Bangladesh - Demographic and Health Survey - 2009

Publication date: 2009

Bangladesh Demographic and Health Survey 2007 B angladesh 2007 D em ographic and H ealth Survey Bangladesh Demographic and Health Survey 2007 National Institute of Population Research and Training (NIPORT) Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh Macro International Calverton, Maryland USA March 2009 This report summarizes the findings of 2007 Bangladesh Demographic and Health Surveys (2007 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. Macro International provided financial and technical assistance for the survey through USAID/Bangladesh. The USAID funding was provided under contract number GPO-C-00-03-00002-00. 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, the Government of Bangladesh, or donor organizations. Additional information about the 2007 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: Macro International 11785 Beltsville Drive Suite 300 Calverton, MD 20705 USA Telephone: 301-572-0200 Fax: 301-572-0999 Email: reports@macrointernational.com Internet: http://www.measuredhs.com Suggested citation: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International. 2009. Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and Training, Mitra and Associates, and Macro International. Contents | iii CONTENTS Page TABLES AND FIGURES . ix FOREWORD . xvii PREFACE. xix CONTRIBUTORS TO THE REPORT . xxi ABBREVIATONS . xxiii SUMMARY OF FINDINGS . xxv MILLENNIUM DEVELOPMENT GOAL INDICATORS.xxxiii MAP OF BANGLADESH .xxxiv 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 2007 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 . 8 1.4.4 Training and Fieldwork . 9 1.4.5 Data Processing . 9 1.4.6 Coverage of the Sample. 10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age, Sex, and Residence. 11 2.2 Household Composition . 13 2.3 Household Characteristics . 14 2.4 Household Possessions. 18 2.5 Wealth Index . 19 2.6 Educational Attainment . 20 2.6.1 School Attendance. 23 2.7 Employment . 24 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Characteristics of Respondents . 25 3.2 Educational Attainment . 27 3.3 Literacy . 30 3.4 Access to Mass Media . 32 3.5 Employment . 35 3.6 Occupation. 38 3.7 Earnings and Continuity of Employment . 41 iv � Contents 3.8 Knowledge and Attitudes Concerning Tuberculosis . 41 3.9 Use of Tobacco. 44 CHAPTER 4 FERTILITY 4.1 Current Fertility Levels . 46 4.2 Fertility Differentials . 47 4.3 Fertility Trends . 49 4.4 Children Ever Born and Living. 51 4.5 Birth Intervals. 53 4.6 Age at First Birth. 54 4.7 Adolescent Fertility. 56 CHAPTER 5 FERTILITY REGULATION 5.1 Knowledge of Family Planning Methods . 57 5.2 Ever Use of Contraception . 58 5.3 Knowledge and Ever Use of Menstrual Regulation. 59 5.4 Current Use of Contraception . 60 5.4.1 Trends in Current Use of Family Planning . 60 5.4.2 Differentials in Current Use of Family Planning . 62 5.5 Number of Children at First Use of Contraception. 64 5.6 Use of Social Marketing Brands . 65 5.7 Age at Sterilization . 66 5.8 Source of Family Planning Method. 67 5.9 Contraceptive Discontinuation . 68 5.10 Future Intentions To Use Family Planning . 69 5.10.1 Future Use of Contraception. 69 5.10.2 Reasons for Not Intending to Use Contraception . 70 5.10.3 Preferred Method for Future Use . 70 5.11 Family Planning Outreach Services. 71 5.12 Discussion about Family Planning between Spouses. 73 5.13 Exposure to Family Planning Messages . 73 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Introduction. 75 6.2 Current Marital Status . 75 6.3 Age At First Marriage . 77 6.4 Age at First Sexual Intercourse. 81 6.5 Postpartum Amenorrhea, Abstinence, and Insusceptibility. 83 6.6 Termination of Exposure to Pregnancy . 86 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 87 7.2 Desire to Limit Childbearing. 89 7.3 Need for Family Planning Services. 91 7.4 Ideal Family Size . 93 7.5 Wanted and Unwanted Fertility . 96 Contents | v CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Assessment of Data Quality . 99 8.2 Levels and Trends in Infant and Child Mortality. 101 8.3 Socioeconomic Differentials in Infant and Child Mortality . 102 8.4 Demographic Differentials in Infant and Child Mortality. 104 8.5 Perinatal Mortality. 105 8.6 High-Risk Fertility Behavior . 106 CHAPTER 9 MATERNAL AND NEWBORN HEALTH 9.1 Antenatal Care . 109 9.1.1 Antenatal Care Coverage . 109 9.1.2 Place of Antenatal Care . 111 9.1.3 Number and Timing of Antenatal Visits . 112 9.1.4 Components of Antenatal Care . 113 9.1.5 Tetanus Toxoid Injections . 115 9.2 Delivery Care. 116 9.2.1 Place of Delivery . 117 9.2.2 Assistance during Delivery . 118 9.2.3 Caesarean Section . 118 9.3 Postnatal Care. 120 9.3.1 Postnatal Care Providers for Mothers and Children . 120 9.3.2 Timing of first Postnatal Checkup of Mothers and Children . 122 9.3.3 Experience of Complications around Delivery. 125 9.3.4 Treatment Seeking for Signs of Maternal Complications . 125 9.4 Newborn Care . 126 9.4.1 Care of the Umbilical Cord. 127 9.4.2 Wiping, Wrapping and Bathing the Newborn . 128 CHAPTER 10 CHILD HEALTH 10.1 Vaccination of Children. 131 10.1.1 Vaccination Coverage . 132 10.1.2 Differentials in Vaccination Coverage . 132 10.1.3 Vaccinations in First Year of Life. 134 10.1.4 Trends in Vaccination Coverage . 134 10.2 Childhood Illness and Treatment. 135 10.2.1 Childhood Diarrhea . 135 10.2.2 Treatment of Diarrhea. 136 10.2.3 Feeding Practices during Diarrhea. 138 10.2.4 Acute Respiratory Infections (ARI) . 139 10.3 Fever. 143 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN 11.1 Nutritional Status of Children . 145 11.2 Breastfeeding and Supplementation . 149 11.2.1 Initiation of Breastfeeding . 149 11.2.2 Age Pattern of Breastfeeding . 152 vi � Contents 11.2.3 Duration of Breastfeeding . 155 11.2.4 Complementary Feeding. 156 11.3 Infant and Young Child Feeding Practices. 158 11.3.1 Micronutrient Intake among Children . 161 11.3.2 Vitamin A Supplementation . 163 11.4 Nutritional Status of Women. 163 11.4.1 Micronutrient Intake among Mothers. 165 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 12.1 Knowledge of HIV/AIDS and Transmission and Prevention Methods . 168 12.1.1 Knowledge of AIDS. 168 12.1.2 Knowledge of HIV Prevention Methods . 169 12.1.3 Rejection of Misconceptions about HIV/AIDS . 171 12.1.4 Comprehensive Knowledge about AIDS. 174 12.1.5 Knowledge of Means of Transmission of HIV . 174 12.2 Attitudes toward Negotiating Safe Sexual Relations with Husbands. 175 12.3 Self-reported Prevalence of Sexually Transmitted Infections (STIs) and STI Symptoms . 177 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 13.1 Employment and Form of Earnings . 181 13.2 Control over Women’s Earnings . 182 13.3 Freedom of Movement . 184 13.4 Women’s Empowerment . 185 13.4.1 Women’s Participation in Decisionmaking: Women’s Perspective . 185 13.4.2 Women’s Participation in Decisionmaking: Men’s Perspective. 186 13.4.3 Women’s Participation in Decisionmaking by Background Characteristics . 186 13.4.4 Men’s Report of Wives’ Participation in Decisionmaking by Background Characteristics . 188 13.5 Attitudes towards Wife Beating . 189 13.5.1 Attitude towards Wife Beating: Women. 190 13.5.2 Attitude towards Wife Beating: Men . 191 13.6 Indicators of Women’s Empowerment . 193 13.7 Current Use of Contraception by Women’s Empowerment . 194 13.8 Ideal Family Size and Unmet Need by Women’s Empowerment. 195 13.9 Reproductive Health Care by Women’s Empowerment. 195 CHAPTER 14 DOMESTIC VIOLENCE 14.1 Measurement of Domestic Violence. 198 14.2 Ethical Considerations . 199 14.3 Special Training for Implementing the Domestic Violence Module . 199 14.4 Characteristics of the Subsample of Respondents for the Violence Module. 200 14.5 Spousal Violence: Women’s Report . 200 Contents | vii 14.5.1 Physical and Sexual Spousal Violence . 200 14.5.2 Spousal Violence by Background Characteristics . 202 14.5.3 Spousal Violence by Husband’s Characteristics and Empowerment Indicators . 205 14.5.4 Frequency of Spousal Violence . 206 14.6 Spousal Violence: Men’s Report. 207 14.6.1 Physical and Sexual Violence . 207 14.6.2 Spousal Violence by Background Characteristics . 209 14.6.3 Spousal Violence by Empowerment Indicators . 211 14.7 Reasons for Spousal Violence . 212 14.8 Discussing Experience of Domestic Violence with Others and Assistance Received . 213 CHAPTER 15 POLICY IMPLICATIONS 15.1 National Policy Environment . 215 15.2 Fertility. 216 15.3 Factors Which Can Affect Fertility. 217 15.3.1 Age at Marriage . 217 15.3.2 Family Planning . 218 15.3.3 BCC (Behavior Change Communication) . 218 15.3.4 Family Planning Service Provision . 219 15.3.5 Long-Acting and Permanent Methods . 220 15.3.6 Contraceptive Supply. 220 15.4 Maternal Health . 221 15.5 Childhood Health and Mortality. 223 15.6 HIV/AIDS-Related Knowledge, Attitudes, and Behaviour . 229 REFERENCES . 231 APPENDIX A SAMPLE DESIGN.239 A.1 Introduction . 239 A.2 Sampling Frame. 239 A.3 Sample Design . 240 A.4 Sampling Probabilities and Sampling Weights . 242 A.5 Survey Implementation. 243 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 245 APPENDIX C DATA QUALITY TABLES . 257 APPENDIX D NUTRITIONAL STATUS OF CHILDREN . 263 APPENDIX E PERSONS INVOLVED IN THE 2007 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY. 265 APPENDIX F QUESTIONNAIRES . 269 APPENDIX G SUMMARY INDICATORS . 345 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews.10 Figure 1.1 Map of 2007 Bangladesh Urban and Rural Sampling Points .7 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.12 Table 2.2 Trends in population by age.13 Table 2.3 Household composition.14 Table 2.4 Household drinking water.15 Table 2.5 Household sanitation facilities.16 Table 2.6 Household characteristics .17 Table 2.7 Household durable goods, land ownership, and livestock .18 Table 2.8 Wealth quintiles.20 Table 2.9.1 Educational attainment of the male household population .21 Table 2.9.2 Educational attainment of the female household population .22 Table 2.10 School attendance .24 Table 2.11 Employment status.24 Figure 2.1 Population Pyramid .12 Figure 2.2 Distribution of the 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, Bangladesh 1993-2007 .23 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents .26 Table 3.2.1 Educational attainment: Women.28 Table 3.2.2 Educational attainment: Men .29 Table 3.3.1 Literacy: Women .31 Table 3.3.2 Literacy: Men .32 Table 3.4.1 Exposure to mass media: Women.33 Table 3.4.2 Exposure to mass media: Men .34 Table 3.5.1 Employment status: Women .36 Table 3.5.2 Employment status: Men.37 Table 3.6.1 Occupation: Women.39 Table 3.6.2 Occupation: Men .40 Table 3.7 Type of employment: Women.41 x | Tables and Figures Table 3.8.1 Knowledge and attitudes concerning tuberculosis: Women.42 Table 3.8.2 Knowledge and attitudes concerning tuberculosis: Men .43 Table 3.9 Use of tobacco: Men .44 Figure 3.1 Trends in Age Differential between Spouses (Husband’s Age Minus Wife’s Age) 1999, 2000, 2004, and 2007 BDHS).27 Figure 3.2 Trends in Education of Couples 1999-2000, 2004, and 2007 BDHS.30 Figure 3.3 Percentage of Ever-Married Women and Men Exposed to Various Media at Least Once a Week.35 CHAPTER 4 FERTILITY Table 4.1 Current fertility rates .46 Table 4.2 Fertility by background characteristics .48 Table 4.3.1 Trends in current fertility rates.50 Table 4.3.2 Trends in age-specific fertility rates.50 Table 4.4 Children ever born and living.52 Table 4.5 Trends in children ever born .52 Table 4.6 Birth intervals.53 Table 4.7 Age at first birth .55 Table 4.8 Median age at first birth .55 Table 4.9 Teenage pregnancy and motherhood.56 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence.47 Figure 4.2 Total Fertility Rates by Background Characteristics .49 Figure 4.3 Trends in Total Fertility Rate, Bangladesh 1971 to 2007.51 CHAPTER 5 FERTILITY REGULATION Table 5.1 Knowledge of contraceptive methods .57 Table 5.2 Ever use of contraception.58 Table 5.3 Trends in ever use of family planning methods.59 Table 5.4 Menstrual regulation .59 Table 5.5 Current use of contraception by age .60 Table 5.6 Trends in current use of contraceptive methods .61 Table 5.7 Current use of contraception by background characteristics .63 Table 5.8 Number of living children at first use of contraception .64 Table 5.9 Use of pill brands.65 Table 5.10 Use of condom brands.66 Table 5.11 Timing of sterilization.66 Table 5.12 Source of modern contraception methods .67 Table 5.13 First-year contraceptive discontinuation rates .68 Table 5.14 Future use of contraception .69 Table 5.15 Reason for not intending to use contraception .70 Table 5.16 Preferred method of contraception for future use.70 Table 5.17 Contact with family planning worker.71 Table 5.18 Satellite clinics .72 Tables and Figures | xi Table 5.19 Discussion of family planning with spouse.73 Table 5.20 Exposure to family planning messages .74 Figure 5.1 Trends in Contraceptive Use among Currently Married Women Age 10-49, Selected Surveys 1975-2007.61 Figure 5.2 Trends in the Contraceptive Method Mix among Currently Married Women Age 10-49 Using a Method, 1991-2007 .62 Figure 5.3 Contraceptive Use by Background Characteristics .64 Figure 5.4 Distribution of Current Users of Modern Contraceptive Methods by Source of Supply.68 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status .76 Table 6.2 Trends in proportion never married .77 Table 6.3 Age at first marriage .78 Table 6.4.1 Median age at first marriage: Women .80 Table 6.4.2 Median age at first marriage: Men.81 Table 6.5 Age at first sexual intercourse: Men.82 Table 6.6 Median age at first intercourse: Men.83 Table 6.7 Postpartum amenorrhea, abstinence, and insusceptibility.84 Table 6.8 Median duration of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility.85 Table 6.9 Menopause.86 Figure 6.1 Trends in Percentage of Women Age 20-24 Who Were First Married by Age 18 .79 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children .87 Table 7.2 Fertility preferences by age .89 Table 7.3 Desire to limit childbearing .90 Table 7.4 Need and demand for family planning among currently-married women.92 Table 7.5 Ideal number of children .94 Table 7.6.1 Mean ideal number of children by background characteristics: Women.95 Table 7.6.2 Mean ideal number of children by background characteristics: Men .96 Table 7.7 Fertility planning status.97 Table 7.8 Wanted fertility rates.98 Figure 7.1 Fertility Preferences among Currently Married Women Age 15-49.88 Figure 7.2 Percentage of Currently Married Women Who Want No More Children, by Number of Living Children.88 Figure 7.3 Percentage of Married Women with Two Children Who Want No More Children, by Background Characteristics .90 Figure 7.4 Trends in Unmet Need for Family Planning among Currently Married Women Age 15-49 by Division, 2004 and 2007 BDHS .93 xii | Tables and Figures Figure 7.5 Trends in Unplanned, Mistimed, and Unwanted Births .96 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 101 Table 8.2 Early childhood mortality rates by socioeconomic characteristics. 103 Table 8.3 Early childhood mortality rates by demographic characteristics. 104 Table 8.4 Perinatal mortality. 106 Table 8.5 High-risk fertility behavior . 107 Figure 8.1 Trends in Infant and Childhood Mortality,1989 to 2006 . 102 Figure 8.2 Under-Five Mortality Rates by Socioeconomic Characteristics . 103 Figure 8.3 Under-Five Mortality Rates by Demographic Characteristics. 104 CHAPTER 9 MATERNAL AND NEWBORN HEALTH Table 9.1 Antenatal care. 110 Table 9.2 Place of antenatal care. 112 Table 9.3 Number of antenatal care visits and timing of first visit . 113 Table 9.4 Components of antenatal care . 114 Table 9.5 Tetanus toxoid injections . 116 Table 9.6 Place of childbirth. 117 Table 9.7 Assistance during childbirth. 119 Table 9.8.1 Postnatal checkup: Women . 121 Table 9.8.2 Type of provider of first postnatal checkup: Children . 122 Table 9.9.1 Timing of first postnatal checkup: Women . 123 Table 9.9.2 Timing of first postnatal checkup: Children . 124 Table 9.10 Experience of signs of complications during labor and childbirth . 125 Table 9.11 Treatment seeking for signs of maternal complications . 126 Table 9.12 Type of instrument used to cut the umbilical cord. 127 Table 9.13 Application of material after the umbilical cord was cut . 128 Table 9.14 Newborn care practices: Timing of wiping and wrapping . 129 Table 9.15 Newborn care practices: Timing of first bath . 130 Figure 9.1 Reasons for Not Seeing Anyone for Antenatal Care . 111 CHAPTER 10 CHILD HEALTH Table 10.1 Vaccinations by source of information. 132 Table 10.2 Vaccinations by background characteristics . 133 Table 10.3 Vaccinations in first year of life. 134 Table 10.4 Prevalence of diarrhea . 136 Table 10.5 Diarrhea treatment . 137 Table 10.6 Diarrhea treatment with ORT and zinc . 138 Table 10.7 Feeding practices during diarrhea . 139 Table 10.8 Prevalence and treatment of symptoms of ARI . 140 Table 10.9 Prevalence and treatment of symptoms of ARI (less restricted definition) . 142 Tables and Figures | xiii Table 10.10 Prevalence and treatment of fever. 143 Figure 10.1 Trends in Vaccination Coverage Among Children Age 12-23 Months . 134 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN Table 11.1 Nutritional status of children . 147 Table 11.2 Initial breastfeeding. 151 Table 11.3 Breastfeeding status by age . 153 Table 11.4 Median duration of breastfeeding . 156 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview. 157 Table 11.6 Infant and young child feeding (IYCF) practices . 160 Table 11.7 Micronutrient intake among children . 162 Table 11.8 Nutritional status of women . 164 Table 11.9 Micronutrient intake among mothers . 166 Figure 11.1 Nutritional Status of Children by Age . 148 Figure 11.2 Trends in Nutritional Status of Children Under Five, 2004 and 2007 . 149 Figure 11.3 Among Last Children Born in the Five Years Preceding the Survey Who Ever Received a Prelacteal Liquid, the Percentage Who Received Various Types of Liquids . 152 Figure 11.4 Infant Feeding Practices by Age. 153 Figure 11.5 Trends in Exclusive Breastfeeding for Children Under Six Months . 154 Figure 11.6 Trends in Complementary Feeding for Children 6-9 Months . 155 Figure 11.7 Infant and Young Child Feeding (IYCF) Practices . 161 Figure 11.8 Trends in Nutritional Status of Ever-Married Women, 2004 and 2007 BDHS. 165 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 12.1 Knowledge of AIDS. 168 Table 12.2 Knowledge of HIV prevention methods. 170 Table 12.3.1 Comprehensive knowledge about AIDS: Women . 172 Table 12.3.2 Comprehensive knowledge about AIDS: Men. 173 Table 12.4 Knowledge of transmission of HIV through unclean needles and unsafe blood transfusions . 175 Table 12.5 Attitudes toward negotiating safer sexual relations with husband . 176 Table 12.6 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 178 Figure 12.1 Percentage of Ever-married Women and Men Who Know All Three Means of HIV Prevention (Abstaining, Being Faithful, and Using Condoms). 171 Figure 12.2 Women and Men Age 15-49 Seeking Advice or Treatment for STIs. 179 xiv | Tables and Figures CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 13.1 Employment and cash earnings of currently married women. 182 Table 13.2 Control over women's cash earnings. 183 Table 13.3 Freedom of movement . 184 Table 13.4.1 Women's participation in decisionmaking . 185 Table 13.4.2 Men’s report of wives’ participation in decisionmaking . 186 Table 13.5.1 Women's participation in decisionmaking by background characteristics. 187 Table 13.5.2 Men's report of wives' participation in decisionmaking by background characteristics . 189 Table 13.6.1 Attitude toward wife beating: Women . 191 Table 13.6.2 Attitude toward wife beating: Men. 192 Table 13.7 Indicators of women's empowerment. 193 Table 13.8 Current use of contraception by women's empowerment. 194 Table 13.9 Women's empowerment, ideal number of children, and unmet need for family planning . 195 Table 13.10 Reproductive health care by women's empowerment . 196 Figure 13.1 Number of Household Decisions in Which Currently Married Women Participate . 188 CHAPTER 14 DOMESTIC VIOLENCE Table 14.1 Forms of spousal violence . 201 Table 14.2 Spousal violence by background characteristics. 203 Table 14.3 Spousal violence by husband's characteristics and empowerment indicators. 205 Table 14.4 Frequency of spousal violence among those who report violence. 206 Table 14.5 Forms of spousal violence perpetrated by men. 209 Table 14.6 Spousal violence committed by men by background characteristics . 210 Table 14.7 Spousal violence reported by men by empowerment indicators . 212 Table 14.8 Reasons for spousal violence . 212 Table 14.9 Help seeking behaviors to stop violence. 213 Table 14.10 Persons told about violence . 214 Figure 14.1 Forms of Spousal Violence Experienced by Ever-Married Women. 202 Figure 14.2 Forms of Spousal Violence Experienced by Ever-Married Women by Division . 204 Figure 14.3 Forms of Spousal Violence Committed by Ever-Married Men. 208 Figure 14.4 Forms of Spousal Violence Committed by Ever-Married Men by Division. 211 CHAPTER 15 POLICY IMPLICATIONS OF THE BDHS 2007 Table 15.1 Source of modern contraception methods by wealth quintile. 219 Table 15.2 Interventions to prevent child deaths . 226 Tables and Figures | xv Figure 15.1 Population Density in "Mega" Countries with Population Exceeding 100 Million . 216 Figure 15.2 Mortality trends . 225 Figure 15.3 Trends in Exclusive Breastfeeding. 226 APPENDIX A SAMPLE DESIGN Table A.1 Distribution of residential households by division and by type of residence (PCPRB 2001) . 240 Table A.2 Sample allocation of clusters by division and by type of residence. 241 Table A.3 Sample allocation of households by division and by type of residence. 241 Table A.4 Sample allocation of completed women interviews by division and by type of residence . 241 Table A.5 Sample implementation: Women . 243 Table A.6 Sample implementation: Men. 244 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 247 Table B.2 Sampling errors for National sample. 248 Table B.3 Sampling errors for Urban sample . 249 Table B.4 Sampling errors for Rural sample. 250 Table B.5 Sampling errors for Barisal sample. 251 Table B.6 Sampling errors for Chittagong sample . 252 Table B.7 Sampling errors for Dhaka sample. 253 Table B.8 Sampling errors for Khulna sample . 254 Table B.9 Sampling errors for Rajshahi sample . 255 Table B.10 Sampling errors for Sylhet sample . 256 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 257 Table C.2.1 Age distribution of eligible and interviewed women . 258 Table C.2.2 Age distribution of eligible and interviewed men. 258 Table C.3 Completeness of reporting . 259 Table C.4 Births by calendar years . 259 Table C.5 Reporting of age at death in days . 260 Table C.6 Reporting of age at death in months. 261 APPENDIX D NUTRITIONAL STATUS OF CHILDREN Table D.1 Nutritional status of children in 2007 according to the NCHS/CDC/WHO international reference population . 263 Table D.2 Nutritional status of children in 2004 according to the new WHO Child Growth Standards. 264 Foreword | xvii Secretary Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh FOREWORD The 2007 Bangladesh Demographic and Health Survey (BDHS) is a nationally representative sample survey designed to provide information on basic national indicators of social progress including fertility, childhood mortality, contraceptive knowledge and use, maternal and child health, nutritional status of mothers and children, awareness of AIDS, and domestic violence. In addition to presenting the main findings from the 2007 BDHS on fertility, family planning, maternal & child health and nutrition, this report highlights the major changes that have taken place in Bangladesh’s demographic and health situation since the previous BDHS surveys. Results of the 2007 BDHS show that the fertility declines have continued in recent years, with the total fertility rate (TFR) dropping to 2.7 children per woman. However, differentials in fertility by administrative divisions are substantial. The TFR is highest in Sylhet division (3.7) and lowest in Khulna (2.0). Similar differentials are observed by wealth quintile. The poorest women have an average of 3.2 children—one child more than women from the richest households (2.2 children). BDHS data also indicate that 17 percent of married women have an unmet need for family planning, and that if unmet need of women could be addressed, the current contraceptive prevalence rate in Bangladesh would reach to 73 percent to achieve a replacement level of fertility. The findings of this report together with other national surveys are very important in assessing the achievements of health, nutrition and population sector program (HNPSP). Information obtained from the 2007 BDHS can be used to review the progress of HNPSP, Millennium Development Goals (MDGs) and Poverty Reduction Strategy (PRS) of Bangladesh. The need, however, for further detailed analysis of BDHS data remains. It is hoped that such analysis will be carried out by the academicians, researchers and program personnel to provide more in- depth knowledge for future direction and effective implementation of a national Health and Family Planning Program. The successful completion of the 2007 BDHS was made possible by the contributions of a number of organizations and individuals. I would like to thank NIPORT, Mitra and Associates and Macro International Inc. for their efforts in conducting the 2007 BDHS. I deeply appreciate the United States Agency for International Development (USAID), Dhaka for providing financial assistance that helped ensure the ultimate success of this important undertaking. (Shaikh Altaf Ali) Preface | xix Director General National Institute of Population Research and Training (NIPORT) PREFACE The 2007 Bangladesh Demographic and Health Survey (BDHS) is the fifth of this kind of survey conducted in Bangladesh. The BDHS was implemented through a collaborative effort of the National Institute of Population Research and Training (NIPORT), Macro International, USA, and Mitra & Associates. The financial support for the survey was provided by the United States Agency for International Development (USAID)/ Bangladesh. BDHS is a periodic survey conducted in Bangladesh to serve as a source of population and health data for policymakers, program managers, and the research community. In general, the aims of the BDHS are to provide information to meet the monitoring and evaluation needs of health and family planning programs, and to provide program managers and policymakers involved in these programs with the information they need to plan and implement future interventions. More specifically, the objectives of the survey are to provide up-to-date information on fertility and childhood mortality levels; fertility preferences; awareness, approval, and use of family planning methods; breastfeeding practices; nutrition levels; maternal and child health; awareness of HIV/AIDS and other sexually transmitted diseases; knowledge of tuberculosis; and domestic violence. Members of the Technical Review Committee (TRC), consisting of experts from government, non-governmental and international organizations as well as researchers and professionals working in the Health Nutrition and Population Sector, put forth their valuable opinion in major phases of the survey. In addition, a Technical Task Force (TTF) was formed with the representatives from NIPORT, ICDDR,B, BRAC University, USAID/Bangladesh, Macro International, and Mitra and Associates for designing and implementing the survey. I would like to extend my gratitude and appreciation to the members of the TRC and TTF for their contributions at different phases of the survey. The preliminary results of the 2007 BDHS, with its major findings, were shared with the stakeholders through a dissemination seminar in December 2007. The final report contains detailed analysis of findings addressing the observations raised in preliminary dissemination. I hope that the survey results would be useful for monitoring as well as development of Health, Nutrition and Population Sector Program in Bangladesh. I express my heartfelt thanks to the professionals of the Research Unit of NIPORT, Macro International, and Mitra & Associates for their sincere efforts in successful completion of the survey. (Nasimul Ghani) Contributors to the Report | xxi CONTRIBUTORS TO THE REPORT Mr. Subrata K. Bhadra, National Institute of Population Research and Training Mr. Mahbub-e-Alam, Engender Health Mr. Karar Zunaid Ahmed, International Center for Diarrheal Disease Research, Bangladesh Mr. Toslim Uddin Khan, Social Marketing Company Mr. Md. Noorunnabi Talukder, Population Council Mrs. Dipika Paul, RTM International Ms. Farhana Urni, International Center for Diarrheal Disease Research, Bangladesh Mr. Mohammed Alamgir Kabir, Jahangeernagar University Dr. Md. Shafiqul Islam, National Institute of Preventative and Social Medicine Mr. Shahidul Islam, Mitra and Associates Dr. Nowrozy K. Jahan, Engender Health Mrs. Shahin Sultana, National Institute of Population Research and Training Dr. Mahmuda Khatun, Dhaka University Dr. Pav Govindasamy, Macro International Ms. Joy Fishel, Macro International Mr. Shane Khan, Macro International Dr. Kanta Jamil, United States Agency for International Development, Dhaka Dr. Ahmed Al-Sabir, National Institute of Population Research and Training Dr. Peter Kim Streatfield, International Center for Diarrheal Disease Research, Bangladesh Dr. Shams El Arifeen, International Center for Diarrheal Disease Research, Bangladesh Abbreviations | xxiii ABBREVIATIONS AIDS Acquired immune deficiency syndrome ANC Antenatal care ARI Acute respiratory infection ASFR Age-specific fertility rates BCC Behavior change communication BCG Bacille-Calmette-Guerin vaccine against tuberculosis BDHS Bangladesh Demographic and Health Survey BFS Bangladesh Fertility Survey BMI Body Mass Index BRAC Bangladesh Rural Advancement Committee CBR Crude birth rate CSBA Community-skilled birth attendant CTS Conflict Tactics Scale DGHS Directorate General of Health Services DHS Demographic and Health Survey DPT Diphtheria, pertussis, and tetanus vaccine EA Enumeration area EmOC Emergency obstetric care EPI Expanded Program on Immunization FP Family planning FPHP Fourth Population and Health Project FWA Family welfare assistant FWV Family welfare visitor GAVI Global Alliance for Vaccination and Immunization GDP Gross domestic product GFR General fertility rate GOB Government of Bangladesh GPS Global positioning system HA Health assistant HDI Human Development Index HIV Human immunodeficiency virus HNPSP Health, Nutrition and Population Sector Program HPI Human Poverty Index HPSP Health and Population Sector Program HPSS Health and Population Sector Strategy ICDDR,B Center for Health and Population Research, Bangladesh ICPD International Conference on Population and Development IDU Injection drug user xxiv | Abbreviations IFS Ideal family size IMCI Integrated management of childhood illness IUD Intrauterine device IYCF Infant and Young Child Feeding practices LDC Least developed country LMP Last menstrual period MA Medical assistant MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR Maternal mortality ratio MR Menstrual regulation NASP National AIDS/STD Programme NGO Nongovernmental organization NIPORT National Institute for Population Research and Training NN Neonatal mortality NNP National Nutrition Project ORS Oral rehydration salts ORT Oral rehydration therapy PNN Postneonatal mortality PRSP Poverty Reduction Strategy Paper PSU Primary sampling unit RTI Reproductive tract infection SACMO Sub-assistant community medical officer SBA Skilled birth attendant SD Standard deviation SMA Statistical metropolitan area SSMP Support for Safer Motherhood Program STI Sexually transmitted infection SWAp Sector-Wide Approach TBA Traditional birth attendant TC-NAC Technical Committee of the National AIDS Council TFR Total fertility rate TT Tetanus toxoid TWFR Total wanted fertility rate UNDP United Nations Development Program UNICEF United Nations Children’s Fund UP Union parishad USAID United States Agency for International Development USBC United States Census Bureau VAD Vitamin A deficiency WHO World Health Organization Summary of Findings | xxv SUMMARY OF FINDINGS The 2007 Bangladesh Demographic and Health Survey (2007 BDHS) is a nationally rep- resentative survey of 10,996 women age 15-49 and 3,771 men age 15-54 from 10,400 house- holds covering 361 sample points (clusters) throughout Bangladesh, 134 in urban areas and 227 in the rural areas. This survey is the fifth in a series of national-level population and health surveys conducted as part of the global Demo- graphic and Health Surveys (DHS) program. It is designed to provide data to monitor the popu- lation and health situation in Bangladesh as a followup to the 1993-1994, 1996-1997, 1999- 2000, and 2004 BDHS surveys. The survey util- ized 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 Syl- het. Data collection took place over a five-month period from 24 March to 11 August 2007. This survey included ever-married women age 10-49 and ever-married men age 15-54. However, the number of ever-married women age 10-14 was very low, and thus this group had to be excluded from the analysis. 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, maternal and child health, and knowledge and attitudes regarding HIV/AIDS and other sexu- ally transmitted infections (STIs). As in the 2004 BDHS, all women eligible to be interviewed and all children under five in the household were eligible for height and weight measurement. The 2007 BDHS was conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Minis- try of Health and Family Welfare. It was imple- mented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. Technical assis- tance was provided by Macro International Inc. through the MEASURE DHS program. Financial support for the survey was provided by the U.S. Agency for International Development (USAID/ Bangladesh). FERTILITY Fertility Levels and Trends. In the period 1971-1975, women in Bangladesh were having on average of 6.3 children. Fifteen years later, the total fertility rate (TFR) declined to 5.1, and to 4.3 in the period 1989-1991. The TFR plateaued at around 3.3 for most of the 1990s, when the first three BDHS surveys took place. After almost a decade-long stag- nation, the Bangladesh fertility rate declined slightly to 3.0 children per woman in the 2004 BDHS. Re- sults of the 2007 BDHS show that the fertility de- cline has continued in recent years, with the TFR dropping to 2.7. Comparison of the Bangladesh TFR with fertility rates in other Asian countries that have implemented a DHS survey indicates that, with a TFR of 2.7, Bangladesh’s fertility level is below that of Pakistan (4.1 in 2006/2007), the Philippines (3.5 in 2003), Cambodia (3.4 in 2005), and Nepal (3.1 in 2006); the same as India (2.7 in 2005/2006); it is higher than that of Indonesia (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 (2.8 and 2.4 children per woman, respectively), although the difference appears to be decreasing. The TFR is highest in Sylhet division (3.7) and lowest in Khulna (2.0). As expected, women’s education is strongly associated with lower levels of fertility; the TFR decreases from 3.0 among women with no education to 2.3 among those who have completed at least their secondary education. Similar differentials are observed by wealth quintile, with the TFR decreasing from 3.2 among women in the lowest wealth quintile to 2.2 among those in the highest wealth quintile. xxvi | Summary of Findings Unplanned Fertility. Despite a steady rise in the level of contraceptive use over the past thirty years, the 2007 BDHS data indicate that unplanned pregnancies are common in Bangla- desh. Overall, three in ten births in Bangladesh are either unwanted (14 percent) or mistimed and wanted later (15 percent). These figures are similar to the findings from the 2004 BDHS. Fertility Preferences. There is considerable desire among currently married Bangladeshi women to stop having children. A total of 57 percent of women age 15-49 reported not want- ing another child, and an additional 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 83 percent of women want either to space their next birth or to limit childbearing altogether. Only 12 percent of women would like to have a child soon (within two years). A comparison of the 2004 and 2007 data shows that the proportion of women who want to limit childbearing has increased slightly. As in the 1999-2000 and 2004 BDHS data, a majority of ever-married women and ever-mar- ried men embrace the two-child family as an ideal (2.3 children for both). 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 (95 percent), and condoms (90 per- cent); these are followed by the IUD (84 per- cent), implants (81 percent), male sterilization (73 percent), periodic abstinence (59 percent), and withdrawal (50 percent). Since overall knowledge of contraceptive methods was already high in 2004, little change has taken place. The most notable change is a decrease in knowledge of the traditional meth- ods of periodic abstinence and withdrawal. Use of Contraception. The contraceptive prevalence rate (any method) among currently married women is 56 percent. The most com- monly used modern method is the pill (29 percent), followed by injectables (7 percent). Female steriliza- tion and male condoms are each used by 5 percent of married women, while Norplant, the IUD, and male sterilization are each used by only 1 percent. Peri- odic abstinence, used by 5 percent of married women, is the most commonly 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 56 percent, while use of modern methods has in- creased almost tenfold, from 5 to 48 percent. How- ever, contraceptive use plateaued or declined slightly between 2004 and 2007. The decline in contracep- tive use can be attributed to a decrease in use of tra- ditional methods from 11 percent to 8 percent. Use of modern methods did not decrease between the 2004 and 2007 BDHS surveys. Trends in the contra- ceptive 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 more than half of all contraceptive use, compared with 35 per- cent in 1991. On the other hand, long-term methods now account for only 13 percent of all contraceptive use, compared with 30 percent in 1991. It is also interesting to note that use of injectables declined from 10 percent in 2004 to 7 percent in 2007, possi- bly reflecting recent problems in procurement of injectables that resulted in stockouts. Differentials in Contraceptive Use. Women in urban areas are slightly more likely to use contracep- tive methods (62 percent) than their rural counter- parts (54 percent); however, the condom is the method that shows the largest differentials in use by urban-rural residence: 10 percent in urban areas compared with only 3 percent in rural areas. Differ- entials are more marked by division: use of any method varies from 32 percent in Sylhet and 44 per- cent in Chittagong to 63 percent in Khulna and 66 percent in Rajshahi. Contraceptive prevalence is 54 percent in Barisal and 56 percent in Dhaka. There is little variation in contraceptive use by level of edu- cation. However, women in economically better-off households tend to use family planning more than those in households in the lowest wealth quintile (60 and 55 percent, respectively). The proportion of women using contraception increases with increas- Summary of Findings | xxvii ing number of children. Nineteen percent of women with no children are currently using a contraceptive method, compared with 56 to 67 percent of women with two or more children. Source of Modern Methods. In Bangla- desh, both the public and private sectors are im- portant sources of modern methods (50 and 44 percent, respectively). The most common public sector source remains government fieldworkers (20 percent), although their share has declined substantially since 1993-1994 (42 percent) and slightly more since 2004 (23 percent). Family Welfare Centres and Upazila health complexes are the second most important public sources (9 percent each). Pharmacies (35 percent) provide most of the methods in the private sector (an increase from 29 percent in 2004). Contraceptive Discontinuation. Almost three in five (57 percent) contraceptive users in Bangladesh stop using their method within 12 months of starting. Discontinuation rates are highest for condoms (76 percent) and with- drawal (67 percent), and lowest for IUD (33 per- cent). Compared with the 2004 BDHS, discon- tinuation rates have increased by 14 percent. Unmet Need for Family Planning. Seven- teen percent of married women have an unmet need for family planning, an increase from 11 percent in the 2004 BDHS. Unmet need for lim- iting (11 percent) is higher than unmet need for spacing (7 percent). Unmet need has increased in all divisions relative to 2004. It is highest in Sylhet division (26 percent) and lowest in Khulna and Rajshahi divisions (12 percent each). Overall, 77 percent of the demand for family planning is currently being met. MATERNAL HEALTH Antenatal Care. Antenatal care coverage with a skilled provider is 52 percent, a slight increase from the 2004 BDHS (49 percent). Thirty-six percent of women received antenatal care from a doctor, and 16 percent received care from a nurse, midwife, or paramedic. Around four in ten women received no antenatal care. This percent is especially in high Sylhet (46 per- cent) and Barisal (48 percent). Sixty percent of women received at least two doses of tetanus toxoid for their most recent birth in the five years preceding the survey, 23 percent re- ceived only one tetanus toxoid injection, and 17 per- cent received none. Taking past tetanus toxoid vac- cinations into account, nine in ten women were pro- tected against neonatal tetanus. Delivery Care. Nationally, 85 percent of births in the past five years occurred at home, and 15 per- cent occurred in a health facility. This is an increase since the 2004 BDHS in which only 9 percent of births took place in a health facility. Delivery in a health facility is substantially higher among women who have at least completed secondary education (43 percent), and among those in the highest wealth quintile (43 percent). The data also show that only 18 percent of babies were delivered by medically trained providers, compared with 63 percent who were delivered by untrained birth assistants. Overall, 8 percent of births were C-section de- liveries. This percentage varies greatly by back- ground characteristics. Women with secondary com- plete or higher education and those in the highest wealth quintile are much more likely than other women to deliver by C-section. The 2007 BDHS also shows that 67 percent of births in the private or NGO sector occur by C-section, as are 35 percent of births in public health facilities. Postnatal Care. One in five women (21 per- cent) with a live birth in the five years preceding the survey received postnatal care from a medically trained provider, and most of them received the care in the first two days after delivery. Similar results were found for postnatal care for children. Maternal Complications around Delivery. One in seven births in the five years preceding the survey had at least one of the following maternal complications around delivery—prolonged labour, excessive bleeding, baby’s hands or feet came first, fever with foul-smelling discharge, convulsions/ eclampsia, and retained placenta. The most common complication was prolonged labour of over 12 hours, associated with one in 15 live births. For 5 percent of births, the mothers experienced excessive bleed- ing and 3 percent (each) of births involved retained placenta and high fever with foul discharge. Two other problems, convulsions and baby’s hands or xxviii | Summary of Findings feet coming first, were reported for 2 percent of births, each. Treatment was sought from a medically trained provider for 43 percent of the cases that had maternal complications around delivery. Nineteen percent of women with complications did not seek any care. Compared with the 2004 BDHS, the 2007 BHDS data show an increase in the percentage of women with complications who sought care from a medially trained pro- vider (from 29 to 43 percent). However, one in five women sought no medical care, and 34 per- cent of women with complications sought help from non-medically trained providers such as unqualified doctors and traditional birth atten- dants. CHILD HEALTH Childhood Mortality. Data from the 2007 BDHS show that under-five mortality (65 deaths per 1,000 live births) has continued its notable decline. Large decreases were observed in both child mortality (age 1-4 years) and postneonatal mortality. One of every 15 Bangladeshi children dies before reaching age five, compared with one in 11 in the 2004 BDHS. Likewise, the number of children who die before reaching the first birthday has decreased from one in fifteen children to one in 19 (52 deaths per 1,000 live births). Around 71 percent of infant deaths occur during the first month of life (neonatal mortal- ity). There is a strong association between under- five mortality and mother’s education. It ranges from 32 deaths per 1,000 live births among chil- dren of women with secondary complete or higher education to 93 deaths per 1,000 live births among children of women with no educa- tion. As in the 2004 BDHS, the highest levels of under-five mortality are observed in Sylhet divi- sion (107 deaths per 1,000 live births), and the lowest under-five mortality is observed in Khulna division (58 deaths per 1,000 live births). Childhood Vaccination Coverage. Eighty- two percent of Bangladeshi children age 12-23 months are fully immunized—most of them by 12 months of age as recommended—while 2 percent have received no vaccinations. More than nine in ten children have received BCG and the first dose of DPT and polio vaccines. There is a decline in cover- age of subsequent doses; however, this decline is smaller than in the 2004 BDHS. Ninety-one percent of children have received three doses of DPT and the same percentage have received three doses of polio vaccine. Eighty-three percent of children have re- ceived measles vaccine. Full vaccination coverage is highest in Barisal division (90 percent) and lowest in Sylhet division (71 percent). Mother’s education is strongly associated with children’s vaccination cov- erage: only 72 percent of children of mothers with no education are fully vaccinated compared with 93 percent of children of highly educated mothers. Child Illness and Treatment. Among children under five years of age, 5 percent were reported to have had symptoms of acute respiratory illness in the two weeks preceding the survey. Of these, 37 per- cent were taken to a health facility or a medically trained provider for treatment while 13 percent re- ceived no treatment at all. Ten percent of children under five years had diarrhoea in the two weeks pre- ceding the survey. Of these, one in five was taken to a health provider. Four in five children with diar- rhoea were treated with oral rehydration therapy, including 77 percent who received commercially available packets of oral rehydration salts (ORS), compared with 67 percent in the 2004 BDHS. Over- all, 85 percent of children with diarrhoea received ORS, recommended home fluids (RHF), or in- creased fluids. Twenty percent of children with diar- rhoea received both oral rehydration therapy (ORT) and zinc. Thirty-eight percent of children under five years had a fever in the two weeks preceding the survey. Of these, 24 percent were taken to a medically trained provider or health facility for treatment. For 23 percent of children with fever, help was sought at a pharmacy. NUTRITION Breastfeeding Practices. Almost all (98 per- cent) Bangladeshi children are breastfed for some period of time. Forty-five percent of last-born infants who were ever breastfed were put to the breast within one hour of birth, and 89 percent started Summary of Findings | xxix breastfeeding within the first day. The median duration of any breastfeeding in Bangladesh is 33 months, but it varies among divisions from 26 months in Chittagong to 37 months in Ra- jshahi. Exclusive breastfeeding of children under six months (based on 24-hour period before the survey) has not improved in the past 15 years; it remained unchanged at around 45 percent be- tween 1993-94 and 1999-2000, declined to 42 percent in 2004, and remained essentially un- changed, 43 percent, in 2007. On the other hand, supplementary feeding of children who are also breastfed has greatly in- creased over the past 15 years. In 1993-1994, only 29 percent of children age 6-9 months re- ceived complementary foods while being breast- fed, compared with 62 percent in 2004 and 74 percent in 2007. The most commonly used com- plementary foods are those made from grains such as rice, wheat, and porridge (over 60 per- cent); one-third of the children in this age group received fruits and vegetables rich in vitamin A. Sixteen percent received meat, fish, poultry, or eggs. Intake of Vitamin A. Ensuring that children 6-59 months receive enough vitamin A may be the single most effective child survival interven- tion because deficiencies in this micronutrient can cause blindness and increase the severity of infections such as measles and diarrhoea. Be- tween the 2004 BDHS and the 2007 BDHS, vi- tamin A supplementation among children 9-59 months increased from 82 to 88 percent. Among children in the 10-11 month age group, vitamin A supplementation increased from 42 percent to 55 percent. Consumption of foods rich in vita- min A is another way to ensure that children are protected from blindness or infection. Overall, 78 percent of children 6 to 59 months of age consumed such foods. Twenty percent of mothers with a birth in the past five years reported receiving a vitamin A dose postpartum. This is an increase from 15 percent in the 2004 BDHS. Nutritional Status of Children. The 2007 BDHS used the new WHO Child Growth Standards to determine the proportion of children undernour- ished. These figures, therefore, are not comparable to those measured in previous BDHS surveys. The 2007 BDHS measured all children under five in the household and found that 43 percent of children in that age group are stunted, and 16 percent are se- verely stunted. Seventeen percent of children under five are wasted, and 3 percent are severely wasted. Weight-for-age results show that 41 percent of chil- dren under five are underweight, with 12 percent are severely underweight. Nutritional Status of Women. The mean height of Bangladeshi women is 150 centimetres, which is above the critical height of 145 centimetres. How- ever, a high proportion of women (15 percent) are below 145 centimetres. Thirty percent of women are chronically malnourished, their body mass index (BMI) being less than 18.5. One in eight women was found to be overweight or obese (BMI 25 or higher). A woman’s place of residence, level of education, and household wealth status are strongly associated with her nutritional status. For example, 33 percent of rural women are considered thin (<18.5), com- pared with 20 percent of their urban counterparts. Among divisions, Sylhet has the highest proportion of women who are thin (39 percent), and Khulna has the least (25 percent). Between the 2004 and 2007 BDHS surveys, the proportion of women below the cutoff point of BMI 18.5 dropped from 34 to 30 per- cent, and the proportion of women who are over- weight or obese increased slightly from 10 percent to 12 percent. The average height of women did not change. 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. In the 2007 BDHS, knowledge of HIV/AIDS increased again to 67 percent. For currently married men, the corresponding proportions are 34, 51, 78 percent, and 87 percent. A respondent’s place of residence, level of edu- cation, and household wealth quintile are strongly associated with HIV/AIDS awareness. Whereas 87 xxx | Summary of Findings percent of women and 95 percent of men in ur- ban areas have heard of AIDS, only 62 percent of women and 84 percent of men in rural areas have heard of the disease. Education is posi- tively associated with knowledge of HIV/ AIDS. It ranges from 42 percent among women with no education, to 75 percent among those who have completed primary school (only), to virtually all women (95 percent) who have com- pleted secondary education. A similar pattern can be found when analyzing the data by wealth quintile. Thirty-two percent of ever-married women and 66 percent of ever-married men age 15-49 know that condom use is a way to avoid con- tracting HIV. About one in three ever-married women and 63 percent of ever-married men know that limiting the number of sexual partners can reduce the likelihood of getting HIV. Simi- larly, around one in three ever-married women and 57 percent of ever-married men know that it is possible to prevent the transmission of HIV by abstaining from sex. Among respondents who know of HIV/ AIDS, 52 percent of ever-married women and 75 percent of ever-married men age 15-49 cor- rectly reported that a healthy-looking person can have HIV. The 2007 BDHS calculated an indicator of comprehensive knowledge of HIV/AIDS that includes knowing that HIV can be prevented by using condoms and having just one, uninfected sexual partner, knowing that a healthy-looking person can have HIV, and rejecting the two most common misconceptions about HIV/AIDS: that HIV can be transmitted by mosquito bites, and that a person can become infected by sharing food with someone who has HIV. Only 6 per- cent of ever-married women and 14 percent of ever-married men age 15-49 have comprehen- sive knowledge of HIV/AIDS. The 2007 BDHS also asked respondents whether HIV can be transmitted by unclean nee- dles and blood transfusions. Knowledge of these means of transmission was relatively high. Al- most six in ten ever-married women and eight in ten ever-married men age 15-49 know that HIV can be transmitted through unclean needles, while similar proportions of ever-married women and men know that HIV can be transmitted through unsafe blood transfusions. Self-reported Symptoms of Sexually Trans- mitted Infections (STIs). Ever-married women and men were asked whether they had experienced an STI or symptoms of an STI during the 12 months preceding the survey. Overall, 11 percent of ever- married women and 4 percent of ever-married men age 15-49 reported experiencing an STI or symp- toms of an STI. Among women, the most commonly reported symptom was abnormal discharge, whereas a genital sore or ulcer was the most common symp- tom reported by men. Attitudes towards Women Refusing Sex. The 2007 BDHS asked ever-married women and men whether they thought that a woman has the right to refuse sex with her husband if he has a sexually transmitted infection. Eighty-six percent of ever- married women and 95 percent of ever-married men age 15-49 said that a woman is justified in refusing sex with her husband if she knows that he has an STI. This proportion ranged from 67 percent of ever- married women in Barisal to 93 percent in Khulna. Among men, the proportion ranged from 69 percent in Barisal to 97 percent in Rajshahi. WOMEN’S STATUS AND GENDER VIOLENCE Data from the 2007 BDHS show that women in Bangladesh are slightly less educated than men. Thirty-four percent of women age 15-49 have never been to school, compared with only 30 percent of men in the same age group. Literacy rates for men and women are fairly comparable, although low overall, with 55 percent of ever-married women and 57 percent of ever-married men being literate. One-third of ever-married women are employed, according to the 2007 BDHS, although 14 percent of employed women are not paid for their work. More than eight in ten employed women earn cash wages. Most of these women (56 percent) decide how to spend their cash earnings jointly with their husband, while 31 percent decide themselves how to spend their earnings, and 12 percent report that their hus- band decides how to spend the woman’s earnings. Summary of Findings | xxxi While 14 percent of married women make the decisions on their own health care, four in ten say that their husband or partner makes such decisions. Decisions on large household pur- chases are typically made jointly by the woman with her husband or partner or by the husband or partner alone. Women are most likely to make decisions about daily household purchases on their own. Around one in three women make decisions about such purchases by themselves. The 2007 BDHS included a module on domestic violence that was administered to both women and men. Women were asked about their experience receiving violence while men were asked whether they had carried out violence against their wife. Almost half of ever-married women (49 percent) reported they had experienced physical violence at the hands of their husband. Eighteen percent reported experiencing sexual vio- lence by their husband. On the other hand, 58 per- cent of men reported having used physical violence against their wife, and 9 percent reported using sex- ual violence. One in four women reported having experienced physical or sexual violence from her husband in the past 12 months. A smaller proportion of men (18 percent) reported using physical or sex- ual violence against their wives in the past 12 months. It is important to note that the domestic vio- lence module was administered to either one women or one man per household. Therefore, data on re- ported violence among couples is not available from both members of the same couple. Millennium Development Goal Indicators | xxxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS Goal Indicator Value Male Female Total 1. Eradicate extreme poverty and hunger 4. Prevalence of underweight children under five years of age 39.9 42.1 41.0 2. Achieve universal primary education 8. Literacy rate of 15-24 year-olds 62.1 74.7 na 3. Promote gender equality and empower women 9. Ratio of girls to boys in primary, secondary and tertiary education na na 1.03 10. Ratio of literate women to men, 15-24 years old na na 1.20 4. Reduce child mortality 13. Under-five mortality rate 65 14. Infant mortality rate 52 15. Percentage of 1 year-old children immunized against measles 82.1 84.0 83.1 5. Improve maternal health 17. Percentage of births attended by skilled health personnel na na 18.0 6. Combat HIV/AIDS, malaria and other diseases 19. Percentage of current users of contraception who are using condoms na 8.1 na 19B. Percentage of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS 17.9 8.0 na 19C. Contraceptive prevalence rate na 55.8 na Urban Rural Total 7. Ensure environmental 29. Percentage of population using solid fuels 62.1 99.3 91.0 sustainability 30. Percentage of population with sustainable access to an improved water source, urban and rural 99.5 96.3 97.0 31. Percentage of population with access to improved sanitation, urban and rural 40.2 25.2 28.5 na = Not applicable xxxiv | Map of Bangladesh 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 it has a tropical climate. The Moguls ruled the country from the 13th century until 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. The present territory of Bangladesh was part of Pakistan. Bangladesh emerged on the world map as a sovereign state on March 26, 1971 after fighting a nine-month war of liberation. Most of Bangladesh is low and flat and consists of 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 subject to frequent 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). Muslims make up almost 90 percent of the population of Bangladesh, Hindus account for about 9 percent, and others constitute the remaining 1 percent. The national language of Bangladesh is Bangla, which is spoken and understood by all. Agriculture is the single largest producing sector of the economy, and it contributes about 22 percent to the Gross Domestic Product (GDP). This sector also accounts for around 48 percent of the total labor force (BBS, 2008b). Average per capita income in Bangladesh increased to US$599 during the fiscal year July 1, 2007- June 30, 2008, mainly due to remittances from citizens working abroad. If average per capita income were to reach US$750, Bangladesh would progress from its present least developed country (LDC) status to a middle income economy (IANS, 2008). 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. 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). The manufacturing sector, although small, is increasing in importance as a result of foreign investments; it contributes about 17 percent of GDP. The manufacturing sector is dominated by the ready-made garments industry (BBS, 2008b). Unemployment and underemployment are serious problems, and pressure on the land in rural areas has led to movement of people from rural to urban areas. 2 | Introduction Bangladesh ranks 140th among nations on the Human Development Index (HDI), as presented in the 2007-2008 Human Development Report. The country’s HDI value is 0.547, placing it in the category of medium human development countries. Within South Asia, Bangladesh only outranks Nepal, which ranks 142nd on the HDI (UNDP, 2007). Bangladesh is still struggling to emerge from poverty. Bangladesh ranks 93rd among 108 developing countries on the Human Poverty Index (HPI) (UNDP, 2007). 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 150 million, with a corresponding population density of more than 920 persons per square kilometer. During the first half of the last century the population increased by 45 percent. This slow increase resulted from a combination of high birth rates and high death rates. In the second half of the twentieth century population growth was rapid, and the population tripled during this period. The relatively young age structure of the population indicates continued rapid population growth in the future. One-third of the population is under 15 years of age, 63 percent are age 15-64 years, and 4 percent are age 65 or older (CIA, 2008) This young age structure creates built-in “population momentum,” which will continue to generate population increases well into the future, even in the face of rapid fertility decline. 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. According to the Bangladesh Population Policy, 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 1996 revision of United Nations projections (United Nations, 1996), both of which estimated a mid-21st century population of 218 million. However, there is a wide disparity between the estimates of the Government of Bangladesh and others on exactly when the population will stabilize. The World Bank forecasts a final stationary population of 263 million by the mid-22nd century, while others have not made projections beyond the mid-21st century. Recently, however, the United Nations revised its estimate for 2050 upward by 25 million (or 11 percent) to 243 million, apparently based on the decade-long plateau in fertility (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. Efforts to slow that growth need to continue, both 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. Introduction | 3 The policy to reduce fertility rates has been repeatedly reaffirmed by the government of Bangladesh since independence in 1971. The First Five-Year Plan (1973-1978) 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). Beginning in 1972 the family planning program received virtually unanimous, high-level political support. All subsequent governments that have come into power in Bangladesh have identified population control as the top priority for government action. This political commitment is crucial in understanding the fertility decline in Bangladesh. In 1976 the government declared the rapid growth of 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 strategy, 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 Health and Population Sector Program (HPSP) was formulated as part of the Fifth Five-Year Plan (1998-2003), keeping in view the principles of the Health and Population Sector Strategy (HPSS) that called for 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. To overcome these multidimensional problems and to meet the challenge in the spirit of the 1994 International Conference on Population and Development (ICPD) in Cairo, the Government of Bangladesh launched the Health, Nutrition and Population Sector Program (HNPSP) in 2003. This program aims to reform the health and population sector. It entails providing a package of essential and good quality health care services that are responsive to the needs of the people, especially children, women, the elderly, and the poor. Recently, the government adopted the Bangladesh Population Policy. Its goals are 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 by 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 are to: � Reduce the total fertility rate (TFR) and increase the use of family planning methods among eligible couples by raising awareness of family planning; � Attain a net reproduction rate equal to one by the year 2010 in order to stabilize population around 2060; 4 | Introduction � Ensure adequate availability of and access to reproductive health services, especially family planning services, for all—including information, counseling, and services for adolescents; � Improve maternal health, with an emphasis on reducing 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; � Promote and actively support programs to eliminate 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 and improve data collection, research and dissemination; � Actively support measures to provide food, social security, and shelter for the disadvantaged, including the elderly, destitute, and physically and mentally retarded persons; � Actively support measures to regulate and reduce rural-to-urban migration; � Support measures for environmental sustainability, with an emphasis on access to safe drinking water; � Support poverty alleviating strategies, and create an environment conducive to improved quality of life; and � Ensure coordination among relevant ministries in strengthening population and development linkages, and make their respective mandates and implementation strategies more population- focused. The government’s policy on 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 services 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 encouraged. There has been considerable variation across the health and population sector in the effectiveness of services. While some projects have been very effective in targeting certain diseases or conditions, others have been less so. Since 1998 the adoption of a Sector-Wide Approach (SWAp) under the HPSP has brought its own set of issues. Throughout these strategy changes, however, the family planning program has continued to function reasonably effectively, and contraceptive use has steadily become more widespread. Many factors have contributed to the increase in contraceptive use over the past 20 years. Elements that have contributed to the success of the program include: 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 govern- Introduction | 5 ment’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 confidence that it is possible to achieve further progress. However, 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 rising number of young people entering childbearing age, the program will have to expand its efforts substantially just to maintain the current level of contraceptive use. If demand for family planning also increases, that will put even more strain on the program. Other concerns are lack of a steady supply of contraceptives from external sources, which affects program performance; the need for further improvement in access to and quality of facilities and services; and the need for men to participate more actively in family planning acceptance. 1.4 ORGANIZATION OF THE 2007 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 1.4.1 Survey Objectives and Implementing Organizations The 2007 Bangladesh Demographic and Health Survey (BDHS) is the fifth BDHS undertaken in Bangladesh. This periodic survey is conducted every three to four years to serve as a source of population and health data for policymakers, program managers, and the research community. In general, the aims of the BDHS are to: � Provide information to meet the monitoring and evaluation needs of health and family planning programs, and � Provide program managers and policy makers involved in these programs with the information they need to plan and implement future interventions. More specifically, the objectives of the survey are 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; maternal and child health; awareness of HIV/AIDS and other sexually transmitted diseases; knowledge of tuberculosis; and domestic violence. Although improvements and additions have been made to each successive survey, the basic structure and design of the BDHS has been maintained over time in order to measure trends in health and family planning indicators. The 2007 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. Macro International Inc., a private research firm located in Calverton, Maryland, USA, provided technical assistance to the survey as part of its international Demographic and Health Surveys program. The U.S. Agency for International Development (USAID)/Bangladesh provided financial assistance. 1.4.2 Sample Design The 2007 BDHS employs a nationally representative sample that covers the entire population residing in private dwelling units in Bangladesh. The survey used the sampling frame provided by the list of census enumeration areas (EAs) with population and household information from the 2001 Population Census. Bangladesh is divided into six administrative divisions: Barisal, Chittagong, Dhaka, Khulna, Rajshahi, and Sylthet. In turn, each division is divided into zilas, and each zila into upazilas. Rural areas in an upazila are divided into union parishads (UPs), and UPs are further divided into mouzas. Urban 6 | Introduction areas in an upazila are divided into wards, and wards are subdivided into mahallas. These divisions allow the country as a whole to be easily divided into rural and urban areas. EAs from the census were used as the Primary Sampling Units (PSUs) for the survey, because they could be easily located with correct geographical boundaries and sketch maps were available for each one. An EA, which consists of about 100 households, on average, is equivalent to a mauza in rural areas and to a mohallah in urban areas. The survey is based on a two-stage stratified sample of households. At the first stage of sampling, 361 PSUs were selected. Figure 1.1 shows the geographical distribution of the 361 clusters visited in the 2007 BDHS. The selection of PSUs was done independently for each stratum and with probability proportional to PSU size, in terms of number of households. The distribution of the sample over different parts of the country was not proportional, because that would have allocated the two smallest divisions, Barisal and Sylhet, too small a sample for statistical precision. Because only a small proportion of Bangladesh’s population lives in urban areas, urban areas also had to be over-sampled to achieve statistical precision comparable to that of rural areas. Therefore, it was necessary to divide the country into strata, with different probabilities of selection calculated for the various strata. Stratification of the sample was achieved by separating the sample into divisions and, within divisions, into urban and rural areas. The urban areas of each division were further subdivided into three strata: statistical metropolitan areas (SMAs), municipality areas, and other urban areas. In all, the sample consisted of 22 strata, because Barisal and Sylhet do not have SMAs. The 361 PSUs selected in the first stage of sampling included 227 rural PSUs and 134 urban PSUs. A household listing operation was carried out in all selected PSUs from January to March 2007. The resulting lists of households were used as the sampling frame for the selection of households in the second stage of sampling. On average, 30 households were selected from each PSU, using an equal probability systematic sampling technique. In this way, 10,819 households were selected for the sample. However, some of the PSUs were large and contained more than 300 households. Large PSUs were segmented, and only one segment was selected for the survey, with probability proportional to segment size. Households in the selected segments were then listed prior to their selection. Thus, a 2007 BDHS sample cluster is either an EA or a segment of an EA. The survey was designed to obtain 11,485 completed interviews with ever-married women age 10-49. According to the sample design, 4,360 interviews were allocated to urban areas and 7,125 to rural areas. All ever-married women age 10-49 in selected households were eligible respondents for the women’s questionnaire. In addition, ever-married men age 15-54 in every second household were eligible to be interviewed. Introduction | 7 8 | Introduction 1.4.3 Questionnaires The 2007 BDHS used five questionnaires: a Household Questionnaire, a Women’s Questionnaire, a Men’s Questionnaire, a Community Questionnaire, and a Facility Questionnaire. Their contents were based on the MEASURE DHS Model Questionnaires. These model questionnaires were adapted for use in Bangladesh during a series of meetings with a Technical Task Force (TTF) that included representatives from NIPORT, Mitra and Associates, ICDDRB: Knowledge for Global Lifesaving Solutions, the Bangladesh Rural Advancement Committee (BRAC), USAID/Dhaka, and Macro International (see Appendix E for a list of members). Draft questionnaires were then circulated to other interested groups and reviewed by the BDHS Technical Review Committee (see Appendix E). The questionnaires were developed in English and then translated and printed in Bangla. The Household Questionnaire was used to list all the usual members of and visitors to selected households. Some basic information was collected on the characteristics of each person listed, including 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 interviews. In addition, the questionnaire collected information about the dwelling unit, such as the source of water, type of toilet facilities, flooring and roofing materials, and ownership of various consumer goods. The Household Questionnaire was also used to record height and weight measurements of all women age 10-49 and all children below six years of age. The Women’s Questionnaire was used to collect information from ever-married women age 10- 49. Women were asked questions on the following topics: � Background characteristics, including age, residential history, education, religion, and media exposure, � Reproductive history, � Knowledge and use of family planning methods, � Antenatal, delivery, postnatal, and newborn care, � Breastfeeding and infant feeding practices, � Vaccinations and childhood illnesses, � Marriage, � Fertility preferences, � Husband’s background and respondent’s work, � Awareness of AIDS and other sexually transmitted diseases, � Knowledge of tuberculosis, and � Domestic violence. The Men’s Questionnaire was used to collect information from ever-married men age 15-54. Men were asked questions on the following topics: � Background characteristics, including respondent’s work, � Marriage, � Fertility preferences, � Participation in reproductive health care, � Awareness of AIDS and other sexually transmitted diseases, � Knowledge of tuberculosis, injuries, and tobacco consumption, and � Domestic violence. Introduction | 9 Questions on domestic violence (which were included in both the Women’s and Men’s Questionnaires) were administered to only one eligible respondent per household, whether female or male. In households with two or more eligible respondents, special procedures were followed to ensure that the selection of the woman or man was random and that these questions were administered in private. The Community and Facility Questionnaires were administered in each selected cluster during listing. These questionnaires collected information about the existence of development organizations in the community and the availability and accessibility of health services and other facilities.1 This information was also used to verify information gathered in the Women’s and Men’s Questionnaires on the type of facilities respondents accessed and the health service personnel they saw. 1.4.4 Training and Fieldwork Forty-two field staff were trained and organized into six teams to carry out the listing of households and delineation of EAs and to administer the Community and Facility Questionnaires. In addition, six supervisors were deployed to check and verify the work of the listing teams. Listers were also trained in the use of Global Positioning System (GPS) units so that they could obtain locational coordinates for each selected EA and for facilities located within each EA. The Household, Women’s, and Men’s Questionnaires were pretested in February 2007. Fourteen interviewers were trained for the pretest. The questionnaires were pretested on 100 women and 100 men in two rural areas in Barisal district and two urban areas in Dhaka. Based on observations in the field and suggestions made by the pretest teams, revisions were made in the wording and translation of the questionnaires. Training for the main survey was conducted for four weeks from February 25 to March 23, 2007. A total of 128 field staff were recruited based on their educational level, prior experience with surveys, maturity, and willingness to spend up to five months on the project. Training included lectures on how to complete the questionnaires, mock interviews between participants, and field practice. Fieldwork for the BDHS was carried out by 12 interview teams, each consisting of one male supervisor, one female field editor, five female interviewers, two male interviewers, and one logistics staff member. Four quality control teams ensured data quality; each team included one male and one female data quality control worker. In addition, NIPORT monitored fieldwork with another set of quality control teams. Data quality was also monitored through field check tables generated concurrently with data processing. This permitted the quality control teams to advise field teams about problems detected during data entry. Tables were specifically generated to check various data quality parameters. Fieldwork was also monitored through visits by representatives from USAID, Macro International, and NIPORT. Fieldwork was implemented in five phases and carried out from March 24 to August 11, 2007. 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 data collected in the field began shortly after fieldwork commenced. Data processing consisted of office editing, coding of open-ended questions, data entry, and editing inconsistencies found by the computer program. The data were processed by 10 data entry operators and two data entry supervisors working in double shifts using six microcomputers. Data processing commenced on April 16 and ended on August 31, 2007. Data processing was carried out using CSPro, a joint software product of the U.S. Census Bureau, Macro International, and Serpro S.A. 1 The results of the community and facility surveys will be addressed in a separate publication. 10 | Introduction 1.4.6 Coverage of the Sample Table 1.1 shows the results of the household and individual women’s and men’s interviews. Of the 10,819 households selected for the survey, 10,461 were found to be occupied. Interviews were successfully completed in 10,400 households, or 99.4 percent of households. A total of 11,178 eligible women age 15-49 were identified in these households and 10,996 were interviewed, for a response rate of 98.4 percent.2 Eligible men in every second household were selected to yield 4,074 potential male respondents, of whom 92.6 percent or 3,771 were successfully interviewed. The principal reason for non-response among eligible women and men was their absence from home despite repeated visits to the household. The household and eligible women’s response rates were similar to the response rates in the 2004 BDHS. However, the male response rate was lower than in the last survey. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Bangladesh 2007 Residence Urban Rural Total Result Number Percent Number Percent Number Percent Households selected 3,993 100.0 6,826 100.0 10,819 100.0 Households occupied 3,849 96.4 6,612 96.9 10,461 96.7 Households absent for extended period 78 2.0 121 1.8 199 1.8 Dwelling vacant or destroyed 59 1.5 73 1.1 132 1.2 Other 7 0.2 20 0.3 27 0.2 Household interviews Households occupied 3,849 96.4 6,612 96.9 10,461 96.7 Households interviewed 3,821 95.7 6,579 96.4 10,400 96.1 Household response rate1 99.3 99.5 99.4 Interviews with women age 15-49 Number of eligible women 4,230 100.0 6,948 100.0 11,178 100.0 Number of eligible women interviewed 4,151 98.1 6,845 98.5 10,996 98.4 Eligible women response rate2 98.1 98.5 98.4 Interviews with men age 15-54 Number of eligible men 1,559 100.0 2,515 100.0 4,074 100.0 Number of eligible men interviewed 1,443 92.6 2,328 92.6 3,771 92.6 Eligible men response rate2 92.6 92.6 92.6 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents 2 The 2007 BDHS sampled all ever-married women age 10-49. The number of eligible women age 10-49 was 11,234, of whom 11,051 were interviewed for a response rate of 98.4 percent. However, there were very few ever- married women age 10-14 (55 unweighted cases or less than one percent). These women have been removed from the data set and weights recalculated for the 15-49 age group. The tables in this report discuss only women age 15- 49. Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter presents information on demographic and socioeconomic characteristics of the household population, including age, sex, educational attainment, and employment status. The chapter also describes the conditions of the households in which the survey population lives, including source of drinking water, sanitation facilities, availability of electricity, housing construction materials, possession of household durable goods, and ownership of a homestead and land. The information on household assets is used to create an indicator of household economic status, the wealth index. A household in the 2007 BDHS is defined as a person or 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 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 who stayed in the household the night before the interview. The 2007 BDHS collected information for all usual residents of selected households (the de jure population) and all persons who stayed in the selected household the night before the interview (the de facto population). The difference between these two populations is very small. The characteristics of the household population are analyzed based on the de facto population, while household characteristics are presented based on the de jure population, in order to maintain comparability of these results with other DHS reports. 2.1 HOUSEHOLD POPULATION BY AGE, SEX, AND RESIDENCE Table 2.1 shows the distribution of the de facto household population by age and sex according to urban and rural residence. The 2007 BDHS enumerated a total of 48,749 persons, with females outnumbering males at 51 percent. The sex ratio is 95 males per 100 females. This is similar to the sex ratio of 96 males per 100 females obtained in the 2004 BDHS, but it is lower than the ratio of 106 males per 100 females obtained in the 2001 Census (BBS, 2008a). The marked difference in the sex ratio between the 2001 Census and the BDHS surveys could be due to the fact that the census’ sex ratio is based on the de jure population, while the sex ratio obtained from the BDHS surveys is based on the de facto household population. The sex composition of the population does not vary markedly by urban-rural residence. More than one-third of the de facto household population (36 percent) is under 15 years of age, and 12 percent is under age five. Persons age 65 and over account for just 5 percent of the total population. The proportion of the population under age 15 is somewhat lower in urban than rural areas, as is the proportion of the population over age 65. The age-sex structure of the population is shown by a population pyramid in Figure 2.1. The pyramid is wider at the base than the top and narrows slightly at the youngest age group. This pattern is typical of a historically high-fertility regime that has recently started to stabilize or decline. Figure 2.2 shows the distribution of the male and female household population by single year of age. The figure shows noticeable heaping at ages ending with 0 and 5, with heaping more prominent among males than females. Ages ending with 1 and 9 are underreported. 12 | Household Population and Housing Characteristics Table 2.2 presents changes in the broad age structure of the population since 1989. The proportion of the population under age 15 has declined from 43 percent in 1989 to 36 percent in 2007. In contrast, the proportion of the population age 15-59 has increased over time, as has the proportion age 60 and over. The median age of the population has increased from 18.4 years in 1993/94 to 21.2 years in 2007. This pattern is consistent with a decline in fertility. 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 2007 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 11.8 10.4 11.1 12.3 12.1 12.2 12.2 11.7 11.9 5-9 11.4 11.1 11.2 13.7 12.5 13.1 13.2 12.2 12.7 10-14 10.7 11.1 10.9 12.5 11.4 12.0 12.1 11.4 11.7 15-19 10.3 12.8 11.6 9.3 11.8 10.6 9.5 12.0 10.8 20-24 9.3 11.8 10.5 7.3 9.9 8.6 7.7 10.3 9.1 25-29 8.3 9.3 8.8 7.2 8.0 7.6 7.5 8.2 7.9 30-34 7.3 6.9 7.1 5.8 6.7 6.3 6.1 6.7 6.4 35-39 6.6 7.3 7.0 6.5 6.1 6.3 6.6 6.4 6.5 40-44 6.2 5.2 5.7 5.6 4.8 5.2 5.7 4.9 5.3 45-49 5.0 4.5 4.7 4.8 4.2 4.5 4.8 4.3 4.5 50-54 4.4 2.8 3.6 4.5 3.0 3.7 4.4 2.9 3.7 55-59 2.5 2.2 2.3 2.0 2.9 2.4 2.1 2.7 2.4 60-64 2.1 1.8 2.0 2.5 2.3 2.4 2.4 2.2 2.3 65-69 1.5 0.9 1.2 1.8 1.3 1.5 1.7 1.2 1.5 70-74 1.3 0.8 1.0 1.8 1.2 1.5 1.7 1.1 1.4 75-79 0.5 0.4 0.4 0.9 0.7 0.8 0.8 0.6 0.7 80 + 0.9 0.8 0.8 1.4 1.2 1.3 1.3 1.1 1.2 Don't know/missing 0.1 0.0 0.1 0.1 0.0 0.0 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,421 5,462 10,882 18,369 19,498 37,867 23,789 24,960 48,749 Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 BDHS 2007 Male Percent Female Age Household Population and Housing Characteristics | 13 Table 2.2 Trends in population by age Percent distribution of the de facto population by age group, selected sources, Bangladesh 1989-2007 Age group 1989 BFS 1989 CPS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS <15 43.2 43.2 42.7 42.6 41.0 39.2 38.2 36.3 15-59 50.9 50.9 51.2 51.2 53.1 54.4 55.1 56.6 60+ 5.9 5.9 6.0 6.2 5.9 6.4 6.6 7.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Median age u u u 18.4 18.8 19.5 20.2 21.2 BFS = Bangladesh Fertility Survey ; CPS = Contraceptive Prevalence Survey ; BDHS = Bangladesh Demographic and Health Survey u = Unknown (not available) Sources: Huq and Cleland, 1990:38; Mitra et al., 1993:14; Mitra et al., 1997:9; NIPORT et al., 2001:11 ; NIPORT et al., 2005 :13 2.2 HOUSEHOLD COMPOSITION Table 2.3 presents information on household composition. Only 13 percent of households are headed by women. The proportion of female-headed households is slightly higher in rural areas than in urban areas (13 percent and 11 percent, respectively). Since the 2004 BDHS, the proportion of female- headed households has increased by about three percentage points. The increase was similar in both urban and rural areas. Figure 2.2 Distribution of the De Facto Household Population by Single Year of Age and Sex � � � �� �� � � � � � � � � � �� � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � �� � � � � � � � � �� �� � � � � � � � � � � �� � � �� � � � � �� � � � � �� � �� �� � � � ��� � �� � � � � � � � �� �� 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70+ 0 1 2 3 4 Percent Female Male� � BDHS 2007 Single year of age 14 | Household Population and Housing Characteristics Half of households in Bangladesh are composed of two to four members. The proportion is the same in urban and rural areas. A comparison of the 2004 and 2007 BDHS surveys shows a change in the distribution of households by household size. The mean household size in Bangladesh has declined from 5.0 members in 2004 to 4.7 members in 2007; this is similar to the figure of 4.8 members found by the 2006 Multiple Indicator Cluster Survey (MICS) (BBS and UNICEF, 2007). The proportion of households with five or fewer members has increased since 2004, while the proportion of households with six or more members has decreased. Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size, and mean size of household, according to residence, Bangladesh 2007 Residence Characteristic Urban Rural Total Sex of head of household Male 88.6 86.8 87.2 Female 11.4 13.2 12.8 Total 100.0 100.0 100.0 Number of usual members 1 1.3 2.3 2.1 2 7.3 8.8 8.5 3 17.2 16.9 17.0 4 25.2 23.8 24.1 5 20.7 20.1 20.2 6 12.7 13.1 13.0 7 6.3 7.1 7.0 8 4.5 3.6 3.8 9+ 4.9 4.2 4.3 Total 100.0 100.0 100.0 Mean size of households 4.8 4.7 4.7 Number of households 2,267 8,133 10,400 Note: Table is based on de jure household members, i.e., usual residents 2.3 HOUSEHOLD CHARACTERISTICS The 2007 BDHS collected information about certain characteristics of households, including the source and treatment of drinking water, type of sanitation facility, access to electricity, main housing materials, and the place and type of fuel used for cooking. These physical characteristics of a household are important because they are used to assess the general well-being and socioeconomic status of household members. Table 2.4 presents information on household drinking water by urban-rural residence. Access to an improved source of drinking water is universal in Bangladesh (97 percent). Tube wells are the most common source of drinking water in both urban (69 percent) and rural areas (96 percent). Piped water is accessible only in urban areas, and just over one in four urban households use piped water. Treating water prior to drinking is uncommon in Bangladesh. Ninety-three percent of households do not treat drinking water. However, around one in five households in urban areas treat water prior to drinking by boiling. Household Population and Housing Characteristics | 15 Table 2.4 Household drinking water Percent distribution of households and de jure population by source of drinking water, and percentage of households and de jure population by treatment of drinking water, according to residence, Bangladesh 2007 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 99.4 96.5 97.1 99.4 96.3 97.0 Piped water into dwelling/yard/plot 27.3 0.1 6.0 26.2 0.2 6.0 Public tap/standpipe 3.0 0.2 0.9 2.6 0.2 0.7 Tube well 69.1 95.7 89.9 70.5 95.5 90.0 Protected dug well 0.1 0.3 0.2 0.1 0.2 0.2 Rainwater 0.0 0.1 0.1 0.0 0.1 0.1 Non-improved source 0.5 3.5 2.8 0.5 3.7 3.0 Unprotected dug well 0.0 0.6 0.5 0.0 0.6 0.5 Unprotected spring 0.1 0.1 0.1 0.1 0.1 0.1 Tanker truck/cart with small tank 0.1 0.0 0.0 0.1 0.0 0.0 Surface water 0.3 2.8 2.2 0.3 2.9 2.3 Bottled water, improved source for cooking/washing1 0.1 0.0 0.0 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 99.5 96.5 97.1 99.5 96.3 97.0 Water treatment prior to drinking2 Boiled 17.5 0.6 4.2 17.1 0.6 4.2 Bleach/chlorine 0.5 0.1 0.2 0.5 0.1 0.2 Strained through cloth 6.9 0.7 2.1 6.8 0.8 2.1 Ceramic, sand, or other filter 3.1 1.7 2.0 3.2 1.7 2.1 Let it stand and settle 0.1 0.1 0.1 0.1 0.1 0.1 Other 1.0 0.8 0.8 1.0 0.8 0.8 No treatment 79.0 96.4 92.6 79.4 96.3 92.5 Percentage using an appropriate treatment method3 20.3 2.9 6.7 19.8 3.0 6.7 Number 2,267 8,133 10,400 10,874 38,045 48,919 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. There were no households that used bottled water as a source for drinking and did not use an improved source for other purposes such as cooking and handwashing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, and filtering. Households without proper sanitation facilities have a greater risk of diseases like diarrhea, dysentery, and typhoid than households with improved sanitation facilities. Overall, one in four households has an improved toilet facility (flush toilet or pit latrine with slab). Nearly two in five urban households have improved toilet facilities, compared with only one in five rural households. Overall, 8 percent of households in Bangladesh do not have a toilet facility. This problem is more common in rural areas where 10 percent of households have no toilet facilities, compared with 2 percent in urban areas. Household sanitation has improved since the 2004 BDHS: the proportion of households with no toilet facilities has declined from 14 percent to 8 percent. 16 | Household Population and Housing Characteristics Table 2.5 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Bangladesh 2007 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility 37.4 22.0 25.3 40.2 25.2 28.5 Flush/pour flush to piped sewer system 5.9 0.1 1.4 6.0 0.2 1.5 Flush/pour flush to septic tank 20.3 5.7 8.9 21.7 6.9 10.2 Flush/pour flush to pit latrine 3.9 3.0 3.2 4.3 3.5 3.7 Pit latrine with slab 7.3 13.1 11.8 8.2 14.6 13.2 Non-improved facility 62.5 78.0 74.6 59.8 74.8 71.4 Any facility shared with other households 21.9 13.0 14.9 19.9 11.5 13.4 Flush/pour flush not to sewer/septic tank/pit latrine 14.0 0.5 3.5 13.5 0.6 3.5 Pit latrine without slab/open pit 19.7 43.1 38.0 19.5 42.3 37.3 Bucket 0.0 0.1 0.1 0.1 0.1 0.1 Hanging toilet/hanging latrine 5.2 11.1 9.8 5.1 11.1 9.8 No facility/bush/field 1.8 10.2 8.4 1.7 9.1 7.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,267 8,133 10,400 10,874 38,045 48,919 Table 2.6 presents information on household characteristics. Almost half of all households in Bangladesh have access to electricity. The percentage of households with electricity has increased somewhat, from 41 percent in 2004 to 47 percent in 2007. However, access to electricity varies widely between urban areas (82 percent) and rural areas (37 percent). Tin is the most common roofing material in Bangladesh. Overall, 86 percent of households live in dwellings with tin roofs. There are large urban-rural differences in the use of cement or ceramic tiles for roofs. Households in urban areas are over ten times more likely to use cement or ceramic tiles than households in rural areas. There has been little change in roofing materials since 2004. Two in five households have walls made of natural materials such as cane, palm, trunks, dirt, or bamboo with mud. Almost as many have walls made of tin. A large majority of rural households have walls made of natural materials or tin, while most urban households have walls of cement or brick. Use of natural materials for walls has decreased by nine percentage points since 2004. Four in five households use earth or bamboo as the main flooring material. These materials are twice as common in rural areas as in urban areas. Cement floors, the second most common flooring material, are more often found in urban than rural areas (57 percent and 8 percent, respectively). More than half of urban households have cement floors. The number of rooms used for sleeping gives an indication of the extent of crowding in households. Crowding in one sleeping room increases the risks of infection. Two in five households use only one room for sleeping, and one in four households has three or more rooms for sleeping. There is no difference in the number of rooms used for sleeping by urban-rural residence. Indoor pollution has important implications for the health of household members. The type of fuel used for cooking, the place where cooking is done, and the type of stove used are all related to indoor air quality and the degree to which household members are exposed to the risk of respiratory infections and other diseases. In Bangladesh, the risk of indoor pollution from cooking fuel is limited because more than four in five households cook in a separate building or outdoors. Urban households are almost three times more likely than rural households to cook in the house. Household Population and Housing Characteristics | 17 Table 2.6 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Bangladesh 2007 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 82.1 36.6 46.5 82.7 38.5 48.3 No 17.9 63.4 53.5 17.3 61.5 51.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Main roof material Thatch/palm leaf/bamboo 1.7 6.1 5.1 1.7 5.9 4.9 Tin 72.1 89.8 86.0 71.2 89.8 85.7 Cement, ceramic tiles 25.1 2.2 7.2 26.1 2.7 7.9 Other 0.9 1.8 1.6 0.9 1.7 1.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Main wall material Cane/palm/trunks, dirt, bamboo with mud 20.2 45.5 40.0 19.9 44.0 38.6 Tin 26.2 40.7 37.5 26.2 41.3 37.9 Cement, stone with lime/cement, bricks 52.8 12.4 21.2 53.2 13.4 22.3 Other 0.7 1.3 1.2 0.7 1.3 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth/sand, palm/bamboo 42.4 91.6 80.8 42.6 90.6 80.0 Wood/planks 0.6 0.5 0.5 0.6 0.5 0.5 Cement, ceramic tiles 56.7 7.8 18.5 56.5 8.7 19.3 Other 0.2 0.1 0.1 0.3 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 39.8 40.1 40.0 32.4 32.6 32.6 Two 34.2 35.1 34.9 34.3 35.3 35.1 Three or more 25.9 24.7 25.0 33.2 32.1 32.3 Total 99.9 100.0 100.0 99.9 100.0 100.0 Place for cooking In the house 33.4 12.3 16.9 34.2 13.2 17.8 In a separate building 52.9 65.6 62.8 53.3 66.8 63.8 Outdoors 10.7 20.7 18.5 9.8 18.7 16.7 Other 2.8 1.3 1.6 2.6 1.1 1.5 Missing 0.2 0.1 0.1 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel LPG/natural gas/biogas 37.9 0.5 8.6 37.4 0.6 8.8 Wood 44.3 43.8 43.9 44.9 45.6 45.5 Agricultural crop, straw/shrubs/grass 13.2 46.2 39.0 13.1 44.0 37.1 Animal dung 3.6 9.4 8.1 3.7 9.7 8.3 Other 1.0 0.2 0.3 0.9 0.1 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 61.5 99.4 91.1 62.1 99.3 91.0 Number of households/population 2,267 8,133 10,400 10,874 38,045 48,919 Type of fire/stove among households using solid fuel1 Closed stove with chimney 0.1 0.0 0.0 0.1 0.0 0.0 Open fire/stove with chimney or hood 1.1 1.8 1.7 1.3 2.3 2.1 Open fire 98.6 97.8 97.9 98.4 97.3 97.5 Other 0.3 0.4 0.4 0.3 0.4 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population using solid fuel 1,394 8,082 9,476 6,756 37,776 44,533 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 18 | Household Population and Housing Characteristics Reducing the proportion of the population that relies on solid fuels is a Millennium Development Goal. About nine in ten households use solid fuels in Bangladesh, and that proportion has declined little since 2004 (from 93 percent to 91 percent). Virtually all rural households use solid fuels for cooking, including wood, agricultural crops, straw, shrubs, grass, animal dung, charcoal, and coal. In urban areas, 62 percent of the households use solid fuels. The proportion of households relying on wood for fuel has increased from 35 percent in 2004 to 44 percent in 2007, and urban and rural households are now equally likely to use wood. Rural households are three times more likely than urban households to use agricultural crops, straw, shrubs, or grass for cooking. Liquid petroleum gas (LPG), natural gas, and biogas are used almost entirely in urban areas. Among households using solid fuels, only 2 percent have a chimney or hood to help ventilate their stove or open fire. The rest do not have any system for ventilating the indoor pollution from cooking fumes. 2.4 HOUSEHOLD POSSESSIONS The 2007 BDHS collected information on household ownership of selected assets. Some of these are used along with other indicators to assess household socioeconomic status and generate a wealth index. Table 2.7 shows the percentage of households that possess various durable goods, land, and livestock by urban-rural residence. Table 2.7 Household durable goods, land ownership, and livestock Percentage of households and de jure population possessing various durable consumer goods, land, and farm animals by residence, Bangladesh 2007 Households Population Ownership Urban Rural Total Urban Rural Total Durable goods Almirah 63.5 37.0 42.8 67.3 40.3 46.3 Table 69.3 66.0 66.7 73.0 69.2 70.0 Chair 71.0 67.8 68.5 74.0 70.9 71.6 Watch 79.3 63.2 66.7 81.5 67.0 70.2 Radio 25.2 23.3 23.7 26.4 25.3 25.6 Television 59.3 21.9 30.0 62.4 24.4 32.9 Bicycle 20.5 27.9 26.3 22.6 30.8 29.0 Motorcycle/scooter 4.7 2.4 2.9 5.4 3.2 3.7 Mobile telephone 54.7 25.3 31.7 57.3 29.1 35.3 Non-mobile telephone 7.0 0.2 1.7 8.0 0.2 2.0 Refrigerator 24.8 2.5 7.3 26.7 3.1 8.3 Animal-drawn cart 0.2 0.6 0.5 0.3 0.8 0.7 Car/truck 1.5 0.2 0.5 1.9 0.2 0.6 Boat with a motor 0.6 0.9 0.9 0.7 1.2 1.1 Rickshaw/van 5.5 6.6 6.4 5.8 6.5 6.3 Does not own any of the specified durable goods 7.8 14.6 13.1 6.2 12.2 10.9 Land ownership Homestead 90.3 95.8 94.6 91.2 96.2 95.1 Other land 38.1 51.0 48.2 39.0 53.4 50.2 Neither of the above 8.5 3.8 4.9 7.6 3.3 4.2 Livestock Ownership Cows, bulls, buffalo 5.0 14.0 12.1 5.6 14.0 12.2 Goats, sheep 3.0 10.2 8.6 3.3 10.3 8.8 Chicken, ducks 3.6 6.7 6.0 3.8 6.4 5.8 Number 2,267 8,133 10,400 10,874 38,045 48,919 More households own a television than a radio (30 percent compared with 24 percent). Urban households are almost three times more likely to own a television than rural households. Since 2004 ownership of a television has increased from 23 percent to 30 percent of households. Over the same Household Population and Housing Characteristics | 19 period, ownership of a radio has declined from 30 percent to 24 percent. The shift from radios to televisions has been more prominent in urban areas. Overall, almost one in three households has a mobile telephone, but urban households are twice as likely to own a mobile telephone as rural households. About 95 percent of households own a homestead, but less than 50 percent own land other than a homestead. Ownership of a homestead or other land is less common in urban than rural areas. Since 2004 ownership of other land has declined slightly from 52 to 48 percent, especially in rural areas, while ownership of a homestead has remained unchanged. Cows, bulls, and buffalos are the most commonly owned type of livestock, owned by one in every eight households. One in eleven households owns goats or sheep, but only one in sixteen households owns chicken or ducks. As expected, rural households are more likely to own each type of livestock than urban households. 2.5 WEALTH INDEX One of the background characteristics used throughout this report is an index of household economic status. The wealth index used in this study was developed and tested in a large number of countries to measure inequalities in household income, use of health services, and health outcomes (Rutstein 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 is constructed from data on household assets, including ownership of durable goods (such as televisions and bicycles) and dwelling characteristics (such as source of drinking water, sanitation facilities, and construction materials). To create the wealth index, each asset was assigned a weight (factor score) generated through principal component 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 entire BDHS sample; there are no separate indices for urban and rural populations. Wealth quintiles are used as a background variable in the rest of the report to assess demographic and health outcomes in relation to socioeconomic status. Table 2.8 presents the wealth quintiles by rural-urban residence and administrative division. More than half of the population residing in urban areas is in the highest wealth quintile, compared with only 9 percent of the rural population. Among the administrative divisions, people living in Dhaka are more likely to fall in the highest wealth quintile than people living in other divisions. In contrast, Rajshahi and Barisal divisions have the highest proportion of the population in the lowest wealth quintile (28 percent and 25 percent, respectively). 20 | Household Population and Housing Characteristics Table 2.8 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, according to residence and division, Bangladesh 2007 Wealth quintile Residence/division Lowest Second Middle Fourth Highest Total Number Residence Urban 5.3 7.5 10.8 18.9 57.5 100.0 10,874 Rural 24.2 23.6 22.6 20.3 9.3 100.0 38,045 Division Barisal 25.2 27.3 23.4 15.8 8.4 100.0 3,087 Chittagong 10.9 19.1 25.6 26.0 18.4 100.0 9,767 Dhaka 21.7 18.6 14.6 17.3 28.0 100.0 15,009 Khulna 13.9 17.6 23.9 26.4 18.2 100.0 5,831 Rajshahi 27.8 21.8 19.1 17.2 14.2 100.0 11,506 Sylhet 18.2 20.8 21.1 17.7 22.2 100.0 3,719 Total 20.0 20.0 20.0 20.0 20.0 100.0 48,919 2.6 EDUCATIONAL ATTAINMENT Studies have shown that education is one of the major socioeconomic factors that influence a person’s behavior and attitudes. In general, the greater a person’s educational attainment, the more knowledgeable he/she is about the use of health services, family planning methods, and the health care of children. For all household members age six or older, data were collected on the level of education last attended and the highest class completed at that level. Tables 2.9.1 and 2.9.2 show the distribution of the male and female household population age six years and older by the highest level of education completed and the median number of years of education completed, according to background characteristics. The majority of Bangladeshis have attended school. Only one in four men and about one in three women have never attended school. There is no gender difference in primary education. However, men are almost twice as likely as women to have completed secondary school or a higher level of education (12 percent and 7 percent, respectively). There has been little change in the proportion of men and women with no education: since 2004 it has declined from 27 percent to 25 percent among men and from 34 percent to 30 percent among women. Changes in educational attainment by successive age groups indicate the long-term trend in a country’s educational achievement. The data show that there has been a marked improvement in the educational attainment of both men and women over the years. The proportion of men with no education is notably higher (49 percent) among those age 65 years or older than among boys age 10-14 years (7 percent). Similarly, 82 percent of women age 65 and over have no education compared with only 4 percent of girls age 10-14 years. Household Population and Housing Characteristics | 21 Table 2.9.1 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median grade completed, according to background characteristics, Bangladesh 2007 Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number Median years completed Age 6-9 13.8 85.4 0.2 0.5 0.0 100.0 2,556 0.0 10-14 7.0 57.7 4.8 30.3 0.1 100.0 2,881 3.0 15-19 10.4 21.0 10.8 46.6 11.2 100.0 2,269 5.4 20-24 14.5 19.4 11.8 33.9 20.4 100.0 1,843 5.2 25-29 21.8 20.6 11.7 24.4 21.4 100.0 1,778 4.5 30-34 31.9 16.9 7.6 22.0 21.6 100.0 1,456 4.1 35-39 34.7 17.9 7.2 21.5 18.7 100.0 1,561 3.6 40-44 39.4 16.1 8.8 19.2 16.4 100.0 1,367 2.8 45-49 39.0 18.0 8.1 19.0 15.8 100.0 1,143 2.4 50-54 40.4 17.4 8.2 17.2 16.8 100.0 1,056 2.2 55-59 40.3 15.7 4.5 16.4 23.0 100.0 496 2.9 60-64 51.6 18.0 5.7 12.2 12.4 100.0 575 0.0 65+ 49.1 19.8 8.3 14.6 8.1 100.0 1,318 0.0 Residence Urban 17.5 27.0 7.1 25.1 23.3 100.0 4,653 4.5 Rural 26.9 34.3 7.5 22.3 9.0 100.0 15,661 2.3 Division Barisal 17.6 36.9 7.0 25.6 12.8 100.0 1,274 3.4 Chittagong 23.3 35.2 7.5 22.3 11.6 100.0 3,802 2.9 Dhaka 26.6 31.7 6.8 21.7 13.1 100.0 6,288 2.6 Khulna 22.7 32.3 6.9 24.2 13.9 100.0 2,521 3.3 Rajshahi 25.5 30.1 7.4 24.4 12.6 100.0 4,915 3.2 Sylhet 27.2 34.8 10.9 20.9 6.2 100.0 1,514 2.1 Wealth quintile Lowest 42.2 39.8 5.4 10.9 1.6 100.0 3,876 0.0 Second 32.0 37.5 8.4 18.1 4.0 100.0 4,076 1.2 Middle 23.9 34.9 9.3 24.7 7.2 100.0 4,110 2.8 Fourth 16.0 30.1 7.9 32.2 13.7 100.0 4,108 4.3 Highest 10.6 21.3 5.9 28.1 34.1 100.0 4,145 7.2 Total 24.7 32.6 7.4 23.0 12.3 100.0 20,314 2.9 Note: Total includes 14 men with don’t know or information missing on educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 22 | Household Population and Housing Characteristics Table 2.9.2 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median grade completed, according to background characteristics, Bangladesh 2007 Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number Median years completed Age 6-9 11.0 88.3 0.2 0.5 0.0 100.0 2,511 0.0 10-14 4.4 53.0 3.9 38.7 0.0 100.0 2,835 3.5 15-19 7.8 14.3 9.1 59.2 9.6 100.0 3,004 6.4 20-24 13.8 19.4 9.0 41.5 16.0 100.0 2,571 5.6 25-29 29.1 21.8 8.2 26.6 14.3 100.0 2,056 3.9 30-34 41.4 22.3 8.1 18.2 10.1 100.0 1,684 1.4 35-39 47.7 20.8 7.3 16.5 7.7 100.0 1,599 0.0 40-44 52.6 23.7 7.2 11.7 4.8 100.0 1,214 0.0 45-49 58.8 19.3 6.3 11.5 4.2 100.0 1,063 0.0 50-54 66.5 15.6 7.2 6.9 3.4 100.0 733 0.0 55-59 68.8 15.8 7.4 6.1 1.9 100.0 680 0.0 60-64 72.5 18.7 4.8 3.8 0.2 100.0 555 0.0 65+ 81.6 12.1 4.0 1.9 0.3 100.0 996 0.0 Residence Urban 23.2 27.2 6.3 27.6 15.7 100.0 4,778 3.9 Rural 32.2 32.5 6.3 24.8 4.1 100.0 16,731 1.7 Division Barisal 22.3 36.0 9.5 25.5 6.7 100.0 1,334 3.1 Chittagong 29.1 30.3 6.7 27.4 6.5 100.0 4,345 2.6 Dhaka 31.1 31.7 5.9 23.7 7.5 100.0 6,566 1.8 Khulna 28.9 31.9 5.2 27.1 6.9 100.0 2,570 2.5 Rajshahi 31.1 30.2 5.8 26.1 6.8 100.0 5,088 2.0 Sylhet 35.2 31.5 7.9 22.2 3.2 100.0 1,606 1.3 Wealth quintile Lowest 44.3 38.7 4.8 11.9 0.3 100.0 4,153 0.0 Second 36.5 35.5 7.0 19.8 1.2 100.0 4,145 0.9 Middle 31.5 32.1 7.2 26.5 2.7 100.0 4,308 1.9 Fourth 24.1 28.6 6.6 33.8 6.9 100.0 4,358 3.6 Highest 16.0 22.8 6.1 33.9 21.1 100.0 4,545 5.2 Total 30.2 31.3 6.3 25.4 6.7 100.0 21,510 2.1 Note: Total includes 9 women with don’t know or information missing on educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. As shown in Figure 2.3, data from previous BDHS surveys also present a trend toward higher educational attainment. Improvements in ever attending school have been greater among women than men and in rural than urban areas. For example, the percentage of rural women who have never attended school decreased from 50 percent in 1993-94 to 32 percent in 2007. Household Population and Housing Characteristics | 23 Overall, levels of educational attainment are higher in urban than rural areas (Tables 2.9.1 and 2.9.2). The proportion of men and women with no education is lower in urban areas (18 percent) than rural areas (27 percent), while the proportion who have completed secondary or higher schooling is greater in urban areas (23 percent) than in rural areas (9 percent). On average, men and women living in urban areas have completed two more years of school than those living in rural areas. There are also regional variations in educational attainment. Barisal division has the highest proportion of men and women with some education (82 percent of men and 78 percent of women) and Sylhet the lowest (73 percent of men and 65 percent of women). Men and women in lower wealth quintiles are less likely to have attended school. Among women, 44 percent of those in the lowest quintile have never attended school compared with 16 percent in the highest quintile. Differences by wealth are equally large among men; 42 percent of men from the lowest quintile have no schooling compared with 11 percent from the highest wealth quintile. A comparison of the 2004 and 2007 BDHS surveys shows a marked rise in primary education among women (NIPORT et al, 2005). Over this three-year period, the percentage of women age 15-19 who have completed at least primary education has increased from 71 percent to 78 percent. In contrast, there has been almost no change in the proportion of men age 15-19 who have completed at least primary education (67 percent in 2004 compared with 69 percent in 2007). 2.6.1 School Attendance Most Bangladeshi children attend school. Almost nine in ten children age 6-10 are in school (Table 2.10). More than seven in ten children age 11-15 also attend school. In both of these age groups school attendance is higher among girls than boys. There is little difference in urban and rural school attendance rates under age 16. Among young men and women age 16-20 and 21-24, however, urban residents are more likely to be in school than their rural counterparts. 34 50 20 37 30 46 17 35 29 40 18 31 28 36 20 29 23 32 18 27 Urban Rural Urban Rural 0 20 40 60 80 Percent 1993-1994 1996-1997 1999-2000 2004 2007 Figure 2.3 Trends in Percentage of Men and Women Age Six and Above With No Education, by Sex and Residence Bangladesh 1993-2007 BDHS 2007 Women Men 24 | Household Population and Housing Characteristics Children age 6-15 are over three times more likely to be in school than children age 16-20 (80 percent versus 26 percent). These data may reflect the impact of recent efforts to promote female education: school attendance is now more common among girls than boys age 6-15, but the reverse is true among those age 16-20. Table 2.10 School attendance Percentage of the de facto household population age 6-24 years attending school, by age, sex, and residence, Bangladesh 2007 Male Female Total Age Urban Rural Total Urban Rural Total Urban Rural Total 6-15 76.7 77.6 77.4 78.8 82.6 81.9 77.8 80.1 79.6 6-10 84.4 84.6 84.6 86.8 88.3 88.0 85.6 86.4 86.3 11-15 68.4 68.6 68.6 70.7 76.0 74.8 69.6 72.4 71.8 16-20 35.1 29.3 30.8 31.4 19.5 22.4 33.1 23.8 26.0 21-24 24.9 11.6 15.3 15.3 4.5 7.2 19.3 7.3 10.5 2.7 EMPLOYMENT The 2007 BDHS Household Questionnaire asked whether each person age eight and over in the sampled households was working at the time of the survey. Table 2.11 presents these data. Employment status varies widely by sex: 68 percent of men and 23 percent of women are currently employed. There is no difference in employment levels between rural and urban areas for either men or women. Male employment rates have not changed since the 2004 BDHS, but female employment rates have increased substantially, rising from 15 percent to 23 percent over the course of the last three years. Table 2.11 Employment status Percentage of male and female de facto household population age eight and over working at the time of the survey, by age, sex, and residence, Bangladesh 2007 Male Female Age Urban Rural Total Urban Rural Total 8-9 3.5 1.5 1.9 3.1 1.1 1.5 10-14 17.0 17.2 17.2 14.2 3.4 5.7 15-19 52.1 57.6 56.2 22.4 14.8 16.6 20-24 73.3 85.2 82.0 25.0 26.3 26.0 25-29 89.2 92.4 91.6 32.9 35.8 35.1 30-34 95.5 96.9 96.5 35.7 44.0 42.1 35-39 98.5 97.3 97.6 32.8 38.6 37.1 40-44 98.7 99.1 99.0 32.9 38.7 37.3 45-49 98.0 98.5 98.4 27.1 36.3 34.2 50-54 94.0 94.9 94.7 20.5 26.3 25.1 55-59 87.7 88.3 88.1 15.1 18.2 17.7 60-64 79.5 80.0 79.9 8.6 11.7 11.2 65+ 51.3 55.3 54.6 4.3 7.9 7.4 Total 69.2 68.0 68.3 23.6 22.7 22.9 Number of population 4,400 14,597 18,997 4,518 15,705 20,222 Characteristics of Survey Respondents | 25 CHARACTERISTICS OF SURVEY RESPONDENTS 3 This chapter describes the demographic and socioeconomic profile of respondents interviewed in the 2007 BDHS. This information is useful in the interpretation of findings and for understanding the results presented later in the report. The survey collected basic information on respondents’ age, level of education, marital status, religion, ethnicity, and economic status. Information was also collected on respondents’ exposure to mass media, literacy, employment status, occupation, and type of earnings. Additional information was collected on respondents’ knowledge and attitudes concerning tuberculosis and men’s use of tobacco. Individual respondents to the 2007 BDHS included 10,996 ever-married women age 15-49 years and 3,771 ever-married men age 15-54 years.1 The tables throughout this chapter present weighted numbers. In most cases, percentages based on 25 to 49 unweighted cases are shown in parentheses, and percentages based on fewer than 25 unweighted cases are suppressed and replaced with an asterisk. This serves to caution readers interpreting the data that a percentage based on fewer than 50 cases may not be statistically reliable.2 For comparability between women and men, the main body of the tables includes women and men age 15-49. Information for men in the age group 50-54 years and a total for all men age 15-54 are provided at the end of each table that includes men. 3.1 CHARACTERISTICS OF RESPONDENTS Table 3.1 shows the distribution of women and men age 15-49 interviewed in the 2007 BDHS by selected background characteristics. Half of the women (50 percent) are under age 30, in contrast to just 29 percent of men. The 2007 BDHS uses an ever-married sample of women and men. In the sample, the majority of the women (93 percent) are married, while 7 percent are divorced, separated, or widowed. Nearly all men (99 percent) are currently married, with just 1 percent divorced, separated, or widowed. The majority of respondents—77 percent of both women and men—reside in rural areas. The respondents are not divided evenly across divisions. Almost one-third of respondents live in Dhaka, one-fourth in Rajshahi, one-sixth in Chittagong, and about one-tenth in Khulna. Only about one in twenty respondents live in Barisal, and a similar proportion live in Sylhet. The distribution of sampled women by division is similar to that in the 2004 BDHS. Education is one of the most influential factors affecting an individual’s knowledge, attitudes, and behavior. Approximately 34 percent of women and 30 percent of men age 15-49 have no education, while 12 percent of women and 18 percent of men have completed secondary or higher education. 1 The survey sampled ever-married women age 10-49. However, very few ever-married women were in the age group 10-14 (55 unweighted cases, or less than one percent). These women have been removed from the data set and the weights recalculated for the 15-49 age group. 2 For mortality rates, parentheses are used if based on 250 to 499 children exposed to the risk of mortality in any of the component rates, and the figures are suppressed if based on fewer than 250 children exposed to the risk of mortality in any of the component rates. 26 | Characteristics of Survey Respondents Data on religious affiliation show that the vast majority (about 90 percent) of the respondents are Muslim, about 9 percent are Hindu, and the remaining 1 percent are Buddhist and Christian. Table 3.1 Background characteristics of respondents Percent distribution of ever-married women and men age 15-49 by selected background characteristics, Bangladesh 2007 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 13.0 1,424 1,348 0.6 20 18 20-24 19.8 2,175 2,174 9.0 290 257 25-29 17.6 1,931 1,935 19.1 616 607 30-34 15.1 1,660 1,661 14.8 476 505 35-39 14.2 1,564 1,596 20.9 674 691 40-44 11.0 1,213 1,218 17.6 567 580 45-49 9.4 1,030 1,064 18.1 583 573 Marital status Currently married 92.7 10,192 10,146 99.2 3,202 3,205 Divorced/separated/widowed 7.3 804 850 0.8 26 26 Residence Urban 22.6 2,482 4,151 23.0 742 1,249 Rural 77.4 8,514 6,845 77.0 2,486 1,982 Division Barisal 6.0 662 1,438 5.8 186 421 Chittagong 18.4 2,023 1,943 16.5 531 523 Dhaka 31.2 3,431 2,340 30.3 977 644 Khulna 12.7 1,396 1,711 13.6 438 539 Rajshahi 25.2 2,776 2,080 28.1 907 687 Sylhet 6.4 707 1,484 5.8 188 417 Educational attainment No education 34.1 3,746 3,525 29.9 964 905 Primary incomplete 21.1 2,320 2,291 26.6 859 814 Primary complete1 8.4 929 962 6.8 218 229 Secondary incomplete 24.4 2,681 2,649 18.8 607 631 Secondary complete or higher2 11.9 1,304 1,547 18.0 580 652 Religion Islam 91.0 10,005 9,924 90.1 2,907 2,894 Hinduism 8.1 893 1,011 8.9 286 316 Buddism 0.6 66 23 0.8 26 9 Christianity 0.2 24 26 0.1 3 4 Other/missing 0.1 8 12 0.2 5 8 Total 15-49 100.0 10,996 10,996 100.0 3,227 3,231 50-54 na na na na 544 540 Total men 15-54 na na na na 3,771 3,771 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Characteristics of Survey Respondents | 27 Because the ever-married men interviewed in the 2007 BDHS were selected from a sub-sample of households in which ever-married women were interviewed, it is possible to match male and female respondents to their spouses in order to obtain a set of matched couples. Figure 3.1 shows age differential between spouses for matched couples in the current and two previous BDHS surveys. Not surprisingly, the husband is older than the wife in almost all couples. Since 2004, the percentage of couples in which the husband is older than his wife by 15 years or more has declined, while the percentage in which the husband is less than 5 years older than the wife has increased. 3.2 EDUCATIONAL ATTAINMENT The educational attainment of its population is an important indicator of a society’s stock of human capital and its level of socioeconomic development. Education also enhances the ability of individuals to achieve desired demographic and health goals. This section discusses differentials in the educational attainment of women and men by selected background characteristics. Tables 3.2.1 and 3.2.2 present the distribution of female and male respondents by the highest level of education completed or attended, according to age, urban-rural residence, division, and household wealth. A majority of both female and male respondents have not gone beyond the primary level of education. More than one in three (34 percent) women age 15-49 have never been to school, 21 percent have only some primary education, 8 percent have completed primary schooling, 24 percent have only some secondary education, and 12 percent have completed secondary school or gone on to higher education (Table 3.2.1). Women who are older and live in rural areas are more likely to have no education. Urban-rural differences in education are pronounced at the secondary and higher levels. For example, urban women are more than twice as likely as rural women to have completed secondary or higher education (22 percent and 9 percent, respectively). 2 14 41 31 12 1 14 40 30 14 1 17 40 30 12 Wife older 0-4 years 5-9 years 10-14 years 15 years + 0 10 20 30 40 50 Percent 1999-2000 2004 2007 Figure 3.1 Trends in Age Differential between Spouses (Husband’s Age Minus Wife’s Age) 1999, 2000, 2004, and 2007 BDHS) 28 | Characteristics of Survey Respondents In five of the six divisions, roughly similar proportions of women (11 to 14 percent) have completed secondary school. Sylhet, where only 5 percent of women have completed secondary education or higher, is an exception. Sylhet also has the highest proportion of women with no education (45 percent), while Barisal has the lowest (22 percent). Educational attainment is related to the economic status of respondents. An analysis of education by household wealth indicates that women in the highest wealth quintile are most likely to complete secondary or higher education. Thirty-one percent of women in the top wealth quintile have completed secondary or higher education, compared with just 3 percent of women in the bottom quintile. Table 3.2.1 Educational attainment: Women Percent distribution of ever-married women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Bangladesh 2007 Educational attainment Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number of women Median years completed Age 15-19 10.0 17.6 10.8 51.5 9.9 100.0 1,424 6.1 20-24 15.4 21.0 10.4 37.5 15.6 100.0 2,175 5.4 25-29 30.1 22.6 8.0 23.1 16.0 100.0 1,931 3.6 30-34 41.1 22.6 7.9 15.5 12.9 100.0 1,660 1.4 35-39 48.1 21.1 7.0 13.0 10.9 100.0 1,564 0.0 40-44 53.1 23.0 7.0 10.6 6.2 100.0 1,213 0.0 45-49 59.2 18.7 7.0 9.7 5.3 100.0 1,030 0.0 Residence Urban 25.2 18.6 8.1 25.9 22.1 100.0 2,482 4.8 Rural 36.7 21.8 8.6 23.9 8.9 100.0 8,514 2.6 Division Barisal 22.3 28.0 12.4 23.9 13.1 100.0 662 4.0 Chittagong 32.2 18.8 9.5 27.6 11.9 100.0 2,023 3.9 Dhaka 35.2 21.4 7.8 23.0 12.5 100.0 3,431 3.0 Khulna 30.1 23.5 6.8 25.4 14.1 100.0 1,396 3.6 Rajshahi 35.9 20.2 7.9 24.5 11.3 100.0 2,776 2.9 Sylhet 45.4 18.5 10.6 20.1 5.0 100.0 707 1.0 Wealth quintile Lowest 56.2 24.7 6.4 9.6 2.7 100.0 2,115 0.0 Second 42.9 24.6 9.3 18.7 4.3 100.0 2,157 0.9 Middle 35.9 22.1 10.7 23.9 7.3 100.0 2,186 3.0 Fourth 24.4 20.2 8.4 34.3 12.7 100.0 2,259 4.6 Highest 13.0 14.3 7.4 34.2 31.0 100.0 2,278 7.6 Total 34.1 21.1 8.4 24.4 11.9 100.0 10,996 3.2 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Three in ten (31 percent) men age 15-49 have no education, 26 percent have only some primary education, seven percent have completed primary school, 19 percent have some secondary education, and 18 percent have completed secondary or higher education (Table 3.2.2). Only 12 percent of men in the highest wealth quintile have never attended school, compared with 54 percent of men in the lowest wealth quintile. Characteristics of Survey Respondents | 29 The median length of schooling is 3.2 years for women and 2.7 years for men. There have been improvements in the educational attainment of women over the past three years. The percentage of women with no education has declined from 41 percent in 2004 to its current level of 34 percent, while the proportion of women who have completed secondary school or higher increased from 7 to 12 percent. However, the percentage of men with no education has remained relatively stable since 2004. Figure 3.2 shows the educational differences between spouses in matched couples. The propor- tion of couples in which both have some education has increased from 44 percent in 1999-2000 to 55 percent in 2007, and the percentage in which neither spouse is educated has decreased from 25 to 16 percent. For three in ten couples, only one partner is educated. Since 1999-2000, the probability that the husband is the only educated partner has decreased, while the probability that the wife is the only educated partner has increased. Table 3.2.2 Educational attainment: Men Percent distribution of ever-married men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Bangladesh 2007 Educational attainment Background characteristic No education Primary incomplete Primary complete1 Secondary incomplete Secondary complete or higher2 Total Number of men Median years completed Age 15-19 * * * * * 100.0 20 * 20-24 25.1 25.8 10.7 23.8 14.7 100.0 290 3.9 25-29 22.9 29.5 8.4 19.5 19.7 100.0 616 3.6 30-34 28.3 23.2 4.4 21.8 22.4 100.0 476 3.7 35-39 33.2 25.4 6.5 15.2 19.8 100.0 674 2.4 40-44 35.5 27.0 5.2 17.3 15.1 100.0 567 1.7 45-49 31.6 27.3 7.1 19.0 14.9 100.0 583 2.1 Residence Urban 23.4 20.2 7.0 21.5 27.9 100.0 857 4.9 Rural 32.8 28.1 6.3 17.6 15.1 100.0 2,914 2.1 Division Barisal 23.3 30.4 8.6 19.4 18.3 100.0 217 3.5 Chittagong 26.6 24.4 9.2 19.6 20.2 100.0 620 3.7 Dhaka 33.7 24.5 7.0 18.4 16.5 100.0 1,146 2.3 Khulna 31.1 27.0 6.3 17.3 18.4 100.0 509 2.9 Rajshahi 30.3 26.6 3.9 19.6 19.6 100.0 1,052 2.6 Sylhet 34.5 34.4 6.8 13.0 11.3 100.0 227 1.6 Wealth quintile Lowest 54.1 30.1 4.1 7.8 3.9 100.0 709 0.0 Second 39.4 30.6 8.8 13.0 8.3 100.0 777 0.6 Middle 30.3 32.8 7.2 19.7 10.1 100.0 777 2.3 Fourth 19.2 24.7 7.7 28.2 20.2 100.0 748 4.8 Highest 11.6 13.5 4.4 23.4 47.1 100.0 759 8.8 Total 15-49 30.7 26.3 6.5 18.5 18.0 100.0 3,771 2.7 50-54 35.5 24.7 4.8 16.6 18.3 100.0 544 1.9 Total men 15-54 30.7 26.3 6.5 18.5 18.0 100.0 3,771 2.7 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 30 | Characteristics of Survey Respondents 3.3 LITERACY Literacy is widely acknowledged to benefit the individual and society and is associated with a number of positive outcomes for health and nutrition. The 2007 BDHS determined literacy based on the respondent’s ability to read all or part of a sentence. To test respondents’ reading ability, interviewers carried a set of cards with simple sentences printed in Bangla during data collection. Respondents who had attended at least some secondary school were assumed to be literate. Only those who had never been to school and those who had not attended school at the secondary level were asked to read the cards during the interview. Tables 3.3.1 and 3.3.2 present the distribution of female and male respondents by different categories of literacy, according to age, urban-rural residence, division, and household wealth. Table 3.3.1 indicates that only 55 percent of women of age 15-49 in Bangladesh are literate. Literacy varies by urban-rural residence. Sixty-five percent of urban women are literate compared with 52 percent of rural women. For women, as age increases, the level of literacy decreases. About 79 percent of women age 15-19 are literate, compared with only 31 percent of women age 45-49. Divisional differences in literacy are notable; the proportion of literate women is highest in Barisal (65 percent) and lowest in Sylhet (48 percent). There is also a marked difference in literacy by household wealth, ranging from a low of 29 percent among women in the bottom wealth quintile to a high of 80 percent among women in the top wealth quintile. 44 21 10 25 49 20 11 20 55 14 15 16 Husband and wife both educated Husband educated, wife not Wife educated, husband not Husband and wife: no education 0 10 20 30 40 50 60 70 Percent 1999-2000 2004 2007 Figure 3.2 Trends in Education of Couples 1999-2000, 2004, and 2007 BDHS Characteristics of Survey Respondents | 31 Table 3.3.1 Literacy: Women Percent distribution of ever-married women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Bangladesh 2007 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all Total Percent literate1 Number Age 15-19 61.5 11.7 5.5 21.3 100.0 78.7 1,424 20-24 53.1 12.8 6.3 27.8 100.0 72.1 2,175 25-29 39.1 11.4 8.2 41.3 100.0 58.6 1,931 30-34 28.4 10.9 7.4 53.3 100.0 46.7 1,660 35-39 23.8 11.2 7.1 57.8 100.0 42.1 1,564 40-44 16.8 11.4 6.5 65.1 100.0 34.7 1,213 45-49 15.0 10.7 5.3 69.0 100.0 30.9 1,030 Residence Urban 48.1 11.6 5.3 34.9 100.0 65.0 2,482 Rural 32.8 11.5 7.2 48.5 100.0 51.5 8,514 Division Barisal 37.0 18.1 10.1 34.6 100.0 65.2 662 Chittagong 39.4 10.8 7.1 42.6 100.0 57.3 2,023 Dhaka 35.5 11.6 6.3 46.6 100.0 53.4 3,431 Khulna 39.5 10.9 6.9 42.7 100.0 57.3 1,396 Rajshahi 35.9 9.6 6.2 48.3 100.0 51.6 2,776 Sylhet 25.3 16.2 6.7 51.9 100.0 48.1 707 Wealth quintile Lowest 12.3 9.9 7.1 70.6 100.0 29.3 2,115 Second 23.0 12.0 8.0 57.0 100.0 43.0 2,157 Middle 31.2 12.6 7.2 49.0 100.0 51.0 2,186 Fourth 47.0 12.3 7.1 33.4 100.0 66.4 2,259 Highest 65.2 10.7 4.5 19.5 100.0 80.4 2,278 Total 36.3 11.5 6.7 45.4 100.0 54.5 10,996 1 Includes women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Men are about as likely as women to be literate. Fifty-seven percent of Bangladeshi men age 15- 49 are literate (Table 3.3.2). Patterns by urban-rural residence, division, and household wealth are similar to those of women. 32 | Characteristics of Survey Respondents Table 3.3.2 Literacy: Men Percent distribution of ever-married men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Bangladesh 2007 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all Total Percent literate1 Number Age 15-19 * * * * 100.0 46.5 20 20-24 38.5 16.0 8.8 36.8 100.0 63.2 290 25-29 39.2 13.8 8.8 38.3 100.0 61.7 616 30-34 44.2 10.7 3.6 41.5 100.0 58.5 476 35-39 35.0 12.6 8.3 44.2 100.0 55.8 674 40-44 32.4 13.5 6.4 47.7 100.0 52.3 567 45-49 33.9 13.5 6.9 45.6 100.0 54.4 583 Residence Urban 50.5 11.5 6.2 31.8 100.0 68.2 742 Rural 32.7 13.7 7.4 46.2 100.0 53.8 2,486 Division Barisal 37.8 14.4 9.5 38.3 100.0 61.7 186 Chittagong 39.8 10.4 8.9 40.9 100.0 59.1 531 Dhaka 35.2 12.6 5.5 46.7 100.0 53.3 977 Khulna 35.9 16.4 6.0 41.7 100.0 58.3 438 Rajshahi 39.3 12.3 7.9 40.4 100.0 59.6 907 Sylhet 25.0 18.8 7.7 48.6 100.0 51.4 188 Wealth quintile Lowest 11.1 10.8 6.1 72.0 100.0 28.0 592 Second 20.8 13.0 6.4 59.8 100.0 40.2 677 Middle 30.0 16.9 10.5 42.7 100.0 57.3 671 Fourth 49.7 15.0 8.8 26.6 100.0 73.4 634 Highest 71.0 9.9 3.9 15.3 100.0 84.7 654 Total 15-49 36.8 13.2 7.1 42.9 100.0 57.1 3,227 50-54 35.0 12.8 4.9 47.0 100.0 52.7 544 Total men 15-54 36.5 13.1 6.8 43.5 100.0 56.4 3,771 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Includes men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 3.4 ACCESS TO MASS MEDIA Access to information through the media is essential to increase people’s knowledge and awareness of what is taking place around them. The 2007 BDHS assessed exposure to media by asking respondents if they listened to a radio, watched television, or read newspapers or magazines at least once a week. It is important to know which subgroups are more or less likely to be reached by specific media in order to plan programs intended to spread information about health and family planning. Tables 3.4.1 and 3.4.2 show the percentage of female and male respondents who are exposed to different types of mass media by selected background characteristics. Characteristics of Survey Respondents | 33 Among women age 15-49, 7 percent read a newspaper at least once a week, 47 percent watch television at least once a week, and 19 percent listen to the radio at least once a week (Table 3.4.1). Only 2 percent of women are exposed to all three media sources each week. Close to half (45 percent) of women have no regular exposure to mass media. Since 2004 the proportion of women listening to the radio every week has decreased markedly from 33 percent to the current level of 19 percent. Young women under 25 years of age are more likely to watch television or listen to the radio than older women. There is also a wide gap in media exposure by urban-rural residence. For example, the proportion of newspaper readers is much higher among urban women (16 percent) than rural women (4 percent). Media exposure is also related to the respondent’s educational level and economic status. Regular exposure to mass media is higher among women with at least some secondary education and women in the top two wealth quintiles. Table 3.4.1 Exposure to mass media: Women Percentage of ever-married women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Bangladesh 2007 Background characteristic 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 at least once a week No media at least once a week Number Age 15-19 5.5 50.6 28.3 2.0 37.3 1,424 20-24 6.7 55.5 23.5 1.8 36.2 2,175 25-29 7.9 48.8 18.3 1.8 43.6 1,931 30-34 7.7 44.6 16.1 1.6 48.4 1,660 35-39 6.7 43.9 16.0 1.8 49.1 1,564 40-44 6.2 39.2 15.4 1.1 52.3 1,213 45-49 4.2 36.8 11.2 0.4 58.0 1,030 Residence Urban 16.4 74.7 15.2 2.6 21.7 2,482 Rural 3.8 38.7 20.1 1.3 52.0 8,514 Division Barisal 8.1 29.0 21.1 1.7 57.7 662 Chittagong 7.5 43.9 21.2 1.9 46.9 2,023 Dhaka 7.1 55.7 18.1 1.3 38.6 3,431 Khulna 5.8 46.2 20.4 1.2 43.0 1,396 Rajshahi 5.6 46.1 18.0 1.7 46.7 2,776 Sylhet 6.1 33.1 15.8 2.2 58.6 707 Educational attainment No education 0.0 29.2 11.3 0.0 64.7 3,746 Primary incomplete 0.4 41.1 18.1 0.1 51.4 2,320 Primary complete1 3.6 49.6 18.6 1.1 41.8 929 Secondary incomplete 10.3 63.1 28.1 2.9 26.8 2,681 Secondary complete or higher2 31.2 72.7 24.1 6.5 17.8 1,304 Wealth quintile Lowest 0.7 17.4 8.4 0.3 77.9 2,115 Second 1.3 24.9 16.6 0.3 64.8 2,157 Middle 1.9 37.5 21.5 0.4 50.9 2,186 Fourth 6.3 67.9 28.7 2.4 22.7 2,259 Highest 22.1 83.1 18.9 4.4 12.8 2,278 Total 6.6 46.8 19.0 1.6 45.1 10,996 Note: Total includes 16 women with information missing on educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 34 | Characteristics of Survey Respondents Men are more likely to be exposed to each type of mass media than women. Thirty-one percent of men age 15-49 read a newspaper at least once a week, 72 percent watch television at least once a week, and 38 percent listen to the radio at least once a week (Table 3.4.2). Around 10 percent of men are exposed to all three media sources each week. Nineteen percent of men have no regular exposure to the mass media. Table 3.4.2 Exposure to mass media: Men Percentage of ever-married men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Bangladesh 2007 Background characteristic 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 at least once a week No media at least once a week Number Age 15-19 * * * * * 20 20-24 29.7 76.2 47.8 9.7 13.7 290 25-29 28.8 78.3 42.3 11.4 15.2 616 30-34 36.9 73.7 36.7 11.6 17.7 476 35-39 32.5 71.2 33.6 10.7 21.0 674 40-44 28.7 64.8 34.1 8.6 23.1 567 45-49 28.4 68.8 36.3 9.2 21.4 583 Residence Urban 49.6 86.1 31.2 11.4 7.9 742 Rural 25.1 67.4 39.6 9.9 22.7 2,486 Division Barisal 29.0 60.0 41.3 8.8 25.0 186 Chittagong 35.5 74.1 43.6 16.3 18.0 531 Dhaka 30.1 79.4 38.7 9.5 14.4 977 Khulna 31.1 68.7 34.5 12.4 22.3 438 Rajshahi 30.3 67.7 35.3 7.2 20.8 907 Sylhet 22.9 61.9 30.8 7.8 28.2 188 Educational attainment No education 0.8 56.1 36.8 0.0 34.1 964 Primary incomplete 9.1 70.0 39.2 3.1 21.7 859 Primary complete1 30.7 76.7 37.3 10.9 15.9 218 Secondary incomplete 58.8 84.6 39.8 21.0 6.8 607 Secondary complete or higher2 82.8 84.6 34.9 26.2 5.5 580 Wealth quintile Lowest 7.6 50.1 32.1 2.8 39.9 592 Second 10.8 60.0 41.0 4.3 27.2 677 Middle 25.1 73.2 45.9 12.7 17.1 671 Fourth 41.1 82.3 37.2 13.5 10.2 634 Highest 67.8 91.3 31.3 17.5 3.5 654 Total 15-49 30.7 71.7 37.7 10.2 19.3 3,227 50-54 26.0 60.8 36.5 9.4 26.7 544 Total men 15-54 30.0 70.1 37.5 10.1 20.4 3,771 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Characteristics of Survey Respondents | 35 Since 2004 the proportion of men who regularly listen to the radio has decreased from 52 percent to the current level of 38 percent. This may account for the decrease in the proportion of men exposed to all three media from 17 percent in 2004 to 10 percent in 2007. For both men and women in Bangladesh, access to specific types of media and to any mass media at all varies widely between subgroups. In all divisions, however, there is much greater exposure to television than other media. Media exposure varies by gender: men are much more likely to be exposed to each type of mass media than women (Figure 3.3). For both men and women, exposure to television is much higher than exposure to the radio or newspaper. 3.5 EMPLOYMENT The 2007 BDHS asked respondents a number of questions regarding their employment status, including whether they had worked in the 12 months before the survey. The results for women and men are presented in Tables 3.5.1 and 3.5.2. At the time of the survey, about 65 percent of ever-married women age 15-49 said they had not been employed in the previous 12 months (Table 3.5.1). Among employed women, most work year- round. The proportion of women who are unemployed decreases with age and then plateaus after age 34 years. Unemployment is highest among women age 15-19 (79 percent) and lowest among those age 30-34 (55 percent). Women who are divorced, separated, or widowed are more likely to be employed than currently married women. Women who have children are also more likely to be employed than those without children. 7 47 19 2 45 31 72 38 10 19 Newspaper Television Radio All three media No media 0 20 40 60 80 Percent Women Men Figure 3.3 Percentage of Ever-Married Women and Men Exposed to Various Media at Least Once a Week BDHS 2007 36 | Characteristics of Survey Respondents Table 3.5.1 Employment status: Women Percent distribution of ever-married women age 15-49 by employment status in the 12 months preceding the survey, according to background characteristics, Bangladesh 2007 Continuity of employment Background characteristic Not employed All year Seasonal Occasional Total Number of women Age 15-19 79.4 15.9 2.1 2.7 100.0 1,424 20-24 70.5 23.5 2.8 3.2 100.0 2,175 25-29 63.0 29.4 3.1 4.5 100.0 1,931 30-34 55.3 36.8 3.8 4.1 100.0 1,660 35-39 60.7 32.2 3.5 3.6 100.0 1,564 40-44 61.3 31.6 4.0 2.9 100.0 1,213 45-49 63.7 30.1 3.6 2.6 100.0 1,030 Marital status Currently married 66.7 26.8 3.1 3.4 100.0 10,192 Divorced/separated/widowed 43.0 47.1 5.0 4.8 100.0 804 Number of living children 0 73.3 20.7 2.9 3.2 100.0 1,212 1-2 64.9 28.7 2.9 3.5 100.0 5,144 3-4 61.6 30.8 3.8 3.8 100.0 3,336 5+ 66.6 27.4 3.2 2.7 100.0 1,304 Residence Urban 67.6 26.3 1.9 4.2 100.0 2,482 Rural 64.2 28.9 3.6 3.2 100.0 8,514 Division Barisal 76.0 14.5 4.2 5.2 100.0 662 Chittagong 76.1 17.3 3.5 3.1 100.0 2,023 Dhaka 63.7 29.5 3.8 3.0 100.0 3,431 Khulna 60.5 34.0 2.5 2.9 100.0 1,396 Rajshahi 53.5 39.2 2.6 4.6 100.0 2,776 Sylhet 83.2 12.5 2.6 1.7 100.0 707 Educational attainment No education 56.1 35.9 4.7 3.3 100.0 3,746 Primary incomplete 61.9 29.7 3.7 4.6 100.0 2,320 Primary complete1 74.2 21.8 2.0 2.0 100.0 929 Secondary incomplete 74.6 19.8 2.4 3.2 100.0 2,681 Secondary complete or higher2 69.6 26.3 0.7 3.4 100.0 1,304 Wealth quintile Lowest 52.7 38.1 4.9 4.3 100.0 2,115 Second 59.3 32.5 4.6 3.6 100.0 2,157 Middle 67.4 26.4 3.5 2.6 100.0 2,186 Fourth 68.8 24.7 2.3 4.2 100.0 2,259 Highest 75.6 20.7 0.9 2.7 100.0 2,278 Total 65.0 28.3 3.2 3.5 100.0 10,996 Note: Total includes 16 women with information missing on educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Moderate variations are observed in the proportion not employed by urban-rural residence and division. A somewhat smaller proportion of rural women are unemployed than urban women (64 percent compared with 68 percent). Women in Rajshahi division are least likely not to be employed (54 percent), and women in Sylhet are most likely not to be employed. A similar pattern was observed in the 2004 BDHS survey. Characteristics of Survey Respondents | 37 The proportion of women who are not employed increases with education. For example, 56 percent of women with no education are not employed, compared with 70 percent of women who have completed secondary or higher education. There is an inverse relationship between wealth and employment. Women living in the poorest households are less likely to be unemployed (53 percent) than women in the wealthiest households (76 percent). The proportion of men who are not employed is much lower than the proportion of women (Table 3.5.2). Only 2 percent of men age 15-49 did not work in the 12 months preceding the survey. There is little variation in the employment status of men by any of the background characteristics in the table, but it can be noted that unemployment is higher among men in Sylhet division and those with secondary or higher education. Table 3.5.2 Employment status: Men Percent distribution of ever-married men age 15-49 by employment status in the 12 months preceding the survey, according to background characteristics, Bangladesh 2007 Continuity of employment Background characteristic Not employed All year Seasonal Occasional Total Number of men Age 15-19 * * * * 100.0 20 20-24 2.8 94.0 3.1 0.2 100.0 290 25-29 1.8 92.9 4.3 0.9 100.0 616 30-34 2.9 92.5 4.2 0.5 100.0 476 35-39 2.3 93.9 3.8 0.1 100.0 674 40-44 1.5 93.8 3.6 1.1 100.0 567 45-49 1.4 93.4 5.1 0.1 100.0 583 Marital status Currently married 1.9 93.5 4.1 0.5 100.0 3,202 Divorced/separated/widowed (18.8) (74.2) (6.9) (0.0) 100.0 26 Residence Urban 2.1 93.7 3.9 0.3 100.0 742 Rural 2.0 93.2 4.2 0.5 100.0 2,486 Division Barisal 1.9 90.4 7.1 0.6 100.0 186 Chittagong 2.6 93.6 3.3 0.5 100.0 531 Dhaka 2.1 93.6 4.2 0.1 100.0 977 Khulna 1.5 95.5 2.8 0.2 100.0 438 Rajshahi 1.2 96.1 1.9 0.8 100.0 907 Sylhet 5.2 76.2 16.9 1.7 100.0 188 Educational attainment No education 1.0 93.7 4.9 0.4 100.0 964 Primary incomplete 1.6 91.4 6.1 1.0 100.0 859 Primary complete1 1.7 95.6 2.5 0.2 100.0 218 Secondary incomplete 2.6 93.5 3.8 0.1 100.0 607 Secondary complete or higher2 4.0 94.8 1.0 0.3 100.0 580 Wealth quintile Lowest 1.0 92.6 5.3 1.0 100.0 592 Second 0.7 92.5 6.7 0.2 100.0 677 Middle 2.4 93.9 3.4 0.4 100.0 671 Fourth 2.6 92.4 4.1 0.8 100.0 634 Highest 3.3 95.2 1.3 0.2 100.0 654 Total 15-49 2.0 93.4 4.1 0.5 100.0 3,227 50-54 3.6 93.1 2.6 0.8 100.0 544 Total men 15-54 2.3 93.3 3.9 0.5 100.0 3,771 Note: 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 Primary complete is defined as completing grade 5. 2Secondary complete is defined as completing grade 10. 38 | Characteristics of Survey Respondents 3.6 OCCUPATION Respondents who had worked in the 12 months preceding the survey were asked about their occupation. The results are presented in Tables 3.6.1 and 3.6.2, which show the distribution of employed women and men by occupation according to background characteristics. Agriculture is the dominant sector of the economy of Bangladesh, and most employed persons work in the agricultural sector. Among working women, 43 percent are engaged in raising poultry or cattle, 12 percent in semi- skilled labor, and one in ten in home-based manufacturing (Table 3.6.1). The relationship between women’s occupation and age is mixed. A notable finding is that younger women are more likely than older women to be engaged in factory work, blue collar services, and home-based manufacturing activities. In contrast, older women are more likely than younger women to work in business or as domestic servants. Urban-rural residence has a marked effect on occupation. As expected, rural women are more than three times as likely as urban women to be engaged in poultry or cattle raising and farming. In contrast, employed women in urban areas are more likely than their rural counterparts to be engaged in factory work or blue collar services, semi-skilled labor, and professional or technical services. Women with higher levels of education are more likely to be employed in professional, technical, and semi-skilled services than less educated women. In contrast, women with little or no education are more likely to be engaged as domestic servants and unskilled labor than those with more education. The majority of women in the lowest wealth quintile work in poultry or cattle raising. Among employed men age 15-49, 33 percent are engaged in farming and agricultural activities, 22 percent are engaged in business, 16 percent are unskilled laborers, and 15 percent are semi-skilled laborers (Table 3.6.2). Older men are more likely to be engaged in business than younger men. As expected, men from the wealthiest households are more likely to be engaged in business, professional, or technical services compared with men from the poorest households. Most men in the lowest wealth quintile are unskilled laborers or work in farming and agriculture. Characteristics of Survey Respondents | 39 Table 3.6.1 Occupation: Women Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Bangladesh 2007 Occupation Background characteristic Professional/ technical Business Factory worker, blue collar service Semi- skilled labor/ service Unskilled labor Farmer/ agricul- tural worker Poultry, cattle raising Home- based manu- facturing Domestic servant Other Missing Total Number of women Age 15-19 2.7 4.3 8.3 14.6 6.7 3.5 42.5 14.4 2.8 0.2 0.0 100.0 294 20-24 2.5 4.9 8.0 17.7 4.6 4.5 41.9 11.3 4.0 0.2 0.3 100.0 642 25-29 4.9 3.1 4.4 13.8 5.5 8.5 41.7 10.2 6.9 0.6 0.5 100.0 714 30-34 3.6 5.3 4.2 8.5 7.1 6.5 45.5 9.8 9.3 0.2 0.0 100.0 742 35-39 3.2 9.5 4.4 9.1 7.1 7.8 40.3 9.8 7.8 0.7 0.2 100.0 614 40-44 2.8 7.4 1.9 8.5 4.9 9.8 47.2 7.2 9.2 0.5 0.6 100.0 469 45-49 2.4 8.4 2.1 7.9 6.9 10.2 39.6 9.4 12.5 0.3 0.3 100.0 374 Marital status Currently married 3.6 5.6 4.6 11.8 5.4 7.3 46.4 10.0 4.7 0.3 0.3 100.0 3,391 Divorced/separated/ widowed 1.2 8.3 5.7 9.4 11.2 7.5 16.3 10.8 28.1 0.9 0.4 100.0 459 Number of living children 0 6.7 3.2 9.3 19.7 7.1 6.7 25.4 12.6 8.6 0.2 0.4 100.0 324 1-2 4.6 6.0 5.5 13.3 5.7 5.3 40.7 10.3 7.7 0.5 0.4 100.0 1,807 3-4 1.5 6.6 2.9 8.9 6.4 9.7 47.4 9.5 6.7 0.3 0.1 100.0 1,282 5+ 0.5 6.1 3.5 5.8 5.9 9.1 50.7 9.3 8.7 0.5 0.0 100.0 436 Residence Urban 6.6 7.7 12.9 20.4 8.4 1.1 15.5 11.4 15.4 0.6 0.1 100.0 805 Rural 2.5 5.5 2.6 9.2 5.4 8.9 50.0 9.8 5.5 0.4 0.3 100.0 3,044 Division Barisal 5.9 8.7 5.8 11.4 6.6 7.7 37.1 10.2 6.0 0.6 0.0 100.0 159 Chittagong 3.7 4.6 7.2 10.5 5.3 14.1 18.8 24.1 10.3 1.0 0.4 100.0 484 Dhaka 3.0 4.7 6.9 12.7 5.3 6.1 44.9 7.4 8.3 0.3 0.4 100.0 1,247 Khulna 4.1 8.1 2.4 12.4 5.3 3.4 48.0 9.5 6.1 0.5 0.2 100.0 551 Rajshahi 2.7 6.5 2.7 10.6 6.0 7.6 50.4 7.3 5.9 0.1 0.1 100.0 1,290 Sylhet 5.2 6.0 2.8 8.2 20.9 5.5 18.7 15.3 15.1 1.4 0.9 100.0 119 Educational attainment No education 0.1 6.9 4.1 4.2 8.7 9.3 42.4 10.0 13.1 0.7 0.4 100.0 1,645 Primary incomplete 0.3 6.8 3.6 7.8 5.2 7.3 49.6 12.1 6.8 0.2 0.3 100.0 884 Primary complete1 1.0 2.7 7.9 11.6 4.6 6.2 54.3 9.8 1.8 0.3 0.0 100.0 239 Secondary incomplete 1.0 4.9 6.9 25.2 3.7 5.6 40.5 10.7 1.2 0.1 0.2 100.0 680 Secondary complete or higher2 28.9 4.3 3.9 26.3 1.9 2.7 26.1 5.6 0.2 0.0 0.0 100.0 396 Wealth quintile Lowest 0.0 5.0 1.1 3.3 6.8 7.8 56.9 7.8 10.0 1.0 0.2 100.0 999 Second 0.8 6.5 5.2 6.9 7.1 8.8 47.2 11.7 5.5 0.1 0.2 100.0 878 Middle 1.1 5.1 3.1 11.0 7.7 10.3 43.6 11.3 5.8 0.4 0.7 100.0 713 Fourth 4.5 8.5 4.4 17.4 4.4 6.5 36.2 13.9 3.7 0.3 0.2 100.0 705 Highest 14.7 4.8 13.1 26.7 3.1 1.1 17.7 5.5 13.4 0.0 0.0 100.0 555 Total 3.3 6.0 4.7 11.5 6.1 7.3 42.8 10.1 7.5 0.4 0.3 100.0 3,849 Note: Total includes 5 women with information missing on educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 40 | Characteristics of Survey Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Bangladesh 2007 Occupation Background characteristic Professional/ technical Business Factory worker, blue collar service Semi- skilled labor/ service Unskilled labor Farmer/ agricul- tural worker Poultry, cattle raising Home- based manu- facturing Domestic servant Other Missing Total Number of men Age 15-19 * * * * * * * * * * * 100.0 20 20-24 0.0 14.1 5.6 23.9 20.0 32.0 0.0 0.0 0.0 1.9 2.4 100.0 287 25-29 3.4 20.6 5.4 18.4 14.4 32.9 0.0 0.0 0.0 2.1 2.8 100.0 614 30-34 7.7 23.8 6.4 14.2 15.3 28.3 0.0 0.1 0.0 1.6 2.5 100.0 468 35-39 5.8 24.7 3.0 13.4 18.8 28.7 0.0 0.0 0.1 2.6 2.8 100.0 671 40-44 4.7 23.7 4.5 10.9 14.0 39.5 0.0 0.3 0.1 1.5 0.8 100.0 561 45-49 5.0 23.1 6.0 12.2 12.3 38.1 0.1 0.0 0.0 1.7 1.6 100.0 578 Marital status Currently married 4.7 22.3 5.0 14.8 15.6 33.2 0.0 0.1 0.0 2.0 2.2 100.0 3,178 Divorced/separated/ widowed * * * * * * * * * * * 100.0 21 Residence Urban 9.6 29.1 9.7 23.3 16.1 8.7 0.1 0.1 0.0 2.0 1.4 100.0 734 Rural 3.3 20.2 3.6 12.2 15.5 40.7 0.0 0.1 0.0 2.0 2.4 100.0 2,465 Division Barisal 6.8 20.5 7.9 11.8 12.6 32.8 0.0 0.0 0.4 4.3 3.1 100.0 184 Chittagong 4.7 25.1 6.3 14.9 16.1 27.7 0.1 0.0 0.1 2.6 2.4 100.0 526 Dhaka 4.3 24.2 6.7 16.2 16.1 28.3 0.0 0.2 0.0 1.8 2.1 100.0 968 Khulna 4.7 25.7 2.7 13.4 16.5 32.6 0.0 0.0 0.0 3.3 1.1 100.0 435 Rajshahi 5.1 17.3 3.0 14.5 15.3 42.3 0.0 0.1 0.0 0.7 1.8 100.0 901 Sylhet 3.2 22.0 4.4 14.3 14.8 34.0 0.0 0.0 0.0 2.1 5.2 100.0 186 Educational attainment No education 0.0 11.9 3.4 10.8 27.5 40.8 0.0 0.2 0.1 3.8 1.5 100.0 958 Primary incomplete 0.0 22.9 3.4 13.5 17.9 37.9 0.0 0.0 0.0 2.2 2.3 100.0 858 Primary complete1 0.5 23.2 8.1 16.9 11.6 35.8 0.0 0.0 0.0 1.1 2.9 100.0 217 Secondary incomplete 0.4 30.7 8.9 18.7 7.1 31.9 0.1 0.0 0.0 0.8 1.5 100.0 598 Secondary complete or higher2 26.0 29.7 4.7 18.5 2.8 14.4 0.0 0.1 0.1 0.1 3.6 100.0 568 Wealth quintile Lowest 0.5 8.3 2.7 5.4 25.0 53.7 0.0 0.3 0.0 3.4 0.7 100.0 587 Second 1.0 13.3 4.3 9.7 19.8 46.6 0.0 0.0 0.0 3.5 1.9 100.0 676 Middle 1.5 19.4 3.7 16.5 15.7 37.4 0.1 0.0 0.0 2.3 3.4 100.0 667 Fourth 4.6 34.9 5.4 18.7 10.7 22.1 0.0 0.0 0.1 0.6 2.8 100.0 627 Highest 15.9 35.1 8.8 23.0 7.4 7.5 0.0 0.1 0.1 0.1 2.0 100.0 642 Total 15-49 4.7 22.3 5.0 14.8 15.6 33.3 0.0 0.1 0.0 2.0 2.2 100.0 3,199 50-54 3.6 23.9 4.2 9.0 9.0 44.7 0.3 0.4 0.0 2.2 2.7 100.0 532 Total men 15-54 4.6 22.5 4.9 14.0 14.7 35.0 0.1 0.1 0.0 2.0 2.3 100.0 3,731 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Characteristics of Survey Respondents | 41 3.7 EARNINGS AND CONTINUITY OF EMPLOYMENT Table 3.7 shows the percent distribu- tion of women by type of earnings and continuity of employment. This table also presents data on whether respondents are involved in agricultural or nonagricultural occupations. Thirty-five percent of women en- gaged in agricultural work are not paid. Another 20 percent are paid entirely in kind. Women are more likely to be paid in cash if they are employed in the nonagricultural sector: about 78 percent of women holding nonagricultural jobs are paid in cash, compared with just 36 percent of women employed in agriculture. Overall, 13 percent of employed women receive no pay at all for their work. About 81 percent of employed women work all year round, while the remaining 19 percent work either seasonally or occasionally. Continuity of employment varies by sector. Around half (48 percent) of the women employed in the agricultural sector are seasonal workers, compared with just 6 percent of those working in the nonagricultural sector. Likewise, 46 percent of women working in the agricultural sector work year round, compared with 84 percent of women engaged in nonagricultural work. 3.8 KNOWLEDGE AND ATTITUDES CONCERNING TUBERCULOSIS Tuberculosis (TB) is a leading cause of death and a major public health problem in the developing world. TB is caused by the bacterium mycobacterium tuberculosis, which is mainly transmitted through the air when infected persons cough or sneeze. The infection is primarily concentrated in the lungs, but in some cases it can be transmitted to other areas of the body. For the first time in 2007, a BDHS collected information about women’s and men’s level of awareness of TB. Specifically, respondents were asked whether they had ever heard of the illness, how it spreads from one person to another, and whether it can be cured. This information is useful in policy formulation and implementation of programs designed to combat and limit the spread of the disease. Tables 3.8.1 and 3.8.2 show the percentage of women and men who have heard of TB and, among those who have heard of it, their knowledge of TB by various background characteristics. Awareness of TB is almost universal in Bangladesh (98 percent of women and 99 percent of men have heard of the disease), with little difference by background characteristics. Among women who have heard of TB, 35 percent know that TB is spread through the air by coughing or sneezing (Table 3.8.1). Urban women are more likely to know this than rural women (42 percent compared with 32 percent). Correct knowledge of how TB is spread is low in the divisions of Chittagong (30 percent) and Barisal (31 percent) and higher in Rajshahi (38 percent) and Sylhet (37 percent). Correct knowledge increases with both education and household wealth. Of those women who Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, and continuity of employment, according to type of employment (agricultural or nonagricultural), Bangladesh 2007 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 35.9 77.7 74.5 Cash and in-kind 8.6 8.5 8.5 In-kind only 20.4 3.0 4.3 Not paid 35.1 10.7 12.5 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Continuity of employment All year 45.9 83.6 80.9 Seasonal 48.0 6.1 9.2 Occasional 6.2 10.2 9.9 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 281 3,559 3,849 Note: Total includes women with information missing on type of employment who are not shown separately 42 | Characteristics of Survey Respondents have heard of TB, four in five believe that it can be cured. Knowledge that TB can be cured is higher in urban than rural areas (91 percent compared with 78 percent). Almost all women who have completed secondary or higher education (94 percent) and who come from the highest wealth quintile (93 percent) believe that TB can be cured, compared with 72 percent of women with no education and 71 percent of those in the lowest wealth quintile. Table 3.8.1 Knowledge and attitudes concerning tuberculosis: Women Percentage of ever-married women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who know that TB is spread through the air by coughing and the percentage who believe that TB can be cured, by background characteristics, Bangladesh 2007 Among women who have heard of TB, the percentage who: Among all women Background characteristic Percentage who have heard of TB Number Report that TB is spread through the air by coughing Believe that TB can be cured Number Age 15-19 97.5 1,424 31.2 84.1 1,389 20-24 97.7 2,175 34.1 83.4 2,125 25-29 96.9 1,931 36.0 80.7 1,870 30-34 98.3 1,660 34.5 79.8 1,631 35-39 97.2 1,564 37.4 80.6 1,520 40-44 98.3 1,213 33.8 77.2 1,192 45-49 96.2 1,030 33.3 75.5 990 Residence Urban 99.0 2,482 41.5 90.9 2,458 Rural 97.0 8,514 32.4 77.6 8,258 Division Barisal 97.7 662 30.6 71.6 647 Chittagong 94.7 2,023 29.8 77.0 1,917 Dhaka 98.8 3,431 35.4 85.1 3,389 Khulna 99.0 1,396 33.1 75.6 1,382 Rajshahi 97.5 2,776 37.6 84.6 2,708 Sylhet 95.2 707 37.2 72.5 673 Educational attainment No education 94.6 3,746 25.9 71.8 3,545 Primary incomplete 98.2 2,320 28.2 77.9 2,277 Primary complete1 98.1 929 31.4 81.3 911 Secondary incomplete 99.5 2,681 41.0 88.2 2,669 Secondary complete or higher2 99.6 1,304 57.6 93.9 1,298 Wealth quintile Lowest 95.4 2,115 27.9 71.4 2,018 Second 96.7 2,157 29.3 73.8 2,086 Middle 97.3 2,186 31.5 78.4 2,128 Fourth 98.4 2,259 35.2 84.8 2,223 Highest 99.3 2,278 47.1 93.4 2,261 Total 97.5 10,996 34.5 80.7 10,716 Note: Total includes 16 women with information missing on educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Characteristics of Survey Respondents | 43 Among men who have heard of TB, 41 percent know that it is spread through the air by coughing or sneezing (Table 3.8.2). Urban men are more likely to know this than rural men (46 percent compared with 40 percent). Correct knowledge of how TB is spread is lowest in Khulna division (35 percent) and highest in Chittagong division (48 percent). As with women, correct knowledge of how TB is spread increases with education and household wealth. Ninety percent of men age 15-49 believe that TB can be cured. Table 3.8.2 Knowledge and attitudes concerning tuberculosis: Men Percentage of ever-married men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who know that TB is spread through the air by coughing and the percentage who believe that TB can be cured, by background characteristics, Bangladesh 2007 Among men who have heard of TB, the percentage who: Among all men Background characteristic Percentage who have heard of TB Number Report that TB is spread through the air by coughing Believe that TB can be cured Number Age 15-19 * * * * 20 20-24 98.7 290 32.5 91.5 286 25-29 99.3 616 37.4 90.2 612 30-34 98.6 476 43.1 91.4 470 35-39 98.2 674 43.0 89.1 662 40-44 98.5 567 42.0 89.0 559 45-49 99.2 583 45.8 88.1 579 Residence Urban 99.5 742 45.8 94.2 738 Rural 98.5 2,486 39.8 88.3 2,449 Division Barisal 98.9 186 38.2 82.5 184 Chittagong 96.5 531 47.9 91.2 513 Dhaka 99.6 977 37.4 92.8 973 Khulna 99.0 438 35.4 86.7 434 Rajshahi 99.3 907 45.9 90.5 901 Sylhet 97.3 188 36.7 79.2 182 Educational attainment No education 97.0 964 26.5 83.1 935 Primary incomplete 99.1 859 35.1 87.1 851 Primary complete1 100.0 218 39.6 91.8 218 Secondary incomplete 99.6 607 50.7 95.5 605 Secondary complete or higher2 99.8 580 64.7 97.1 578 Wealth quintile Lowest 99.4 592 30.2 82.2 588 Second 98.1 677 33.4 87.1 664 Middle 98.2 671 41.0 87.7 658 Fourth 98.7 634 46.8 95.0 625 Highest 99.6 654 54.0 95.8 651 Total 15-49 98.8 3,227 41.2 89.7 3,187 50-54 99.9 544 44.5 83.5 543 Total men 15-54 98.9 3,771 41.7 88.8 3,730 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 44 | Characteristics of Survey Respondents 3.9 USE OF TOBACCO Smoking tobacco has negative effects on health, including an increased risk of lung and heart disease. Men interviewed in the 2007 BDHS were asked about their use of tobacco products. Table 3.9 shows the percentage of men who smoke cigarettes or use other tobacco products and the percent distribution of cigarette smokers by the number of cigarettes smoked in the preceding 24 hours, according to background characteristics. Tobacco use is common among Bangladeshi men: 60 percent smoke cigarettes and 20 percent consume other forms of tobacco. Overall, seven in ten Bangladeshi men use some form of tobacco. Use of tobacco is more common among older men, those living in rural areas, men with no education, and men in the lowest wealth quintile. Regional variations are notable; cigarette use ranges from 45 percent in Barisal to 73 percent in Sylhet. More than half of men who smoke cigarettes smoked at least one cigarette in the 24 hours preceding the survey. One-fourth of men who smoke reported consuming more than 10 cigarettes in the previous 24 hours. Although rural men are more likely to smoke cigarettes then urban men, urban smokers tend to smoke more cigarettes per day than their rural counterparts. Table 3.9 Use of tobacco: Men Percentage of ever-married men age 15-49 who smoke cigarettes or use other tobacco products, and the percent distribution of cigarette smokers by number of cigarettes smoked in preceding 24 hours, according to background characteristics, Bangladesh 2007 Number of cigarettes in the past 24 hours Background characteristic Smoked cigarettes Uses other tobacco Does not use tobacco Number of men 0 1-2 3-5 6-9 10+ Total Number of cigarette smokers Age 15-19 * * * * * * * * * 100.0 11 20-24 63.7 10.2 32.8 290 31.9 16.8 26.6 9.3 15.4 100.0 185 25-29 53.9 16.3 39.3 616 32.7 12.3 21.8 8.8 24.5 100.0 332 30-34 57.7 15.3 34.7 476 31.8 9.5 17.6 10.4 30.6 100.0 275 35-39 57.6 19.6 32.1 674 43.7 6.6 12.6 9.2 27.9 100.0 389 40-44 62.2 24.7 26.3 567 51.5 7.1 12.8 5.7 22.5 100.0 353 45-49 67.7 27.9 19.5 583 48.9 4.7 10.6 9.2 26.7 100.0 395 Residence Urban 54.3 17.7 37.0 742 16.0 7.4 19.4 15.0 42.2 100.0 403 Rural 61.8 20.5 28.8 2,486 48.0 9.0 15.1 7.1 20.8 100.0 1,537 Division Barisal 45.3 20.5 42.1 186 39.1 14.5 21.1 6.6 18.7 100.0 84 Chittagong 61.8 12.8 33.2 531 25.0 2.8 13.1 10.7 48.3 100.0 328 Dhaka 66.3 15.8 27.9 977 43.9 8.2 15.4 9.7 22.8 100.0 648 Khulna 51.8 23.8 36.7 438 49.5 7.9 17.4 5.4 19.7 100.0 227 Rajshahi 56.9 25.3 30.0 907 45.3 12.9 16.8 7.8 16.9 100.0 516 Sylhet 72.9 24.3 15.9 188 40.7 6.9 16.9 9.9 25.6 100.0 137 Educational attainment No education 73.4 23.1 18.4 964 61.2 5.1 10.6 3.9 19.0 100.0 707 Primary incomplete 63.1 24.6 25.9 859 42.4 12.2 15.0 7.0 23.5 100.0 542 Primary complete1 67.1 12.5 28.2 218 33.7 11.8 14.0 11.0 29.6 100.0 146 Secondary incomplete 52.8 16.8 37.8 607 22.9 7.8 24.0 16.2 29.1 100.0 321 Secondary complete or higher2 38.6 13.2 51.7 580 7.3 10.6 25.2 16.2 40.8 100.0 223 Wealth quintile Lowest 70.9 24.1 18.9 592 70.7 8.7 6.0 4.6 9.7 100.0 419 Second 65.4 23.3 24.8 677 58.3 9.0 13.6 5.6 13.5 100.0 443 Middle 61.7 23.1 28.2 671 35.2 11.7 19.7 6.8 26.6 100.0 414 Fourth 56.9 15.0 35.2 634 22.9 6.1 21.6 13.7 35.7 100.0 360 Highest 46.4 13.7 45.6 654 6.3 7.2 21.4 15.7 49.5 100.0 303 Total 15-49 60.1 19.8 30.7 3,227 41.3 8.7 16.0 8.7 25.2 100.0 1,940 50-54 59.4 30.7 23.6 544 57.4 7.3 10.7 6.7 17.6 100.0 323 Total men 15-54 60.0 21.4 29.7 3,771 43.6 8.5 15.2 8.4 24.1 100.0 2,263 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Fertility | 45 FERTILITY 4 The Government of Bangladesh (GOB) outlined its first population policy in 1976; this made the population and family planning program an integral component of development activities. It gave couples the opportunity to choose from different methods of family planning, strengthened mother and child health care activities, initiated educational programs on family planning issues, developed research and training activities, and emphasized adherence to marriage at the legal age (GOB, 1976). Approximately two decades later, the Ministry of Health and Family Welfare prepared “Strategic Directions for the Bangladesh National Family Planning Program: 1995-2005,” which focused on a client-oriented approach to expand good quality family planning services. The policy aimed to achieve replacement fertility in ten years (GOB, 1996). The population policy was last reviewed and updated in 2004. The targets of this latest policy are to stabilize population growth and improve the living standard of the people of Bangladesh. The 2004 Population Policy also envisions a reduction in the total fertility rate and an increase in the use of family planning methods among eligible couples by raising awareness of family planning. Other aims of the policy are to attain a net reproduction rate (NRR) equal to one by the year 2010 (in order to attain a stable population by 2060) and to improve maternal and child health, with an emphasis on the reduction of maternal and child mortality. Following an impressive decline in fertility in the late 1970s and 1980s from 6.3 to 3.4 births per woman, fertility in Bangladesh began to plateau, causing concern among policy makers. Multiple sources of data show that the total fertility rate stalled at 3.3 for about ten years during the 1990s and then resumed its decline during the early 2000s (Mitra et al., 1994; Mitra et al., 1997; NIPORT et al., 2001; NIPORT et al, 2005; ICDDR,B, 1994; ICDDR,B, 2002). A major objective of the 2007 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 describes current and past fertility, cumulative fertility and family size, birth intervals, age at first birth, and the reproductive behavior of adolescents. Most of the fertility measures are based on the birth histories collected during interviews with ever- married women age 15-49. Each woman was asked a series of questions that could be used to construct 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. 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: 46 | Fertility Age-specific fertility rates1 (ASFR) are expressed as the number of births per 1,000 women in a certain age group. They are a valuable measure to assess the current age pattern of childbearing. ASFRs are defined as the number of live births during a specific period to women in a particular age group, divided by the number of woman-years lived in that age group during the specified period. The 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 currently observed ASFRs. The TFR is obtained by summing the ASFRs and multiplying by five. The general fertility rate (GFR) is the number of live births that occur during a specified period per 1,000 women of reproductive age. The crude birth rate (CBR) is the number of births per 1,000 population during a specified period. The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to the calendar years 2004-2006. A three-year period was chosen because it reflects the current situation without unduly increasing sampling error. Despite efforts to improve data quality, data from the BDHS are subject to the same types of errors that are inherent in all retrospective sample surveys: the possibility of omitting some births (especially births of children who died at a very young age) and the difficulty of accurately determining each child’s date of birth. These errors can bias estimates of fertility trends, which therefore have to be interpreted within the context of data quality and sample sizes. A summary of the quality of the BDHS data appears in the tables in Appendix C. 4.1 CURRENT FERTILITY LEVELS Age-specific and total fertility rates for Bangladesh as a whole and for urban and rural areas are shown in Table 4.1, along with the general fertility rate and crude birth rate. According to the 2007 BDHS, the total fertility rate for women age 15-49 is 2.7. This means that a Bangladeshi woman would have, on average, 2.7 children in her lifetime if the current age- specific fertility rates remained constant. This is 10 percent lower than the TFR of 3.0 children found by the 2004 BDHS. For the three-year period preceding the survey, the general fertility rate in Bangladesh was 105 births per 1,000 women of reproductive age. Data show a crude birth rate of 26 births per 1,000 population for the same 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 of the mother (in five-year groups) 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. Because 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. 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 residence, Bangladesh 2007 Residence Age group Urban Rural Total 15-19 90 137 126 20-24 161 177 173 25-29 123 129 127 30-34 66 71 70 35-39 31 35 34 40-44 7 11 10 45-49 0 1 1 TFR 2.4 2.8 2.7 GFR 92 109 105 CBR 24.7 26.5 26.1 Note: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility | 47 Bangladeshi women exhibit a pattern of early childbearing (Figure 4.1). According to current fertility rates, women will have 23 percent of their children before reaching age 20, on average. They will have more than half of their children (55 percent) during their twenties, and one-fifth during their thirties. 4.2 FERTILITY DIFFERENTIALS Table 4.2 shows differentials in fertility by urban-rural residence, administrative division, educational attainment, and household wealth. As expected, the TFR is higher for rural women than urban women. On average, rural women will give birth to 0.4 children more than urban women. Nevertheless, the differential in rural-urban fertility has narrowed over the past decade, from 1.3 births in the 1996-97 BDHS to 0.4 births in the 2007 BDHS. Urban-rural differentials remain large at younger ages (Figure 4.1), which probably reflects the fact that urban women spend more years in school and marry later than rural women. Fertility varies widely by administrative divisions (Figure 4.2). Khulna has reached replacement level fertility, and Rajshahi is close to it. Sylhet has the highest TFR (3.7 births) followed by Chittagong (3.2 births). As expected, women’s education is strongly associated with fertility. The TFR decreases from 3.0 births for women with no education to 2.3 births for women who have completed secondary or higher education. Fertility is also negatively associated with wealth; the difference in fertility between women in the lowest and highest wealth quintiles amounts to one child per woman, on average. � � � � � � � � � � � � � � 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age 0 50 100 150 200 Births per 1,000 women Urban Rural� � BDHS 2007 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence 48 | Fertility Table 4.2 presents the percentage of women who reported that they were pregnant at the time of the survey, according to age group. These reports may be underestimates, especially in the case of pregnancies at early stages, because some women may be unaware of or unwilling to reveal their current status. At the time of the survey, 5 percent of women age 15-49 reportedly were pregnant. The percentage of women currently pregnant is higher in rural areas than urban areas (6 percent and 5 percent, respectively). Seven percent of women are currently pregnant in Sylhet, compared with 5 per- cent in Dhaka and Khulna. The relationship between the percentage currently pregnant and education is U-shaped, rising from a low of 4 percent among women with no education to a high of 7 percent among women with some secondary education, and then dipping again to 4 percent among women who have completed secondary or higher education. Women in the lower three wealth quintiles are somewhat more likely to be currently pregnant (6 percent) than women in the highest two quintiles (4 percent). Table 4.2 also presents the TFR and the mean number of children ever born to women age 40-49, which allows a crude assessment of trends in fertility. The former is a measure of current fertility, while the latter is a measure of past or completed fertility. Although comparing completed fertility among women age 40-49 with the total fertility rate can provide an indication of fertility change, it is vulnerable to the understatement of parity by older women. Findings on age at marriage and contra- ceptive use are also of crucial importance in reach- ing a balanced judgment about fertility trends. Unless there is evidence of increased age at marriage and/or appreciable use of contraception, it is unlikely that fertility has declined. However, the comparison of past and present fertility indicators, together with corresponding increases in contraceptive use and women’s age at marriage, suggests a decline of two children per woman, from 4.6 to 2.7 children. There has been a substantial decline in fertility in both urban and rural areas, and in all administrative divisions. Fertility declined by two or more children in three of Bangladesh’s six divisions: Barisal, Chittagong, and Khulna. Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49 years, by background characteristics, Bangladesh 2007 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 2.4 4.6 4.1 Rural 2.8 5.6 4.7 Division Barisal 2.8 5.8 4.9 Chittagong 3.2 5.8 5.2 Dhaka 2.8 4.9 4.5 Khulna 2.0 4.9 4.0 Rajshahi 2.4 5.4 4.1 Sylhet 3.7 6.9 5.5 Educational attainment No education 3.0 3.8 4.8 Primary incomplete 2.9 6.1 4.7 Primary complete1 2.9 5.7 4.6 Secondary incomplete 2.5 7.1 4.0 Secondary complete or higher2 2.3 4.3 3.1 Wealth quintile Lowest 3.2 6.0 4.9 Second 3.1 6.4 4.8 Middle 2.7 6.1 4.9 Fourth 2.5 4.3 4.5 Highest 2.2 4.4 3.9 Total 2.7 5.4 4.6 Note: Total fertility rates are for the period 1-36 months prior to interview. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10 . Fertility | 49 4.3 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 three decades, beginning with the 1975 Bangladesh Fertility Survey (BFS). Data from the 2007 BDHS and previous surveys show that following a nearly decade-long plateau in fertility from 1993 to 2000, fertility in Bangladesh has resumed its decline. The estimates shown in Table 4.3.1 describe the ongoing fertility transition in Bangladesh. Fertility has declined sharply, from 6.3 births per woman in 1971-75 to 2.7 births per woman in 2004-2006 (Table 4.3.1 and Figure 4.3). There was an initial rapid decline in fertility of nearly two children per women up to the early 1990s. Fertility then plateaued at around 3.3 births per woman for most of the 1990s. This was followed by another noteworthy decline in fertility during the current decade. The 2007 BDHS data, along with earlier rounds of the survey beginning in 1993, indicate that the decline in fertility has continued during the last three years, reaching 2.7 births per woman. Since 2001, a marked decline in fertility has been observed in Khulna, Chittagong, and Sylhet divisions. The decline in fertility in the last two decades occurred mostly among older women (Mitra et al., 1994; Mitra et al., 1997 ; NIPORT et al., 2001; NIPORT et al., 2005). 2.7 2.4 2.8 2.8 3.2 2.8 2.0 2.4 3.7 3.0 2.9 2.9 2.5 2.3 BANGLADESH RESIDENCE Urban Rural DIVISION Barisal Chittagong Dhaka Khulna Rajshahi Sylhet EDUCATION No education Primary incomplete Primary complete Secondary incomplete Secondary complete or higher 0.0 1.0 2.0 3.0 4.0 5.0 Total fertility rate BDHS 2007 Figure 4.2 Total Fertility Rates by Background Characteristics 50 | Fertility Table 4.3.1 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, 1975-2007 Survey and approximate time period 1975 BFS 1989 BFS 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS 2004 BDHS 2007 BDHS Age group 1971- 1975 1984- 1988 1989- 1991 1991- 1993 1994- 1996 1997- 1999 2001- 2003 2004- 2006 15-19 109 182 179 140 147 144 135 126 20-24 289 260 230 196 192 188 192 173 25-29 291 225 188 158 150 165 135 127 30-34 250 169 129 105 96 99 83 70 35-39 185 114 78 56 44 44 41 34 40-44 107 56 36 19 18 18 16 10 45-49 35 18 13 14 6 3 3 1 TFR 15-49 6.3 5.1 4.3 3.4 3.3 3.3 3.0 2.7 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), 1999-2000 BDHS (NIPORT et al., 2001:34) and 2004 BDHS (NIPORT et al., 2005: 53) Another way to assess trends in fertility is by using retrospective data on birth histories collected from respondents to the same survey. This method of examining trends controls for differences in quality between surveys. The age-specific fertility rates for successive five-year periods preceding the 2007 BDHS are presented in Table 4.3.2. The results show that fertility has dropped substantially among all age groups over the past two decades. The largest fertility decline is observed between the two most recent five-year periods. Fertility decline is steepest among the cohort age 30-34, with a 45 percent decline between the period 15-19 years before the survey and the period 0-4 years before the survey. Table 4.3.2 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age at the time of the birth, Bangladesh 2007 Number of years preceding survey Mother's age at birth 0-4 5-9 10-14 15-19 15-19 133 174 187 207 20-24 172 207 226 244 25-29 132 167 177 210 30-34 78 109 124 [142] 35-39 38 55 [76] - 40-44 12 [23] - - 45-49 [1] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Fertility | 51 4.4 CHILDREN EVER BORN AND LIVING Table 4.4 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 2.3, while currently married women have 2.8 births on average. Allowing for mortality of children, Bangladeshi women have, on average, 2.0 living children. Currently married women have an average of 2.4 living children. Currently married women age 45-49 have given birth to an average of 5.0 children, of whom 4.1 survived. Among all women age 15-49, the average number of children who have died per woman is 0.29. Among currently married women, it is 0.34; that is, 12 percent of children born to currently married women have died. The percentage of children 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 7 percent for women age 20-24 to 19 percent for women age 45-49. Nearly three-fourths of women age 15-19 have never given birth. However, this proportion declines to 25 percent among women age 20-24 years and rapidly decreases further for older women, except for a slight increase among women age 45-49. The percentage of women who have never given birth is extremely low, (less than 3 percent among women age 35-44), indicating that childbearing among Bangladeshi women is nearly universal. The percentage of women in their forties who have never had children is an indicator of the level of primary infertility—that is, 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 2007 BDHS results suggest that primary infertility is low, at slightly more than 3 percent. (This estimate does not include secondary infertility, that is, women who may have had one or more births but who are unable to have additional children.) Figure 4.3 Trends in Total Fertility Rate Bangladesh 1971 to 2007 6.3 5.1 4.8 4.3 3.4 3.3 3.3 3.0 2.7 1971-75 1984-88 1986-88 1989-91 1991-93 1994-96 1997-99 2001- 2003 2004- 2006 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Bi rth s pe r w om an 52 | Fertility Table 4.4 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born, and mean number of living children, according to age group, Bangladesh 2007 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 73.4 21.7 4.4 0.4 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 3,019 0.32 0.29 20-24 25.1 36.2 27.9 8.4 2.0 0.2 0.1 0.1 0.0 0.0 0.0 100.0 2

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