MOHALLA, RECORD ‘00’. IF DISTANCE DON’T KNOW, RECORD ‘98’. MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 MILE . 1 KILOMETER . 2 2. Identification of Health facilities and Pharmacies Now, I will ask you questions about health facilities that offer health services to the villagers. The purpose of this section is to identify the sources of health services available to the villagers. Please mention all facilities that offer services. 201. HEALTH FACILITY 202. Where is the HEALTH FACILITY located? 203. What is the HEALTH FACILITY’s operating authority? 204. How far in miles/kilometers is the HEALTH FACILITY located from the center of the village? IF LOCATED IN THE VILLAGE/MOHALLA, RECORD ‘00’. 204. How many minutes does it take to go to the FACILITY using the most common type of transportation? 206. When did FACILITY first open? 206A. For how long has HEALTH FACILITY been open? 207. Is HEALTH FACILITY in this District/ Thana/ union? 01A. HOSPITAL (Nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 02A NO.2 01B 01B. HOSPITAL (DISTRICT) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 02A. MATERNAL AND CHILD WELFARE CENTER (MCWC) (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 03A NO.2 02B 02B. MATERNAL AND CHILD WELFARE CENTER (MCWC) (DISTRICT) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 03A. THANA HEALTH CENTER (THC) (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 04A NO.2 03B 201. HEALTH FACILITY 202. Where is the HEALTH FACILITY located? 203. What is the HEALTH FACILITY’s operating authority? 204. How far in miles/kilometers is the HEALTH FACILITY located from the center of the village? IF LOCATED IN THE VILLAGE/MOHALLA, RECORD ‘00’. 204. How many minutes does it take to go to the FACILITY using the most common type of transportation? 206. When did FACILITY first open? 206A. For how long has HEALTH FACILITY been open? 207. Is HEALTH FACILITY in this District/ Thana/ union? 03B. THANA HEALTH CENTER (THC) (THANA) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 04A. FAMILY WELFARE CENTER (FWC) (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 05A NO.2 04B 04B. FAMILY WELFARE CENTER (FWC) (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 05A. RURAL DISPENSARY (RD) (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 05A NO.2 04B 05B. RURAL DISPENSARY (RD) (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 998 206A YEARS . DON’T KNOW. 98 201. HEALTH FACILITY 202. Where is the HEALTH FACILITY located? 203. What is the HEALTH FACILITY’s operating authority? 204. How far in miles/kilometers is the HEALTH FACILITY located from the center of the village? IF LOCATED IN THE VILLAGE/MOHALLA, RECORD ‘00’. 204. How many minutes does it take to go to the FACILITY using the most common type of transportation? 206. When did FACILITY first open? 206A. For how long has HEALTH FACILITY been open? 207. Is HEALTH FACILITY in this District/ Thana/ union? 06A. COMMUNITY CLINIC (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 07A NO.2 06B 06B. COMMUNITY CLINIC (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 07A. SATELLITE CLINIC (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 08A NO.2 07B 07B. SATELLITE CLINIC (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 08A. NGO CLINIC (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ NGO.02 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 09A NO.2 08B 08B. NGO CLINIC (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ NGO.02 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 201. HEALTH FACILITY 202. Where is the HEALTH FACILITY located? 203. What is the HEALTH FACILITY’s operating authority? 204. How far in miles/kilometers is the HEALTH FACILITY located from the center of the village? IF LOCATED IN THE VILLAGE/MOHALLA, RECORD ‘00’. 204. How many minutes does it take to go to the FACILITY using the most common type of transportation? 206. When did FACILITY first open? 206A. For how long has HEALTH FACILITY been open? 207. Is HEALTH FACILITY in this District/ Thana/ union? 09A. PRIVATE CLINIC (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 10A NO.2 09B 09B. PRIVATE CLINIC (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 10A. PHARMACY (nearest) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 YES .1 11A NO.2 10B 10B. PHARMACY (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 11. OTHER HEALTH CENTER (UNION) NAME:______________ DON’T KNOW NONE DISTRICT: _________________ THANA: _________________ LOCATION: _________________ GOVERNMENT.01 NGO.02 PRIVATE.03 RELIGIOUS.04 OTHER.96 DK .98 MILES . 1 KILOMETERS. 2 DON’T KNOW. 998 MINUTES DON’T KNOW. 998 MINUTES 207 DON’T KNOW . 9998 206A YEARS . DON’T KNOW. 98 3: List of the Health and Family Planning Workers. Please provide us the name of all fieldworkers working in this cluster/village Title and Name of the worker 301 What name he/sheis known? 302: Does he/she live in this locality? 303a. Does he/she live? 303b. How frequent does he/she visit this village/mohalla? 304. What type of services does he/she provide? 01. Is there any a government family planning worker (FWA) in this village/mohalla? YES. 1 NAME: _____________ NO. 2 NEXT Known as: __________________ YES . 1 (GO TO 304) NO. 2 DISTRICT _________ THANA ___________ UNION____________ VILLAGE __________ ONCE A WEEK.1 ONCE IN 15 DAYS .2 ONCE A MONTH .3 LESS THAN A MONTH.4 ALMOST NEVER.5 DON’T KNOW.8 HEALTH .1 FAMILY PLANNING .2 BOTH .3 DON’T KNOW .8 02. Is there any government health assistance (HA) in this village/mohalla? YES. 1 NAME: _____________ NO. 2 NEXT Known as: __________________ YES . 1 (GO TO 304) NO. 2 DISTRICT _________ THANA ___________ UNION____________ VILLAGE __________ ONCE A WEEK.1 ONCE IN 15 DAYS .2 ONCE A MONTH .3 LESS THAN A MONTH.4 ALMOST NEVER.5 DON’T KNOW.8 HEALTH .1 FAMILY PLANNING .2 BOTH .3 DON’T KNOW .8 03A. Is there any non- government health/family planning worker in this village/mohalla? YES. 1 NAME: _____________ NO. 2 NEXT Known as: __________________ YES . 1 (GO TO 304) NO. 2 DISTRICT _________ THANA ___________ UNION____________ VILLAGE __________ ONCE A WEEK.1 ONCE IN 15 DAYS .2 ONCE A MONTH .3 LESS THAN A MONTH.4 ALMOST NEVER.5 DON’T KNOW.8 HEALTH .1 FAMILY PLANNING .2 BOTH .3 DON’T KNOW .8 03B. Is there any other non- government health/family planning worker in this village/mohalla? YES. 1 NAME: _____________ NO. 2 401 Known as: __________________ YES . 1 (GO TO 304) NO. 2 DISTRICT _________ THANA ___________ UNION____________ VILLAGE __________ ONCE A WEEK.1 ONCE IN 15 DAYS .2 ONCE A MONTH .3 LESS THAN A MONTH.4 ALMOST NEVER.5 DON’T KNOW.8 HEALTH .1 FAMILY PLANNING .2 BOTH .3 DON’T KNOW .8 4: Availability of Doctors (allopathic, homeopathic) and Pharmacies Please tell us about the doctors and pharmacies working in this village/mohalla. No. QUESTIONS AND FILTERS CODING CATEGORIES SKIP TO 401 Are there any allopathic/MBBS doctors in this village/mohalla? YES .1 NO .2 403 402 How many allopathic/MBBS doctors are in this village/mohalla? NUMBER . DON'T KNOW.98 PLEASE COMPLETE THE LIST OF DOCTORS IN NEXT PAGE 403 How far away is the nearest allopathic/MBBS doctor? MILE .1 KILOMETER .2 DK . 998 ENTER 'OO' IF IN THIS VILLAGE/ MOHALLA 404 Are there any homeopathic doctors in this village/mohalla? YES .1 NO .2 406 405 How many homeopathic doctors are in this village/mohalla? NUMBER . DON'T KNOW.98 406 How far away is the nearest homeopathic doctor? MILE .1 KILOMETER .2 DK . 998 ENTER 'OO' IF IN THIS VILLAGE/ MOHALLA 407 Are there any ayurvedic/unani doctors in this village/mohalla? YES .1 NO .2 409 408 How many ayurvedic/unani doctors are in this village/mohalla? NUMBER . DON'T KNOW.98 409 How far away is the nearest ayurvedic/unani doctor? MILE .1 KILOMETER .2 DK . 998 ENTER 'OO' IF IN THIS VILLAGE/ MOHALLA 410 Are there any pharmacies in this village/mohalla? YES .1 NO .2 412 411 How many pharmacies are in this village/mohalla? NUMBER . DON'T KNOW.98 412 How far away is the nearest pharmacy? MILE .1 KILOMETER .2 DK . 998 ENTER 'OO' IF IN THIS VILLAGE/ MOHALLA 5: List of doctors (allopathic). 501. Please provide us the name of all doctors working in this village/mohalla. 1NAME OF DOCTOR (known as) TYPE OF DOCTOR Is the (NAME) qualified doctor? NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 NAME _______________________ ALLOPATHIC . 1 HOMEOPATHIC. 2 AYURVEDIC/UNANI. 3 HAVE A CERTIFICATE .1 HAVE A CERTIFICATE (PALLI DOCTOR) 2 NO CERTIFICATE.3 ENDING TIME HOUR. MINUTES . Appendix F | 341 SUMMARY INDICATORS APPENDIX F Bangladesh Demographic and Health Survey Indicator 1993-1994 1996-1997 1999-2000 2004 Fertility Total fertility rate (TFR) 15-49 3.4 3.3 3.3 3.0 Contraceptive Prevalence Rate Any method Any modern method Pill IUD Injection Condom Female Sterilization Male Sterilization Norplant Any traditional method 44.6 36.2 17.4 2.2 4.5 3.0 8.1 1.1 - 8.4 49.2 41.6 20.8 1.8 6.2 3.9 7.6 1.1 0.1 7.7 53.8 43.4 23.0 1.2 7.2 4.3 6.7 0.5 0.5 10.3 58.1 47.3 26.2 0.6 9.7 4.2 5.2 0.6 0.8 10.8 Contraceptive Use among Married Adolescent Percent of currently married adolescent girls using a modern contraceptive method Age 10-14 Age 15-19 10.5 19.6 9.1 27.8 16.1 31.2 21.9 34.1 Unmet Need for Family Planning Percentage of currently married women under age 50 with unmet need for family planning 19.4 15.8 15.3 11.3 Field worker visit Percentage of currently married women who reported having been visited by a family planning fieldworker in the six months prior to the survey 43.0 35.2 21.2 18.2 Antenatal Coverage Percentage of last live births in the five years preceding the survey for which women received at least one ANC from a medically trained provider - 29.0 33.3 48.7 Skilled Assistance at Delivery Percentage of births in the five years preceding the survey attended by medically trained provider 9.51 8.0 12.1 13.4 Postnatal Care Percentage of last live births where the mother received PNC from a trained provider within 42 days of delivery - - 13.7 17.8 Percentage of last live births in the five years preceding the survey where the child received PNC from a trained provider within 42 days of delivery - - - 17.5 342 | Appendix F Childhood mortality Neonatal Mortality Post-neonatal Mortality Infant Mortality Rate Child Mortality Rate Under 5 Mortality Rate 52 35 87 50 133 48 34 82 37 116 42 24 66 30 94 41 24 65 24 88 Vaccination Coverage Percentage of children age 12-23 months who received specific vaccines at any time before the survey BCG DPT3 Polio3 Measles All vaccines 85.4 66.0 66.8 68.9 58.9 86.2 69.3 62.3 69.9 54.1 91.0 72.1 70.8 70.8 60.4 93.4 81.0 82.3 75.7 73.1 Vitamin A Supplementation Percentage of children (9-59 months) receiving vitamin- A capsules in the 6 months preceding the survey - - 80.4 81.8 Treatment for Diarrhea Percentage of children under five years of age with diarrhea s treated with ORT (ORS or home made solution) Increased Fluid intake 58.32 50.92 61.0 55.7 73.6 49.7 74.6 52.3 Treatment for ARI Percentage of children under five years of age with symptoms of ARI seeking care from a trained provider 28.02 32.9 27.2 20.3 Indicator 1993-1994 1996-1997 1999-2000 2004 Nutritional Status of Children Percentage of children under five years of age considered malnourished according to three anthropometric indices of nutritional status Height-for-age (stunting) Severe Moderate or severe Weight for-height (wasting) Severe Moderate or severe Weight-for-age (underweight) Severe Moderate or severe - - - - - - 28.0 54.6 3.7 17.7 20.6 56.3 18.3 44.7 1.1 10.3 12.9 47.7 16.9 43.0 1.3 12.8 12.8 47.5 Knowledge of HIV/AIDS Percentage of women/men who have heard of HIV/AIDS Ever-married women Currently married men Never married men - - - 18.7 33.1- 30.8 50.2 - 60.0 78.0 89.3 Percentage of women/men who know at least two correct ways to avoid HIV/AIDS Ever-married women Currently married men Never married men - - - - - - 7.2 18.0 - 29.7 45.3 58.8 Sanitary excreta disposal Percent of households with flush toilets, pit toilets/latrines Education Percent of females 15-19 with completed primary education Percent of males 15-19 with completed primary education Percent of females 20-24 with completed secondary education Percent of males 20-24 with completed secondary education 40.7 33.1 43.3 9.0 20.9 43.2 51.6 57.2 13.1 22.7 54.1 62.9 65.2 16.7 22.7 58.6 70.4 66.7 16.4 23.8 Appendix F | 343 Breastfeeding Percent of children under 6 months who are exclusively breastfed (based on 24 hour recall) Percent of children under 6 months who are exclusively breastfed (based on 7 days recall) Percent of children age 6-9 months receiving breast milk and complementary food (based on 24 hour recall) Percent of children age 6-9 months receiving breast milk and complementary food (based on 7 days recall) Maternal nutrition Percent of mothers under age 50 who have children under 5 years with low BMI(<18.5) Percent of ever married women under age 50 with low BMI 45.9 -- 28.5 -- -- -- 45.1 -- 28.4 -- 52.0 -- 46.1 -- 58.9 -- 45.4 -- 42.2 36.4 62.3 69.2 37.9 34.3 1Rate refer to births in the three years preceding the survey 2 Rate refers to children under three years of age Front Matter Title Page Citation Table of Contents Tables and Figures Preface Foreword Summary of Findings Map of Bangladesh Chapter 01 - Introduction Chapter 02 - Household Population and Housing Characteristics Chapter 03 - Characteristics of Survey Respondents Chapter 04 - Fertility Chapter 05 - Fertility Regulation Chapter 06 - Other Proximate Determinants of Fertility Chapter 07 - Fertility Preferences Chapter 08 - Infant and Child Mortality Chapter 09 - Causes of Death in Children Under Five Years of Age Chapter 10 - Maternal and Child Health Chapter 11 - Infant Feeding and Nutritional Status of Children and Women Chapter 12 - Knowledge, Attitudes and Behavior Related to HIV/AIDS and Other Sexually Transmitted Infections Chapter 13 - Community Characteristics Chapter 14 - Policy Implications of the 2004 BDHS References Appendix A - Sample Implementation Appendix B - Estimates of Sampling Errors Appendix C - Data Quality Tables Appendix D - Bangladesh Demographic and Health Survey Personnel Appendix E - Questionnaires Appendix F - Summary Indicators

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