Bangladesh Demographic and Health Survey 2014

Publication date: 2016

Bangladesh Demographic and Health Survey 2014 B angladesh 2014 D em ographic and H ealth Survey BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2014 National Institute of Population Research and Training Ministry of Health and Family Welfare Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh The DHS Program ICF International Rockville, Maryland, U.S.A. March 2016 Cover motif: Nakshi Katha tapestry by Suraiya The 2014 Bangladesh Demographic and Health Survey (2014 BDHS) was implemented under the authority of the National Institute of Population Research and Training (NIPORT), Ministry of Health and Family Welfare. The survey was conducted by Mitra and Associates from June to November 2014. Funding was provided by the United States Agency for International Development (USAID)/Bangladesh. ICF International provided technical assistance through The DHS Program, a USAID-funded project. Information about the BDHS may be obtained from the National Institute of Population Research and Training (NIPORT), Azimpur, Dhaka, Bangladesh (Telephone: 5861-1206; Internet: http://www.niport.gov.bd) or from Mitra and Associates, 2/17 Iqbal Road, Mohammadpur, Dhaka, Bangladesh; Telephone: 911-5503; Fax: 912-6806; Internet: www.mitra.bd.com. Information about The DHS Program may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; Telephone: 301-407-6500; Fax: 301-407-6501; E-mail: info@DHSprogram.com; Internet: www.DHSprogram.com. Suggested citation: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. 2016. Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. Contents • iii CONTENTS TABLES AND FIGURES . vii FOREWORD . xiii PREFACE . xv CONTRIBUTORS TO THE REPORT . xvii ABBREVIATIONS . xix MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxiii MAP OF BANGLADESH . xxiv 1 INTRODUCTION . 1 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 2014 Bangladesh Demographic and Health Survey . 4 1.4.1 Survey Objectives and Implementing Organizations . 4 1.4.2 Sample Design . 5 1.4.3 Questionnaires . 5 1.4.4 Training and Fieldwork . 6 1.4.5 Data Processing . 7 1.4.6 Coverage of the Sample . 7 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 9 2.1 Household Characteristics . 10 2.1.1 Water and Sanitation . 10 2.1.2 Housing Characteristics . 13 2.1.3 Household Possessions . 15 2.2 Socioeconomic Status Index . 16 2.3 Household Population by Age and Sex . 17 2.4 Household Composition . 19 2.5 Birth Registration . 19 2.6 School Attendance . 20 2.7 Education of Household Population . 21 2.7.1 Educational Attainment of the Household Population . 21 2.7.2 School Attendance Ratios . 24 2.8 Employment . 26 2.9 Ownership of Mobile Phones . 27 3 CHARACTERISTICS OF RESPONDENTS . 29 3.1 Characteristics of Survey Respondents . 29 3.2 Educational Attainment . 30 3.3 Literacy . 31 3.4 Access to Mass Media . 32 3.5 Employment . 34 3.6 Occupation . 35 3.7 Earnings, Employers, and Continuity of Employment . 37 4 MARRIAGE AND SEXUAL ACTIVITY . 39 4.1 Introduction . 39 4.2 Current Marital Status . 40 iv • Contents 4.3 Age at First Marriage . 41 4.4 Age at First Sexual Intercourse . 43 4.5 Recent Sexual Activity . 44 4.7 Spousal Separation . 45 4.8 Perception Toward Age at First Marriage . 47 5 FERTILITY . 49 5.1 Current Fertility . 50 5.2 Fertility Differentials . 51 5.3 Fertility Trends . 52 5.4 Children Ever Born and Living . 55 5.5 Birth Intervals . 56 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 58 5.7 Menopause . 60 5.8 Age at First Birth . 61 5.9 Teenage Pregnancy and Motherhood . 62 6 FERTILITY PREFERENCES . 65 6.1 Desire for More Children . 65 6.2 Desire to Limit Childbearing . 66 6.3 Ideal Family Size . 68 6.4 Fertility Planning . 69 6.5 Wanted Fertility Rates . 70 6.6 Spousal Agreement in Desired Number of Children . 72 7 FERTILITY REGULATION . 73 7.1 Current Use of Contraception . 74 7.2 Differentials in Current Use of Family Planning . 74 7.3 Trends in Current Use of Family Planning . 76 7.4 Timing of Sterilization. 79 7.5 Knowledge and Use of Menstrual Regulation . 79 7.6 Knowledge of Fertile Period . 80 7.7 Knowledge and Use of ECP . 81 7.8 Knowledge and Practice of Lactational Amenorrhea Method . 82 7.9 Sources of Family Planning Methods . 82 7.10 Use of Social Marketing Brands . 85 7.11 Contraceptive Discontinuation . 86 7.12 Future Use of Contraception . 89 7.13 Reasons for Not Intending to Use Contraception . 90 7.14 Unmet Need for Family Planning Services . 91 7.15 Exposure to Family Planning Messages . 93 7.16 Fieldworker Visits . 95 7.17 Satellite Clinics . 96 7.18 Community Clinics . 97 8 INFANT AND CHILD MORTALITY . 99 8.1 Assessment of Data Quality . 100 8.2 Levels and Trends in Infant and Child Mortality . 101 8.3 Socioeconomic Differentials in Infant and Child Mortality . 103 8.4 Demographic Differentials in Infant and Child Mortality . 104 8.5 Perinatal Mortality . 106 8.6 High-Risk Fertility Behavior . 108 Contents • v 9 MATERNAL AND NEWBORN HEALTH . 111 9.1 Antenatal Care . 112 9.1.1 Antenatal Care Coverage . 112 9.1.2 Place of Antenatal Care . 114 9.1.3 Number of Antenatal Visits . 116 9.1.4 Components of Antenatal Care . 117 9.2 Delivery Care . 118 9.2.1 Place of Delivery. 118 9.2.2 Caesarean Section . 120 9.2.3 Assistance during Delivery . 122 9.3 Postnatal Care for Mothers and Children . 124 9.3.1 Postnatal Checkup for Mother . 124 9.3.2 Postnatal Checkup for the Newborn . 128 9.4 Newborn Care . 130 9.4.1 Care of the Umbilical Cord . 130 9.4.2 Drying and Bathing the Newborn . 132 9.4.3 Essential Newborn Care . 134 10 CHILD HEALTH . 137 10.1 Child’s Size at Birth . 137 10.2 Vaccination of Children . 138 10.2.1 Vaccination Coverage . 139 10.2.2 Differentials in Vaccination Coverage . 140 10.2.3 Trends in Vaccination Coverage . 141 10.3 Childhood Illness and Treatment . 141 10.3.1 Childhood Diarrhea . 141 10.3.2 Treatment of Childhood Diarrhea . 142 10.3.3 Feeding Practices during Diarrhea . 145 10.3.4 Acute Respiratory Infections . 147 10.4 Fever . 148 11 NUTRITION OF CHILDREN AND WOMEN . 151 11.1 Nutritional Status of Children . 152 11.1.1 Measurement of Nutritional Status among Young Children . 152 11.1.2 Data Collection . 153 11.1.3 Levels of Child Malnutrition . 153 11.1.4 Trends in Children’s Nutritional Status . 156 11.2 Breastfeeding and Complementary Feeding . 157 11.2.1 Initiation of Breastfeeding . 157 11.2.2 Prelacteal Feeding . 157 11.3 Breastfeeding Status by Age . 158 11.4 Duration of Breastfeeding . 162 11.5 Types of Complementary Foods . 162 11.6 Infant and Young Child Feeding Practices . 164 11.7 Micronutrient Intake among Children . 167 11.7.1 Consumption of Micronutrient-rich Foods . 167 11.7.2 Micronutrient Supplementation . 169 11.7.3 Deworming . 169 11.8 Nutritional Status of Women . 169 11.9 Micronutrient Intake among Mothers . 173 vi • Contents 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 175 12.1 Knowledge of HIV/AIDS and Transmission and Prevention Methods . 177 12.1.1 Knowledge of HIV/AIDS . 177 12.1.2 Knowledge of HIV Prevention Methods . 177 12.1.3 Comprehensive Knowledge about AIDS . 178 12.2 Knowledge about Mother-to-Child Transmission of HIV . 180 12.3 Knowledge of Means of Transmission of HIV . 181 12.4 Attitude toward Negotiating Safe Sexual Relations with Husbands . 182 12.5 Self-reported Prevalence of Sexually Transmitted Infections (STIs) and STI Symptoms . 183 13 WOMEN’S EMPOWERMENT AND HEALTH SEEKING BEHAVIOR . 187 13.1 Employment and Form of Earnings . 188 13.2 Women’s Control over their Own Earnings . 189 13.3 Freedom of Movement . 190 13.4 Women’s Empowerment . 191 13.5 Attitudes toward Wife Beating . 194 13.6 Indicators of Women’s Empowerment . 195 13.7 Current Use of Contraception by Women’s Empowerment . 196 13.8 Ideal Family Size and Unmet Need by Women’s Empowerment . 197 13.9 Reproductive Health Care by Women’s Empowerment . 198 13.10 Infant and Child Mortality and Women’s Empowerment . 199 14 COMMUNITY CHARACTERISTICS . 201 REFERENCES . 207 APPENDIX A: SAMPLE DESIGN AND IMPLEMENTATION . 213 A.1 Introduction . 213 A.2 Sampling Frame . 213 A.3 Sample Design . 214 A.4 Sampling Weight . 216 APPENDIX B: ESTIMATES OF SAMPLING ERRORS . 219 APPENDIX C: DATA QUALITY TABLES . 233 APPENDIX D: PERSONS INVOLVED IN THE SURVEY . 235 APPENDIX E: QUESTIONNAIRES . 243 APPENDIX F: SUMMARY INDICATORS . 327 Tables and Figures • vii TABLES AND FIGURES 1 INTRODUCTION . 1 Table 1.1 Basic demographic indicators . 2 Table 1.2 Results of the household and individual interviews . 7 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 9 Table 2.1 Household drinking water . 10 Table 2.2 Household sanitation facilities . 11 Table 2.3 Hand washing: availability of cleansing agents . 12 Table 2.4 Hand washing: location . 13 Table 2.5 Housing characteristics . 14 Table 2.6 Cooking amenity . 15 Table 2.7 Household possessions . 15 Table 2.8 Wealth quintiles . 17 Table 2.9 Household population by age, sex, and residence . 17 Table 2.10 Trends in population by age . 19 Table 2.11 Household composition . 19 Table 2.12 Birth registration of children under age 5 . 20 Table 2.13 School attendance . 21 Table 2.14.1 Educational attainment of the male household population . 22 Table 2.14.2 Educational attainment of the female household population . 23 Table 2.15 School attendance ratios . 25 Table 2.16 Employment status . 26 Table 2.17 Availability of mobile phone among household members . 27 Figure 2.1 Availability of electricity by urban-rural residence . 13 Figure 2.2 Population pyramid . 18 Figure 2.3 Household age distribution by sex . 18 Figure 2.4 Trend in completed median of years of schooling of men and women age 6 and over, 1999-2014 . 24 Figure 2.5 Age-specific attendance rates of the de facto population age 5-24 . 26 3 CHARACTERISTICS OF RESPONDENTS . 29 Table 3.1 Background characteristics of respondents . 29 Table 3.2 Educational attainment . 30 Table 3.3 Literacy . 32 Table 3.4 Exposure to mass media . 33 Table 3.5 Employment status . 35 Table 3.6 Occupation . 36 Table 3.7 Type of employment . 37 Figure 3.1 Trends in education of ever-married women, 2007-2014 . 31 Figure 3.2 Trends in exposure to mass media of ever-married women, 2007-2014 . 34 4 MARRIAGE AND SEXUAL ACTIVITY . 39 Table 4.1 Current marital status . 40 Table 4.2 Trends in proportion never married . 40 Table 4.3 Age at first marriage . 41 viii • Tables and Figures Table 4.4 Median age at first marriage by background characteristics . 42 Table 4.5 Age at first sexual intercourse . 43 Table 4.6 Median age at first sexual intercourse by background characteristics . 44 Table 4.7 Recent sexual activity . 45 Table 4.8 Husband’s visit . 46 Table 4.9 Preferred age at first marriage . 47 Figure 4.1 Trends in proportion of women age 20-24 who were first married by age 18 . 42 5 FERTILITY . 49 Table 5.1 Current fertility . 50 Table 5.2 Fertility by background characteristics . 52 Table 5.3.1 Trends in age-specific fertility rates . 53 Table 5.3.2 Trends in current fertility rates. 53 Table 5.4 Children ever born and living . 56 Table 5.5 Birth intervals . 57 Table 5.6 Postpartum amenorrhea, abstinence and insusceptibility . 58 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 60 Table 5.8 Menopause . 60 Table 5.9 Age at first birth . 61 Table 5.10 Median age at first birth . 62 Table 5.11 Teenage pregnancy and motherhood . 63 Figure 5.1 Age-specific fertility rates by urban-rural residence . 51 Figure 5.2 Trends in total fertility rates, 1975-2014 . 54 Figure 5.3 Trends in age-specific fertility rates, 2004-2014 . 54 Figure 5.4 Trends in total fertility by division, 2011 and 2014 . 55 6 FERTILITY PREFERENCES . 65 Table 6.1 Fertility preferences by number of living children . 66 Table 6.2 Desire to limit childbearing . 68 Table 6.3 Ideal number of children by number of living children . 69 Table 6.4 Mean ideal number of children . 69 Table 6.5 Fertility planning status . 70 Table 6.6 Wanted fertility rates . 71 Table 6.7 Comparison in desired number of children . 72 Figure 6.1 Trends in fertility preferences among currently married women age 15-49, 2004-2014 . 66 Figure 6.2 Trends in currently married women with two children who want no more children, 1993-2014 . 67 Figure 6.3 Trends in gap between wanted and unwanted fertility rates, 1993 2014 . 71 7 FERTILITY REGULATION . 73 Table 7.1 Current use of contraception by age . 74 Table 7.2 Current use of contraception by background characteristics . 75 Table 7.3 Trends in current use of contraceptive methods . 77 Table 7.4 Timing of sterilization . 79 Table 7.5 Knowledge and use of menstrual regulation . 80 Table 7.6 Source of service for menstrual regulation in last three years . 80 Table 7.7 Knowledge of fertile period . 81 Tables and Figures • ix Table 7.8 Knowledge and use of ECP by background characteristics by background characteristics . 81 Table 7.9 Knowledge and use of LAM by background characteristics by background characteristics . 82 Table 7.10 Source of modern contraception methods . 83 Table 7.11 Knowledge of source of specific source of family planning method services . 85 Table 7.12 Use of pill brands by residence . 86 Table 7.13 Use of condom brands by residence . 86 Table 7.14 First-year contraceptive discontinuation rates . 87 Table 7.15 Reasons for discontinuation . 88 Table 7.16 Future use of contraception . 89 Table 7.17 Preferred method of contraception for future use . 90 Table 7.18 Reason for not intending to use contraception . 90 Table 7.19 Need and demand for family planning among currently married women . 92 Table 7.20 Exposure to family planning messages . 94 Table 7.21 Contact with family planning fieldworkers: Type of service . 95 Table 7.22 Contact with family planning fieldworkers: Type of fieldworker . 96 Table 7.23 Satellite clinics . 97 Table 7.24 Community clinics . 98 Figure 7.1 Contraceptive use by background characteristics . 76 Figure 7.2 Trends in contraceptive use among currently married women, 1975-2014 . 77 Figure 7.3 Trends in modern method use by age of currently married women, 2011 2014 . 78 Figure 7.4 Trends in use of modern contraceptives by division, 2007-2014. 78 Figure 7.5 Trends in contraceptive method mix among currently married women age 10-49, 1975-2014 . 79 Figure 7.6 Distribution of current users of modern methods by source of supply . 84 Figure 7.7 Trends in source of contraceptive methods, 2004-2014 . 84 Figure 7.8 Trends in all method contraceptive discontinuation rates, 1993/94-2014 . 88 Figure 7.9 Trends in future intention to use contraception by currently married women who are not using a contraceptive method, age 15-49, from 2004-2014 . 89 Figure 7.10 Trends in unmet need for family planning among currently married women age 15-49, 2011 and 2014 BDHS . 93 Figure 7.11 Trends in unmet need for family planning services among currently married women age 15-49, by division, 2011-2014 . 93 8 INFANT AND CHILD MORTALITY . 99 Table 8.1 Early childhood mortality rates . 102 Table 8.2 Trend in early childhood mortality . 102 Table 8.3 Early childhood mortality rates by socioeconomic characteristics . 103 Table 8.4 Early childhood mortality rates by demographic characteristics . 105 Table 8.5 Perinatal mortality . 107 Table 8.6 High-risk fertility behavior . 108 Figure 8.1 Trends in childhood mortality rates, 1989-2014 . 103 Figure 8.2 Under-5 mortality rates by socioeconomic characteristics . 104 Figure 8.3 Under-5 mortality rates by demographic characteristics . 106 9 MATERNAL AND NEWBORN HEALTH . 111 Table 9.1 Antenatal care . 113 Table 9.2 Place of antenatal care . 115 Table 9.3 Number of antenatal care visits . 116 Table 9.4 Components of antenatal care . 118 x • Tables and Figures Table 9.5 Place of delivery . 119 Table 9.6 Length of stay in the health facility after delivery . 121 Table 9.7 Reasons for C-section . 122 Table 9.8 Assistance during delivery . 123 Table 9.9 Postnatal care for mothers and children . 125 Table 9.10 Timing of first postnatal checkup for the mother . 126 Table 9.11 Type of provider of first postnatal checkup for the mother . 127 Table 9.12 Components of postnatal care for the mother . 127 Table 9.13 Timing of first postnatal checkup for the children . 128 Table 9.14 Type of provider of first postnatal checkup for the newborn . 129 Table 9.15 Components of postnatal checkup for the newborn . 129 Table 9.16 Type of instrument used to cut the umbilical cord . 130 Table 9.17 Application of material after the umbilical cord was cut . 132 Table 9.18 Newborn care practices: timing of drying . 133 Table 9.19 Newborn care practices: Timing of first bath . 134 Table 9.20 Essential newborn care . 134 Figure 9.1 Trend in use of antenatal care, 2004-2014 . 114 Figure 9.2 Trend in place of antenatal care, 2011-2014 . 116 Figure 9.3 Trend in number of antenatal care visits, 2004-2014 . 117 Figure 9.4 Trend in facility births, 2004-2014 . 120 Figure 9.5 Health facility delivery by wealth quintile, 2011 and 2014 . 120 Figure 9.6 Trend in births delivered by C-section, 2004-2014 . 121 Figure 9.7 Trend in skilled attendance at deliveries, 2004-2014 . 124 Figure 9.8 Trend in use of postnatal care for women and children from a medically trained provider within two days of delivery, 2004-2014 . 125 Figure 9.9 Trend in use of appropriate cord care, 2007-2014 . 131 Figure 9.10 Trend in use of essential newborn care practices, 2011-2014 . 135 10 CHILD HEALTH . 137 Table 10.1 Child’s size and weight at birth. 138 Table 10.2 Vaccinations by source of information . 139 Table 10.3 Vaccinations by background characteristics . 140 Table 10.4 Prevalence of diarrhea . 142 Table 10.5 Diarrhea treatment . 143 Table 10.6 Diarrhea treatment with ORT and zinc . 145 Table 10.7 Feeding practices during diarrhea . 146 Table 10.8 Prevalence and treatment of symptoms of ARI . 147 Table 10.9 Prevalence and treatment of fever . 149 Table 10.10 First source of treatment of fever . 150 Figure 10.1 Trend in vaccination coverage by age 12 months, 2004-2014 . 141 Figure 10.2 Trend in use of ORT and zinc for treatment of diarrhea in children under age 5, 2007-2014 . 144 11 NUTRITION OF CHILDREN AND WOMEN . 151 Table 11.1 Nutritional status of children . 154 Table 11.2 Initial breastfeeding . 158 Table 11.3 Breastfeeding status by age . 159 Table 11.4 Median duration of breastfeeding . 162 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 163 Table 11.6 Infant and young child feeding (IYCF) practices . 166 Tables and Figures • xi Table 11.7 Micronutrient intake among children . 168 Table 11.8 Nutritional status of ever-married women . 170 Table 11.9 Micronutrient intake among mothers . 173 Figure 11.1 Nutritional status of children by age . 156 Figure 11.2 Trends in nutritional status of children under age 5, 2004-2014 . 156 Figure 11.3 Infant feeding practices by age . 160 Figure 11.4 Trends in exclusive breastfeeding practices among children age 0-5 months, 2004-2014 . 161 Figure 11.5 IYCF indicators on breastfeeding status . 161 Figure 11.6 Trends in complementary feeding for breastfeeding children age 6-9 months . 164 Figure 11.7 Percentage fed according to minimum standard of acceptable feeding practices . 167 Figure 11.8 Percentage of undernourishment (BMI <18.5) among ever-married women age 15-49 years . 171 Figure 11.9 Trends in nutritional status of ever-married women, 2004-2014 . 172 Figure 11.10 Trend in BMI among ever-married women age 15-49, 1996, 2000, 2004, 2007, 2011, and 2014 BDHS . 172 Figure 11.11 Trends in postpartum vitamin A supplementation among mothers, 2004-2014 . 174 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 175 Table 12.1 Knowledge of AIDS . 177 Table 12.2 Knowledge of HIV prevention methods . 178 Table 12.3 Comprehensive knowledge about AIDS . 179 Table 12.4 Knowledge of prevention of mother to child transmission of HIV . 181 Table 12.5 Knowledge of transmission of HIV through unclean needles and unsafe blood transfusions . 182 Table 12.6 Attitudes toward negotiating safer sexual relations with husband . 183 Table 12.7 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 184 Figure 12.1 Comprehensive knowledge about AIDS among ever-married women age 15-49 . 180 Figure 12.2 Care seeking for STIs of women, 2011 and 2014 . 185 13 WOMEN’S EMPOWERMENT AND HEALTH SEEKING BEHAVIOR . 187 Table 13.1 Employment and cash earnings of currently married women . 189 Table 13.2 Control over women’s cash earnings . 190 Table 13.3 Freedom of movement . 191 Table 13.4 Participation in decision-making . 192 Table 13.5 Women’s participation in decision-making by background characteristics . 193 Table 13.6 Women’s attitude toward wife beating . 195 Table 13.7 Indicators of women’s empowerment . 196 Table 13.8 Current use of contraception by women’s empowerment . 197 Table 13.9 Women’s empowerment and ideal number of children and unmet need for family planning . 198 Table 13.10 Reproductive health care by women’s empowerment . 199 Table 13.11 Early childhood mortality rates by women’s empowerment . 200 Figure 13.1 Number of decisions in which currently married women participate, Bangladesh 2014 . 194 xii • Tables and Figures 14 COMMUNITY CHARACTERISTICS . 201 Table 14.1 Distance to the nearest service location . 202 Table 14.2 Distance to the nearest education facility. 202 Table 14.3 Availability of income-generating organizations . 203 Table 14.4 Availability of health facility . 204 Table 14.5 Availability of health and family planning workers . 205 Table 14.6 Availability of family planning and other health services . 205 Table 14.7 Means of transport to upazila headquarters . 205 Table 14.8 Means of transport to district headquarters . 206 APPENDIX A: SAMPLE DESIGN AND IMPLEMENTATION . 213 Table A.1 Percent distribution of households by division and type of residence . 213 Table A.2 Sample allocation of clusters by division and type of residence . 215 Table A.3 Sample allocation of households by division and type of residence . 215 Table A.4 Sample allocation of completed women interviews by division and type of residence . 215 Table A.5 Sample implementation . 216 APPENDIX B: ESTIMATES OF SAMPLING ERRORS . 219 Table B.1 List of selected variables for sampling errors, Bangladesh 2014 . 221 Table B.2 Sampling errors: Total sample, Bangladesh DHS 2014 . 222 Table B.3 Sampling errors: Urban sample, Bangladesh DHS 2014 . 223 Table B.4 Sampling errors: Rural sample, Bangladesh DHS 2014 . 224 Table B.5 Sampling errors: Barisal sample, Bangladesh DHS 2014 . 225 Table B.6 Sampling errors: Chittagong sample, Bangladesh DHS 2014 . 226 Table B.7 Sampling errors: Dhaka sample, Bangladesh DHS 2014 . 227 Table B.8 Sampling errors: Khulna sample, Bangladesh DHS 2014 . 228 Table B.9 Sampling errors: Rajshahi sample, Bangladesh DHS 2014 . 229 Table B.10 Sampling errors: Rangpur sample, Bangladesh DHS 2014 . 230 Table B.11 Sampling errors: Sylhet sample, Bangladesh DHS 2014 . 231 APPENDIX C: DATA QUALITY TABLES . 233 Table C.1 Household age distribution . 233 Table C.2 Age distribution of eligible and interviewed women . 233 Table C.3 Completeness of reporting . 234 Table C.4 Births by calendar years . 234 Table C.5 Reporting of age at death in days . 235 Table C.6 Reporting of age at death in months . 236 Foreword • xiii FOREWORD Secretary Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh angladesh Demographic and Health Survey (BDHS) 2014 is the seventh national-level demographic and health survey designed to provide information to address the monitoring and evaluation needs of the Health, Population and Nutrition Sector Development Program (HPNSDP) and to provide managers and policy makers involved in this program with the information that they need to effectively plan and implement future interventions. The survey generates evidences on basic national indicators of social progress including fertility, childhood mortality, fertility preferences and fertility regulation, maternal and child health, nutritional status of mothers and children, and awareness and attitude towards HIV/AIDS. In addition to presenting the main findings from BDHS 2014 on fertility, family planning, maternal and child health and nutrition, this report highlights the major changes that have taken place in Bangladesh’s demographic and health situation since 1993-94. Results of BDHS 2014 illustrate that Bangladesh has achieved the Millennium Development Goal (MDG) 4 target ahead of time. There are evidences that Bangladesh is moving ahead in achieving MDG 5. Since BDHS 2004, deliveries attended by skilled providers have increased by 2.6 times and deliveries in health facilities have increased by more than 3 times. Khulna and Rangpur divisions have reached HPNSDP target of total fertility rate 2.0. Rajshahi and Barisal divisions are near to reach the target. Fertility also continues to decline in Chittagong and Sylhet divisions. BDHS data show continuous improvement in nutritional status of children. HPNSDP targets for prevalence of stunting and underweight have already been achieved. The findings of this report and its policy and programmatic implications will be instrumental in monitoring and evaluation of HPNSDP and in designing the next HPN sector program in Bangladesh. The need, however, for further detailed analysis of BDHS data remains. I hope 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 program implementation in the coming years. The successful completion of BDHS 2014 was made possible by the contributions of a number of organizations and individuals. I would like to thank NIPORT, Mitra & Associates and ICF International for their efforts in conducting BDHS 2014. I deeply appreciate the United States Agency for International Development (USAID), Bangladesh for providing financial assistance that helped ensure the ultimate success of this important national survey. Syed Monjurul Islam B Preface • xv PREFACE Director General National Institute of Population Research and Training Ministry of Health and Family Welfare angladesh Demographic and Health Survey (BDHS) 2014 is the seventh survey of its kind conducted in Bangladesh. This survey was implemented through a collaborative effort of the National Institute of Population Research and Training (NIPORT), ICF International, USA and Mitra & Associates. The financial support for the survey was provided by the United States Agency for International Development (USAID), Bangladesh. The wealth of demographic and health data that BDHS 2014 provides is essential and instrumental in monitoring and evaluating the performance of the Health, Population and Nutrition Sector Development Program (HPNSDP). BDHS presents estimates for 18 indicators of the Results Framework of HPNSDP and considered as a major source of information for program monitoring. We hope the survey data will assist policymakers and program managers in monitoring and designing programs and strategies for improving health, family planning, and nutrition services in the country. Members of the Technical Review Committee (TRC), consisting of experts from government, Non- government and international organizations as well as researchers and professionals working in the Health Nutrition and Population Sectors were involved and gave their expert opinion in various phases of the survey implementation. A Technical Working Group (TWG) was also formed with the representatives from NIPORT, PMMU-MOHFW, University of Dhaka, icddr,b, USAID/Bangladesh, Save the Children, ICF International and Mitra and Associates for designing the survey questionnaires and the implementation of the survey. I would like to put on record my sincere appreciation to TRC and TWG members for their sincere effort in different stages of the survey. I extend sincere thanks to the Bangladesh Bureau of Statistics (BBS) for their support in selecting sample clusters and providing Enumeration Area (EA) maps for the survey. The preliminary results of BDHS 2014, with its key indicators were released through a dissemination seminar in April 2015. This final report brings more comprehensive analysis of the survey results. Along with the key results, detailed findings and possible interpretations are presented in the final report. This report is an outcome of contributions of the professionals of NIPORT, NIPSOM, University of Dhaka, icddr,b, ICF International, MEASURE Evaluation, USAID/Bangladesh, SMC, and Mitra & Associates. I would like to acknowledge everyone for their contributions to BDHS 2014 Final Report. I would like to congratulate all the professionals of Research Unit of NIPORT for the successful completion of the survey. I also extend my thanks to ICF International and Mitra & Associates for completing the task in a professional manner. Finally, USAID/Bangladesh deserves special thanks for providing technical and financial support for the survey. Rownaq Jahan B Contributors to the Report • xvii CONTRIBUTORS TO THE REPORT Mr. Shahidul Islam, Mitra and Associates Mr. Moinuddin Haider, International Center for Diarrheal Disease Research, Bangladesh Mr. Mohammed Ahsanul Alam, National Institute of Population Research and Training Mr. Md. Rabiul Haque, University of Dhaka Ms. Shahin Sultana, National Institute of Population Research and Training Mr. Shamal Chandra Karmaker, University of Dhaka Mr. Md. Moshiur Rahman, Social Marketing Company Mr. Toslim Uddin Khan, Social Marketing Company Ms. Rashida-E-Ijdi, Measure Evaluation Ms. Shumona Sharmin Salam, International Center for Diarrheal Disease Research, Bangladesh Dr. Afsana Bhuiyan, International Center for Diarrheal Disease Research, Bangladesh Dr. Md. Shafiqul Islam, National Institute of Preventative and Social Medicine Dr. Mahamudul Hasan, International Center for Diarrheal Disease Research, Bangladesh Ms. Shusmita Hossain Khan, Measure Evaluation Mr. Subrata K. Bhadra, National Institute of Population Research and Training Dr. Mahmuda Khatun, University of Dhaka Ms. Sri Poedjastoeti, ICF International Dr. Ahmed Al-Sabir, ICF International Prof. Nitai Chakraborty, ICF International Dr. Kanta Jamil, United States Agency for International Development (USAID)/Bangladesh Abbreviations • xix ABBREVIATIONS AIDS acquired immune deficiency syndrome ANC antenatal care ARI acute respiratory infection ASA Association of Social Advancement ASFR age-specific fertility rates BBS Bangladesh Bureau of Statistics 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 BMMS Bangladesh Maternal Mortality Survey BRAC Bangladesh Rural Advancement Committee CBR crude birth rate CDC Centers for Disease Control and Prevention CPS Contraceptive Prevalence Survey CSBA community-skilled birth attendant DGFP Directorate General of Family Planning 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 FWA family welfare assistant FWV family welfare visitor GAR gross attendance ratio GAVI Global Alliance for Vaccination and Immunization GDP gross domestic product GFR general fertility rate GOB Government of Bangladesh GPI gender parity index GPS global positioning system HA health assistant HDI human development index HIV human immunodeficiency virus HMN Health Metrics Network HNPSP Health, Nutrition and Population Sector Program HPI human poverty index xx • Abbreviations HPNSDP Health, Population and Nutrition Sector Development Program HPSP Health and Population Sector Program ICDDR,B International Center for Diarrhoeal Disease Research, Bangladesh ICPD International Conference on Population and Development IDU injection drug user IMCI integrated management of childhood illness IUD intrauterine device IYCF Infant and Young Child Feeding LAPM long-acting and permanent method LDC least developed country LMP last menstrual period LPG liquid petroleum gas MA medical assistant MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR maternal mortality ratio MOHFW Ministry of Health and Family Welfare MR menstrual regulation MSM men who have sex with men MTCT mother-to-child transmission NAR net attendance ratio NASP National AIDS/STD Programme NCD noncommunicable diseases NGO nongovernmental organization NID National Immunization Day NIPORT National Institute for Population Research and Training NN neonatal mortality ORS oral rehydration salts ORT oral rehydration therapy PHC Population and Housing Census PIP program implementation plan 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 SMC Social Marketing Company 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 Abbreviations • xxi TWFR total wanted fertility rate TWG Technical Working Group UESD Utilization of Essential Service Delivery Survey UNDP United Nations Development Program UNICEF United Nations Children’s Fund UP Union Parishad USAID United States Agency for International Development VAD vitamin A deficiency VAQ verbal autopsy questionnaire WHO World Health Organization Millennium Development Goal Indicators • xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators by sex Bangladesh 2014 Value Goal Female Male Total 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under age 5 33.1 32.2 32.6 2. Achieve universal primary education 2.1 Net enrollment ratio in primary education1 91.4 88.6 89.9 2.3 Literacy rate of 15-24 year olds2 85.9 na na 3. Promote gender equality and empower women 3.1a Ratio of girls to boys in primary education3 na na 1.02 3.1b Ratio of girls to boys in secondary education3 na na 1.04 3.1c Ratio of girls to boys in tertiary education3 na na 0.64 4. Reduce child mortality 4.1 Under-5 mortality rate (per 1000 live births)4 48 44 46 4.2 Infant mortality rate (per 1000 live births)4 39 37 38 4.3 Proportion of 1 year-old children immunized against measles 86.4 85.9 86.1 5. Improve maternal health 5.1 Proportion of births attended by skilled health personnel5 na na 42.1 5.2 Contraceptive prevalence rate6 62.4 na na 5.3 Adolescent birth rate7 113 na na 5.4a Antenatal care coverage: at least one visit by skilled health professional5 63.9 na na 5.4b Antenatal care coverage: at least four visits by any provider5 31.2 na na 5.5 Unmet need for family planning 12.0 na na 6. Combat HIV/AIDS, malaria, and other diseases 6.1 Percentage of population age 15-24 with comprehensive knowledge of HIV/AIDS8 12.7 na na na = Not applicable 1 The ratio is based on reported attendance, not enrollment, in primary education among primary school age children (age 6-10). The rate also includes children of primary school age enrolled in secondary education. This is a proxy for MDG indicator 2.1, Net enrollment ratio. 2 Refers to respondents age 15-24 who attended secondary school or higher or who could read a whole sentence or part of a sentence 3 Based on reported net attendance, not gross enrollment, among 6-10 year-olds for primary, 11-17 year-olds for secondary, and 18-24 year-olds for tertiary education 4 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a five-year reference period preceding the survey. 5 Rate refers to live births in the three years preceding the survey. 6 Percentage of currently married women age 15-49 using any method of contraception 7 Equivalent to the age-specific fertility rate for women age 15-19, expressed in terms of births per 1,000 women age 15-19 8 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. Millennium Development Goal Indicators by residence Bangladesh 2014 Goal Urban Rural Total 7. Ensure environmental sustainability 7.1 Percentage of population using an improved drinking water source1 99.1 97.1 97.6 7.2 Percentage of population with access to improved sanitation2 52.2 46.2 47.8 1 Proportion whose main source of drinking water is a household connection (piped), public standpipe, borehole, protected dug well or spring, or rainwater collection. 2 Improved sanitation technologies are: flush toilet, ventilated improved pit latrine, traditional pit latrine with a slab, or composting toilet. xxiv • Map of Bangladesh Introduction • 1 INTRODUCTION 1 1.1 GEOGRAPHY AND ECONOMY angladesh 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 (see map on facing page). It lies between latitudes 20° 34′ and 26° 38′ north and longitudes 88° 01′ and 92° 41′ east. The Moguls ruled the country from the 13th 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 a part of Pakistan. Bangladesh emerged on March 26, 1971, as an independent country on the world’s map following a war of liberation. Most of Bangladesh is low, flat land that consists of alluvial soil. The most significant feature of the terrain is the extensive network of rivers that is 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 tropical 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 through the end of February. The fertile delta is subject to frequent natural calamities, such as floods, cyclones, tidal bores, and drought. The administrative divisions of the country consist of 7 divisions, 64 districts, and 545 upazilas/thanas. Muslims make up almost 90 percent of the population of Bangladesh, Hindus account for about 9 percent, and other religions constitute the remaining 1 percent (BBS 2014). The national language of Bangladesh is Bangla, which is spoken and understood by all. Industry has emerged as the largest sector of the economy, contributing about 30 percent of the gross domestic product (GDP). The GDP has continued to grow over 6 percent in the last five years and exhibited a robust growth rate of 6.5 percent in fiscal year (FY) 2014-2015 (BBS 2015a). The overall growth was led by the manufacturing and construction sectors, which recorded impressive expansions of 20 and 7 percent, respectively, in FY 2014-2015. The accelerated growth in these sectors was mainly due to huge investments in large and medium-scale industry. Agriculture is the second largest sector of the economy, contributing 16 percent to the total GDP in FY 2014-2015. The largest contributor in the agricultural sector is crops and horticulture (9 percent) followed by the fishery sector (4 percent). The gross national income (GNI) per capita in Bangladesh has increased to US$1,314 in FY 2014-2015 (BBS 2015b). Bangladesh thus becomes a lower middle-income country based on a new income classification of world economies (World Bank 2015). Recent socioeconomic development of Bangladesh is reflected in the human development index (HDI) of the United Nations Development Program (UNDP 2013). Bangladesh’s HDI value for 2014 is 0.570—which is in the medium human development category—positioning the country at 142 out of 188 countries and territories (UNDP 2015). Between 1990 and 2014, the country’s HDI value increased from 0.386 to 0.570, an annual increase of about 1.64 percent. Among the eight South Asian countries, Bangladesh is in fifth position based on HDI rank, following Sri Lanka, Maldives, India, and Bhutan. B 2 • Introduction 1.2 POPULATION Bangladesh is the most densely populated country in the world, excluding city-states such as Singapore, Bahrain, and the Vatican. Table 1.1 summarizes the basic demographic indicators for Bangladesh. According to recent estimates from the Bangladesh Bureau of Statistics (BBS), the population of the country is about 158 million, with a population density of 1,070 persons per square kilometer in 2014. After Census 2011, the population of Bangladesh increased by 8 million, with an annual increase of more than 2.0 million. The growth rate between 2001 and 2011 censuses was 1.37 percent. The life expectancy at birth in Bangladesh is 71 years, with women having slightly longer lifespans than men (72 years versus 69 years). The country is now experiencing a demographic transition. The continuous decline of the natural growth rate is expected to lead to a small population increase in coming decades. In comparison with other countries in the region, Bangladesh is in an intermediate position between low-growth countries, such as Thailand, Sri Lanka, and Myanmar, and medium-growth countries, such as India and Malaysia (BBS 2011). The 2015 projections (medium variant) by the United Nations estimated that the population of Bangladesh in 2050 would be about 202 million (UN 2015). Table 1.1 Basic demographic indicators Demographic indicators from selected sources, Bangladesh 2011 and 2014 Indicators 20111 20142 Population (millions) 149.8 157.9 Intercensal growth rate (percent) 1.37 - Density (population/km2) 1,015 1,070 Percent urban3 28.0 - Life expectancy (year)4 Both 69.0 70.7 Male 67.9 69.1 Female 70.3 71.6 Source: 1 BBS 2012; 2 BBS 2015a; 3 BBS 2014; 4 BBS 2015b 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 of Bangladesh, recognizing the urgency of its goal to achieve moderate population growth, adopted family planning as a government sector program in 1965. The policy to reduce fertility rates has been repeatedly reaffirmed by the government of Bangladesh since the country’s 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). Beginning in 1972, the family planning program received virtually unanimous, high-level political support. All subsequent governments have identified population control as a top priority for government action. This political commitment plays a crucial role in the fertility decline in Bangladesh. In 1976, the government declared the rapid growth of the population to be the country’s number one problem and adopted a broad-based, multisectoral family planning program along with an official population policy (GOB 1994). Population planning was seen as an integral part of the total development process and was incorporated into the successive five-year plans. Policy guidelines and strategies for the population program are formulated by the National Population Council, which is chaired by the country’s prime minister. Introduction • 3 In the mid-1970s the government instituted the deployment of full-time, local family welfare assistants, who served as community-based family planning motivators and distributors. At its height a few years ago, this program had a staff of almost 24,000. During the same period, a social marketing program to promote the sale of birth control pills and condoms was initiated. The population program involves more than 200 nongovernmental organizations (NGOs). Since 1980 the family planning program has emphasized the importance of integrating health and family planning services. The goal is to provide an essential integrated package of high quality, client- centered reproductive and child health care, family planning, communicable disease control, and curative services at a one-stop service point. Since 1998 the health program in Bangladesh has drawn on the sector-wide approach (SWAp). The SWAp program aims to provide a package of essential, quality health care services that respond to population needs, especially those of children, women, the elderly, and the poor. The first SWAp—the Health and Population Sector Program (HPSP)—was formulated as part of the fifth Five-Year Plan (1998-2003). It was followed by the second SWAp, the Health, Nutrition and Population Sector Program (HNPSP), which began in 2003 and expired in June 2011. The Ministry of Health and Family Welfare (MOHFW) initiated the Health, Population, Nutrition Sector Development Program (HPNSDP) for five years, from July 2011 to June 2016. The HPNSDP is the SWAp for the overall improvement of health, population, and nutrition sectors. The main objectives of the HPNSDP are to create conditions that allow the Bangladeshi people to reach and maintain the highest attainable level of health as a fundamental human right and an issue of social justice. The government of Bangladesh (GOB) is working toward achieving Millennium Development Goals (MDGs). Of the eight MDGs, three relate to health (child mortality, maternal health, and HIV/AIDS and malaria), and these could exert a direct impact on the Bangladeshi population. Furthermore, three other goals (universal primary education, poverty eradication, and gender equity) closely relate to human resource development. The revised HPNSDP Program Implementation Plan (PIP) sets out sector-specific strategies to achieve its goal (MOHFW 2014). These strategies are as follows: • Streamline and expand the access to and quality of maternal, neonatal, and child health services, and, in particular, supervised deliveries (MDG 4 and MDG 5). • Revitalize various family planning interventions to attain replacement-level fertility. • Improve and strengthen nutritional services by mainstreaming nutrition within the regular Directorate General for Health Services (DGHS) and Directorate General for Family Planning (DGFP) services (MDG 1). • Strengthen preventive approaches and control programs for communicable diseases (MDG 6). • Expand noncommunicable disease control efforts at all levels by streamlining referral systems and strengthening hospital accreditation and management systems. • Strengthen the various support systems by increasing the health workforce at all service levels, including their capacity building and enhanced focus on coordinated implementation of operational plans, timely procurement, and effective logistic management, financial management, and monitoring and evaluation (M&E). • Strengthen drug management and improve quality drug provision. 4 • Introduction • Pursue priority institutional and policy reforms involving stewardship and oversight functions of the public sector, including quality assurance, community participation, and accountability. HPNSDP has introduced a Results Framework (RFW) with 8 goal levels and 32 intermediate outcome indicators to monitor progress and program impact. A Performance Monitoring Plan (PMP) also elaborates on MOHFW’s commitments to (1) collect specific information for the RFW indicators and (2) assess program progress for decision making. Recently, MOHFW elaborated on the M&E framework for the HPNSDP sector with the lists of the data sources, regular updating of the indicators, and analysis and reporting of results (PMMU 2015). The Bangladesh Demographic and Health Survey (BDHS) is identified as one of the major sources of data for up-to-date information on 6 goals and 12 output levels of RFW indicators of HPNSDP. These are used as a basis to confirm the occurrence of change. 1.4 ORGANIZATION OF THE 2014 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 1.4.1 Survey Objectives and Implementing Organizations The 2014 Bangladesh Demographic and Health Survey (BDHS) is the seventh DHS undertaken in Bangladesh, following those implemented in 1993-94, 1996-97, 1999-2000, 2004, 2007, and 2011. The main objectives of the 2014 BDHS are to: • Provide information to meet the monitoring and evaluation needs of the health, population, and nutrition sector development program (HPNSDP) • Provide program managers and policy makers involved in the program with the information they need to plan and implement future interventions The specific objectives of the 2014 BDHS were as follows: • To provide up-to-date data on demographic rates, particularly fertility and infant, and child mortality rates, at the national and divisional level • To measure the level of contraceptive use of currently married women • To provide data on maternal and child health, including antenatal care, assistance at delivery, postnatal care, newborn care, breastfeeding, immunizations, and prevalence and treatment of diarrhea and other diseases among children under age 5 • To assess the nutritional status of children (under age 5) and women by means of anthropometric measurements (weight and height), and to assess infant and child feeding practices • To provide data on knowledge and attitudes of women about sexually transmitted infections and HIV/AIDS • To measure key education indicators, including school attendance ratios • To provide community-level data on accessibility and availability of health and family planning services The 2014 BDHS was conducted under the authority of the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The survey was implemented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. ICF International of Rockville, Maryland, USA, provided technical assistance to the project as part of its international Demographic and Health Surveys (DHS) Program. The U.S. Agency for International Development (USAID) provided financial support. Introduction • 5 1.4.2 Sample Design The sample for the 2014 BDHS is nationally representative and covers the entire population residing in noninstitutional dwelling units in the country. The survey used a sampling frame from the list of enumeration areas (EAs) of the 2011 Population and Housing Census of the People’s Republic of Bangladesh, provided by the Bangladesh Bureau of Statistics (BBS). The primary sampling unit (PSU) for the survey is an EA created to have an average of about 120 households. Bangladesh is divided into seven administrative divisions: Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet. Each division is divided into zilas, and each zila into upazilas. Each urban area in an upazila is divided into wards, which are further subdivided into mohallas. A rural area in an upazila is divided into union parishads (UPs) and, within UPs, into mouzas. These divisions allow the country as a whole to be separated into rural and urban areas. The survey is based on a two-stage stratified sample of households. In the first stage, 600 EAs were selected with probability proportional to the EA size, with 207 EAs in urban areas and 393 in rural areas. A complete household listing operation was then carried out in all of the selected EAs to provide a sampling frame for the second-stage selection of households. In the second stage of sampling, a systematic sample of 30 households on average was selected per EA to provide statistically reliable estimates of key demographic and health variables for the country as a whole, for urban and rural areas separately, and for each of the seven divisions. With this design, the survey selected 18,000 residential households, which were expected to result in completed interviews with about 18,000 ever-married women (see Appendix A for the details of the sample design). Any analysis using the 2014 BDHS data requires that sampling weights be applied to ensure the actual representation of the survey results at the national and domain levels. Although the weighted distribution of urban-rural households in the survey was based on the urban-rural distribution in the 2011 population census, the sampling weights were adjusted to reflect a modified urban-rural household distribution recently reported by the BBS. After adjusting for undercount and including statistical metropolitan areas (SMAs) among the urban areas, the BBS estimated that the urban population was 28 percent (BBS 2014). The adjustment in the 2014 BDHS sampling weight was to generate a revised urban- rural population distribution and was not expected to lead to any significant differences in the overall survey indicators. 1.4.3 Questionnaires The 2014 BDHS used three types of questionnaires: a Household Questionnaire, a Woman’s Questionnaire, and a Community Questionnaire. The contents of the Household and Woman’s questionnaires 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 Working Group (TWG) that consisted of representatives from NIPORT, Mitra and Associates, International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B), USAID/Bangladesh, and ICF International (see Appendix D for a list of members). Draft questionnaires were then circulated to other interested groups and were reviewed by the 2014 BDHS Technical Review Committee (see Appendix D). The questionnaires were developed in English and then translated into and printed in Bangla. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, current work status, birth registration, and individual possession of mobile phones. The main purpose of the Household Questionnaire was to identify women who were eligible for the individual interview. Information was collected about the dwelling unit, such as the source of water, type of toilet facilities, materials used to construct the floor, roof, and walls, ownership of various consumer goods, and availability of hand washing facilities. In addition, this questionnaire was used to record the height and weight measurements of ever-married women age 15-49 and children under age 6. 6 • Introduction The Woman’s Questionnaire was used to collect information from ever-married women age 15-49. Women were asked questions on the following topics: • Background characteristics (e.g., age, education, religion, media exposure) • Reproductive history • Use and source of family planning methods • Antenatal, delivery, postnatal, and newborn care • Breastfeeding and infant feeding practices • Child immunizations and illnesses • Marriage • Fertility preferences • Husband’s background and respondent’s work • Awareness of AIDS and other sexually transmitted infections The Community Questionnaire was administered in each selected cluster during the household listing operation and included questions about the existence of development organizations in the community and the availability and accessibility of health services and other facilities. During the household listing operation, the geographic coordinates and altitude at the center of each cluster were also recorded using Garmin eTrex Legend H units1. A list of health facilities and health service providers in each selected EA was provided to the interviewing teams to verify information gathered in the Woman’s Questionnaires on the types of facilities accessed and health services personnel seen. The Community Questionnaire was administered to a group of four to six key informants who were knowledgeable about socioeconomic conditions and the availability of health and family planning services/facilities in the cluster. Key informants included community leaders, teachers, government officials, social workers, religious leaders, traditional healers, and health care providers among others. 1.4.4 Training and Fieldwork Fifty-four people were trained to carry out the listing of households, to delineate EAs, and to administer Community Questionnaires. They were also trained in the use of global positioning system (GPS) units to obtain locational coordinates for each selected EA. The training lasted a total of five days from May 14-20, 2014. A household listing operation was carried out in all selected EAs from May 21 to August 17, 2014, in four phases, each about three weeks in duration. Initially, 20 teams of two persons each were deployed to carry out the listing of households and to administer the Community Questionnaires. The number of teams was reduced to 19 in the third phase and to 11 in the final phase. In addition, ten supervisors were deployed to check and verify the work of the listing teams. Training for the fieldworkers of the main survey was conducted from June 1 to 26, 2014. A total of 164 fieldworkers were recruited based on their educational level, prior experience with surveys, maturity, and willingness to spend up to four months on the project. Training included lectures on how to complete the questionnaires, mock interviews between participants, and field practice. A former NIPORT staff member gave a talk about family planning methods and maternal and child health, including HPNSDP. Fieldwork for the BDHS was carried out by interviewing teams, each consisting of one male supervisor, one female field editor, five female interviewers, and one logistics staff person. Data collection was implemented in four phases, starting on June 28, 2014, and ending on November 9, 2014. The number of teams declined with each subsequent phase, starting with 20 teams in the first phase and ending with 16 teams by the end of data collection. Data quality measures were implemented through several activities. There were four quality control teams from Mitra and Associates, each comprised of one male and one female staff person. They were sent 1 http://buy.garmin.com/en-US/US/on-the-trail/discontinued/etrex-legend-h/prod30120.html Introduction • 7 to the field to visit the interviewing teams throughout the data collection period. Moreover, the professionals of the survey team made several visits to check the fieldwork. In addition, NIPORT monitored fieldwork by sending two quality control teams, each comprised of three members. The teams went to the field for about three weeks in each phase. They oversaw use of the household listings and maps, observed one household and one individual interview of each interviewer, and spot-checked the completed questionnaires. The teams also revisited half of the households of one completed cluster for each survey team and checked whether selected households were visited and eligible respondents were properly identified and interviewed. Debriefing sessions were held between fieldworkers’ tours to discuss problems encountered in the field, clarifications, and administrative matters. Data quality was also monitored through field check tables generated concurrently with data processing. The main purpose of the tables was to allow the quality control teams to advise field teams of problems detected during data entry. Representatives from USAID, The DHS Program, and NIPORT, and other Technical Review Committee members, also monitored fieldwork through several field visits. 1.4.5 Data Processing The completed 2014 BDHS questionnaires were periodically returned to Dhaka for data processing at Mitra and Associates. The data processing began shortly after fieldwork commenced. Data processing consisted of office editing, coding of open-ended questions, data entry, and editing of inconsistencies found by the computer program. Eight data entry operators and two data entry supervisors processed the data. Data processing commenced on July 24, 2014, and ended on November 20, 2014. The task was carried out using the Census and Survey Processing System (CSPro), a software jointly developed by the U.S. Census Bureau, ICF Macro, and Serpro S.A. 1.4.6 Coverage of the Sample Table 1.2 shows the results of the household and individual women’s interviews. Among a total of 17,989 selected households, 17,565 were found occupied. Interviews were successfully completed in 17,300, or 99 percent of households. A total of 18,245 ever-married women age 15-49 were identified in these households and 17,863 were interviewed, for a response rate of 98 percent. Response rates for households and eligible women are similar to those in the 2011 BDHS. The principal reason for nonresponse among women was their absence from home despite repeated visits to the household. The response rates do not vary notably by urban-rural residence. Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Bangladesh 2014 Residence Total Result Urban Rural Household interviews Households selected 6,210 11,779 17,989 Households occupied 6,062 11,503 17,565 Households interviewed 5,930 11,370 17,300 Household response rate1 97.8 98.8 98.5 Interviews with women age 15-49 Number of eligible women 6,324 11,921 18,245 Number of eligible women interviewed 6,167 11,696 17,863 Eligible women response rate2 97.5 98.1 97.9 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 9 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 This chapter provides an overview of socioeconomic characteristics of the population, including household conditions, sources of drinking water, sanitation facilities, hand washing practices, availability of electricity, housing facilities, possession of household durable goods, and ownership of a homestead and land. Information on household assets is used to create an indicator of household economic status, the wealth index. This chapter also describes the demographic characteristics of the household population, including age, sex, educational attainment, and employment status. A household in the 2014 BDHS is defined as a person or group of related and unrelated persons who usually live together 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. Information is collected from all usual residents of a selected household (de jure population) as well as persons who stayed in the selected household the night before the interview (de facto population). The difference between these two populations is very small, and all tables in this report refer to the de facto population, unless otherwise specified, to maintain comparability with other BDHS reports. Key Findings • Almost everyone (98 percent) in Bangladesh has access to an improve source of drinking water that is they are having water from pipe, tube well, protected well, rain or bottle. • One in 10 households uses an appropriate water treatment method, which includes boiling, bleaching, filtering, and solar disinfecting. The proportion has not changed since 2011. • Thirty-seven percent of households where a place of washing hands was observed had water and a cleansing agent for hand washing. In 2011, this proportion was 31 percent. • The proportion of households having an improved toilet facility that is not shared with other households increased from 34 percent in 2011 to 45 percent in 2014. Four percent of households lack toilet facilities. • The proportion of households with electricity increased from 60 percent in 2011 to 73 percent in 2014. Eleven percent of households use solar electricity; usage is 15 percent in rural and 3 percent in urban areas. • Eighty-two percent of households use solid fuel for cooking. • Household possession of mobile phones has increased sharply from 78 percent in 2011 to 89 percent in 2014; ownership is 93 percent in urban areas and 87 percent in rural areas. • One-third of the population is under age 15. • Thirteen percent of households are headed by a woman. • Twenty-three percent of men and 27 percent of women age 6 and over have not attended school. • Sixty-five percent of men and 24 percent of women age 8 and over are currently working. • Fifty-three percent of household members age 13 and older own a mobile phone; ownership is 64 percent in urban and 48 percent in rural areas. Forty-five percent of adolescents (age p15-19) own a mobile phone; male adolescents are twice as likely as female adolescents to own a mobile phone (63 percent versus 31 percent). 10 • Housing Characteristics and Household Population 2.1 HOUSEHOLD CHARACTERISTICS Physical characteristics of a household are used to assess the general wellbeing and socioeconomic status of its members. These characteristics include access to safe drinking water and sanitation facilities. Other characteristics are the structure of housing, its crowdedness, and the type of fuel used for cooking. 2.1.1 Water and Sanitation Access to safe water and sanitation are basic determinants of better health. Limited access to safe drinking water and sanitation facilities and poor hygiene are associated with skin diseases, acute respiratory infections (ARIs), and diarrheal diseases, the leading preventable diseases in Bangladesh. ARI remains the leading cause of child deaths in Bangladesh. Diarrheal deaths and prevalence of diarrheal diseases among children under age 5 have declined, although 5 percent of under-5 children were reported to have had diarrhea in the two-week period in 2011 (NIPORT et al. 2013). Table 2.1 presents information on household drinking water by urban-rural residence. Access to an improved source of drinking water is almost universal in Bangladesh (98 percent). The most common source of drinking water in urban areas is a tube well or borehole (67 percent), followed by water piped into the dwelling (14 percent), water piped to the yard or plot (9 percent), and a public tap or standpipe (8 percent). In contrast, a tube well or borehole is practically the only source of drinking water in rural areas (94 percent). For 76 percent of households, the source of drinking water is within the premises. One in five households spends less than 30 minutes round trip to obtain water. As expected, it takes longer to obtain drinking water in rural areas than in urban areas. Table 2.1 Household drinking water Percent distribution of households and de jure population by source, time to collect, and by treatment of drinking water, according to residence, Bangladesh 2014 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 99.1 97.0 97.6 99.1 97.1 97.6 Piped into dwelling 13.7 0.6 4.3 13.7 0.6 4.2 Piped to yard/plot 9.2 1.0 3.3 8.6 0.8 3.0 Public tap/standpipe 8.1 0.6 2.7 7.6 0.6 2.5 Tube well or borehole 67.1 93.9 86.4 68.3 94.3 87.2 Protected well 0.1 0.3 0.2 0.0 0.3 0.2 Rain water 0.2 0.5 0.4 0.2 0.4 0.3 Bottled water 0.9 0.1 0.3 0.7 0.1 0.3 Non-improved source 0.8 2.8 2.2 0.8 2.7 2.2 Unprotected well 0.0 0.9 0.6 0.0 0.8 0.6 Unprotected spring 0.0 0.4 0.3 0.0 0.4 0.3 Tanker truck/cart with drum 0.5 0.0 0.2 0.5 0.0 0.2 Surface water 0.3 1.5 1.2 0.3 1.5 1.2 Other 0.1 0.2 0.1 0.1 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 99.1 97.0 97.6 99.1 97.1 97.6 Time to obtain drinking water (round trip) Water on premises 78.7 74.3 75.5 78.6 74.1 75.4 Less than 30 minutes 17.7 21.2 20.2 17.8 21.2 20.3 30 minutes or longer 3.3 4.4 4.1 3.3 4.6 4.2 Don’t know/missing 0.3 0.1 0.2 0.3 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 18.8 0.8 5.8 18.6 0.7 5.6 Bleach/chlorine added 0.4 0.2 0.2 0.4 0.2 0.2 Strained through cloth 2.6 0.7 1.3 2.6 0.7 1.2 Ceramic, sand, or other filter 10.9 2.1 4.6 11.1 2.1 4.6 Other 0.2 0.1 0.2 0.2 0.1 0.1 No treatment 73.1 95.9 89.5 73.2 96.0 89.8 Percentage using an appropriate treatment method2 26.5 3.4 9.9 26.4 3.4 9.7 Number 4,844 12,456 17,300 21,101 56,225 77,326 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. Housing Characteristics and Household Population • 11 Nationally, 10 percent of households use an appropriate water treatment method, which has not changed since 2011 (NIPORT et al. 2013). Rural households are much less likely than urban households to treat their water appropriately (3 percent and 27 percent, respectively). Overall, boiling water prior to drinking is the most common treatment method (6 percent). However, only one in five urban households boil the water for drinking, while less than 1 percent of rural households do so. Households without proper sanitation facilities have a greater risk of diseases like diarrhea, dysentery, and typhoid than households with improved sanitation facilities that are not shared with other households. Table 2.2 shows that 45 percent of households have an improved (not shared) toilet facility, which increased from 34 percent in 2011 (NIPORT et al. 2013). Another 24 percent of households use a facility that would be considered improved if it were not shared with other households. Facilities that are shared are not considered to be as hygienic as those that are not shared. About one-third of the households use a non-improved toilet facility (31 percent); 22 percent of households use pit latrines without slabs, and 3 percent use a hanging toilet. Four percent of households have no toilet facility, nearly unchanged since 2011, when 5 percent of households had no toilet facility (NIPORT et al. 2013). Rural households are more likely than urban households to have no toilet facility (5 percent versus 1 percent). Although the majority of households (65 percent) do not share their toilet, rural households are more likely than urban households to use a toilet facility that is not shared (67 versus 58 percent, respectively). However, rural households are twice as likely to have non-improved toilet facilities as urban households (36 compared with 19 percent). Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Bangladesh 2014 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility 48.6 43.6 45.0 52.2 46.2 47.8 Flush/pour flush to piped sewer system 6.5 0.2 2.0 6.7 0.2 2.0 Flush/pour flush to septic tank 15.8 4.5 7.6 17.0 5.0 8.2 Flush/pour flush to pit latrine 1.3 0.7 0.9 1.3 0.7 0.9 Ventilated improved pit (VIP) latrine 11.1 10.9 11.0 11.9 11.6 11.7 Pit latrine with slab 13.8 27.3 23.5 15.3 28.7 25.1 Shared facility1 32.6 20.3 23.8 29.5 17.7 20.9 Flush/pour flush to piped sewer system 4.6 0.1 1.3 4.1 0.1 1.2 Flush/pour flush to septic tank 8.1 1.7 3.5 7.0 1.4 3.0 Flush/pour flush to pit latrine 1.0 0.3 0.5 0.9 0.2 0.4 Ventilated improved pit (VIP) latrine 7.4 4.0 5.0 6.9 3.7 4.5 Pit latrine with slab 11.5 14.3 13.6 10.7 12.3 11.8 Non-improved facility 18.9 36.0 31.2 18.3 36.1 31.3 Flush/pour flush not to sewer/septic tank/pit latrine 8.3 0.4 2.6 7.7 0.3 2.3 Pit latrine without slab/open pit 8.6 26.9 21.8 8.7 27.4 22.3 Hanging toilet/hanging latrine 1.0 3.9 3.1 1.0 4.2 3.3 No facility/bush/field 1.0 4.7 3.7 0.9 4.2 3.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Shared sanitation facility Not shared 57.7 67.3 64.6 61.8 71.2 68.7 Shared with 1-4 households 23.9 28.7 27.3 21.6 25.2 24.2 5-9 households 10.4 3.2 5.2 9.2 2.8 4.6 10 + households 7.9 0.8 2.8 7.3 0.7 2.5 Don’t know/missing 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 Number 4,844 12,456 17,300 21,101 56,225 77,326 1 Shared facility of an otherwise improved type Hand washing, which protects against communicable diseases, is promoted by the government of Bangladesh and its development partners. Table 2.3 provides information on designated places for hand washing in households and on the use of water and cleansing agents for washing hands, according to place of residence (urban or rural), divisions, and wealth quintiles. 12 • Housing Characteristics and Household Population In the 2014 BDHS, interviewers were instructed to observe the place where household members usually wash their hands. They looked for regularity of water supply, observed whether the household had cleansing agents near the place of hand washing, and noted the location of the place of hand washing. The interviewers found designated places for hand washing in almost all the households (96 percent), an improvement since 2011, when 86 households had a designated place for hand washing (NIPORT et al. 2013). Twenty-nine percent of households have soap and water in the place where household members wash their hands, 8 percent have water and other cleansing agents (ash, mud, sand, etc.), and the majority (59 percent) have water only. Overall, 4 percent of households do not have water, soap, or any cleansing agent. Forty-eight percent of urban households have soap and water compared with 21 percent of rural households. Availability of hand washing facilities with soap and water varies across divisions, ranging from 32 percent of households in Dhaka and Chittagong to 20 percent in Barisal. The use of soap and water for hand washing increases with an increase in household wealth. For example, use of soap and water is lowest among households in the lowest wealth quintile (6 percent) and highest (75 percent) among those in the highest wealth quintile. Table 2.3 Hand washing: availability of cleansing agents Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, Bangladesh 2014 Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed Number of households with place for hand washing observed Background characteristics Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Missing Total Residence Urban 98.2 4,844 47.9 5.5 43.8 0.1 0.0 2.5 0.1 100.0 4,758 Rural 94.5 12,456 20.9 9.4 64.9 0.2 0.3 4.3 0.1 100.0 11,765 Division Barisal 90.7 1,071 19.9 8.7 68.4 0.0 0.0 3.0 0.0 100.0 972 Chittagong 92.9 3,098 31.8 4.3 59.6 0.1 0.1 4.1 0.0 100.0 2,879 Dhaka 96.6 6,047 31.6 8.9 56.9 0.0 0.3 2.1 0.1 100.0 5,843 Khulna 98.1 1,786 24.7 7.8 61.9 0.2 0.1 5.1 0.2 100.0 1,752 Rajshahi 96.8 2,125 28.3 10.0 54.1 0.5 0.3 6.7 0.0 100.0 2,058 Rangpur 97.8 2,023 27.4 13.1 57.5 0.2 0.2 1.6 0.1 100.0 1,979 Sylhet 90.6 1,150 21.2 4.1 64.6 0.8 0.0 9.2 0.1 100.0 1,042 Wealth quintile Lowest 89.9 3,523 5.7 9.2 76.7 0.1 0.7 7.4 0.1 100.0 3,166 Second 94.0 3,498 8.2 11.5 74.7 0.1 0.1 5.3 0.1 100.0 3,288 Middle 96.5 3,393 18.0 11.4 66.4 0.2 0.1 3.8 0.0 100.0 3,275 Fourth 98.0 3,447 33.9 8.0 55.8 0.2 0.1 1.9 0.2 100.0 3,377 Highest 99.4 3,438 74.5 1.7 22.6 0.2 0.0 0.8 0.1 100.0 3,418 Total 95.5 17,300 28.6 8.3 58.8 0.2 0.2 3.8 0.1 100.0 16,524 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent Table 2.4 shows that 25 percent of households have a designated place for hand washing, which is covered and located inside the dwelling. For 31 percent of households, this place is in open space but not shared, and for the remaining 44 percent of households the hand washing place is in an open space and shared. Urban households are more likely to have a covered place for hand washing located inside the dwelling (46 percent) compared with rural households (17 percent). Only 6 percent of households in the lowest wealth quintile were observed to have a place for hand washing that is covered and located inside the dwelling, compared with 68 percent of households in the highest wealth quintile. Housing Characteristics and Household Population • 13 Table 2.4 Hand washing: location Among households in which the place for washing hands was observed, percent distribution by type of place for hand washing, by background characteristics, Bangladesh 2014 Background characteristics Covered, inside dwelling Open space, not shared Open space, shared Total Number of households with place for hand washing observed Residence Urban 46.1 19.4 34.5 100.0 4,758 Rural 16.9 35.4 47.7 100.0 11,765 Division Barisal 14.0 26.4 59.6 100.0 972 Chittagong 29.1 27.6 43.3 100.0 2,879 Dhaka 29.2 26.9 43.8 100.0 5,843 Khulna 17.3 38.5 44.2 100.0 1,752 Rajshahi 23.9 35.0 41.1 100.0 2,058 Rangpur 23.1 42.5 34.2 100.0 1,979 Sylhet 23.5 22.0 54.4 100.0 1,042 Wealth quintile Lowest 5.6 33.3 61.1 100.0 3,166 Second 7.4 35.3 57.3 100.0 3,288 Middle 13.8 39.0 47.2 100.0 3,275 Fourth 28.8 30.5 40.5 100.0 3,377 Highest 68.3 16.6 15.2 100.0 3,418 Total 25.3 30.8 43.9 100.0 16,524 Note: Total may not sum to 100 percent due to missing cases. 2.1.2 Housing Characteristics Housing characteristics and household assets can be used to measure the socioeconomic status of household members. Figure 2.1 shows that 73 percent of households in Bangladesh have access to electricity, either from the national grid or solar power connections. Independently, the national grid covers 62 percent of households throughout the country, with more coverage in urban areas (91 percent) and less in rural areas (51 percent). In contrast, solar power is predominantly used in rural areas (15 percent, compared with 3 percent in urban areas) and independently serves 11 percent of households in Bangladesh. Overall, access to electricity, either from the national grid or solar power, has increased substantially in the last three years, from 60 percent in 2011 to 73 percent in 2014. This expansion took place mostly in rural areas (from 49 percent in 2011 to 65 percent in 2014) rather than in urban areas (from 90 percent in 2011 to 93 percent in 2014) (NIPORT et al. 2013). Figure 2.1 Availability of electricity by urban-rural residence 3 15 11 91 51 62 93 65 73 Urban Rural Total Percent Solar National grid National grid or solar BDHS 2014 14 • Housing Characteristics and Household Population Table 2.5 presents information on type of flooring material, type of roof and wall materials, and number of rooms for sleeping. Earth and sand are the most common flooring materials used in Bangladesh (68 percent). These materials are predominantly used in rural areas (82 percent), while in urban areas the most common flooring material is cement (61 percent). Tin is the most common roofing material in Bangladesh. Overall 85 percent of households live in dwellings with tin roofs. There is a large urban-rural difference in the use of cement or ceramic tiles for roofs. Households in urban areas are more than five times as likely to use cement tiles as households in rural areas. Tin is the predominant material of outer walls in 2014 (43 percent), while in the 2007 BDHS walls in 40 percent of households were made of natural materials such as cane, palm, trunks, dirt, or bamboo with mud (NIPORT et al. 2009). Twenty-six percent of households have walls made of cement. Rural households are more likely to have walls made of tin (48 percent) than urban households (30 percent). On the other hand, urban households are more than three times as likely to have cement walls (53 percent) as rural households (16 percent). The number of rooms used for sleeping indicates the extent of crowding in households. Overcrowding increases the risk of contracting infectious diseases, such as tuberculosis, measles, and meningitis (Aaby, P. 1988; Acevedo-Garcia, D. 2000; Alirol, E. et al. 2011). One in three households has only one room for sleeping. The proportion of households using one room for sleeping has decreased from 40 percent in 2007 to 35 percent in 2011 to 33 percent in 2014 (NIPORT et al. 2009; NIPORT et al. 2013). There are small differences in the number of rooms used for sleeping by urban-rural residence. Another measure of crowdedness is the number of persons per sleeping room households. The last panel in Table 2.5 shows that in two thirds of households a sleeping room is shared by one or two persons. In the remaining 35 percent of households, sleeping rooms are shared by three or more persons. Comparison with data from the 1993-94 BDHS reveals that the proportion of households with three or more persons per sleeping room has decreased from 65 percent in 1993-94 to 35 percent in 2014 (Mitra et al. 1994). This is an evidence that households are much less crowded in 2014 than two decades ago. There are only slight differences between urban and rural households in the extent of crowding. 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 influence indoor air quality and the degree to which household members are exposed to the risk of respiratory infections and other diseases. Table 2.6 presents information on type of fuel used for cooking and place where cooking is done. In Bangladesh, the risk of indoor pollution from cooking fuel is limited because only 15 percent of households cook in the house; 68 percent of households cook in a separate building, and 17 percent cook outdoors. Urban households are much more likely than rural households to cook in the house (28 versus 10 percent, respectively). Table 2.5 Housing characteristics Percent distribution of households by housing characteristics, according to residence, Bangladesh 2014 Housing characteristics Residence Total Urban Rural Flooring material1 Earth, sand 32.5 81.5 67.8 Wood planks 0.4 0.2 0.2 Ceramic tiles 5.6 0.3 1.8 Cement 61.0 17.7 29.8 Roof materials Natural roof 0.2 1.7 1.3 Palm/bamboo 0.1 0.1 0.1 Wood plank/card board 0.1 0.0 0.0 Tin 70.0 90.8 85.0 Wood 0.2 0.2 0.2 Ceramic tiles 0.5 0.1 0.2 Cement 28.4 5.3 11.8 Roofing shingles 0.3 1.5 1.1 Other 0.1 0.3 0.2 Wall materials Jute stick/palm trunk 0.8 2.9 2.3 Mud/dirt 4.4 14.5 11.7 Bamboo with mud 4.5 8.9 7.7 Tin 30.2 48.3 43.3 Cement 52.6 15.9 26.2 Stone with lime/cement 1.6 0.5 0.8 Bricks 4.9 7.0 6.4 Wood planks 0.6 1.1 1.0 Other 0.3 0.9 0.7 Rooms used for sleeping One 37.2 31.7 33.2 Two 36.2 37.7 37.3 Three or more 26.7 30.6 29.5 Total 100.0 100.0 100.0 Persons per sleeping room 1-2 63.2 66.2 65.3 3-4 29.1 26.4 27.2 5-6 6.5 6.5 6.5 7+ 1.2 0.8 1.0 Total 100.0 100.0 100.0 Number 4,844 12,456 17,300 1“Other” flooring material is a combination of palm, bamboo, parquet, polished wood, and carpet Housing Characteristics and Household Population • 15 Overall, 82 percent of households use solid fuel, including wood, agricultural crops, animal dung, straw, shrubs, grass, and charcoal: 50 percent in urban areas and virtually all (95 percent) in rural areas. The proportion of households that rely on wood for fuel has increased from 45 percent in 2011 to 50 percent in 2014. The increase occurred in both urban (35 percent in 2011 to 37 percent in 2014) and rural areas (48 percent in 2011 to 55 percent in 2014). As expected, use of liquid petroleum gas, natural gas, and biogas is mostly limited to urban areas (48 percent). Reducing the proportion of the population that relies on solid fuels is one of the Millennium Development Goals. The 2014 BDHS shows that Bangladesh is gradually making progress toward this goal. The proportion of households that use solid fuel in Bangladesh continues to decline from 91 percent in 2007 to 86 percent in 2011 and to 82 percent in 2014 (NIPORT et al. 2009; NIPORT et al. 2013). 2.1.3 Household Possessions Possession of durable consumer goods is another useful indicator of household socioeconomic status. The possession and use of household durable goods have multiple effects and implications. For instance, access to a radio or television exposes household members to updated daily events, information, and educational materials. Similarly, a refrigerator prolongs food storage and keeps food fresh and hygienic. Ownership of transportation allows greater access to services away from the local area and enhances social and economic activities. Table 2.7 shows that mobile telephones are the most common information and communication device possessed in Bangladesh. Possession of mobile phones has increased sharply from 78 percent in 2011 to 89 percent in 2014. Mobile phones have been widely available in the majority of households since 2011. In rural areas possession of mobile phones increased from 75 percent in 2011 to 87 percent in 2014, while in urban areas the corresponding increase was from 89 percent in 2011 to 93 percent in 2014 (NIPORT et al. 2013). Table 2.6 Cooking amenity Percent distribution of households by place for cooking and type of cooking fuel, and percentage using solid fuel for cooking, according to residence, Bangladesh 2014 Residence Total Housing characteristic Urban Rural Place for cooking In the house 28.0 9.9 15.0 In a separate building 60.1 71.3 68.1 Outdoors 11.7 18.7 16.7 No food cooked in household 0.1 0.1 0.1 Total 100.0 100.0 100.0 Cooking fuel Electricity 1.2 0.1 0.4 LPG/natural gas/biogas 48.0 4.8 16.9 Kerosene 0.3 0.1 0.1 Coal/lignite 0.1 0.2 0.2 Charcoal 0.3 0.2 0.3 Wood 36.9 54.6 49.6 Straw/shrubs/grass 1.1 1.1 1.1 Agricultural crop 9.0 30.3 24.3 Animal dung 2.6 8.5 6.8 Other 0.4 0.1 0.2 No food cooked in household 0.1 0.1 0.1 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 50.0 94.9 82.3 Number 4,844 12,456 17,300 LPG = Liquid petroleum gas 1Includes coal/lignite, charcoal, wood, straw/shrubs/grass, agricultural crops, and animal dung. Table 2.7 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Bangladesh 2014 Residence Total Possession Urban Rural Ownership of durable goods Radio 3.2 3.6 3.5 Television 70.6 33.0 43.5 Mobile telephone 93.4 86.7 88.5 Non-mobile telephone 4.2 0.5 1.6 Refrigerator 40.6 12.3 20.2 Almirah/wardrobe 59.9 38.6 44.6 Electric fan 85.9 48.5 59.0 DVD/VCD player 12.1 4.8 6.8 Water pump 10.9 5.7 7.1 IPS/generator 7.1 1.0 2.7 Air conditioning 1.3 0.1 0.4 Computer/laptop 11.8 2.4 5.1 Ownership of transport Car/truck/microbus 1.2 0.6 0.8 Autobike/tempo/CNG 1.1 2.0 1.8 Rickshaw/van 5.5 5.5 5.5 Bicycle 16.7 28.4 25.1 Motorcycle/motor scooter 8.0 5.7 6.4 Ownership of agricultural land Homestead 87.4 93.5 91.8 Other land 36.6 48.5 45.2 Neither 10.4 5.9 7.2 Ownership of farm animals Bulls/buffaloes 0.0 0.3 0.3 Cows 11.1 41.3 32.8 Goats/sheep 6.6 24.3 19.3 Chicken/ducks 23.7 67.0 54.9 Number 4,844 12,456 17,300 16 • Housing Characteristics and Household Population The proportion of households possessing a television has increased from 40 percent in 2011 to 44 percent in 2014. Televisions are more likely to be found in urban households (71 percent) than in rural households (33 percent). In contrast, possession of a radio has decreased from 8 percent in 2011 to 4 percent in 2014. A refrigerator is available in 20 percent of households, with urban households more than three times as likely (41 percent) as rural households (12 percent) to own one. Six in ten households possess an electric fan; 86 percent in urban areas and 49 percent in rural areas. Seven percent of households own a DVD/VCD player; 12 percent in urban areas and 5 percent in rural areas. Bicycling is the most common means of transportation in Bangladesh; 25 percent of households own a bicycle, and ownership is much more common in rural areas (28 percent) than in urban areas (17 percent). Only 6 percent of households own a rickshaw or van (person-driven three wheeler), with no difference between rural and urban households. Only 6 percent of households own a motorcycle/motor scooter. Ninety-two percent of households own a homestead, while 45 percent own land other than a homestead. Ownership of a homestead or other land is less common in urban than in rural areas. Ownership of land other than a homestead showed a slight decline from 47 percent in 2011 to 45 percent in 2014; 49 percent of urban households and 37 percent of rural households owned other land (NIPORT et al. 2013). Fifty-five percent of households own chicken or ducks, the most commonly owned type of livestock. One-third of households owns cows, and one in five households owns goats or sheep. As expected, rural households are more likely than urban households to own any type of livestock. 2.2 SOCIOECONOMIC STATUS INDEX The wealth index used in this survey is a measure that has been used in many DHS and other country-level surveys to measure inequalities: in household characteristics, in the use of health and other services, and in health outcomes (Rutstein et al. 2000). It serves as an indicator of household-level wealth that is consistent with expenditure and income measures (Rutstein 1999). The index is constructed using household asset data via principal components analysis. In its current form, which takes better account of urban-rural differences in scores and indicators of wealth, the wealth index is created in three steps. In the first step, a subset of indicators common to urban and rural areas is used to create wealth scores for households in both areas. Categorical variables are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then examined using a principal components analysis to produce a common factor score for each household. In the second step, separate factor scores are produced for households in urban and rural areas using area- specific indicators. The third step combines the separate area-specific factor scores to produce a nationally- applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. This three-step procedure permits greater adaptability of the wealth index in both urban and rural areas. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are obtained by assigning the household score to each de jure household member, ranking each person in the population by his or her score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. Table 2.8 presents the wealth quintiles by urban-rural residence and administrative division. There are sharp differences between urban and rural areas. Half of the urban population (49 percent) is in the highest wealth quintile, compared with 9 percent in rural areas. Among the administrative divisions, people in Dhaka are more likely to fall in the highest wealth quintile than people in other divisions. In contrast, Rangpur and Sylhet divisions have the highest proportion of the population in the lowest wealth quintile (30 and 29 percent, respectively). Housing Characteristics and Household Population • 17 Table 2.8 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini Coefficient, according to residence and region, Bangladesh 2014 Wealth quintile Total Number of persons Gini coefficient Residence/region Lowest Second Middle Fourth Highest Residence Urban 7.1 5.8 12.1 25.6 49.4 100.0 21,101 24.32 Rural 24.8 25.3 23.0 17.9 8.9 100.0 56,225 37.80 Division Barisal 21.1 30.1 19.8 15.0 14.0 100.0 4,883 28.55 Chittagong 14.5 17.6 22.2 22.7 23.1 100.0 14,998 35.93 Dhaka 16.7 16.1 16.1 23.0 28.0 100.0 26,248 35.48 Khulna 17.9 21.0 23.4 21.5 16.3 100.0 7,407 29.23 Rajshahi 23.3 21.9 24.3 18.9 11.5 100.0 8,729 28.12 Rangpur 30.4 26.2 22.1 12.9 8.5 100.0 8,575 24.19 Sylhet 29.4 21.8 18.6 14.5 15.8 100.0 6,484 31.04 Total 20.0 20.0 20.0 20.0 20.0 100.0 77,326 30.50 Table 2.8 also includes information on the Gini coefficient, which indicates the level of concentration of wealth. This ratio is expressed as a proportion between 0 and 1, 0 being an equal distribution and 1 being a totally unequal distribution. Wealth inequality, as measured by the Gini coefficient, is higher in rural than in urban areas (38 percent versus 24 percent). Inequality in wealth is similar in Dhaka and Chittagong (35 percent and 36 percent, respectively). Inequality in Dhaka has declined from 41 percent in 2011 to 35 percent in 2014. On the other hand, it increased slightly in Chittagong from 33 percent in 2011 to 36 percent in 2014. In all other divisions inequality shows a slight decline between 2011 and 2014 (NIPORT et al. 2013). 2.3 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.9 shows the distribution of the de facto household population by age, sex, and residence. The 2014 BDHS enumerated a total of 77,313 persons (37,672 males and 39,641 females). The sex ratio is 95 males per 100 females. This is similar to the sex ratio of 93 males per 100 females obtained in the 2011 BDHS, but it is lower than the ratio of 100.3 males per 100 females obtained in the 2011 Census (BBS 2011). The marked difference in the sex ratio between the 2011 Census and the BDHS surveys could be because the census’s 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. One-third of the de facto household population (33 percent) is under age 15, and 10 percent is under age 5. People age 65 and older account for 6 percent of the total population. The proportion of population under age 15 is lower in urban than rural areas, as is the proportion of population older than age 65. Table 2.9 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 2014 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 10.2 9.0 9.6 11.3 9.9 10.6 11.0 9.6 10.3 5-9 10.6 9.8 10.2 12.3 11.0 11.6 11.8 10.7 11.2 10-14 10.3 10.9 10.6 13.1 11.8 12.4 12.3 11.5 11.9 15-19 9.7 11.9 10.9 9.3 11.3 10.3 9.4 11.5 10.5 20-24 7.7 10.7 9.2 6.4 9.5 8.0 6.7 9.8 8.3 25-29 9.1 9.7 9.4 7.0 8.8 7.9 7.6 9.1 8.3 30-34 7.5 8.4 8.0 6.3 7.6 7.0 6.7 7.9 7.3 35-39 7.0 6.3 6.7 6.1 5.9 6.0 6.3 6.0 6.2 40-44 6.5 6.0 6.2 5.4 5.2 5.3 5.7 5.4 5.6 45-49 5.2 4.8 5.0 4.4 4.5 4.4 4.6 4.6 4.6 50-54 4.2 3.1 3.6 4.6 3.1 3.8 4.5 3.1 3.8 55-59 3.4 3.0 3.2 3.4 3.8 3.6 3.4 3.6 3.5 60-64 3.2 2.2 2.7 3.4 2.8 3.1 3.4 2.6 3.0 65-69 2.1 1.4 1.7 2.5 1.7 2.1 2.4 1.6 2.0 70-74 1.5 1.2 1.4 2.0 1.2 1.6 1.9 1.2 1.5 75-79 0.8 0.6 0.7 1.0 0.5 0.8 1.0 0.5 0.8 80+ 0.8 0.9 0.9 1.5 1.3 1.4 1.3 1.2 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 10,443 10,778 21,221 27,229 28,862 56,092 37,672 39,641 77,313 18 • Housing Characteristics and Household Population The age-sex structure of the population is shown by the population pyramid in Figure 2.2. 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 2.3 shows the distribution of the male and female household populations by single years of age. The figure shows that age reporting is less accurate for males than for females. Age heaping is prominent at specific ages, such as 10 and 18, for males and females. Figure 2.2 Population pyramid Figure 2.3 Household age distribution by sex 0.0 1.0 2.0 3.0 4.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 Percent Age (years) Women Men BDHS 2014 Housing Characteristics and Household Population • 19 Table 2.10 presents changes in the broad age structure of the population since 1989. The proportion of population under age 15 has declined from 43 percent in 1989 to 34 percent in 2014. In contrast, populations age 15-59 and age 60 and over have increased over time. Table 2.10 Trends in population by age Percent distribution of the de facto population by age group, selected sources, Bangladesh 1989-2014 Age group 1989 BFS 1989 CPS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS <15 43.2 43.2 42.7 42.6 41.0 39.2 38.2 36.3 35.3 33.5 15-59 50.9 50.9 51.2 51.2 53.1 54.4 55.1 56.6 56.5 58.0 60+ 5.9 5.9 6.0 6.2 5.9 6.4 6.6 7.1 8.2 8.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 BFS = Bangladesh Fertility Survey; CPS = Contraceptive Prevalence Survey; BDHS = Bangladesh Demographic and Health Survey Sources: Huq and Cleland 1990:38; Mitra et al. 1994:14; Mitra et al. 1997:9; NIPORT et al. 2001:11; NIPORT et al. 2005:13; NIPORT et al. 2009:12, NIPORT et al. 2013:20. 2.4 HOUSEHOLD COMPOSITION Information on household composition is critical to an understanding of family size and household headship, which can be used to plan meaningful population-based policies and programs. Household composition is also a determinant of general health status and well-being. Table 2.11 presents information on household composition. The majority (88 percent) of households are headed by men. The proportion of female-headed households has increased from 11 percent in 2011 to 13 percent in 2014, with no urban-rural difference. More than half of the households in Bangladesh are composed of two to four members. The overall average household size is 4.5 persons, as compared with 4.6 in 2011. The household size is slightly larger in rural (4.5 persons) than in urban areas (4.4 persons). 2.5 BIRTH REGISTRATION According to the amended Birth and Death Registration Act of 2004, which came into force in 2006, all children born in Bangladesh must be registered within 45 days of birth and have a birth certificate (http://bdlaws.minlaw.gov.bd/bangla_all_sections.php?id=921). The act empowers all union councils, municipalities, cantonment boards, city corporations, and Bangladesh missions to act as birth registration registrars. In 2010, the government initiated an online birth registration system with 5,082 offices administering registrations online. To keep the birth and death database permanent and dynamic, the government amended the existing law of birth and death registration in 2013 and announced the establishment of the Office of the Registrar General of Birth and Death, which is yet to be set up (http://br.lgd.gov.bd/english.html). Birth certificates are made mandatory for school enrolment, passports, marriage registrations, job applications, driving licenses, insurance policies, land registrations, voter registrations, and national identification cards. In the 2014 BDHS, information on birth registration was solicited for children under age 5. Table 2.12 shows that 2 in 10 children under age 5 had their births registered in 2014, and 17 percent of children had a birth certificate. Table 2.11 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 2014 Residence Total Characteristic Urban Rural Household headship Male 87.3 87.6 87.5 Female 12.7 12.4 12.5 Total 100.0 100.0 100.0 Number of usual members 1 1.4 1.9 1.7 2 10.4 10.4 10.4 3 21.9 18.3 19.3 4 28.1 25.2 26.0 5 18.0 20.2 19.6 6 9.2 11.7 11.0 7 5.6 5.8 5.7 8 2.3 3.3 3.0 9+ 3.1 3.3 3.3 Total 100.0 100.0 100.0 Mean size of households 4.4 4.5 4.5 Number of households 4,844 12,456 17,300 Note: Table is based on de jure household members, i.e., usual residents. 20 • Housing Characteristics and Household Population Although the law requires that a newborn be registered within 45 days of birth, Table 2.12 indicates that children under age 2 are much less likely to be registered than children age 2-4 (13 and 25 percent, respectively). The registration of older children is primarily driven by the practice of asking parents to produce a child’s birth certificate for school admission. Table 2.12 shows that birth registration is higher in urban (23 percent) than in rural (19 percent) areas. There is no difference regarding the extent of birth registration among male and female children. Among the administrative divisions, the highest and lowest proportions of children whose births are registered are from Sylhet (26 percent) and Rajshahi (13 percent). Birth registration of children under age 5 for all groups is lower in 2014 than in 2011 (NIPORT et al. 2013). Further investigation is needed to determine reasons for this decline. Table 2.12 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Bangladesh 2014 Children whose births are registered Number of children Background characteristic Percentage who had a birth certificate Percentage who did not have a birth certificate Percentage registered Age <2 9.7 2.9 12.6 3,091 2-4 21.2 3.9 25.1 4,707 Sex Male 16.6 3.6 20.3 4,045 Female 16.6 3.4 20.0 3,753 Residence Urban 18.9 3.8 22.8 2,001 Rural 15.8 3.4 19.3 5,797 Division Barisal 15.9 4.7 20.6 450 Chittagong 18.4 2.7 21.1 1,702 Dhaka 16.6 3.1 19.7 2,687 Khulna 17.6 5.0 22.6 596 Rajshahi 9.2 3.8 13.0 807 Rangpur 15.1 3.6 18.7 776 Sylhet 21.8 4.6 26.3 780 Wealth quintile Lowest 11.6 3.8 15.4 1,652 Second 16.1 2.6 18.7 1,442 Middle 15.1 2.4 17.5 1,404 Fourth 17.0 3.4 20.4 1,583 Highest 22.9 5.1 28.0 1,717 Total 16.6 3.5 20.2 7,798 2.6 SCHOOL ATTENDANCE In the 2014 BDHS, information was collected about school attendance of household members age 6 to 24. Table 2.13 shows that the proportion of the population that attends school declines with age. Whereas 91 percent of children age 6-10 are in school, the percentage decreases to 82 percent for children age 11-15, and to 40 percent for children age 16-20. School attendance is higher among girls than among boys age 6- 15, but boys age 16-20 and age 21-24 are more likely to be in school than girls. These data may reflect the impact of recent efforts to promote universal education, especially among girls. Housing Characteristics and Household Population • 21 Table 2.13 School attendance Percentage of the de facto household population age 6-24 attending school, by age, sex, and residence, Bangladesh 2014 Age Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-15 84.1 85.0 84.8 86.3 89.4 88.6 85.2 87.2 86.7 6-10 91.8 90.4 90.7 91.0 92.6 92.2 91.4 91.4 91.4 11-15 75.7 79.1 78.3 81.8 86.1 85.0 78.9 82.6 81.7 16-20 46.9 46.2 46.4 36.5 34.6 35.2 41.1 39.6 40.0 21-24 27.3 21.4 23.3 17.8 10.3 12.6 21.5 14.5 16.7 School attendance rates for children under age 16 are slightly higher in rural areas than in urban areas. In contrast, urban men and women age 16-24 are more likely to be in school than their rural counterparts. School attendance among age groups has increased since 2011. For example, the proportion of children age 6-15 who are attending school has increased from 84 percent in 2011 (NIPORT et al. 2013) to 87 percent in 2014. 2.7 EDUCATION OF HOUSEHOLD POPULATION Education is one of the major socioeconomic influences on a person’s behaviors and attitudes. In general, the greater a person’s educational attainment, the more knowledgeable he or she is about the use of health services, family planning, and the health care of children. The government of Bangladesh enacted a mandatory primary education law in 1990 to achieve universal primary enrolment by 2005, which is in line with the UN Child Rights Convention. Bangladesh must provide free and equal primary education of quality for all children (GOB 1990). To meet the demand for education, the government of Bangladesh has increased investment in the educational sector. Education is divided into two broad categories, primary and secondary. In addition, the government has recently initiated opening up non-grade-level schools at pre-primary education. The government also implements non-formal education for adults to increase the literacy rate. To promote job- oriented education, skill development institutes that have a vocational and technical focus have increased over the years in various parts of the country. The National Education Policy of Bangladesh (MOE 2010) explicitly stipulated that education would be free up to the secondary level in the public sector and provided subsidies to create demand for education of the poor and of girls in an effort to meet MDG targets. 2.7.1 Educational Attainment of the Household Population For all household members age 6 or older, data were collected on the level of education last attended and the highest class completed at that level. The findings are presented in Tables 2.14.1 and 2.14.2. The majority of Bangladeshis age 6 and older have attended school. Twenty-three percent of men and 27 percent of women have never attended school. Gender difference in primary education is very little. However, men are more likely to complete secondary school or to attain a higher education compared with women (17 percent versus 12 percent). There has been an increase in the proportions of men and women who have completed secondary or higher education since 2011. For men, the proportion has increased from 15 percent to 17 percent, and for women it has increased from 10 percent to 12 percent in 2014. Changes in educational attainment by successive age groups indicate the long-term trend in a country’s educational achievement. The data show marked improvement in the educational attainment of both men and women over the years. The proportion of men with no education is notably higher (39 percent) among those age 45-49 than among boys age 10-14 (6 percent). Similarly, 50 percent of women age 45-49 have no education compared with only 3 percent of girls age 10-14. 22 • Housing Characteristics and Household Population Overall, levels of educational attainment are higher in urban than in rural areas (Tables 2.14.1 and 2.14.2). The proportions of men and women with no education are lower in urban areas (17 percent of men and 21 percent of women) than in rural areas (25 percent of men and 29 percent of women), while the proportions who have completed secondary or higher schooling are greater in urban areas (26 percent of men and 20 percent of women) than in rural areas (13 percent of men and 9 percent of women). On average, men and women living in urban areas have completed 2 more years of school than those in rural areas. There are also regional variations in educational attainment. Barisal division has the highest proportion of men and women with some education (83 percent of men and 82 percent of women). Table 2.14.1 Educational attainment of the male household population Percent distribution of the de facto male household population age 6 and older by highest level of schooling attended or completed and median years completed, according to background characteristics, Bangladesh 2014 Background characteristic No education Primary incomplete Completed primary1 Secondary incomplete Completed secondary2 More than secondary Total Number Median years completed Age 6-9 22.2 77.7 0.0 0.1 0.0 0.0 100.0 3,702 0.0 10-14 5.8 56.4 6.5 31.2 0.1 0.0 100.0 4,648 3.2 15-19 6.7 15.9 9.2 43.0 7.0 18.2 100.0 3,543 8.0 20-24 10.2 16.9 13.9 28.0 5.4 25.6 100.0 2,536 7.4 25-29 13.3 15.9 14.9 30.7 7.4 17.8 100.0 2,859 7.0 30-34 21.5 17.2 11.8 28.4 5.4 15.7 100.0 2,508 5.0 35-39 28.9 17.8 9.8 20.2 6.0 17.2 100.0 2,384 4.3 40-44 36.3 14.4 9.5 18.4 6.8 14.5 100.0 2,144 3.9 45-49 38.6 13.1 9.6 16.4 7.2 15.1 100.0 1,736 3.6 50-54 37.5 18.2 9.6 16.8 6.1 11.7 100.0 1,679 3.1 55-59 39.8 13.2 8.7 20.3 6.2 11.9 100.0 1,274 3.3 60-64 43.2 14.2 8.6 14.2 7.7 12.0 100.0 1,263 2.2 65+ 46.8 16.1 9.7 13.7 5.9 7.9 100.0 2,479 1.1 Residence Urban 16.8 23.8 8.2 25.1 6.0 20.1 100.0 9,161 5.6 Rural 25.2 30.6 9.2 22.0 4.4 8.6 100.0 23,604 3.2 Division Barisal 16.9 30.3 9.6 23.7 7.4 12.1 100.0 2,078 4.3 Chittagong 20.1 30.6 9.6 23.9 5.7 10.1 100.0 6,099 3.9 Dhaka 25.0 26.5 8.3 22.4 4.5 13.3 100.0 11,213 3.7 Khulna 20.1 28.0 7.1 26.7 5.8 12.3 100.0 3,184 4.3 Rajshahi 25.4 27.2 8.5 21.0 4.4 13.6 100.0 3,794 3.6 Rangpur 22.5 29.4 8.4 23.9 4.1 11.6 100.0 3,733 3.7 Sylhet 25.0 33.8 12.8 18.8 2.7 7.0 100.0 2,664 2.8 Wealth quintile Lowest 40.3 36.8 7.1 12.7 1.1 2.0 100.0 6,302 0.6 Second 28.7 34.2 10.6 19.9 2.3 4.3 100.0 6,704 2.4 Middle 21.8 29.0 10.9 25.5 4.6 8.2 100.0 6,541 3.9 Fourth 16.0 24.9 9.2 30.1 6.8 13.1 100.0 6,523 5.0 Highest 8.4 18.9 6.7 25.9 9.1 31.0 100.0 6,694 8.8 Total 22.9 28.7 8.9 22.9 4.8 11.8 100.0 32,765 3.8 Note: Total includes eight men with missing information on age. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. For men and women, wealth exerts a positive influence on educational attainment. For instance, 40 percent of men in the lowest quintile have never attended school compared with 8 percent of men in the highest quintile. While 45 percent of men in the lowest wealth quintile had no education in 2011, in 2014 this proportion has declined to 40 percent. For women, the corresponding proportions are 47 and 41 percent, respectively. Housing Characteristics and Household Population • 23 Table 2.14.2 Educational attainment of the female household population Percent distribution of the de facto female household population age 6 and older by highest level of schooling attended or completed and median years completed, according to background characteristics, Bangladesh 2014 Background characteristic No education Primary incomplete Completed primary1 Secondary incomplete Completed secondary2 More than secondary Total Number Median years completed Age 6-9 21.4 78.5 0.1 0.1 0.0 0.0 100.0 3,485 0.1 10-14 2.7 52.7 6.4 38.1 0.2 0.0 100.0 4,578 3.7 15-19 3.6 11.8 9.2 50.6 8.5 16.3 100.0 4,541 8.3 20-24 8.8 13.3 11.1 41.5 5.9 19.5 100.0 3,888 7.9 25-29 14.6 16.2 11.9 38.3 6.9 12.1 100.0 3,588 6.8 30-34 27.1 19.4 9.5 28.2 6.4 9.3 100.0 3,115 4.4 35-39 36.7 20.2 11.3 19.1 5.6 7.2 100.0 2,390 3.0 40-44 46.2 21.8 9.3 12.8 4.3 5.6 100.0 2,158 0.7 45-49 49.7 20.4 9.9 13.3 2.5 4.2 100.0 1,815 0.0 50-54 60.9 18.2 8.5 7.5 2.2 2.7 100.0 1,242 0.0 55-59 66.2 15.5 8.0 6.9 1.0 2.3 100.0 1,425 0.0 60-64 70.2 14.0 7.1 6.2 0.9 1.6 100.0 1,037 0.0 65+ 78.8 9.6 5.9 3.9 0.8 0.9 100.0 1,799 0.0 Residence Urban 21.1 23.8 8.1 27.2 5.8 14.0 100.0 9,609 4.6 Rural 28.8 28.2 8.4 25.9 3.3 5.3 100.0 25,454 3.1 Division Barisal 17.8 30.6 12.4 24.8 5.5 8.8 100.0 2,241 4.1 Chittagong 24.4 27.0 8.4 28.3 5.7 6.3 100.0 6,892 3.8 Dhaka 28.6 25.4 8.0 25.9 3.5 8.6 100.0 11,781 3.5 Khulna 24.8 26.8 6.7 30.2 3.8 7.7 100.0 3,456 3.8 Rajshahi 28.4 25.9 8.5 26.0 3.7 7.6 100.0 3,896 3.3 Rangpur 28.9 27.8 6.5 25.6 3.0 8.3 100.0 3,950 3.1 Sylhet 28.5 31.5 10.8 20.7 2.9 5.6 100.0 2,846 2.6 Wealth quintile Lowest 40.5 35.2 7.6 15.1 0.6 1.1 100.0 6,852 0.7 Second 32.6 30.8 9.3 22.9 1.9 2.5 100.0 6,836 2.3 Middle 25.5 27.5 8.5 30.3 3.5 4.7 100.0 7,086 3.6 Fourth 22.8 23.4 9.3 31.2 4.9 8.5 100.0 7,166 4.4 Highest 13.1 18.6 7.0 31.4 8.8 21.2 100.0 7,122 7.7 Total 26.7 27.0 8.3 26.3 4.0 7.7 100.0 35,063 3.5 Note: Total includes 1 woman with missing information on age. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. A comparison of the completed median years of schooling since 2000 is presented in Figure 2.4. In 2000, the completed median years of schooling was 2.6 for men and 1.2 for women. Between 2000 and 2014 the completed median years of schooling had increased to 3.8 among men and to 3.5 among women. Although the completed median years of schooling continues to be higher for men than for women, the gender difference has declined from 1.4 years in 2000 to 0.3 years in 2014. 24 • Housing Characteristics and Household Population Figure 2.4 Trend in completed median of years of schooling of men and women age 6 and over, 1999-2014 2.7.2 School Attendance Ratios The net attendance ratio (NAR) indicates participation in primary schooling for the population age 6-10 and participation in secondary schooling for the population age 11-17. The gross attendance ratio (GAR) measures participation at each level of schooling among those of any age. The GAR is almost always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level. A NAR of 100 percent would indicate that all of those in the official age range for that level are attending at that level. The GAR can exceed 100 percent if there is significant over-age or under-age participation at a given level of schooling. Table 2.15 shows that the NAR at the primary level is 86 percent (86 percent for males and 87 percent for females) and the NAR at the secondary level is 43 percent (42 percent for males and 44 percent for females). The differences in NAR at the primary and secondary school levels between urban and rural areas are small. Among the administrative divisions, Dhaka has the lowest NAR and GAR at the primary level. Sylhet has the highest NAR and GAR at the primary level, but the lowest NAR and GAR at the secondary level. At the primary level, the NAR and GAR show no clear pattern by wealth quintile. The NAR and GAR at secondary school level are lowest among the children from the lowest wealth quintile. Table 2.15 also shows the Gender Parity Index (GPI), which represents the ratio of the NAR and GAR for females to the NAR and GAR for males. It is a more precise indicator of gender differences in the schooling system. A GPI greater than 1.00 indicates that a higher proportion of females than males attends school. The GPI at the primary and secondary levels is slightly higher than 1.00 indicating that gender differences in schools are in favor of girls. 2.6 2.7 2.9 3.4 3.8 1.2 1.6 2.1 2.9 3.5 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 Years Men Women Housing Characteristics and Household Population • 25 Table 2.15 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Bangladesh 2014 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 84.2 85.3 84.8 1.01 113.6 116.7 115.1 1.03 Rural 86.0 88.0 87.0 1.02 119.6 124.2 121.8 1.04 Division Barisal 90.7 91.4 91.0 1.01 126.2 128.6 127.4 1.02 Chittagong 84.5 87.2 85.9 1.03 120.4 124.1 122.2 1.03 Dhaka 82.7 85.0 83.8 1.03 110.0 117.6 113.6 1.07 Khulna 91.5 90.1 90.8 0.98 121.1 121.3 121.2 1.00 Rajshahi 84.6 86.6 85.6 1.02 124.7 115.0 119.7 0.92 Rangpur 88.7 89.8 89.2 1.01 121.5 130.2 125.5 1.07 Sylhet 87.0 88.7 87.9 1.02 124.9 130.2 127.6 1.04 Wealth quintile Lowest 81.4 86.7 84.1 1.07 117.8 125.8 121.9 1.07 Second 87.8 87.2 87.5 0.99 118.0 130.8 123.8 1.11 Middle 88.6 90.1 89.3 1.02 122.8 124.6 123.7 1.01 Fourth 83.8 89.3 86.6 1.07 119.7 117.5 118.6 0.98 Highest 86.5 83.8 85.2 0.97 112.7 110.9 111.8 0.98 Total 85.6 87.4 86.4 1.02 118.2 122.3 120.2 1.04 SECONDARY SCHOOL Residence Urban 40.7 42.4 41.6 1.04 46.5 46.5 46.5 1.00 Rural 42.5 44.0 43.3 1.04 47.8 48.4 48.1 1.01 Division Barisal 43.5 46.8 45.1 1.08 47.2 50.9 49.1 1.08 Chittagong 40.8 42.5 41.7 1.04 46.5 47.5 47.0 1.02 Dhaka 42.4 42.3 42.4 1.00 49.6 46.4 47.9 0.94 Khulna 45.6 53.6 50.0 1.18 48.9 57.9 53.8 1.18 Rajshahi 44.1 47.6 45.8 1.08 48.7 52.2 50.4 1.07 Rangpur 45.3 42.4 43.7 0.93 49.3 45.4 47.2 0.92 Sylhet 33.1 35.6 34.4 1.08 37.5 41.0 39.3 1.09 Wealth quintile Lowest 28.4 30.8 29.6 1.08 32.7 33.4 33.1 1.02 Second 36.1 40.0 38.1 1.11 42.0 45.1 43.6 1.07 Middle 47.0 48.3 47.6 1.03 52.0 52.5 52.2 1.01 Fourth 48.6 48.0 48.2 0.99 54.3 51.6 52.9 0.95 Highest 50.1 49.7 49.9 0.99 56.1 55.7 55.9 0.99 Total 42.0 43.6 42.8 1.04 47.4 47.9 47.7 1.01 1 The NAR for primary school is the percentage of the primary-school-age (6-10 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (11-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary- school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of over-age and under-age students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. Figure 2.5 shows that, for ages 5-14, girls have a higher level of school attendance than boys. The pattern reverses at age 16 and older. Attendance is highest at age 9 for boys and at age 11 for girls. 26 • Housing Characteristics and Household Population Figure 2.5 Age-specific attendance rates of the de facto population age 5-24 2.8 EMPLOYMENT The 2014 BDHS collected information regarding the working status of each person age 8 and older at the time of the survey. Table 2.16 shows that men are much more likely than women to be employed (65 percent and 24 percent, respectively). Table 2.16 also shows that the urban population is more likely to be employed than the rural population. For men, the proportion is 69 percent in urban and 63 percent in rural areas, and for women, the proportion is 25 percent and 24 percent, respectively. Table 2.16 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 2014 Male Female Age Urban Rural Total Urban Rural Total 8-9 1.2 0.9 1.0 1.4 0.5 0.7 10-14 10.9 9.7 10.0 7.7 2.6 3.9 15-19 43.6 39.6 40.8 21.1 12.8 15.1 20-24 73.4 74.9 74.4 30.6 26.7 27.9 25-29 90.7 91.9 91.5 35.3 37.0 36.5 30-34 96.9 97.2 97.1 36.0 41.5 39.9 35-39 98.6 98.2 98.4 39.7 41.4 40.9 40-44 96.0 98.2 97.5 38.1 43.3 41.8 45-49 98.8 97.5 97.9 33.4 38.2 36.8 50-54 94.3 94.8 94.6 22.8 26.5 25.5 55-59 90.4 89.7 89.9 23.8 26.1 25.6 60-64 78.8 81.9 81.1 12.3 16.1 15.2 65+ 50.8 48.4 48.9 5.8 6.2 6.1 Total 68.8 63.1 64.7 25.2 23.7 24.1 Number of persons 8,669 22,181 30,850 9,170 24,072 33,242 0 10 20 30 40 50 60 70 80 90 100 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percent Age Male Female BDHS 2014 Housing Characteristics and Household Population • 27 2.9 OWNERSHIP OF MOBILE PHONES Information regarding ownership of mobile phones among household members age 13 and older was collected during the 2014 BDHS. Table 2.17 shows that 53 percent of the population owns a mobile phone. Urban people are more likely to own a mobile phone (64 percent) than rural people (48 percent). Men are almost twice as likely as women to own a mobile phone. In urban areas, 78 percent of men own a mobile phone compared with 50 percent of women. In rural areas the corresponding proportions are 66 percent and 33 percent, respectively. Men and women in the age groups 20-29 and 30-39 are more likely to own a mobile phone than other age groups. Among adolescents age 15-19, 45 percent own a mobile phone. Male adolescents are twice as likely to own a mobile phone as female adolescents. Adolescents in urban areas are slightly more likely to own mobile phones compared with those in rural areas (51 percent versus 43 percent). Table 2.17 Availability of mobile phone among household members Percentage of de-facto household members age 13 or more who have a mobile phone by age and sex, according to residence, Bangladesh 2014 Urban Rural Total Age group Male Female Total Male Female Total Male Female Total 13-14 20.4 3.1 11.5 13.2 2.7 7.9 15.0 2.8 8.8 15-19 66.8 38.1 50.8 61.5 27.8 42.5 63.0 30.7 44.9 20-29 92.1 67.1 78.2 88.2 48.9 64.9 89.5 54.2 69.0 30-39 91.7 65.5 78.3 84.6 44.5 63.1 86.8 50.6 67.6 40-49 86.3 52.1 69.7 74.5 33.3 53.3 78.2 38.8 58.3 50+ 64.6 28.8 48.7 48.1 13.9 32.6 52.2 17.5 36.6 Total 77.7 50.0 63.5 65.8 32.7 48.3 69.3 37.5 52.6 Characteristics of Respondents • 29 CHARACTERISTICS OF RESPONDENTS 3 his chapter presents the demographic and socioeconomic profile of ever married women age 15-49 interviewed in BDHS 2014. The information helps one to interpret findings and understand results presented in the report. The chapter begins by describing basic background characteristics, including age, marital status, residence, education, and wealth status. Information is also presented on exposure to mass media and employment status. The 2014 BDHS includes results from completed interviews with 17,863 ever-married women age 15-49. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Basic background characteristics of the 17,863 ever-married women are presented in Table 3.1. About half of the women (48.4 percent) are under age 30. The majority of women (94 percent) are currently married. Seven in ten respondents (72 percent of women) reside in the rural areas. The respondents are not evenly distributed across geographic divisions. More than one-third (35 percent) of the respondents live in Dhaka, 19 percent reside in Chittagong, 12 percent each in Rajshahi and Rangpur, 10 percent in Khulna, 7 percent in Sylhet, and 6 percent in Barisal. The proportion of sampled women in Chittagong and Rangpur divisions is similar to that in the 2011 BDHS. However, the proportion in three divisions has increased; in Dhaka by 2.5 percent, in Sylhet by 1.5 percent, and in Barisal by 0.6 percent. On the other hand, it decreased in two divisions; in Rajshahi by 3.1 percent and in Khulna by 1.7 percent. Twenty-five Table 3.1 Background characteristics of respondents Percent distribution of ever-married women age 15-49 by selected background characteristics, Bangladesh 2014 Background characteristic Weighted percent Weighted number Unweighted number Age 15-19 11.4 2,029 2,023 20-24 18.0 3,224 3,161 25-29 19.0 3,390 3,343 30-34 17.1 3,047 3,012 35-39 13.0 2,315 2,340 40-44 11.7 2,092 2,170 45-49 9.9 1,766 1,814 Marital status Currently married 94.4 16,858 16,830 Divorced/separated/ widowed 5.6 1,005 1,033 Residence Urban 28.3 5,047 6,167 Rural 71.7 12,816 11,696 Division Barisal 6.2 1,111 2,142 Chittagong 18.5 3,301 2,865 Dhaka 34.8 6,223 3,093 Khulna 10.3 1,838 2,581 Rajshahi 11.8 2,103 2,512 Rangpur 11.5 2,056 2,531 Sylhet 6.9 1,232 2,139 Education No education 24.9 4,455 4,206 Primary incomplete 18.0 3,223 3,148 Primary complete1 11.1 1,986 2,078 Secondary incomplete 31.5 5,628 5,645 Secondary complete or higher2 14.4 2,571 2,786 Religion Islam 90.1 16,096 16,135 Hinduism 8.3 1,476 1,592 Buddhism 1.3 234 100 Christianity (0.2) 44 32 Wealth quintile Lowest 18.8 3,359 3,251 Second 19.1 3,408 3,360 Middle 19.9 3,560 3,621 Fourth 21.0 3,758 3,769 Highest 21.1 3,778 3,862 Total - 17,863 17,863 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. T Key Findings: • Twenty-five percent of ever-married women age 15-49 have no education. The percentage of women with no education has decreased since 2007, and the percentage of women with secondary or higher education has gradually increased over the same period. • Forty-seven percent of women have no regular exposure to radio, television, or a newspaper. • Thirty-six percent of women were employed in the 12 months preceding the survey, with the highest percentages employed in raising of poultry/cattle (41 percent), semi-skilled services (14 percent), and factory or blue collar services (8 percent). 30 • Characteristics of Respondents percent of women age 15-49 have no education, while 14 percent of women have completed secondary or higher-level education. The vast majority of the respondents (90 percent) are Muslim, and 8 percent are Hindu. Very few of the respondents are Buddhist or Christian. 3.2 EDUCATIONAL ATTAINMENT Education is one of the most influential determinants of an individual’s knowledge, attitudes, and behaviors. The educational attainment of a population is an important indicator of the society’s stock of human capital and level of socioeconomic development. Education enhances the ability of individuals to achieve desired demographic and health goals. Table 3.2 presents differentials in the educational attainment of women by selected background characteristics. Table 3.2 Educational attainment 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 2014 Highest level of schooling Total Median years completed Number of women Background characteristic No education Primary incomplete Completed primary1 Secondary incomplete Secondary complete or higher2 Age 15-24 7.8 14.9 11.9 47.6 17.8 100.0 7.4 5,253 15-19 5.1 14.9 11.8 50.7 17.5 100.0 7.5 2,029 20-24 9.5 14.9 12.0 45.6 18.0 100.0 7.4 3,224 25-29 15.0 16.8 12.3 39.1 16.8 100.0 6.6 3,390 30-34 27.0 19.9 10.0 27.9 15.3 100.0 4.3 3,047 35-39 37.4 19.9 11.3 19.1 12.3 100.0 2.8 2,315 40-44 46.3 21.9 9.4 13.0 9.4 100.0 0.7 2,092 45-49 49.8 19.6 10.2 13.6 6.8 100.0 0.0 1,766 Residence Urban 19.3 15.2 10.0 31.0 24.5 100.0 6.8 5,047 Rural 27.2 19.2 11.5 31.7 10.4 100.0 4.3 12,816 Division Barisal 15.1 20.8 15.9 28.8 19.3 100.0 4.9 1,111 Chittagong 21.6 16.6 9.6 36.3 16.0 100.0 6.3 3,301 Dhaka 27.2 17.1 11.0 29.9 14.8 100.0 4.5 6,223 Khulna 21.6 19.8 9.1 36.6 12.9 100.0 4.9 1,838 Rajshahi 25.5 18.4 11.7 31.0 13.4 100.0 4.5 2,103 Rangpur 27.2 19.1 9.6 30.9 13.1 100.0 4.4 2,056 Sylhet 31.8 19.1 16.0 23.6 9.4 100.0 3.9 1,232 Wealth quintile Lowest 45.5 24.4 11.9 17.0 1.2 100.0 1.0 3,359 Second 32.6 22.7 13.5 26.6 4.6 100.0 3.4 3,408 Middle 21.2 19.3 11.4 38.6 9.4 100.0 4.8 3,560 Fourth 18.8 15.6 12.0 38.3 15.3 100.0 6.4 3,758 Highest 9.4 9.4 7.2 35.3 38.7 100.0 9.2 3,778 Total 24.9 18.0 11.1 31.5 14.4 100.0 4.6 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Table 3.2 shows that 25 percent of ever-married women age 15-49 have never been to school, 18 percent have completed some primary education, 11 percent have completed all primary education, 32 percent have completed some secondary education, and 14 percent have completed all secondary education or continued on to higher education. Older women, women in rural areas, and those in the lowest wealth quintile are most likely to have no education. Urban-rural differences in education are prominent at the secondary and higher levels. For example, urban women are almost two and half times more likely than rural women to have completed secondary or higher education (25 percent and 10 percent, respectively). Between 13 and 19 percent of women in all geographic divisions have completed secondary or higher-level education except in Sylhet, where the percentage is only 9 percent. Sylhet also has the highest proportion of women with no education (32 percent). Women in the highest wealth quintile are most likely to complete secondary or higher-level education; 39 percent of women in the highest wealth quintile achieved this level. Characteristics of Respondents • 31 In Bangladesh, women age 15-49 have completed a median of 4.6 years of schooling. The differentials across subgroups of women are reflected in the medians. For example, the median number of years of schooling for women in the highest wealth quintile is 9.2 years compared with 1 year for women in the lowest quintile. Figure 3.1 Trends in education of ever-married women, 2007-2014 There have been improvements in educational attainment in Bangladesh over the past seven years. The percentage of ever-married women with no education has declined, from 28 percent in 2011 to 25 percent in 2014. Another indicator of progress in education is the median length of schooling. For women, it increased from 4.3 years in 2011 to 4.6 years in 2014 (NIPORT et al. 2013). 3.3 LITERACY Literacy is widely acknowledged as benefiting both the individual and society. Particularly among women, literacy is associated with positive outcomes, including intergenerational health and nutrition benefits. The ability to read and write empowers both women and men. Knowledge of the level of literacy that a population may attain is important for policymakers and program managers who design information materials. The 2014 BDHS defined 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. Respondents who had attended at least some secondary school were assumed to be literate. Respondents 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. Table 3.3 presents the findings. Table 3.3 indicates that 66 percent of ever-married women age 15-49 are literate. The level of literacy decreases as age increases; 86 percent of women age 15-24 are literate compared with 39 percent of women age 45-49. Literacy varies by urban-rural residence; 74 percent of urban women are literate, compared with 63 percent of rural women. 34 21 8 24 12 28 18 12 30 12 25 18 11 32 14 No education Primary incomplete Completed primary Secondary incomplete Secondary complete or higher Percent BDHS 2007 BDHS 2011 BDHS 2014 32 • Characteristics of Respondents Divisional differences in literacy are notable. The proportion of women who are literate ranges from 57 percent in Sylhet to 76 percent in Barisal. Literacy has improved in the past three years in all divisions except Sylhet. The improvement ranges from 1 percent in Khulna to 8 percent in Rangpur. There is also a marked difference in literacy level by household wealth, ranging from 41 percent among women in the lowest wealth quintile to 87 percent among women in the highest wealth quintile. Table 3.3 Literacy 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 2014 Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all Age 15-24 65.4 8.9 11.6 14.1 100.0 85.9 5,251 15-19 59.7 8.7 12.3 19.4 100.0 80.6 6,614 20-24 63.6 9.2 11.6 15.6 100.0 84.4 3,224 25-29 55.9 8.3 12.9 22.9 100.0 77.1 3,390 30-34 43.2 7.9 12.0 36.9 100.0 63.0 3,047 35-39 31.4 9.3 12.1 47.1 100.0 52.8 2,315 40-44 22.4 7.8 12.5 57.3 100.0 42.7 2,092 45-49 20.3 7.2 11.6 60.8 100.0 39.1 1,766 Residence Urban 55.5 8.4 10.1 25.9 100.0 74.0 5,047 Rural 42.1 8.3 12.8 36.7 100.0 63.3 12,816 Division Barisal 48.1 12.0 15.8 23.9 100.0 76.0 1,111 Chittagong 52.3 7.6 9.8 30.3 100.0 69.6 3,301 Dhaka 44.7 8.4 12.5 34.4 100.0 65.6 6,223 Khulna 49.5 7.3 11.2 31.9 100.0 68.0 1,838 Rajshahi 44.4 7.6 12.7 35.2 100.0 64.7 2,103 Rangpur 44.1 7.2 12.2 36.5 100.0 63.5 2,056 Sylhet 33.0 11.7 12.6 42.5 100.0 57.4 1,232 Wealth quintile Lowest 18.2 7.8 15.1 58.9 100.0 41.1 3,359 Second 31.3 10.2 15.4 43.2 100.0 56.8 3,408 Middle 48.0 9.4 12.1 30.4 100.0 69.5 3,560 Fourth 53.6 8.6 11.5 26.3 100.0 73.7 3,758 Highest 74.1 6.0 7.0 12.9 100.0 87.1 3,778 Total 45.9 8.4 12.1 33.6 100.0 66.3 17,863 Note: Total includes a small number of women who had no card with the required language, are blind or visually impaired, or with missing information. 1 Refers to women who attended secondary school or higher and women 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 takes place around them. The 2014 BDHS assessed exposure to media by asking respondents if they listened to the radio, watched television, or read newspapers or magazines at least once a week. To plan effective programs to disseminate information about health and family planning, it is important to know which subgroups of population are most likely to be reached by specific media. Table 3.4 shows that 51 percent of ever-married women age 15-49 watch television at least once a week, 6 percent read a newspaper at least once a week, and 3 percent listen to the radio at least once a week. Less than 1 percent of women are exposed to all three media sources each week. Close to half (47 percent) of women have no exposure to any of the mass media on a weekly basis. Characteristics of Respondents • 33 Table 3.4 Exposure to mass media Percentage of ever-married women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Bangladesh 2014 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 Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 5.5 51.2 4.3 0.4 45.8 2,029 20-24 5.3 57.1 2.8 0.5 41.4 3,224 25-29 6.9 52.7 3.1 0.6 45.4 3,390 30-34 6.6 51.2 2.6 0.4 47.0 3,047 35-39 5.6 47.6 1.7 0.1 50.9 2,315 40-44 6.3 45.8 1.6 0.3 53.3 2,092 45-49 4.8 46.0 2.1 0.2 52.8 1,766 Residence Urban 13.2 77.7 2.6 0.7 21.3 5,047 Rural 3.1 40.4 2.7 0.3 57.6 12,816 Division Barisal 7.6 38.5 2.0 0.3 59.6 1,111 Chittagong 5.2 54.8 2.6 0.3 43.6 3,301 Dhaka 7.6 58.1 2.6 0.5 40.3 6,223 Khulna 5.0 51.0 2.8 0.2 47.5 1,838 Rajshahi 4.4 50.3 2.6 0.4 48.5 2,103 Rangpur 4.6 39.8 3.9 0.4 56.8 2,056 Sylhet 4.4 35.0 1.4 0.2 64.1 1,232 Education No education 0.0 30.2 1.0 0.0 69.3 4,455 Primary incomplete 0.5 41.2 1.9 0.0 57.4 3,223 Primary complete1 1.0 45.6 2.3 0.1 53.0 1,986 Secondary incomplete 5.5 61.5 3.2 0.5 36.2 5,628 Secondary complete or higher2 27.8 80.0 5.6 1.7 16.7 2,571 Wealth quintile Lowest 0.9 10.2 1.6 0.2 88.2 3,359 Second 1.3 21.0 2.0 0.0 76.9 3,408 Middle 2.6 53.3 3.0 0.3 44.3 3,560 Fourth 4.1 73.1 3.0 0.5 25.4 3,758 Highest 19.6 89.7 3.5 1.0 9.0 3,778 Total 5.9 50.9 2.7 0.4 47.4 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Figure 3.2 shows the proportion of women listening to the radio every week has decreased markedly over the years, dropping from 19 percent in 2007, to 5 percent in 2011 and 3 percent in 2014. Television reaches the most women throughout the period (47 percent in 2007, 48 percent in 2011, and 51 percent in 2014). Younger women are more likely to watch television or listen to the radio than older women. There is a wide gap in media exposure by urban-rural residence. For example, the proportion of urban women who watch television once a week is 78 percent compared with 40 percent of rural women. Media exposure is positively related to the respondent’s educational level and economic status. Regular exposure to mass media is highest among women with secondary or higher education and women in the highest wealth quintile. 34 • Characteristics of Respondents Figure 3.2 Trends in exposure to mass media of ever-married women, 2007-2014 3.5 EMPLOYMENT The 2014 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 are presented in Table 3.5. At the time of the survey, 33 percent of ever-married women age 15-49 were currently employed. Three percent were not working, although they had worked in the 12 months prior to the survey, while the remaining 64 percent said that they had not been employed in the previous 12 months (Table 3.5). The proportion currently employed is lowest among women age 15-19 (16 percent) and peaks at 40 percent in the 40-44 age group. The level of employment increases with the number of children. Women who have five or more children are more likely to be employed (37 percent) compared with women with no children (23 percent). Rural women are more likely than urban women to be employed (34 percent compared with 31 percent). Variations are found across geographic divisions. The proportion of women who are employed ranges from 42 percent in Rajshahi to 18 percent in Sylhet. The proportion of women who are currently employed decreases with education. For example, 42 percent of women with no education are employed compared with 25 percent of women who completed secondary level. Women in the lowest wealth quintile are more likely to be currently employed compared with women in the highest wealth quintile (41 percent and 25 percent, respectively). 7 47 19 45 6 48 5 49 6 51 3 47 Newspaper Television Radio No media Percent BDHS 2007 BDHS 2011 BDHS 2014 Characteristics of Respondents • 35 Table 3.5 Employment status Percent distribution of ever-married women age 15-49 by employment status, according to background characteristics, Bangladesh 2014 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Background characteristic Currently employed1 Not currently employed Age 15-19 16.2 1.7 82.1 100.0 2,029 20-24 26.1 2.0 71.9 100.0 3,224 25-29 34.1 2.9 63.0 100.0 3,390 30-34 39.0 2.6 58.4 100.0 3,047 35-39 39.3 2.7 58.0 100.0 2,315 40-44 39.8 3.0 57.2 100.0 2,092 45-49 37.1 2.5 60.4 100.0 1,766 Marital status Currently married 31.9 2.4 65.7 100.0 16,858 Divorced/separated/ widowed 53.8 3.1 43.1 100.0 1,005 Number of living children 0 22.8 2.2 75.1 100.0 1,814 1-2 33.0 2.5 64.5 100.0 9,478 3-4 35.9 2.8 61.3 100.0 5,180 5+ 36.7 1.5 61.8 100.0 1,391 Residence Urban 31.1 2.2 66.6 100.0 5,047 Rural 33.9 2.6 63.5 100.0 12,816 Division Barisal 26.5 2.7 70.8 100.0 1,111 Chittagong 26.3 0.9 72.8 100.0 3,301 Dhaka 34.9 3.1 62.0 100.0 6,223 Khulna 33.9 3.3 62.9 100.0 1,838 Rajshahi 42.3 3.6 54.0 100.0 2,103 Rangpur 40.8 2.1 57.1 100.0 2,056 Sylhet 18.4 1.1 80.5 100.0 1,232 Education No education 42.1 3.1 54.8 100.0 4,455 Primary incomplete 37.5 3.1 59.4 100.0 3,223 Primary complete2 34.8 3.0 62.1 100.0 1,986 Secondary incomplete 26.6 1.9 71.5 100.0 5,628 Secondary complete or higher3 24.8 1.4 73.7 100.0 2,571 Wealth quintile Lowest 40.7 2.6 56.6 100.0 3,359 Second 36.7 4.0 59.3 100.0 3,408 Middle 32.8 2.5 64.7 100.0 3,560 Fourth 31.8 2.2 65.9 100.0 3,758 Highest 24.6 1.2 74.2 100.0 3,778 Total 33.1 2.5 64.4 100.0 17,863 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 3.6 OCCUPATION Respondents who had worked in the 12 months preceding the survey were asked about their occupation. The results are presented in Table 3.6, which shows the distribution of employed women by occupation, according to background characteristics. Four in ten working women are engaged in poultry or cattle raising (41 percent), 14 percent work as semi-skilled labor, and 6 percent perform professional or technical services. Eight percent each of women are engaged in business and factory or blue collar services, and 7 percent each perform home-based manufacturing work or serve as domestic servants. The relationship between women’s occupation and age is mixed; younger women are more likely than older women to be engaged in factory work, semi-skilled labor services, and home-based manufacturing activities. In contrast, older women are more likely than younger women to work in business, in agriculture, or as domestic servants. 36 • Characteristics of Respondents Table 3.6 Occupation Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Bangladesh 2014 Background characteristic Profes- sional/ technical Business Factory worker, blue collar service Semi- skilled labor/ service Unskilled labor Farmer/ agri- cultural worker Poultry/ cattle raising Home based manu- facturing Domestic servant Other Missing Total Number of women Age 15-19 6.0 3.5 16.2 25.2 1.1 2.1 28.3 14.9 2.2 0.3 0.1 100.0 363 20-24 4.9 6.4 11.2 24.7 1.1 3.8 35.7 8.1 3.0 0.3 0.7 100.0 906 25-29 8.2 6.1 8.4 16.4 3.7 5.0 36.4 8.7 6.5 0.1 0.6 100.0 1,253 30-34 5.3 8.3 7.8 13.3 1.9 5.6 44.8 5.7 6.6 0.2 0.5 100.0 1,267 35-39 6.4 10.8 8.3 11.5 3.1 7.2 38.0 6.0 8.0 0.4 0.4 100.0 972 40-44 7.5 7.7 5.8 8.0 5.3 4.9 46.1 4.4 9.4 0.7 0.2 100.0 896 45-49 3.7 8.7 4.3 5.4 2.2 6.6 51.4 5.3 10.4 0.8 1.1 100.0 699 Marital status Married or living together 6.4 7.8 7.8 14.5 1.8 5.0 43.0 7.1 5.5 0.4 0.6 100.0 5,784 Divorced/separated/ widowed 3.3 6.4 13.0 12.7 12.7 8.0 18.1 5.0 20.2 0.4 0.1 100.0 572 Number of living children 0 14.0 3.5 16.7 25.7 0.9 1.8 20.6 10.5 4.9 1.0 0.4 100.0 453 1-2 8.3 7.3 8.0 17.6 3.1 4.9 37.2 6.8 6.0 0.3 0.5 100.0 3,368 3-4 2.3 8.9 8.0 9.0 2.7 6.1 47.0 6.7 8.2 0.3 0.8 100.0 2,004 5+ 0.3 8.4 3.9 3.9 2.7 7.9 57.4 6.2 8.6 0.5 0.1 100.0 531 Residence Urban 12.2 6.5 13.7 23.9 1.9 1.5 14.2 10.2 15.1 0.3 0.4 100.0 1,683 Rural 4.0 8.1 6.3 10.9 3.1 6.7 50.4 5.8 3.9 0.4 0.6 100.0 4,673 Division Barisal 10.7 6.9 3.4 10.5 3.2 1.4 46.2 7.7 7.9 2.0 0.2 100.0 324 Chittagong 7.1 5.7 9.2 18.1 0.6 11.9 31.7 9.7 5.6 0.4 0.1 100.0 897 Dhaka 6.3 7.5 11.9 18.1 3.1 2.6 36.2 6.0 7.7 0.2 0.2 100.0 2,365 Khulna 4.4 11.3 5.8 12.4 3.4 6.3 40.8 7.8 6.7 0.2 0.8 100.0 682 Rajshahi 4.6 9.2 5.9 11.2 2.2 3.3 48.7 9.4 4.0 0.4 1.2 100.0 967 Rangpur 5.3 5.5 2.8 7.6 3.1 9.1 55.3 4.3 5.7 0.1 1.1 100.0 881 Sylhet 9.5 8.0 13.4 10.5 6.6 3.8 27.5 2.6 17.2 0.8 0.1 100.0 240 Educational attainment No education 0.9 8.7 9.7 4.5 5.9 9.3 40.7 5.7 13.7 0.4 0.4 100.0 2,015 Primary incomplete 0.1 7.3 8.8 12.3 3.1 6.6 46.1 7.4 7.8 0.1 0.6 100.0 1,310 Primary complete1 0.6 7.5 9.7 17.3 1.3 1.9 44.7 11.0 5.3 0.2 0.4 100.0 751 Secondary incomplete 2.6 7.4 8.1 23.1 0.6 2.9 45.1 8.1 1.0 0.5 0.7 100.0 1,605 Secondary complete or higher2 48.3 6.0 2.0 23.4 0.0 0.5 16.0 2.7 0.1 0.5 0.7 100.0 675 Wealth quintile Lowest 0.5 5.9 6.7 4.1 6.6 13.3 45.1 8.9 7.5 0.4 0.9 100.0 1,457 Second 2.6 8.6 4.3 7.8 3.1 6.3 54.5 7.8 4.5 0.2 0.3 100.0 1,388 Middle 3.9 9.6 5.0 13.2 1.8 3.4 50.6 7.4 4.5 0.3 0.4 100.0 1,255 Fourth 5.1 8.1 14.7 22.4 1.1 0.8 32.9 6.5 7.6 0.6 0.3 100.0 1,280 Highest 24.0 5.6 12.1 29.9 0.3 0.4 12.5 2.8 11.2 0.4 0.8 100.0 976 Total 6.2 7.7 8.3 14.3 2.8 5.3 40.8 7.0 6.8 0.4 0.5 100.0 6,356 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Urban-rural residence has a marked effect on occupation. As expected, rural women are more likely than urban women to be engaged in agriculture, poultry or cattle raising, and unskilled labor or business. In contrast, women in urban areas are more likely to be engaged in professional or technical services, factory work or blue collar services, semi-skilled labor/services, home-based manufacturing work, and as domestic servants. About one in two women (48 percent) with secondary or higher levels of education are employed in professional or technical jobs, and about one in four work in semi-skilled services. In contrast, women with little or no education are more likely than those with more education to be engaged in factory or blue collar services and as domestic servants. The majority of women in the highest wealth quintile are engaged in professional/technical work (24 percent), worked in factory or blue collar services (12 percent), semi- skilled labor/service (30 percent), and as domestic servants (11 percent). The majority of women in the lowest wealth quintile are unskilled laborers and farmers or agriculture workers. Characteristics of Respondents • 37 3.7 EARNINGS, EMPLOYERS, AND CONTINUITY OF EMPLOYMENT Table 3.7 shows the percent distribution of ever-married women employed in the 12 months prior to the survey by type of earnings, type of employer, and continuity of employment. This table presents data by whether respondents work in the agricultural or nonagricultural sector. Overall, 8 in 10 women who were employed work for cash only, and 6 percent receive cash and in-kind payment. There are significant variations in cash payment between women who work in agriculture (80 percent) and those who do not work in agriculture (91 percent). Table 3.7 Type of employment Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Bangladesh 2014 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 79.7 90.9 84.9 Cash and in-kind 7.6 4.3 6.1 In-kind only 1.2 1.8 1.5 Not paid 11.2 2.9 7.4 Missing 0.1 0.2 0.2 Total 100.0 100.0 100.0 Type of employer Employed by family member 61.7 26.9 45.6 Employed by nonfamily member 14.0 58.4 34.7 Self-employed 24.1 14.4 19.5 Missing 0.2 0.3 0.2 Total 100.0 100.0 100.0 Continuity of employment All year 87.6 82.8 85.4 Seasonal 5.7 7.4 6.5 Occasional 6.5 9.5 7.9 Missing 0.2 0.3 0.3 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 3,371 2,952 6,356 Note: Total includes women with missing information on type of employment who are not shown separately. Agriculture work includes farmer, land owner, agricultural worker, fisherman, raiser of poultry/cattle The proportion of women in agricultural work who receive cash payment has declined from 90 percent in 2011 to 85 percent in 2014. At the same time, the proportion of women who were paid entirely in kind is almost similar to that in an earlier survey (about 2 percent) (NIPORT et al. 2013). Less than half of women (46 percent) are employed by family members, one in three women (35 percent) are employed by a nonfamily member, and 20 percent are self-employed. Women who work in agriculture are more likely than women who work in the nonagricultural sector to be employed by a family member (62 and 27 percent, respectively), while women who work in the nonagricultural sector are more often employed by a nonfamily member (58 and 14 percent, respectively). Eighty-five percent of employed women work all year round, and 15 percent work either seasonally (7 percent) or occasionally (8 percent). Continuity of employment varies by sector. Eighty-eight percent of women who work in the agricultural sector work year round, compared with 83 percent of women engaged in nonagricultural work. Twelve percent of women who are employed in agricultural sector are seasonal or occasional workers. Marriage and Sexual Activity • 39 MARRIAGE AND SEXUAL ACTIVITY 4 4.1 INTRODUCTION his chapter addresses the principal factors, other than contraception, that affect a woman’s risk of becoming pregnant: nuptiality and sexual intercourse, postpartum amenorrhea and abstinence from sexual relations, and menopause. The chapter also includes information on more direct measures of the beginning of exposure to pregnancy and the level of exposure: age at first sexual intercourse and the frequency of intercourse. Finally, measures of several other proximate determinants of fertility which, like marriage and sexual intercourse, influence exposure to the risk of pregnancy are presented: durations of postpartum amenorrhea, postpartum abstinence, and menopause. Marriage is a primary indication of the exposure of women to the risk of pregnancy and, therefore, is important for the understanding of fertility. Populations in which age at marriage is low tend to be populations with early childbearing and high fertility. For this reason, there is an interest in trends in age at marriage. Only women who had been married or were married were interviewed with the 2014 BDHS Woman’s Questionnaire. However, a number of the tables presented in this chapter are based on all women, both ever-married and never-married. For these tables, the number of ever-married women interviewed in the survey is multiplied by an inflation factor that equals the ratio of all women to ever married women, as reported in the Household Questionnaire. This procedure expands the denominators in those tables, so that they represent all women. The inflation factors are calculated by single years of age. When the results are presented by background characteristics, single-year inflation factors are calculated separately for each category of the characteristic. The definition of marriage is not universal for all countries and religions. In Bangladesh, it is common for a woman to wait several months or even years after formal marriage before starting to live with her husband. Since the 2014 BDHS is interested in marriage mainly as it affects exposure to the risk of pregnancy, interviewers were instructed to ask questions about marriage in terms of cohabitation rather than T Key Findings • Age at first marriage among women has risen slowly over the past two decades. The median age at first marriage among women age 20-49 increased from 14.4 years in 1993-94 to 16.1 years in 2014. • Fifty-nine percent of women age 20-24 now marry before age 18. Between 2000 and 2011, the percentage that married before age 18 changed very little. In the last three years, however, this percentage has dropped noticeably, from 65 percent in 2011 to 59 percent in 2014. • Seventy-eight percent of ever-married women were sexually active within the past four weeks, and another 12 percent were active within the past 1 to 12 months. • Thirteen percent of currently married women reported that their husbands lived elsewhere, and 5 percent of currently married women said they had not seen their spouse in the 12 months preceding the survey. • Almost 40 percent of women age 15-49 would have preferred to marry later than they actually did. Half of the women who married before age 18 would have preferred to marry later. 40 • Marriage and Sexual Activity formal marriage. Additionally, questions in the BDHS 2014 explore the consequences of marriage on education and employment. 4.2 CURRENT MARITAL STATUS Table 4.1 shows the current marital status of women age 15-49 by age. The proportion of never married women age 15-49 is 15 percent. This proportion falls sharply with increasing age. It declines from 55 percent for women age 15-19 to less than 1 percent among women age 35 or older. The low proportion of women age 25-29 who have never been married (4 percent) indicates that marriage is universal in Bangladesh and that more than nine in ten women marry before age 30. Eight in ten women (80 percent) are currently married. Three percent of women age 15-49 are widowed. The proportion of women who are widowed increases sharply with age and is mostly limited to older age groups: 8 percent of women age 40-44 and 13 percent of women age 45-49 are widowed. Divorce and separation are uncommon in Bangladesh. Two percent of women age 15-49 are either divorced or separated. The proportion divorced or separated does not vary markedly by age group. Table 4.1 Current marital status Percent distribution of women age 15-49 by current marital status, according to age, Bangladesh 2014 Marital status Total Percentage of respondents currently in union Number of respon- dents Age Never married Married Divorced Separated Widowed 15-19 54.8 44.2 0.4 0.5 0.1 100.0 44.2 4,485 20-24 15.5 83.0 0.8 0.6 0.2 100.0 83.0 3,816 25-29 4.1 92.0 0.8 1.7 1.4 100.0 92.0 3,534 30-34 1.2 94.6 0.7 0.9 2.6 100.0 94.6 3,084 35-39 0.8 92.3 0.9 2.1 3.9 100.0 92.3 2,334 40-44 0.6 89.0 0.8 1.5 8.1 100.0 89.0 2,105 45-49 0.2 85.5 0.4 1.5 12.5 100.0 85.5 1,769 Total 15.4 79.8 0.7 1.1 3.0 100.0 79.8 21,127 Table 4.2 shows the trend in the percentage of women who have never married by age group for the 1975-2014 period. The proportion of women who have never married affects fertility levels in a society like Bangladesh, where childbearing outside of marriage is uncommon. The proportion of never-married women age 15-19 has increased from 30 percent in 1975 to 55 percent in 2014. Similarly, the proportion of never- married women age 20-24 increased from 5 percent in 1975 to 19 percent in 1999-2000 and then declined with some fluctuations to 16 percent in 2014. Table 4.2 Trends in proportion never married Percentage of women who have never married, by age group, as reported in various surveys, Bangladesh 1975-2014 Age 1975 BFS 1983 CPS 1985 CPS 1989 BFS 1989 CPS 1991 CPS 1993- 1994 BDHS 1996- 1997 BDHS 1999- 2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS 10-14 91.2 98.0 98.7 96.2 96.4 98.5 95.2 95.2 92.7 88.6 u u u 15-19 29.8 34.2 47.5 49.0 45.8 46.7 50.5 49.8 51.9 52.1 52.8 54.3 54.8 20-24 4.6 4.0 7.1 12.0 9.3 12.3 12.4 17.2 18.5 15.2 14.3 13.4 15.5 25-29 1.0 0.7 1.0 2.3 1.6 2.8 2.2 3.4 4.2 4.2 4.3 3.0 4.1 30-34 0.2 0.4 0.1 0.3 0.5 0.5 0.3 0.5 0.1 1.2 0.6 1.2 1.2 35-39 0.4 - - 0.1 0.5 0.1 0.3 0.0 0.2 0.4 0.6 0.8 0.8 40-44 0.1 0.1 - 0.2 0.2 0.3 0.7 0.0 0.0 0.3 0.2 0.3 0.6 45-49 0.0 0.1 - 0.1 0.1 - 0.2 0.0 0.0 0.0 0.8 0.2 0.2 - = Less than 0.1 percent u = Unknown/not available Sources: 1975 BFS (MHPC 1978:49); 1983, 1985, 1989, and 1991 CPS (Mitra et al. 1993:24); 1989 BFS (Huq and Cleland 1990:43); 1993-1994 BDHS (Mitra et al. 1994:72); 1996-1997 BDHS (Mitra et al. 1997:82); 1999-2000 BDHS (NIPORT et al. 2001:78); 2004 BDHS (NIPORT et al. 2005: 93); 2007 BDHS (NIPORT et al. 2009:77); 2011 BDHS (NIPORT et al. 2013:49). Marriage and Sexual Activity • 41 4.3 AGE AT FIRST MARRIAGE Marriage is the leading social and demographic indicator of the exposure of women to the risk of pregnancy. Marriage in Bangladesh marks the point in a woman’s life when childbearing becomes socially acceptable. Age at first marriage has a major effect on childbearing because the risk of pregnancy depends primarily on the age at which women first marry. Women who marry early, on average, are more likely to have their first child at a young age and give birth to more children overall, contributing to higher fertility. As never-married women were not interviewed in the BDHS, tables on age at marriage were generated using expansion factors. The expansion factors are based on the assumption that the reporting of age and marital status in the Household Questionnaire is correct. This means that there was no bias in the reporting of age of ever-married women and that there were no errors in the reporting of marital status, especially of young women. Table 4.3 shows, by current ages, the percentages of women who have married, the percentages who have never married, and the median age at first marriage. Marriage occurs early for women in Bangladesh. Among women age 20-49, 71 percent married by age 18, and 85 percent married by age 20. Within each age cohort, the proportion of women marrying by a specific age increases. For example, among women age 25- 29, 69 percent married by age 18 and 94 percent married by age 25. The proportion of women marrying in their early teens continues to decline. For example, the proportion of women marrying by age 15 has declined by more than two-thirds over time, from 46 percent among women now age 45-49 to 16 percent among women age 15-19. Similarly, the proportion of women marrying by age 18 and age 20 decreases substantially from the oldest to the youngest cohort. Table 4.3 shows a slow but steady increase over the last three decades in the age at which Bangladeshi women first marry, from a median age of 15 years for women in their mid to late forties to 17.2 years for those in their early twenties. Table 4.3 Age at first marriage Percentage of women age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Bangladesh 2014 Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage Current age 15 18 20 22 25 15-19 16.3 na na na na 54.8 4,485 a 20-24 22.4 58.6 76.5 na na 15.5 3,816 17.2 25-29 30.7 68.7 83.1 88.7 93.7 4.1 3,534 16.4 30-34 35.5 72.8 88.2 93.3 96.8 1.2 3,084 16.0 35-39 39.8 77.1 89.5 94.5 97.0 0.8 2,334 15.6 40-44 45.3 80.1 90.9 95.3 97.4 0.6 2,105 15.3 45-49 46.2 80.7 91.8 96.1 98.1 0.2 1,769 15.3 20-49 34.4 71.0 85.3 na na 4.9 16,642 16.1 25-49 38.0 74.7 88.0 93.0 96.3 1.7 12,826 15.8 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women began living with their spouse or partner for the first time before reaching the beginning of the age group. A comparison of the 2014 BDHS survey results with findings from prior surveys confirms that the median age at first marriage for women in Bangladesh continues to increase. The median age at marriage among women age 20-49 has increased by almost two years, from 14.4 years in 1993-94 (Mitra et al. 2004) to 16.1 years in 2014. The legal age of marriage for women in Bangladesh is 18 years, but a large proportion of marriages still take place before the woman reaches her legal age. The 2014 BDHS found that 59 percent of women age 20-24 were married before age 18 (Figure 4.1). Between 2000 and 2011, the proportion who married 42 • Marriage and Sexual Activity before age 18 had hardly changed. But between 2011 and 2014 this proportion declined from 65 percent to 59 percent, the largest change ever observed between two BDHS surveys. Over the past two decades, the proportion of women marrying before the legal age has decreased by 14 percentage points overall from 73 percent in 1993-94 to 59 percent in 2014. Figure 4.1 Trends in proportion of women age 20-24 who were first married by age 18 Table 4.4 examines the median age at first marriage for women age 20-49 and 25-49, according to background characteristics. The median age at first marriage among women age 20-49 is 16.1 years. Urban women marry one year later than their rural counterparts (16.9 years versus 15.8 years). The median age at marriage varies among administrative divisions. It ranges from 15.3 years in Rangpur to 17.6 years in Sylhet. Women’s education shows a strong positive association with age at marriage. For example, women who have completed secondary or higher education marry almost five years later than those with no education. Similarly, age at marriage increases with household wealth. Women in the highest wealth quintile marry two years later than those in the lowest wealth quintile. 73 69 65 68 66 65 59 1993-94 BDHS 1996-97 BDHS 1999-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent Table 4.4 Median age at first marriage by background characteristics Median age at first marriage among women age 20-49 and age 25-49, according to background characteristics, Bangladesh 2014 Background characteristic Women age 20-49 25-49 Residence Urban 16.9 16.6 Rural 15.8 15.6 Division Barisal 16.1 15.8 Chittagong 16.8 16.5 Dhaka 16.2 15.9 Khulna 15.5 15.3 Rajshahi 15.5 15.3 Rangpur 15.3 15.0 Sylhet 17.6 16.9 Education No education 15.0 14.9 Primary incomplete 15.3 15.1 Primary complete1 15.7 15.5 Secondary incomplete 16.4 16.3 Secondary complete or higher2 19.9 19.6 Wealth quintile Lowest 15.3 15.2 Second 15.7 15.4 Middle 16.0 15.7 Fourth 16.3 15.8 Highest 17.6 17.3 Total 16.1 15.8 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/ partner. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Marriage and Sexual Activity • 43 4.4 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is often used as a proxy for first exposure to intercourse and risk of pregnancy. But these two events may not occur at the same time because some people may engage in sexual activity before marriage. To obtain insight into onset of sexual activity, the 2014 BDHS asked ever-married women how old they were when they first had sexual intercourse. It was recognized that the answer to this question might be biased since the respondent may have been uncomfortable providing information on premarital sex. In fact, the BDHS results show that virtually no ever-married women reported initiating sexual activity before they first married. Table 4.5 shows the percentage of women age 15-49 who had first sexual intercourse by specific ages, the percentage who never had sexual intercourse, and the median age of first sexual intercourse. The table was generated using the information on the age at first sex from the ever-married women interviewed in the BDHS and assuming that never-married women have not had intercourse. Given the conservative nature of the Bangladeshi society, that assumption is likely correct for many never-married women. However, it is clearly a source of potential for bias in the reporting of age at first intercourse, because some women who have never married are likely to have initiated sexual activity. It also must be recognized that not all ever married women who engaged in premarital sexual activity are likely to report that behavior in the survey, adding to the bias in the results shown in Table 4.5. Nevertheless, the data in Table 4.5 are useful since they document the information the BDHS was able to obtain on premarital sexual activity in Bangladeshi society. Table 4.5 shows that the median age at first sexual intercourse among women age 20-49 (16.2 years) is almost equal to the median age at first marriage (16.1 years). The median age at first sexual intercourse is higher among women age 20-24 than among older women. Looking at specific ages, 33 percent of women age 20-49 had sexual intercourse by age 15, which compares with 69 percent by age 18, and 83 percent by age 20. Five percent of women age 20-49 had never experienced sexual intercourse. Table 4.5 Age at first sexual intercourse Percentage of women age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, Bangladesh 2014 Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse Current age 15 18 20 22 25 15-19 15.0 na na na na 55.0 4,485 a 20-24 21.2 56.0 74.5 na na 15.6 3,816 17.4 25-29 29.8 66.3 81.3 86.9 91.7 4.2 3,534 16.5 30-34 34.0 70.6 85.9 90.8 94.3 1.2 3,084 16.1 35-39 39.0 75.2 87.2 92.1 94.7 0.8 2,334 15.7 40-44 43.9 78.2 88.5 92.7 94.5 0.6 2,105 15.4 45-49 45.1 78.8 89.7 93.8 95.5 0.2 1,769 15.4 20-49 33.3 68.8 83.2 na na 4.9 16,642 16.2 25-49 36.9 72.6 85.8 90.7 93.8 1.7 12,826 15.9 15-24 17.9 na na na na 36.8 8,301 a na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group 44 • Marriage and Sexual Activity Table 4.6 examines the median age at first sexual intercourse among women age 20-49 by background characteristics. Women living in rural areas tend to initiate sexual intercourse earlier than their urban counterparts. There is greater variation in median age at first sexual intercourse among administrative division than by urban or rural residence. Women in Sylhet are likely to start having sexual intercourse about two years later than women in Rangpur. Women age 25-49 who have completed secondary or higher education initiate sex about five years later than women with no education. Age at first sexual intercourse also increases with household wealth. 4.5 RECENT SEXUAL ACTIVITY In the absence of contraception, the possibility of pregnancy is positively related to the frequency of sexual intercourse. Thus, information on intercourse is important for refining measurement of exposure to pregnancy. All ever-married women were asked how long ago their last sexual contact occurred. As the length of time since their last sexual contact increased, the chance of becoming pregnant decreased. Table 4.7 shows the percent distribution of ever-married women age 15-49 by timing of their last sexual intercourse, according to background characteristics. The data show that 78 percent of ever-married women age 15-49 were sexually active during the four weeks preceding the survey. An additional 12 percent were sexually active in the 12 months preceding the survey, and 10 percent had their last sexual intercourse one or more years prior to the survey. Women in the oldest group (45-49), are the least likely to have had their last sexual intercourse in the past four weeks (64 percent) compared with the youngest women. More than 8 in 10 married women age 20-24, 25-29, and 30-34 had their last sexual intercourse in the four weeks preceding the survey. There are no noticeable variations in recent sexual activity by marital duration and by urban-rural residence. There are large variations in the timing of last sexual intercourse by administrative divisions. The proportion of women who were sexually active in the past four weeks ranges from 70 percent in Chittagong to 85-86 percent in Rajshahi and Rangpur. The relationship between a woman’s education and sexual activity shows no clear pattern; however, women with no education are the least likely to have been sexually active in the past four weeks (75 percent). In contrast, women in the lowest wealth quintile are the most likely to have had their last sexual intercourse in the past four weeks (80 percent) when compared with women in the higher quintiles. Table 4.6 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 20-49 and age 25-49, according to background characteristics, Bangladesh 2014 Background characteristic Women age 20-49 25-49 Residence Urban 17.0 16.7 Rural 15.9 15.6 Division Barisal 16.2 15.8 Chittagong 17.0 16.6 Dhaka 16.3 16.0 Khulna 15.6 15.4 Rajshahi 15.6 15.4 Rangpur 15.4 15.1 Sylhet 17.8 17.1 Education No education 15.0 15.0 Primary incomplete 15.3 15.2 Primary complete1 15.8 15.6 Secondary incomplete 16.5 16.4 Secondary complete or higher2 a 19.7 Wealth quintile Lowest 15.3 15.2 Second 15.7 15.4 Middle 16.0 15.8 Fourth 16.4 15.9 Highest 17.9 17.6 Total 16.2 15.9 a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Marriage and Sexual Activity • 45 Table 4.7 Recent sexual activity Percent distribution of ever-married women age 15-49 by timing of last sexual intercourse, according to background characteristics, Bangladesh 2014 Timing of last sexual intercourse Never had sexual intercourse Total Number of women Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 78.1 16.0 5.3 0.1 0.4 100.0 2,029 20-24 81.7 11.2 7.0 0.0 0.1 100.0 3,224 25-29 81.0 9.5 9.4 0.0 0.1 100.0 3,390 30-34 81.9 9.1 9.0 0.0 0.0 100.0 3,047 35-39 78.5 9.5 12.0 0.0 0.0 100.0 2,315 40-44 74.0 12.1 13.9 0.1 0.0 100.0 2,092 45-49 63.9 16.5 19.4 0.1 0.0 100.0 1,766 Marital status Married or living together 82.8 11.6 5.5 0.0 0.1 100.0 16,858 Divorced/separated/ widowed 0.1 9.2 90.0 0.0 0.7 100.0 1,005 Marital duration2 0-4 years 79.6 14.9 5.2 0.1 0.3 100.0 3,341 5-9 years 84.1 10.2 5.7 0.0 0.0 100.0 2,822 10-14 years 85.7 8.6 5.6 0.0 0.0 100.0 2,916 15-19 years 85.9 8.1 6.1 0.0 0.0 100.0 2,383 20-24 years 84.8 9.9 5.3 0.0 0.0 100.0 1,908 25+ years 78.6 15.8 5.4 0.1 0.0 100.0 2,920 Married more than once 81.3 14.2 4.5 0.0 0.0 100.0 569 Residence Urban 79.6 10.3 9.9 0.1 0.1 100.0 5,047 Rural 77.6 12.0 10.4 0.0 0.1 100.0 12,816 Division Barisal 75.1 16.4 8.3 0.0 0.2 100.0 1,111 Chittagong 69.9 14.3 15.8 0.0 0.1 100.0 3,301 Dhaka 79.2 10.9 9.7 0.1 0.1 100.0 6,223 Khulna 78.2 12.6 9.2 0.0 0.0 100.0 1,838 Rajshahi 84.8 8.7 6.3 0.0 0.2 100.0 2,103 Rangpur 85.5 8.0 6.4 0.0 0.1 100.0 2,056 Sylhet 73.6 11.6 14.8 0.0 0.1 100.0 1,232 Education No education 74.5 11.0 14.4 0.0 0.0 100.0 4,455 Primary incomplete 79.3 10.8 9.7 0.0 0.1 100.0 3,223 Primary complete3 80.2 10.8 9.0 0.0 0.0 100.0 1,986 Secondary incomplete 78.9 11.7 9.2 0.1 0.1 100.0 5,628 Secondary complete or higher4 79.4 13.3 7.2 0.0 0.1 100.0 2,571 Wealth quintile Lowest 80.3 10.8 8.9 0.0 0.1 100.0 3,359 Second 81.2 10.4 8.3 0.1 0.1 100.0 3,408 Middle 77.3 12.6 9.9 0.0 0.2 100.0 3,560 Fourth 75.7 11.5 12.7 0.0 0.1 100.0 3,758 Highest 76.6 12.2 11.2 0.0 0.0 100.0 3,778 Total 78.1 11.5 10.3 0.0 0.1 100.0 17,863 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. 4.7 SPOUSAL SEPARATION Repeated seasonal migration has the potential to lower birth rates. The effect of spousal separation in reducing fertility varies with the length of separation. It is expected that the cumulative impact of spousal separation is greatest in areas of relatively high fertility and low modern contraceptive prevalence. However, this has been difficult to ascertain as there have not been many studies to illustrate the effect of spouse separation on fertility. Table 4.8 shows the percentage of currently married women age 15-49 whose husband lives elsewhere and the frequency of the husband’s visits in the last 12 months. Overall, 13 percent of currently married women have a husband who lives elsewhere. Younger women, age 15-19 (19 percent), women who 46 • Marriage and Sexual Activity Table 4.8 Husband’s visit Percentage of currently married woman age 15-49 whose husband lives elsewhere, and among currently married women whose husband lives elsewhere, percent distribution by frequency of husband’s visit in the last 12 months, according to background characteristic, Bangladesh 2014 Background characteristic Percentage of women whose husband lives elsewhere Number of women Among currently married women whose husband lives elsewhere, frequency of husband’s visit to the household in the past 12 months Total Number of women 0 1-5 6-11 12+ Missing Age 15-19 18.8 1,984 35.0 43.2 15.9 5.5 0.5 100.0 374 20-24 16.7 3,166 40.6 37.3 11.9 9.6 0.6 100.0 529 25-29 13.6 3,249 47.1 32.5 10.3 10.1 0.0 100.0 441 30-34 12.1 2,919 49.0 30.3 14.0 5.7 1.0 100.0 354 35-39 10.6 2,153 41.8 35.6 12.4 9.3 0.8 100.0 227 40-44 5.9 1,874 36.8 37.0 20.2 6.0 0.0 100.0 111 45-49 4.4 1,512 36.0 44.6 11.6 7.7 0.0 100.0 66 Marital duration 0-4 years 20.1 3,341 36.1 40.8 13.6 9.3 0.3 100.0 671 5-9 years 13.9 2,822 43.3 35.3 11.9 8.7 0.8 100.0 392 10-14 years 12.3 2,916 49.5 30.7 12.0 7.3 0.5 100.0 359 15-19 years 12.1 2,383 49.4 28.7 14.9 6.3 0.7 100.0 289 20-24 years 9.9 1,908 41.7 42.1 8.2 7.3 0.8 100.0 188 25+ years 5.1 2,920 39.5 37.7 18.0 4.9 0.0 100.0 148 Married more than once 9.7 569 32.3 38.1 16.6 13.1 0.0 100.0 55 Residence Urban 9.7 4,709 40.8 35.4 15.4 7.6 0.7 100.0 458 Rural 13.5 12,149 42.6 36.4 12.5 8.1 0.4 100.0 1,644 Division Barisal 18.9 1,051 19.9 50.8 23.3 5.0 1.0 100.0 198 Chittagong 23.7 3,121 49.8 34.6 9.0 6.2 0.3 100.0 740 Dhaka 10.6 5,857 42.5 33.0 13.5 10.3 0.8 100.0 624 Khulna 9.5 1,729 39.8 35.1 15.1 9.6 0.5 100.0 164 Rajshahi 7.0 2,007 34.6 36.8 18.4 10.2 0.0 100.0 141 Rangpur 5.2 1,946 14.8 54.3 17.1 13.8 0.0 100.0 101 Sylhet 11.7 1,147 63.3 25.1 8.1 3.5 0.0 100.0 134 Education No education 5.9 3,949 43.6 33.0 14.2 8.7 0.4 100.0 232 Primary incomplete 9.4 3,032 46.6 30.8 17.1 4.1 1.3 100.0 285 Primary complete1 11.4 1,884 37.0 39.2 14.2 9.6 0.0 100.0 215 Secondary incomplete 15.9 5,477 46.7 35.5 10.6 6.8 0.5 100.0 873 Secondary complete or higher2 19.8 2,516 33.3 40.6 14.3 11.4 0.4 100.0 497 Wealth quintile Lowest 6.0 3,097 23.5 43.0 20.0 13.0 0.5 100.0 187 Second 9.5 3,223 34.7 36.8 19.8 8.7 0.0 100.0 305 Middle 14.5 3,394 44.0 32.8 15.3 7.1 0.9 100.0 494 Fourth 16.8 3,556 48.8 34.4 7.7 8.3 0.9 100.0 598 Highest 14.5 3,587 44.0 38.7 10.9 6.4 0.0 100.0 519 Total 12.5 16,858 42.2 36.2 13.1 8.0 0.5 100.0 2,102 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. have been married fewer than 5 years (20 percent), and rural women (14 percent) are more likely than other women to have husbands who live elsewhere. One in four women in Chittagong (24 percent) have husbands who live elsewhere compared with only 5 percent of women in Rangpur. The proportion of women with a husband who lives elsewhere increases with the woman’s education and wealth status. Only 6 percent of women with no education live apart from their husbands compared with 20 percent of those with secondary or higher education. Similarly, 6 percent of women in the lowest wealth quintile live separately from their husbands compared with 17 percent of women in the fourth quintile. Women whose husbands live elsewhere were asked how often their husband came to visit in the past 12 months. Forty-two percent of women say that their husband did not come home in the past 12 months, 36 percent reported that their husband visited 1 to 5 times, 13 percent visited 6 to 11 times, and 8 percent visited 12 or more times. Close to half of women age 30-34 and those married 10-14 and 15-19 years are more likely than other women to report that their husbands did not come home in the past 12 months. There is no substantial variation by urban-rural residence or educational attainment. The number of husband’s visits varied widely by administrative division: only 15 percent of women in Rangpur were not visited by their Marriage and Sexual Activity • 47 husbands in the past 12 months compared with 63 percent of women in Sylhet. The percentage of women whose husbands did not visit in the past year has a negative association with wealth quintile. Husbands of women in the three highest quintiles are less likely to visit their wives compared with those in the lower quintiles, possibly because they are more likely to be employed overseas rather than locally. 4.8 PERCEPTION TOWARD AGE AT FIRST MARRIAGE Table 4.9 shows the percentage of women age 15-49 by preferred age at marriage, according to background characteristics. Overall, more than 50 percent of women think that their marriage took place at an appropriate age, 39 percent would have preferred to marry later, and 8 percent would have preferred to marry at an earlier age. Older women (age 21-49) are more likely than younger women to say that their marriage took place at the right time (54 versus 28 percent). Half of the women (49 percent) who married before age 18 would have preferred to marry later. There are small urban-rural variations regarding preferred and actual age at first marriage. However, there are greater differences across divisions. Whereas 62-63 percent women in Sylhet and Chittagong think that their marriage was took place at the right age, only 43-44 percent of women in Rangpur and Khulna share this opinion. Seven in 10 women who have completed secondary or higher education think that they married at the right age compared with 51 percent of women with no education. Variations across wealth quintiles are less notable. It is interesting to note that 40 percent of women with no education and 39 percent of women belonging to the lowest quintile want to marry later than their actual age at marriage. Table 4.9 Preferred age at first marriage Percent distribution of women age 15-49 by preference for time of first marriage, according to background characteristics, Bangladesh 2014 Background characteristics Married at right time Preferred to marry earlier Preferred to marry later Missing Total Number of women Current age 15-17 27.5 11.6 59.6 1.4 100.0 879 18-20 48.3 9.0 40.9 1.8 100.0 1,799 21-49 53.6 7.2 38.0 1.2 100.0 15,186 Actual age at first marriage <18 40.8 8.8 49.4 1.0 100.0 13,657 18-20 87.3 2.9 7.4 2.3 100.0 3,183 21+ 86.9 6.0 5.0 2.1 100.0 1,024 Residence Urban 53.2 5.1 41.3 0.4 100.0 5,047 Rural 51.2 8.6 38.6 1.6 100.0 12,816 Division Barisal 49.8 12.1 35.8 2.4 100.0 1,111 Chittagong 61.9 3.6 32.6 1.9 100.0 3,301 Dhaka 50.9 8.8 39.4 0.8 100.0 6,223 Khulna 43.6 6.3 48.3 1.8 100.0 1,838 Rajshahi 47.7 3.0 48.1 1.2 100.0 2,103 Rangpur 43.4 9.4 46.1 1.1 100.0 2,056 Sylhet 63.3 14.8 21.0 1.0 100.0 1,232 Education No education 50.7 9.3 39.7 0.3 100.0 4,455 Primary incomplete 46.3 7.1 45.6 1.1 100.0 3,223 Primary complete1 47.6 7.5 43.7 1.2 100.0 1,986 Secondary incomplete 48.8 7.4 41.8 2.0 100.0 5,628 Secondary complete or higher2 70.1 5.7 22.3 1.9 100.0 2,571 Wealth quintile Lowest 47.9 11.6 39.3 1.2 100.0 3,359 Second 52.3 8.6 37.5 1.7 100.0 3,408 Middle 50.4 7.0 41.0 1.6 100.0 3,560 Fourth 50.2 5.9 42.4 1.5 100.0 3,758 Highest 57.4 5.3 36.6 0.6 100.0 3,778 Total 51.7 7.6 39.4 1.3 100.0 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Fertility • 49 FERTILITY 5 ertility is one of the three principal components of population dynamics that determine the size, structure, and composition of the population in any country. The focus on fertility is due to its important role in determining Bangladesh’s population growth rate and its impact on economic development. The government of Bangladesh (GOB), which has formulated a National Population Policy (MOHFW 2012), seeks to reduce fertility to replacement level by 2015. The Health, Population and Nutrition Sector Development Program (HPNSDP) of Bangladesh embraced program and strategies for reducing fertility through improved access to health, family planning, and nutrition services for the poor and geographically marginalized population (MOHFW 2011a, MOHFW 2011b). Examining current fertility levels, trends, and differentials in Bangladesh will help the policy makers and program managers to monitor and evaluate the HPNSDP. This chapter describes current and past fertility, cumulative fertility, birth intervals, age at first birth, and the reproductive behavior of adolescents. Most of the fertility measures are based on the birth history data collected during interviews with ever-married women age 15-49. In the 2014 BDHS 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. The interviewer then asked for a history of all births, including month and year, name, sex, and survival status of each birth. The interviewers were given extensive training in probing techniques designed to help respondents report this information accurately. F Key Findings • The total fertility rate for the three years preceding the survey is 2.3 births per woman, the same as in the 2011 BDHS. The aim of the 2011-2016 health sector program is to reach a fertility level of 2.0 births per woman by 2016. • Between the 2011 and 2014 BDHS, fertility declined or remained the same in 6 of 7 divisions. Dhaka is the only division where the total fertility rate increased from 2.2 to 2.3. • The total fertility rate in urban areas is nearly half a child lower than in rural areas (2.0 and 2.4 births per woman, respectively). • Khulna and Rangpur divisions have passed the fertility level target of 2.0 births per woman (1.9 births per woman), while Rajshahi and Barisal are close behind (2.1 and 2.2 births per woman, respectively). Sylhet has the highest fertility (2.9 births per woman). • Childbearing begins early in Bangladesh, with almost half of women age 25-49 giving birth by age 18 and nearly 70 percent giving birth by age 20. • Birth intervals are generally long in Bangladesh, with a median interval of 52 months. The median interval increased from 47 months in 2011. The proportion of women with a birth interval of less than 36 months declined from 32 percent in 2011 to 29 percent in 2014. • Thirty-one percent of adolescents age 15-19 in Bangladesh are already mothers or pregnant with their first child. This proportion has not changed in the last three years. 50 • Fertility The following measures of current fertility are derived from the birth history data: • Age-specific fertility rates1 (ASFRs) 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) represents the average number of children a woman would have by the end of her reproductive period if her experience followed the currently prevalent age- specific fertility rates. The TFR is calculated as the sum of the age-specific fertility rates multiplied by five (each age group covers five years of age). • The general fertility rate (GFR) is expressed as the annual number of live births per 1,000 women age 15-44, and the crude birth rate (CBR) provides a measure of the annual number of live births per 1,000 population. The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to the calendar years 2012-2014. 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 then 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. 5.1 CURRENT FERTILITY Some current fertility measures are presented in Table 5.1 for the three-year period preceding the survey. ASFRs and the TFR for Bangladesh as a whole and for urban and rural areas are shown, along with the GFR and crude birth rate. The TFR is a useful measure of the level of recent fertility. The 2014 BDHS shows that the TFR for the three-year period before the survey is 2.3 children per woman. The overall age pattern of fertility, as reflected in the ASFRs, indicates that Bangladeshi women have a pattern of early childbearing (Figure 5.1). According to current fertility rates, on average, women will have 25 percent of their births before reaching age 20, 55 percent during their twenties, and 18 percent during their thirties. Fertility is 113 births per 1,000 women age 15-19, which increases to a peak of 143 births per 1,000 women age 20-24, and declines thereafter. 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 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Bangladesh 2014 Residence Total Age group Urban Rural 15-19 98 120 113 20-24 125 151 143 25-29 94 116 110 30-34 61 56 57 35-39 16 28 24 40-44 3 5 4 45-49 8 3 5 TFR(15-49) 2.0 2.4 2.3 GFR 79 94 90 CBR 20.8 22.8 22.2 Notes: 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 age 15-44 CBR: Crude birth rate, expressed per 1,000 population Fertility • 51 The TFR in the rural areas is higher than in urban areas (2.4 compared with 2.0 births per woman). As the ASFRs show, the pattern of higher rural fertility is prevalent in all age groups. The urban-rural difference in fertility is most pronounced for women in the 20-24 age group (125 births per 1,000 women in urban areas versus 151 births per 1,000 women in rural areas). Figure 5.1 Age-specific fertility rates by urban-rural residence 5.2 FERTILITY DIFFERENTIALS Table 5.2 shows that fertility varies widely by administrative divisions. Khulna and Rangpur divisions have the lowest fertility (1.9 births per woman) and thus have achieved the aim of HPNSDP to reduce fertility to 2.0 births per woman by 2016. Rajshahi and Barisal, with TFRs of 2.1 and 2.2, respectively, are very close to achieving the HPNSDP aim. Although fertility is still high in Sylhet and Chittagong divisions, it has declined from that in the 2011 BDHS. Between the 2011 BDHS and the 2014 BDHS, the TFR in Sylhet declined from 3.1 to 2.9 births per woman and in Chittagong declined from 2.8 to 2.5 births per woman. The only division where fertility has increased is Dhaka. Since Dhaka Division constitutes about one-third of Bangladesh’s population, it has the largest impact on the national fertility rate. As expected, women’s education is associated with fertility. The TFR decreases from 2.4 births for women with no education to 2.0 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 0.8 child per woman, on average. As shown in Table 5.2, at the time of the survey, 5 percent of women age 15-49 reported that they were pregnant. 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. The percentage of women currently pregnant is higher in rural areas than in urban areas (5 percent and 4 percent, respectively). The percentage of women age 15-49 currently pregnant varies by administrative division. Nine percent of women are currently pregnant in Sylhet, compared with 4 percent in Khulna and Rajshahi. The relationship between the percentage currently pregnant and education is U-shaped, rising from a low of 3 percent among women with no education to a high of 6 percent among women with some secondary education, and then dipping again to 5 percent among women who have completed secondary or higher education. Women in the lowest wealth quintile are more likely to be currently pregnant (7 percent) than women in the highest quintile (4 percent). 98 125 94 61 16 3 8 120 151 116 56 28 5 3 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Births per 1,000 women Age group Urban Rural BDHS 2014 52 • Fertility Table 5.2 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, by background characteristics, Bangladesh 2014 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 2.0 4.4 3.4 Rural 2.4 5.3 4.1 Division Barisal 2.2 5.3 4.2 Chittagong 2.5 5.4 4.4 Dhaka 2.3 4.9 3.7 Khulna 1.9 3.9 3.4 Rajshahi 2.1 4.3 3.5 Rangpur 1.9 4.5 3.7 Sylhet 2.9 8.5 4.9 Educational No education 2.4 3.0 4.2 Primary incomplete 2.5 5.3 4.1 Primary complete1 2.4 5.6 3.9 Secondary incomplete 2.4 6.3 3.4 Secondary complete or higher2 2.0 4.8 2.4 Wealth quintile Lowest 2.8 6.6 4.3 Second 2.4 5.7 4.2 Middle 2.2 4.7 4.1 Fourth 2.1 4.5 3.8 Highest 2.0 4.3 3.1 Total 2.3 5.1 3.9 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. Table 5.2 also presents the mean number of children ever born to women age 40-49, which allows for a crude assessment of trends in fertility. Whereas TFR is a measure of current fertility, the mean number of children ever born to women age 40-49 is a measure of past or completed fertility. Although comparing completed fertility among women age 40-49 with the TFR can provide an indication of fertility change, it is vulnerable to the understatement of parity by older women. Findings on age at marriage and contraceptive use are also of critical importance in reaching a balanced judgment about fertility trends. Unless there is evidence of increased age at marriage and/or an appreciable use of contraception, it is unlikely that fertility has declined. In Bangladesh, 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 almost two children per woman, from 3.9 to 2.3 children. There has been a substantial decline in fertility in both urban and rural areas, in all regions, and for all wealth quintiles. The difference between current and completed fertility is highest in rural areas (1.7 births), in Barisal and Sylhet (2 births), and among women in the second and middle wealth quintiles (1.8 and 1.9 births). 5.3 FERTILITY TRENDS Trends in fertility can be assessed in two ways. The first way is to use retrospective data from birth histories collected in the 2014 BDHS. The second is to compare the TFR from the 2014 BDHS with estimates obtained in earlier surveys. Fertility • 53 Trends in fertility over time can be examined by comparing age-specific fertility rates from the 2014 BDHS for successive five-year periods preceding the survey, as presented in Table 5.3.1. The rates for older age groups become progressively more truncated for periods more distant from the survey date, because women age 50 and older were not interviewed in the survey. For example, rates cannot be calculated for women age 35-39 for the period 15- 19 years before the survey because these women would have been over age 50 at the time of the survey and therefore not eligible to be interviewed. Nonetheless, 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 58 percent decline (from 141 births to 59 births) between the period 15-19 years before the survey and the period 0-4 years before the survey. 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 four decades, beginning with the 1975 Bangladesh Fertility Survey (BFS). The TFRs for the seven BDHS surveys since 1993-1994 and the three preceding surveys carried out since 1975 are presented in Table 5.3.2 and Figure 5.2, and age-specific fertility rates from 2004 to 2014 are presented in Figure 5.3. The data indicate that fertility in Bangladesh has been declining since the 1970s. The TFR declined sharply from 6.3 births per woman in 1971-1975 to 5.1 births per woman in 1984-1988, followed by another rapid decline in the next decade of 1.8 births per woman to reach 3.3 births per woman in 1994-1996. Following a decade-long plateau in fertility during the 1990s at around 3.3 births per woman, the TFR declined further by one child and remains at 2.3 births per woman since the 2011 BDHS. Table 5.3.2 Trends in current fertility rates Age-specific and total fertility rates (TFR) among women age 15-49, various sources, Bangladesh, 1975 to 2014 Age group Survey and approximate time period 1975 BFS (1971-1975) 1989 BFS (1984-1988) 1991 CPS (1989-1991) 1993-1994 BDHS (1991-1993) 1996-1997 BDHS (1994-1996) 1999-2000 BDHS (1997-1999) 2004 BDHS (2001-2003) 2007 BDHS (2004-2006) 2011 BDHS (2009-2011) 2014 BDHS (2012-2014) 15-19 109 182 179 140 147 144 135 126 118 113 20-24 289 260 230 196 192 188 192 173 153 143 25-29 291 225 188 158 150 165 135 127 107 110 30-34 250 169 129 105 96 99 83 70 56 57 35-39 185 114 78 56 44 44 41 34 21 25 40-44 107 56 36 19 18 18 16 10 6 4 45-49 35 18 13 14 6 3 3 1 3 4 TFR 15-49 6.3 5.1 4.3 3.4 3.3 3.3 3.0 2.7 2.3 2.3 Note: For the 1975 and 1989 BFS surveys, the rates refer to the 5-year period preceding the survey; for the other surveys, the rates refer to the 3-year period preceding the survey. The BFS and BDHS surveys utilized full birth histories, while the 1991 CPS used an 8-year truncated birth history. Source: 1975 BFS (MOHPC, 1978:73); 1989 BFS (Huq and Cleland, 1990:103); 1991 CPS (Mitra et al., 1993:34); 1993-94 BDHS (Mitra et al., 1994:24); 1996-97 BDHS (Mitra et al., 1997:30); 1999-2000 BDHS (NIPORT et al., 2001:32); 2004 BDHS (NIPORT et al., 2005:50) ; 2007 BDHS (NIPORT et al., 2009:50); 2011 BDHS (NIPORT et al., 2013:60). Table 5.3.1 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 2014 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 117 150 178 190 20-24 142 172 212 213 25-29 111 127 151 172 30-34 59 77 108 [141] 35-39 23 43 [57] - 40-44 5 [10] - - 45-49 [5] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 54 • Fertility Figure 5.2 Trends in total fertility rates, 1975-2014 An examination of the changes in the age-specific fertility rates in Table 5.3.2 and Figure 5.3 indicates that while the peak childbearing age has remained in the 20-24 age group, the largest absolute change in fertility also occurred in this age group, declining from 192 births per 1,000 women in the 2004 BDHS to 143 births per 1,000 women in the 2014 BDHS. Figure 5.3 Trends in age-specific fertility rates, 2004-2014 Figure 5.4 shows that in the 2014 BDHS, Khulna and Rangpur divisions have the lowest TFR (1.9 births per woman), and Sylhet division has the highest TFR (2.9 births per woman). The data indicate that in the last three years fertility has slightly declined in four divisions (Barisal, Chittagong, Rangpur, and Sylhet), remained the same in two divisions (Khulna and Rajshahi) and slightly increased in Dhaka division. Since Dhaka is by far the largest division—comprising one-third of Bangladesh’s population—the fertility rate of this division has a large impact on the national fertility rate. Changes in fertility over time should be interpreted with caution in the absence of sampling errors. 6.3 5.1 4.3 3.4 3.3 3.3 3.0 2.7 2.3 2.3 BFS 1975 BFS 1989 CPS 1991 BDHS 1993-94 BDHS 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 Births per woman 0 50 100 150 200 250 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Births per 1,000 women Age group 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Fertility • 55 Table 5.3.3 Current fertility by division Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the three years preceding the survey, by division, Bangladesh 2014 Division Bangladesh Age group Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet 15-19 100 117 113 118 127 118 93 113 20-24 151 167 129 142 135 122 176 143 25-29 103 118 121 80 97 79 152 110 30-34 56 60 70 35 41 37 85 57 35-39 22 26 28 7 17 15 65 24 40-44 1 5 4 4 2 0 14 4 45-49 0 14 4 1 3 2 2 5 TFR (15-49) 2.2 2.5 2.3 1.9 2.1 1.9 2.9 2.3 GFR 83 101 92 72 81 75 111 90 CBR 19.7 25.9 23.0 18.1 19.7 18.4 26.3 22.2 Notes: 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 age 15-44 CBR: Crude birth rate expressed per 1,000 population Figure 5.4 Trends in total fertility by division, 2011 and 2014 5.4 CHILDREN EVER BORN AND LIVING Table 5.4 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 2.1, while currently married women have 2.5 births on average. Allowing for mortality of children, Bangladeshi women have, on average, 1.9 living children. Currently married women have an average of 2.2 living children. 2.3 2.8 2.2 1.9 2.1 2.1 3.1 2.2 2.5 2.3 1.9 2.1 1.9 2.9 Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Births per woman Division BDHS 2011 BDHS 2014 56 • Fertility Table 5.4 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 2014 Number of children ever born Total Number of women Mean number of children ever born Mean number of living children Age 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 75.4 22.1 2.3 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 4,485 0.27 0.26 20-24 27.5 40.9 25.4 5.2 0.9 0.1 0.0 0.0 0.0 0.0 0.0 100.0 3,816 1.11 1.06 25-29 8.9 21.4 41.5 19.6 6.5 1.6 0.5 0.0 0.1 0.0 0.0 100.0 3,534 2.01 1.87 30-34 3.3 9.1 32.3 30.5 14.9 6.5 2.2 0.8 0.2 0.1 0.0 100.0 3,084 2.79 2.59 35-39 2.0 7.0 25.9 27.9 17.7 9.9 6.2 2.0 0.8 0.4 0.2 100.0 2,334 3.26 2.96 40-44 2.4 6.3 17.9 25.2 19.3 13.8 8.0 4.2 1.7 0.7 0.5 100.0 2,105 3.66 3.23 45-49 1.6 4.1 13.2 21.0 20.3 18.4 10.7 5.9 2.3 1.4 1.1 100.0 1,769 4.15 3.56 Total 23.5 18.7 22.5 16.1 9.0 5.2 2.8 1.3 0.5 0.3 0.2 100.0 21,127 2.08 1.89 CURRENTLY MARRIED WOMEN 15-19 45.5 49.0 5.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,984 0.60 0.58 20-24 13.8 48.3 30.4 6.3 1.1 0.1 0.0 0.0 0.0 0.0 0.0 100.0 3,166 1.33 1.26 25-29 4.6 22.3 42.8 20.9 7.0 1.6 0.5 0.0 0.1 0.0 0.0 100.0 3,249 2.11 1.97 30-34 2.0 8.2 33.0 31.3 15.1 6.8 2.3 0.9 0.2 0.1 0.0 100.0 2,919 2.86 2.65 35-39 0.9 5.7 25.7 28.6 18.6 10.3 6.6 2.1 0.8 0.5 0.2 100.0 2,153 3.36 3.05 40-44 1.6 5.1 17.6 25.8 19.9 14.2 8.4 4.6 1.5 0.8 0.5 100.0 1,874 3.76 3.33 45-49 1.2 3.6 12.7 21.1 20.7 18.7 11.1 6.1 2.2 1.5 1.2 100.0 1,512 4.21 3.63 Total 9.6 22.2 26.7 19.1 10.6 6.1 3.3 1.5 0.5 0.3 0.2 100.0 16,858 2.45 2.23 Currently married women age 45-49 have given birth to an average of 4.2 children, of whom 3.6 have survived. Among all women age 15-49, the average number of children who have died per woman is 0.19. Among currently married women, it is 0.22; that is, 9 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 5 percent for women age 20-24 to 14 percent for women age 45-49. The proportion of children for currently married women age 20-24 and 45-49 who have died slightly decreases in the last three years. Nearly one-quarter (24 percent) of all women age 15-49 have never given birth. This proportion is highest among women age 15-19, as 75 percent of women in this age group have never given birth. However, this proportion declines to 28 percent among women age 20-24 and rapidly decreases further for older women. The percentage of women who have never given birth is quite low (less than 2.5 percent) among all women age 35-44, indicating that childbearing among Bangladeshi women is nearly universal. Overall, 10 percent of currently married women age 15-49 have never given birth. The difference in the mean number of children ever born between all women and currently married women is due to the substantial proportion of young and unmarried women in the former category. 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 2014 BDHS results suggest that primary infertility is low in Bangladesh, at slightly more than 2 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. 5.5 BIRTH INTERVALS Birth interval is the length of time between two successive live births. Examination of birth intervals provides insight into birth spacing patterns and, subsequently, maternal, infant, and childhood mortality. Short birth intervals are associated with an increased risk of death for mother and child. Studies have shown that children born less than 24 months after a previous sibling risk poor health as well. Short birth intervals also threaten maternal health. Fertility • 57 Table 5.5 shows the percent distribution of non-first births that occurred in the five years preceding the survey by number of months since the previous birth, according to background characteristics. Birth intervals are generally long in Bangladesh, with a median interval of 52 months. Lengthy breastfeeding and a long period of postpartum amenorrhea are likely to contribute to the relatively high percentage of births occurring after an interval of 24 months or more in Bangladesh. More than 70 percent of non-first births occur three or more years after the previous birth, while 18 percent of births take place 24-35 months after the previous birth. Eleven percent of children are born after an interval that is considered “too short,” i.e., less than 24 months. Table 5.5 Birth intervals Percent distribution of non-first births in the five years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Bangladesh 2014 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 15-19 16.8 32.5 30.3 12.3 2.0 6.1 100.0 114 24.1 20-29 5.4 7.4 20.3 17.1 16.1 33.7 100.0 2,989 47.9 30-39 2.1 4.3 13.8 13.1 13.0 53.6 100.0 1,696 63.2 40-49 0.7 4.9 12.9 11.0 7.8 62.7 100.0 137 73.2 Sex of preceding birth Male 5.2 6.9 16.6 14.8 13.6 42.9 100.0 2,427 53.1 Female 3.7 6.8 19.6 16.0 15.3 38.6 100.0 2,510 50.6 Survival of preceding birth Living 3.1 6.2 17.5 15.9 14.9 42.5 100.0 4,593 53.5 Dead 22.8 15.8 25.7 9.6 9.3 16.8 100.0 344 28.3 Birth order 2-3 4.6 6.4 17.0 14.9 14.5 42.6 100.0 3,716 53.2 4-6 3.6 8.0 20.2 16.8 14.9 36.4 100.0 1,077 48.6 7+ 5.5 10.1 31.0 17.8 11.2 24.5 100.0 145 39.1 Residence Urban 4.0 6.3 14.2 15.1 16.7 43.6 100.0 1,144 55.5 Rural 4.6 7.1 19.3 15.5 13.8 39.8 100.0 3,793 50.5 Division Barisal 3.3 5.7 12.9 15.5 17.1 45.4 100.0 263 57.6 Chittagong 5.1 7.6 19.9 17.9 18.3 31.1 100.0 1,085 47.7 Dhaka 4.0 6.9 18.2 13.6 13.7 43.6 100.0 1,709 53.9 Khulna 3.1 5.2 9.7 12.4 13.6 56.0 100.0 359 63.8 Rajshahi 4.1 3.8 14.0 13.8 11.7 52.6 100.0 491 61.9 Rangpur 2.4 7.5 11.9 14.5 12.4 51.4 100.0 478 60.7 Sylhet 8.0 9.3 31.2 20.3 12.8 18.4 100.0 551 36.6 Educational attainment No education 4.0 6.8 19.7 17.0 14.1 38.5 100.0 1,105 49.9 Primary incomplete 4.3 5.6 21.9 15.6 13.4 39.3 100.0 924 49.9 Primary complete1 4.3 9.4 17.8 12.6 13.5 42.3 100.0 593 52.4 Secondary incomplete 4.7 7.2 16.5 16.0 14.0 41.6 100.0 1,769 51.9 Secondary complete or higher2 4.9 5.5 13.9 13.3 19.5 42.9 100.0 545 56.2 Wealth quintile Lowest 4.8 6.8 25.2 16.2 14.5 32.5 100.0 1,316 45.6 Second 5.4 7.6 17.0 14.4 13.6 41.9 100.0 980 52.3 Middle 5.0 7.3 15.4 16.6 14.4 41.3 100.0 935 51.9 Fourth 3.6 8.0 14.8 16.2 13.5 44.0 100.0 897 54.2 Highest 2.8 4.4 14.7 13.4 16.6 48.1 100.0 809 58.5 Total 4.4 6.9 18.1 15.4 14.5 40.7 100.0 4,937 51.7 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. The median number of months since a preceding birth increases significantly with age, from 24 months among mothers age 15-19 to 73 months among mothers age 40-49. There is no marked difference in the length of the median birth interval by sex of the preceding birth. However, birth interval decreases with birth order. 58 • Fertility The length of the birth interval is closely associated with the survival status of the previous sibling. The median birth interval is 25 months shorter when the previous sibling has died than when the previous sibling is still alive (28 and 54 months, respectively). The percentage of births occurring within a very short interval (less than 18 months) is almost eight times higher for children whose previous sibling died than for children whose previous sibling survived (23 and 3 percent, respectively). The shorter interval following the death of a child is partly due to a shortened period of breastfeeding (or no breastfeeding) for the preceding child, which leads to an earlier return of ovulation and hence increased chance of pregnancy. Minimal use of contraception, presumably because of a desire to have another child as soon as possible, could also be partly responsible for the shorter birth interval in these cases. Birth intervals are slightly longer in urban (56 months) than in rural (51 months) areas. There are marked differences in median birth intervals by administrative divisions. The median birth interval is longest in Khulna (64 months) and shortest in Sylhet (37 months). The median number of months since the preceding birth increases both with the mother’s education and the household’s wealth. The birth interval increases from 50 months among women with no education to 52 months among women with an incomplete secondary education and to 56 months among those with a complete secondary education or higher. Similarly, the median birth interval for the highest wealth quintile is nearly 5 years (59 months), whereas for the three lowest quintiles it is 52 months or less. A comparison with earlier BDHS surveys shows that the median birth interval has increased markedly, rising from 35 months in 1993-1994 to 44 months in 2007, to 47 months in 2011, and 52 months in 2014. Between 1993 and 2014, the median birth interval increased by 49 percent. 5.6 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY Fertility levels in most populations can be explained by four key proximate determinants that affect a woman’s risk of becoming pregnant: nuptiality (including age at first marriage and age at first sexual intercourse); postpartum amenorrhea and sexual abstinence; menopause; and contraceptive use. Table 5.6 addresses two principal factors that influence fertility. Postpartum amenorrhea and sexual abstinence affect the duration of a woman’s insusceptibility to pregnancy, which affects birth spacing. The onset of menopause marks the end of a woman’s reproductive life. These variables taken together determine the length and pace of a woman’s reproductive life, and therefore are important for understanding fertility levels and differentials. Table 5.6 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the three years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, by number of months since birth, and median and mean durations, Bangladesh 2014 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 <2 93.8 89.0 99.0 174 2-3 46.3 32.2 58.9 237 4-5 41.4 8.9 45.7 260 6-7 28.1 8.7 32.1 269 8-9 24.7 5.8 28.5 297 10-11 20.4 9.8 29.1 309 12-13 16.9 7.4 23.1 299 14-15 15.7 3.5 19.2 302 16-17 5.9 10.3 15.5 279 18-19 6.1 4.7 10.5 258 20-21 5.9 6.0 11.8 259 22-23 9.9 7.2 15.8 293 24-25 4.2 5.4 9.3 297 26-27 3.6 4.2 7.1 237 28-29 2.7 9.0 11.7 247 30-31 1.5 5.5 6.5 291 32-33 1.6 5.6 6.9 279 34-35 1.8 2.1 3.9 287 Total 16.6 10.7 22.3 4,874 Median 3.2 2.1 4.0 na Mean 6.9 4.8 8.9 na Note: Estimates are based on status at the time of the survey. na = Not applicable 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth Fertility • 59 Postpartum amenorrhea is the interval between the birth of a child and the resumption of menstruation during which the risk of pregnancy is very low. Postpartum protection from conception can be influenced by the intensity and length of breastfeeding. Postpartum abstinence refers to the period of voluntary sexual inactivity after childbirth. Delaying the resumption of sexual relations after a birth prolongs the period of postpartum protection. A woman is considered insusceptible to pregnancy if she is not exposed to the risk of pregnancy either because she is amenorrheic or because she is abstaining from sexual intercourse following a birth. The duration of amenorrhea and sexual abstinence following birth jointly determine the length of insusceptibility. In the 2014 BDHS, information was obtained about the duration of amenorrhea and the duration of postpartum sexual abstinence for births in the three years preceding the survey. Table 5.6 shows that Bangladeshi women are amenorrheic for a median of 3.2 months, abstain for a median of 2.1 months, and are insusceptible to pregnancy for a median of 4.0 months. Almost all women (99 percent) are insusceptible to pregnancy during the first two months following childbirth. In general, the proportion of women who are amenorrheic or abstaining decreases as months after delivery increase. The proportion of women who are amenorrheic drops from 94 percent in the first two months after birth to a low of less than 2 percent at 30-35 months. The majority (89 percent) of Bangladeshi women abstain from sex during the first two months following a birth. The proportion abstaining drops sharply to 32 percent at 2 to 3 months and then drops to 9 percent at 4 to 5 months. The period of postpartum amenorrhea is considerably longer than the period of postpartum abstinence and is by far the major determinant of the length of postpartum insusceptibility to pregnancy. At 6 to 7 months after birth, more than one-fourth of all women are still amenorrheic, but only 9 percent are abstaining. At 16 to 17 months after birth, the proportion amenorrheic is 6 percent, while 10 percent of women are abstaining. A comparison of the 2014 BDHS with earlier BDHS surveys indicates that the duration of abstinence has remained constant since 1993-1994, possibly because of the Muslim tradition of abstaining for 40 days after birth. The median duration of postpartum amenorrhea has steadily decreased over time, from 10.3 months in 1993-1994 to 8.4 months in 1996-1997, 7.9 months in 1999-2000, 6.1 months in 2004, 5.8 months in 2007, 4.3 months in 2011, and 3.2 months in 2014 (Mitra et al. 1994:77, Mitra et al. 1997:86; NIPORT et al. 2001:82; NIPORT et al. 2005:97; NIPORT et al. 2009:84; NIPORT et al. 2013:68). Similarly, there has been a slow and steady decline in the median duration of insusceptibility, from 10.8 months in 1993-1994 to 6.5 months in 2004. Between 2004 and 2007 the median duration of insusceptibility did not change, but thereafter the duration of insusceptibility declined from 5.1 months in 2011 to 4.0 months in 2014. Table 5.7 shows that the median duration of postpartum amenorrhea, abstinence, and insusceptibility varies little by background characteristics. The median duration of postpartum amenorrhea and postpartum insusceptibility are almost two months longer among women age 30-49 than among women age 15-29. Rural women have a shorter median duration of amenorrhea than urban women, and hence a shorter period of insusceptibility. There are substantial variations by administrative division for the period of insusceptibility. Postpartum insusceptibility ranges from 5.6 months among women in Sylhet to 2.8 months in Rangpur, while the median among women in the other divisions ranges between 3.7 and 4.5 months. The duration of postpartum amenorrhea is longer among women with no education than among women with some primary or secondary education. The median duration of postpartum amenorrhea and insusceptibility is shortest among women in the lowest quintile. 60 • Fertility Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility Median number of months of postpartum amenorrhea, postpartum abstinence, and postpartum insusceptibility following births in the three years preceding the survey, by background characteristics, Bangladesh 2014 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother’s age 15-29 3.0 2.1 3.8 30-49 4.8 * 5.4 Residence Urban 4.1 2.1 4.6 Rural 2.9 2.1 3.8 Division Barisal 3.0 (2.2) 4.2 Chittagong 3.2 (2.4) 4.5 Dhaka 2.9 * 3.7 Khulna 3.6 2.6 4.4 Rajshahi 3.3 (2.1) 3.7 Rangpur 2.7 * 2.8 Sylhet 5.0 (1.4) 5.6 Educational attainment No education 4.1 * 4.5 Primary incomplete 3.0 (1.4) 3.5 Primary complete2 3.3 (2.3) 3.7 Secondary incomplete 3.1 2.1 3.9 Secondary complete or higher3 3.0 (2.4) 4.4 Wealth quintile Lowest 3.0 (1.8) 3.2 Second 3.9 (2.2) 4.2 Middle (2.4) (2.1) 3.3 Fourth 3.9 (2.2) 4.7 Highest 3.3 (2.2) 4.4 Total 3.2 2.1 4.0 Note: Medians are based on the status at the time of the survey (current status). Figures in parentheses are based on 25-49 unweighted number of birth used to create a 3-month moving average. An asterisk indicates that the unweighted number of births used to create a 3-month moving average is less than 25. 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 5.7 MENOPAUSE The risk of becoming pregnant declines with age. After age 30, women’s susceptibility to pregnancy declines as an increasing proportion of women become infecund. The term infecundity denotes a process rather than a well-defined event. Although the onset of infecundity is difficult to determine for an individual woman, there are ways of estimating it for a group of women. One indicator of infecundity is the onset of menopause. Menopause is the culmination of a gradual decline in fecundity with increasing age. The 2014 BDHS defines menopausal women as women who are neither pregnant nor postpartum amenorrheic, but who have not had a menstrual period in the six months preceding the survey. Women who report that they have had a hysterectomy are also defined as menopausal. Table 5.8 shows that 23 percent of women age 30-49 are estimated to be menopausal. The proportion menopausal increases with age, from 8 percent among women age 30-34 to 68 percent among women age 48-49. The proportion of women age 30-49 who are menopausal increased from 20 percent in the 2011 BDHS to 23 percent in the 2014 BDHS. Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Bangladesh 2014 Age Percentage menopausal1 Number of women 30-34 7.7 3,047 35-39 12.7 2,315 40-41 23.5 828 42-43 27.6 854 44-45 37.8 828 46-47 55.3 662 48-49 68.4 686 Total 22.9 9,221 1Percentage of women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey Fertility • 61 5.8 AGE AT FIRST BIRTH Age at first birth has a direct effect on fertility. Early initiation of childbearing lengthens the reproductive period and subsequently increases fertility. In many countries, postponement of first births— reflecting an increase in the age at marriage—has contributed greatly to overall fertility decline. Moreover, bearing children at a young age involves substantial risks to the health of both the mother and child. Early childbearing also tends to restrict educational and economic opportunities for women. Table 5.9 presents the percentage of all women who had given birth by specific ages for different age cohorts. The median age at first birth is not shown for young women age 15-19 because a large majority had not become mothers. The median age at first birth is about 18 years across all age cohorts, except for women age 20-24 and 25-29, whose median age at first birth is 19. The proportion of women who had a child before age 15 has decreased; 12 to 14 percent of women in their forties reported having had their first birth by age 15, compared with 4 percent of women age 15-19. Close to half of Bangladeshi women (48 percent) have given birth before reaching age 18, while 70 percent have given birth by age 20. These findings are similar to those in the 2011 BDHS. Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by exact ages, percentage who have never given birth, and median age at first birth, according to current age, Bangladesh 2014 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 4.4 na na na na 75.4 4,485 a 20-24 8.3 35.7 58.2 na na 27.5 3,816 19.2 25-29 11.5 44.4 67.0 78.3 87.1 8.9 3,534 18.5 30-34 12.3 49.1 71.2 83.3 92.1 3.3 3,084 18.1 35-39 11.3 50.9 71.4 83.8 92.3 2.0 2,334 17.9 40-44 13.5 51.3 72.4 83.4 91.3 2.4 2,105 17.9 45-49 12.2 46.3 68.1 81.4 91.6 1.6 1,769 18.3 20-49 11.2 45.3 67.2 na na 9.6 16,642 18.4 25-49 12.1 48.1 69.8 81.8 90.6 4.2 12,826 18.2 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group 62 • Fertility Table 5.10 summarizes the median age at first birth for different age cohorts by respondents’ background characteristics. Among women age 20-49, the median age at first birth is one year higher in urban areas than in rural areas. Among administrative divisions, it is highest in Sylhet (19.5 years). Women who have some secondary education start childbearing 1.1 years later than those with little or no education. Median age at first birth is more than two years higher for women age 25-29 in the highest wealth quintile (19.7 years), compared with those in the lowest wealth quintile (17.4 years). 5.9 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy and motherhood is a major social and health concern. Early teenage pregnancy can cause serious health problems for both the mother and the child. The 2012 Bangladesh Population Policy focused on a specific adolescent welfare program with an aim to increase awareness about family planning, reproductive health, STIs, and HIV/AIDS and to intensify information and counseling services (MOHFW 2012). Teenage mothers are more likely to suffer from severe complications during delivery, which result in high morbidity and mortality for both themselves and their children. In addition, young mothers may not be sufficiently emotionally mature to bear the burden of childbearing and rearing. Moreover, an early start to childbearing greatly reduces women’s educational and employment opportunities and is associated with higher levels of fertility. This hurts their job prospects, which often lowers their status in society. Table 5.11 shows that 31 percent of adolescents age 15-19 in Bangladesh have begun childbearing; one in four teenagers have given birth and another 6 percent are pregnant with their first child. As expected, the proportion of women age 15-19 who have begun childbearing rises rapidly with age, from 9 percent among women age 15 to 58 percent among women age 19. Early childbearing among teenagers is more common in rural than in urban areas (32 versus 27 percent, respectively) and among women in Rajshahi and Rangpur divisions (37 percent each) compared with other divisions. Childbearing begins later in Sylhet than in other divisions. Delayed childbearing is strongly related to education among women age 15-19. Eighteen percent of teenagers who completed secondary or higher education in Bangladesh have begun childbearing compared with almost half of those with no education (48 percent). Childbearing begins earlier in the lowest wealth quintile: 41 percent of adolescents in this group have begun childbearing compared with 23 percent in the highest wealth quintile. The proportion of adolescents age 15-19 who have begun childbearing remained the same (33 percent) in the 2004 and 2007 BDHS surveys (NIPORT et al. 2009:56). However, early childbearing among teenage women had slightly declined, to 30 percent in 2011, and remained almost the same in 2014 (NIPORT et al. 2013). Table 5.10 Median age at first birth Median age at first birth among women age 20-49 and 25-49 years, according to background characteristics, Bangladesh 2014 Background characteristic Women age 20-49 Women age 25-49 Residence Urban 19.3 19.1 Rural 18.1 17.8 Division Barisal 18.4 18.0 Chittagong 18.8 18.6 Dhaka 18.5 18.3 Khulna 18.0 17.8 Rajshahi 17.9 17.7 Rangpur 17.6 17.4 Sylhet 19.5 19.0 Education No education 17.3 17.3 Primary incomplete 17.4 17.4 Primary complete1 17.9 17.8 Secondary incomplete 18.5 18.4 Secondary complete or higher2 a 22.3 Wealth quintile Lowest 17.4 17.4 Second 17.9 17.7 Middle 18.1 17.8 Fourth 18.6 18.2 Highest a 19.7 Total 18.4 18.2 a = Omitted because less than 50 percent of the women had a birth before reaching the beginning of the age group 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Fertility • 63 Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Bangladesh 2014 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 5.3 3.9 9.2 892 16 12.4 3.8 16.2 922 17 24.5 6.7 31.1 867 18 31.8 9.6 41.4 1,004 19 51.0 6.7 57.8 800 Residence Urban 21.0 6.4 27.4 1,259 Rural 26.0 6.1 32.1 3,223 Division Barisal 23.1 8.3 31.4 273 Chittagong 21.0 5.4 26.4 1,036 Dhaka 25.6 6.2 31.8 1,489 Khulna 25.3 5.9 31.2 379 Rajshahi 30.9 5.7 36.6 421 Rangpur 29.6 7.3 36.9 473 Sylhet 18.1 6.3 24.4 411 Education No education 39.6 8.7 48.3 164 Primary incomplete 38.6 6.6 45.2 519 Primary complete1 35.2 7.9 43.0 407 Secondary incomplete 23.7 6.2 29.9 2,363 Secondary complete or higher2 13.0 4.9 17.8 1,028 Wealth quintile Lowest 32.7 8.4 41.1 777 Second 26.4 6.7 33.2 847 Middle 25.7 5.8 31.5 952 Fourth 22.6 5.4 28.0 1,026 Highest 17.5 5.4 22.9 842 Total 24.6 6.2 30.8 4,485 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Fertility Preferences • 65 FERTILITY PREFERENCES 6 nformation on fertility preferences can improve understanding of future fertility patterns and demand for contraception. Fertility preferences are also used to construct measures of unmet need for contraception and of unwanted or mistimed births. Fertility preferences also help to assess the overall attitudes of women toward childbearing and the general course of fertility. Like previous BDHS surveys, the 2014 BDHS asked women a series of questions to ascertain their fertility preferences. The resulting data are used to quantify these preferences—whether couples want to cease childbearing altogether or merely delay the next pregnancy, for example. Data can also be used to determine the demand for family planning—combined with data on contraceptive use—to estimate unmet need for family planning, including the need for spacing and limiting births. The ideal number of children is another important indicator of fertility preferences that shows the number of children a woman would want if she could start her family anew. The information on ideal family size provides two measures. First, among women who have not yet started a family the data provide an idea of future fertility (to the extent that women are able to realize their fertility desires). Second, the excess of past fertility over ideal family size provides a measure of unwanted fertility. Other topics discussed in this chapter are fertility planning, the effect of unwanted births on fertility rates, and how fertility preferences between husband and wife differ. The interpretation of data on fertility preferences is often difficult because respondents’ reported preferences are, in a sense, hypothetical and thus subject to change and rationalization. Still, data on fertility preferences indicate the direction of future fertility to the extent that individuals and couples will act to achieve their preferred family sizes. 6.1 DESIRE FOR MORE CHILDREN Information about the desire for more children is important for understanding future reproductive behavior. The provision of adequate and accessible family planning services depends on the availability of such information. In the 2014 BDHS, currently married women (whether pregnant or not) were asked about their intentions to have another child and, if they had such intentions, how soon they wanted the child. The same question was phrased differently for pregnant women to ensure children after completion of the current pregnancy were wanted. Sterilized women and men were considered to want no more children, and therefore they were not asked questions about their desire for more children. Table 6.1 shows the percent distribution of currently married women by desire for another child, according to the number of living children. I Key Findings • Sixty-three percent of currently married women in Bangladesh want to limit child bearing; 57 percent want no more children and 6 percent have been sterilized. The percentage who desire to limit family size declined slightly from 65 percent in 2011 to 63 percent in 2014. • The desire to stop childbearing among currently married women with two children has increased rapidly over the past decade, from 67 percent in 2004 to 79 percent in 2014. • Since 2004, the mean ideal number of children has declined from 2.4 children to 2.2 children in 2014. The figure remains unchanged since 2011. • Bangladeshi women have 0.7 children more than they want. The total fertility rate would be 30 percent lower if unwanted births were avoided. The gap between wanted and actual fertility rates has narrowed over the years; from 1.0 children in 2004 to 0.7 children in 2014. 66 • Fertility Preferences Table 6.1 Fertility preferences by number of living children Percent distribution of currently married women age 15-49 by desire for children, according to number of living children, Bangladesh 2014 Number of living children1 Total 15-49 Desire for children 0 1 2 3 4 5 6+ Have another soon2 59.1 18.2 4.4 1.3 0.7 0.9 0.1 10.5 Have another later3 30.0 56.5 9.5 3.3 0.9 0.3 0.2 19.7 Have another, undecided when 1.7 3.0 0.9 0.2 0.1 0.0 0.0 1.2 Undecided 2.8 4.5 3.5 0.9 0.9 1.6 0.6 2.7 Want no more 1.5 15.4 74.3 80.1 80.6 78.4 79.9 56.7 Sterilized4 0.3 0.8 4.9 11.1 10.5 11.9 10.1 5.8 Declared infecund 4.7 1.5 2.4 3.2 6.3 6.9 9.0 3.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,243 4,128 5,108 3,378 1,670 798 533 16,858 1 The number of living children includes the current pregnancy. 2 Wants next birth within two years 3 Wants to delay next birth for two or more years 4 Includes both female and male sterilization Overall, 63 percent of married women age 15-49, including 6 percent who have been sterilized, do not want any more children. The proportion of women who want to stop childbearing or are sterilized increases rapidly with the number of living children, from 16 percent of women with one child to 79 percent of women with two living children, and over 90 percent of women with three or more children. On the other hand, the proportion of women who want to have another child decreases with the number of living children. More than three in four women with one living child want to have another child. The proportion of women who want to have another child declines sharply to 15 percent among women with two living children. Thus, the vast majority of married women want to either space their next birth or cease childbearing altogether. 6.2 DESIRE TO LIMIT CHILDBEARING The proportion of women who want no more children is an important and easily understood measure of fertility preference. Figure 6.1 shows that the proportion of currently married women who either want no more children or who have been sterilized increased from 59 percent in 2004 to 63 percent in 2014. However, there has been a slight decline in the proportion that desires to limit child bearing from 65 percent in 2011 to 63 percent in 2014 (NIPORT et al. 2005). Figure 6.1 Trends in fertility preferences among currently married women age 15-49, 2004-2014 13 12 11 11 21 21 20 20 59 62 65 63 7 5 4 7 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Have another soon Have another later Want no more or sterilized Other Percent Fertility Preferences • 67 Bangladesh’s National Population Policy promotes a two-child family norm, with a message that two chidren are enough, but one is better. Figure 6.2 shows that the percentage of currently married women with two children who want to have no more children increased by 12 percentage points in the last decade, from 67 percent in 2004 to 79 percent in 2014 (NIPORT et al. 2005). This trend is marked by a slight decline in the proportion desiring to limit childbearing between 2011 and 2014. Figure 6.2 Trends in currently married women with two children who want no more children, 1993-2014 Table 6.2 shows, by number of living children, the percentage of currently married women who desire to stop childbearing by urban-rural residence, division, education, and household wealth. Overall, rural women are more likely than urban women to want no more children because they already have more children than urban women do. With three or more living children, women in urban and rural areas are equally likely to want no more children. With one or two living children, urban women are more likely than rural women to want no more children. For example, among women with two children, 83 percent of urban women want no more children compared with 78 percent of rural women. Overall, differences among women in their desire to limit childbearing are relatively small by administrative division. Two in three currently married women in Khulna, Rajshahi, and Rangpur do not want to have another child compared with three in five currently married women in Dhaka, Chittagong, and Sylhet. The desire to limit childbearing varies somewhat among currently married women with two children. For example, 64 percent of currently married women with two children in Sylhet do not want to have another child compared with 87 percent of women in Rangpur. There are major differences in women’s fertility preferences by level of education. Overall, the desire to limit childbearing is higher among women with no education than among women with education. For example, 81 percent of currently married women with no education want to stop childbearing compared with 46 percent of those who have completed secondary education. There are differences in the desire to limit childbearing by household wealth. Overall, the desire not to have any more children declines with wealth; women in the lowest wealth quintile are most likely to want no more children (69 percent) while women in the highest wealth quintile are least likely to want no more children (58 percent). The results by specific number of living children are less clear. At lower parities, however, women in the higher wealth quintiles are more likely to want no more children than women in the lower wealth quintiles. 58 64 66 67 74 82 79 1993-94 BDHS 1996-97 BDHS 1990-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent Includes male and female sterilization. 68 • Fertility Preferences Table 6.2 Desire to limit childbearing Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Bangladesh 2014 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 0.8 19.8 83.4 91.7 91.2 90.8 91.0 60.3 Rural 2.2 14.5 77.5 90.9 91.1 90.1 90.0 63.4 Division Barisal 2.1 16.8 80.5 94.3 96.1 94.0 97.4 64.3 Chittagong 0.3 9.5 69.2 88.8 95.2 90.1 94.4 60.2 Dhaka 2.2 16.8 77.4 91.5 89.4 90.9 80.4 60.3 Khulna 3.1 27.0 85.6 90.3 89.1 86.6 95.3 66.4 Rajshahi 1.4 21.7 85.5 94.9 94.4 93.6 100.0 66.8 Rangpur 1.4 12.6 87.0 93.7 89.4 76.6 90.3 65.8 Sylhet 1.2 10.1 64.4 83.3 84.4 96.2 88.6 60.0 Education No education 9.3 35.7 83.2 89.7 90.0 89.0 89.5 81.1 Primary incomplete 0.0 20.6 79.0 92.1 90.1 91.5 90.6 71.2 Primary complete2 3.0 11.3 76.9 90.6 91.9 93.1 92.4 62.6 Secondary incomplete 1.0 11.5 77.0 91.0 93.5 91.1 91.1 51.9 Secondary complete or higher3 1.1 17.3 82.3 95.2 97.5 90.2 87.2 46.0 Wealth quintile Lowest 2.5 16.5 78.7 90.7 91.1 95.4 93.8 68.8 Second 0.8 16.2 78.7 91.3 91.5 90.6 93.8 66.4 Middle 2.0 15.1 77.7 90.6 91.1 86.9 91.1 61.8 Fourth 2.3 14.0 78.8 91.8 89.3 87.2 75.4 58.6 Highest 1.2 19.1 81.8 91.3 92.8 90.1 90.5 58.2 Total 1.8 16.3 79.3 91.1 91.1 90.3 90.1 62.5 Note: Women who have been sterilized are considered to want no more children. 1 The number of living children includes the current pregnancy. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 6.3 IDEAL FAMILY SIZE To assess ideal family size, women in the 2014 BDHS were asked two questions. Respondents without any living children were asked, “If you could choose exactly the number of children to have in your lifetime, how many would that be?” For respondents with living children, the question was rephrased as follows, “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your lifetime, how many would that be?” Although these questions are based on hypothetical situations, they provide two measures. First, for women who have not yet started childbearing, the data provide an idea of future fertility. Second, for older and high parity women, the excess of past fertility over the ideal family size provides a measure of unwanted fertility. Women in Bangladesh prefer a small family size (2.2 children on average). Table 6.3 shows that 72 percent of ever-married women consider a two-child family to be ideal, 13 percent prefer three children, 6 percent prefer four children, and 1 percent prefers five or more children. There has been a decline in the mean ideal number of children among women since 2004. The women’s ideal number decreased by 0.1 in each survey, from 2.4 children in 2004 to 2.2 in 2011. This finding could explain the declining total fertility rates in the same period. However, the mean ideal number of children and the total fertility rate have remained constant since 2011. The ideal number of children increases with the number of living children. Women with six or more living children have an ideal family size of 3, compared with 2.0 for those with no children or one child. The positive association between actual and ideal number of children is due to two factors. First, to the extent that women are able to implement their fertility desires, women who want smaller families will tend to achieve smaller families. Second, some women may have difficulty admitting their desire for fewer children if they could begin childbearing again and may in fact report their actual number as their preferred number. Despite this tendency to rationalize, the data provide evidence of unwanted fertility, with the vast majority of women with three or more children reporting an ideal family size of fewer than their actual number of children. Fertility Preferences • 69 Table 6.3 Ideal number of children by number of living children Percent distribution of ever-married women age 15-49 by ideal number of children and mean ideal number of children, for ever- married women and for currently married women, according to the number of living children, Bangladesh 2014 Number of living children1 Total Ideal number of children 0 1 2 3 4 5 6+ 0 0.7 0.2 0.2 0.2 0.3 0.1 0.0 0.2 1 13.1 11.2 4.7 3.0 1.8 1.8 1.7 6.1 2 75.4 79.6 80.5 67.3 61.1 48.7 33.9 72.3 3 6.4 6.3 11.1 21.5 16.9 25.3 25.6 13.4 4 2.6 1.7 2.5 5.9 16.0 14.2 24.9 5.6 5 0.3 0.1 0.1 0.4 0.6 4.3 1.1 0.5 6+ 0.0 0.0 0.0 0.1 0.2 0.7 3.6 0.2 Non-numeric responses 1.6 0.9 0.8 1.6 3.0 4.8 9.1 1.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,350 4,384 5,382 3,546 1,781 848 572 17,863 Mean ideal number of children for:2 Ever-married women 2.0 2.0 2.1 2.3 2.5 2.7 3.0 2.2 Number of ever-married women 1,328 4,345 5,339 3,489 1,727 807 520 17,556 Currently married 2.0 2.0 2.1 2.3 2.5 2.7 3.0 2.2 Number of currently married 1,225 4,094 5,072 3,329 1,624 762 492 16,598 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. Table 6.4 presents data on the mean ideal number of children for ever-married women age 15-49, by background characteristics. The ideal family size increases with age from 2.0 children for women age 15-19 to 2.5 children for women age 45-49. Ideal family size is similar in rural areas and urban areas, and it is inversely related to the woman’s education and household wealth. Divisional variations in ideal family size are modest, ranging from 2.1 in Khulna, Rajshahi, and Rangpur to 2.5 children in Sylhet. 6.4 FERTILITY PLANNING There are two ways of estimating levels of unwanted fertility from the BDHS data. One is based on women’s response to a question as to whether each birth in the five years preceding the survey was planned (wanted then), mistimed (wanted but at a later time), or unwanted (wanted no more children). These data are likely to result in underestimates of unplanned childbearing since women may rationalize unplanned births and declare them to be planned once the children are born. Another way of measuring unwanted fertility uses data on ideal family size to calculate what the total fertility rate would be if all unwanted births were avoided. This measure may also suffer from underestimation to the extent that women are unwilling to report an ideal family size lower than their actual family size. Estimates of unwanted fertility using both of these approaches are presented here. Interviewers asked women a series of questions regarding each child born in the five years preceding the survey and any current pregnancy to determine whether each birth or current pregnancy was wanted then, wanted later, or unwanted. These questions provide a powerful indicator of the degree to which couples successfully control fertility. Also, the data can be used to gauge the effect of preventing unwanted births on fertility rates. Table 6.4 Mean ideal number of children Mean ideal number of children for ever-married women age 15-49, by background characteristics, Bangladesh 2014 Background characteristic Mean Number of women1 Age 15-19 2.0 2,014 20-24 2.1 3,202 25-29 2.1 3,365 30-34 2.2 3,017 35-39 2.3 2,251 40-44 2.4 2,030 45-49 2.5 1,678 Residence Urban 2.1 4,986 Rural 2.2 12,570 Division Barisal 2.2 1,094 Chittagong 2.4 3,211 Dhaka 2.2 6,129 Khulna 2.1 1,816 Rajshahi 2.1 2,077 Rangpur 2.1 2,041 Sylhet 2.5 1,187 Education No education 2.4 4,322 Primary incomplete 2.2 3,164 Primary complete2 2.2 1,950 Secondary incomplete 2.1 5,570 Secondary complete or higher3 2.0 2,550 Wealth quintile Lowest 2.3 3,302 Second 2.3 3,337 Middle 2.2 3,490 Fourth 2.2 3,692 Highest 2.1 3,735 Total 15-49 2.2 17,556 1 Number of women who gave a numeric response 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 70 • Fertility Preferences Table 6.5 shows that almost three in four births in the five years before the survey were planned, 15 percent were mistimed, and 11 percent were unwanted. The proportion of unwanted births decreased by 3 percentage points from 14 percent in the 2007 BDHS, while the proportion of planned births increased from 71 percent in 2007 to 74 percent in the same period. The proportion of wanted births decreases and the proportion of unwanted births increases with increasing birth order, a pattern similar to that found in previous surveys. Eighty-six percent of first-order births are wanted at the time they are conceived, but 26 percent of third-order births and 42 percent of fourth and higher-order births are not wanted at all. Mistimed births are most common among second-order births (21 percent); these births then decline with third- and fourth-order births. The proportion of planned births is highest (78 percent) among mothers who give birth before age 20. Interestingly, mistimed births are also more common among younger mothers (under age 20) than among older mothers. The percentage of unwanted births increases with mother’s age at birth, rising from less than 1 percent among women who became mothers before age 20 to 40 percent of those who were mothers at age 35-39. Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the five years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Bangladesh 2014 Planning status of birth Total Number of births Birth order and mother’s age at birth Wanted then Wanted later Wanted no more Missing Birth order 1 86.0 13.9 0.0 0.1 100.0 2,424 2 75.4 21.1 3.3 0.3 100.0 1,781 3 59.7 14.1 26.0 0.2 100.0 964 4+ 50.3 7.9 41.5 0.2 100.0 805 Mother’s age at birth <20 78.4 21.3 0.2 0.1 100.0 1,874 20-24 75.8 17.5 6.3 0.3 100.0 1,937 25-29 74.0 9.8 16.0 0.2 100.0 1,324 30-34 60.4 5.8 33.8 0.0 100.0 602 35-39 56.1 4.3 39.6 0.0 100.0 191 40-44 (19.8) (5.0) (75.3) (0.0) 100.0 29 45-49 * * * * 100.0 16 Total 73.8 15.3 10.8 0.2 100.0 5,974 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 6.5 WANTED FERTILITY RATES The wanted fertility rate measures the potential demographic impact of avoiding unwanted births. It is calculated in the same manner as the total fertility rate but excludes unwanted births from the numerator. A birth is considered wanted if the number of living children at the time of conception is lower than the ideal number of children reported by the respondent. The gap between wanted and actual fertility shows how successful women are in achieving their reproductive goals. This measure may be an underestimate because women may not report an ideal family size lower than their actual family size. Fertility Preferences • 71 The total wanted fertility rates (TWFR) in Table 6.6 represent the levels of fertility that would have prevailed in the three years preceding the survey if all unwanted births had been avoided. Overall, the TWFR and the total fertility rate (TFR) for Bangladesh are 1.6 and 2.3 children respectively. This implies that Bangladeshi women have 0.7 children more than their wanted number of children, and the TFR would be 30 percent lower if unwanted births were avoided. A wide gap exists between wanted and observed fertility rates by characteristics of women. The gap is wider among women who live in rural areas (0.7 children more than wanted) than among women who live in urban areas (0.5 children more). The gap is also wider among women residing in Sylhet (1.1 children) than women residing in Khulna (0.3 children). The gap between wanted and observed total fertility rates narrows with increasing education and wealth. Women with no education have 0.9 children more than they want, compared with 0.3 children among women with a secondary or higher level of education. Similarly, the gap between wanted and actual fertility rates ranges from 0.4 children among women in the highest wealth quintile to 1.0 children among women in the lowest wealth quintile. The gap between wanted and actual fertility rates has narrowed over the years; from 1.0 children in 2004 to 0.7 children in 2014 (Figure 6.3). Figure 6.3 Trends in gap between wanted and unwanted fertility rates, 1993-2014 2.1 2.1 2.2 2.0 1.9 1.6 1.6 3.4 3.3 3.3 3.0 2.7 2.3 2.3 1993-94 BDHS 1996-97 BDHS 1999-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Actual fertility Wanted fertility Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the three years preceding the survey, by background characteristics, Bangladesh 2014 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 1.5 2.0 Rural 1.7 2.4 Division Barisal 1.6 2.2 Chittagong 1.8 2.5 Dhaka 1.6 2.3 Khulna 1.6 1.9 Rajshahi 1.6 2.1 Rangpur 1.5 1.9 Sylhet 1.8 2.9 Educational attainment No education 1.5 2.4 Primary incomplete 1.7 2.5 Primary complete1 1.7 2.4 Secondary incomplete 1.9 2.4 Secondary complete or higher2 1.6 1.9 Wealth quintile Lowest 1.8 2.8 Second 1.6 2.4 Middle 1.6 2.2 Fourth 1.6 2.1 Highest 1.6 2.0 Total 1.6 2.3 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 72 • Fertility Preferences 6.6 SPOUSAL AGREEMENT IN DESIRED NUMBER OF CHILDREN Currently married women who were not sterilized in the 2014 BDHS sample were asked, “Does your husband want the same number of children that you want, or does he want more or fewer than you want?” Responses to these questions are presented as spousal agreement in desired number of children in Table 6.7 by background characteristics of women. Table 6.7 Comparison in desired number of children Percent distribution of currently married women age 15-49 by husband’s desired number of children, by background characteristics, Bangladesh 2014 Husband wants Total Number of women Background characteristic Same number More children Fewer children Don’t know Missing Residence Urban 80.2 10.1 7.3 2.5 0.0 100.0 4,709 Rural 78.5 11.5 7.0 3.0 0.1 100.0 12,149 Division Barisal 78.6 11.6 6.8 3.0 0.1 100.0 1,051 Chittagong 78.0 12.1 6.4 3.3 0.1 100.0 3,121 Dhaka 79.6 11.5 6.0 2.9 0.0 100.0 5,857 Khulna 76.3 9.3 11.6 2.7 0.0 100.0 1,729 Rajshahi 79.5 8.6 9.6 2.2 0.0 100.0 2,007 Rangpur 84.1 7.9 5.9 2.1 0.0 100.0 1,946 Sylhet 73.0 18.3 5.2 3.4 0.0 100.0 1,147 Educational attainment No education 76.5 12.9 6.5 4.1 0.1 100.0 3,949 Primary incomplete 75.3 14.2 7.9 2.7 0.0 100.0 3,032 Primary complete1 80.2 10.6 6.2 2.9 0.0 100.0 1,884 Secondary incomplete 80.7 9.5 7.5 2.2 0.1 100.0 5,477 Secondary complete or higher2 82.4 8.7 6.7 2.2 0.0 100.0 2,516 Wealth quintile Lowest 76.2 13.6 6.7 3.4 0.1 100.0 3,097 Second 78.7 11.4 7.1 2.8 0.0 100.0 3,223 Middle 80.7 10.0 7.0 2.2 0.1 100.0 3,394 Fourth 78.4 10.7 7.6 3.2 0.1 100.0 3,556 Highest 80.5 10.1 6.9 2.5 0.0 100.0 3,587 Total 78.9 11.1 7.1 2.8 0.0 100.0 16,858 Note: Among women and men who had not been sterilized. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Overall, four in five women report that their husbands want the same number of children as they do. Eleven percent of women say their husbands want more children than they want, and 7 percent say their husbands want fewer children. These figures remain almost unchanged since the 2011 BDHS. There are no urban or rural differences in spousal agreement in the desired number of children. Relatively small variations exist by education. Spousal agreement on the desired number of children tends to increase with household wealth, ranging from 76 percent among women in the lowest quintile to 81 percent in the highest quintile. Spousal agreement in desired number of children by division varies little, ranging from 78 to 84 percent, except in Sylhet and Khulna where agreement is 73 percent and 76 percent, respectively. Fertility Regulation • 73 FERTILITY REGULATION 7 amily planning is important for the health of a mother and her children, as well as for the family’s economic situation. Family planning and access to contraception reduce maternal and child deaths. The Health, Population and Nutrition Sector Development Program (HPNSDP) of Bangladesh adopted strategies for making family planning services available, accessible, acceptable, and affordable to all women and men of reproductive age to increase overall use of family planning to 72 percent by 2016 (MOHFW 2011a; MOHFW 2011b). Moreover, according to the commitment of Family Planning 2020 this F Key Findings • Sixty-two percent of married women in Bangladesh use some method of contraception, and 54 percent use a modern method. Economic status does not appear to influence contraception use among couples. • Contraceptive use, while still increasing, is doing so at a slower pace. Between 2004 and 2014, use increased by 4 percentage points, from 58 to 62 percent. In contrast, use increased 13 percentage points from 1994 to 2004, rising from 45 percent to 58 percent. • Currently, the four most popular modern methods used by married women are the pill (27 percent), injectables (12 percent), the male condom (6 percent), and female sterilization (5 percent). • Only 8 percent of currently married couples use a long-acting reversible contraceptive (LARC) or permanent methods (PM), such as an IUD, implant, or sterilization. In the last 10 years use of LARC-PM increased by less than 1 percentage point. • Fourteen percent of currently married women have ever heard of the emergency contraceptive pill (ECP), 13 percent of them have ever used it, and 6 percent used it within the last 12 months. • Three in 10 users of contraception have discontinued a method within 12 months of starting its use. • The government sector remains the major provider of contraceptive methods, catering to 49 percent of users, with government fieldworkers providing supplies to 20 percent of users. The private sector provides contraceptives to 47 percent of all users, with pharmacies supplying 38 percent. The private sector share in providing family planning methods has increased from 43 in 2011 to 47 percent in 2014, while provision by the public sector has fallen by 3 percentage points. • Twelve percent of currently married women in Bangladesh have an unmet need for family planning services; 7 percent have an unmet need for limiting births, and 5 percent have an unmet need for spacing births. • Thirty percent of currently married women reported having seen/heard of a family planning message within the month prior to the survey. Television is the most popular source of family planning messages in Bangladesh, with 19 percent of women having seen a family planning message in this media. • Recent exposure to family planning messages continues to decline. In 2004, 44 percent of currently married women reported having seen or heard family planning messages in the last month compared with only 30 percent in 2014. 74 • Fertility Regulation effort will be increased to 80 percent by 2021 (Family Planning 2020). Examining current levels, trends, and differentials of use of family planning will be useful for monitoring the progress of HPNSDP. This chapter presents results of contraceptive use and related information from the 2014 BDHS. Use of family planning is one of the primary determinants of family size. Information is presented on current use of contraceptives, use of socially marketed brands of pills and condoms, contraceptive discontinuation, unmet need for family planning, intention to use in the future, knowledge of fertile period, knowledge and use of menstrual regulation, contact with family planning workers, exposure to family planning messages in the media, and other issues associated with family planning. 7.1 CURRENT USE OF CONTRACEPTION In BDHS surveys, current use of contraception is defined as the proportion of currently married women who report that they are using a family planning method at the time of the survey. Overall, 62 percent of currently married Bangladeshi women age 15-49 are currently using a contraceptive method, and 54 percent use modern methods (Table 7.1). The pill is by far the most widely used method (27 percent), followed by injectables (12 percent). Eight percent of currently married women use a long-acting or permanent method such as female or male sterilization, implants, and IUDs. Traditional methods are used by 8 percent of women, of which the majority (6 percent) use periodic abstinence. Current use of contraception varies by age, reaching a peak of 74 percent among women age 30-34, followed closely by women age 35-39 (73 percent). The oral pill is the most widely used method among all age groups except those age 45-49, who are more likely to use periodic abstinence. As expected, women in older groups (age 30-49) are more likely to be sterilized than younger women. Table 7.1 Current use of contraception by age Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to age, Bangladesh 2014 Any method Any modern method Modern method Any tradi- tional method Traditional method Not cur- rently using Total Number of womenAge Pill Inject- ables Con- doms Female sterili- zation Male sterili- zation IUD Im- plants Periodic absti- nence With- drawal Other 15-19 51.2 46.7 29.7 9.6 6.2 0.0 0.0 0.2 0.9 4.4 3.1 1.3 0.0 48.8 100.0 1,984 20-24 59.2 54.5 30.1 13.5 7.0 0.5 0.5 0.3 2.6 4.6 3.0 1.6 0.0 40.8 100.0 3,166 25-29 67.7 62.7 32.4 16.1 7.4 2.9 1.0 1.0 1.8 5.0 2.9 2.0 0.1 32.3 100.0 3,249 30-34 73.7 64.7 31.1 14.6 7.8 7.0 1.6 0.9 1.8 9.0 6.6 2.1 0.3 26.3 100.0 2,919 35-39 72.9 60.6 26.6 14.3 6.6 8.9 2.3 0.3 1.6 12.3 10.0 2.3 0.0 27.1 100.0 2,153 40-44 60.9 45.2 17.3 8.7 5.4 8.4 2.6 1.0 1.9 15.6 12.8 2.4 0.4 39.1 100.0 1,874 45-49 38.1 25.0 9.8 3.7 2.1 7.3 1.0 0.6 0.6 13.0 10.1 1.4 1.5 61.9 100.0 1,512 Total 62.4 54.1 27.0 12.4 6.4 4.6 1.2 0.6 1.7 8.4 6.2 1.9 0.3 37.6 100.0 16,858 Note: If more than one method is used, only the most effective method is considered in this tabulation. 7.2 DIFFERENTIALS IN CURRENT USE OF FAMILY PLANNING Table 7.2 and Figure 7.1 show that contraceptive use varies by place of residence. Use of contraception is higher in urban (66 percent) than in rural areas (61 percent). With regard to method use, after oral pills, rural women are more likely to use injectables while urban couples prefer condoms. The contraceptive use rates are 63 percent or higher in all divisions except Chittagong (55 percent) and Sylhet (48 percent). According to FP 2020, these two divisions demand special focus to increase the use of contraceptives to 60 percent by 2021 (Family Planning 2020). In contrast, Rangpur and Rajshahi have the highest contraceptive use rates—almost 70 percent. There is a very little variation in contraceptive use by women’s education. Some variations in method choice are observed. Contraceptive pills are favored by women of all educational levels (between 20 and 32 percent). Women with no education are more likely to use female sterilization and traditional methods than educated women. Condom use is most popular among women with secondary or higher education (19 percent). Fertility Regulation • 75 There is no difference in contraceptive use levels between women in the lowest and highest wealth quintiles. There are some differences in method choice of women by wealth quintiles. Overall, injectable use declines and condom use increases as economic status, measured by wealth quintile, increases. For example, 18 percent of women in the lowest wealth quintile use injectables compared with 6 percent of those in the highest wealth quintile. Condom use is only 1 percent among couples in the lowest wealth quintile compared with 16 percent among those in the highest wealth quintile. In addition, the use of any long-acting and permanent methods of contraception declines as economic status increases. Table 7.2 Current use of contraception by background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Bangladesh 2014 Any method Any modern method Modern method Any tradi- tional method Traditional method Not cur- rently using Total Number of women Background characteristic Pill Inject- ables Con- doms Female sterili- zation Male sterili- zation IUD Im- plants Periodic absti- nence With- drawal Other Number of living children 0 26.5 22.6 14.1 0.2 8.0 0.0 0.2 0.0 0.0 3.9 2.4 1.5 0.0 73.5 100.0 1,707 1-2 66.6 58.9 31.6 13.7 8.0 2.4 0.7 0.5 1.9 7.7 5.5 2.1 0.1 33.4 100.0 8,948 3-4 68.5 58.6 25.5 14.5 4.3 9.1 2.1 1.1 2.0 10.0 7.8 1.9 0.3 31.5 100.0 4,901 5+ 58.1 44.7 17.8 12.0 1.4 8.4 3.0 0.4 1.7 13.4 10.5 1.5 1.4 41.9 100.0 1,302 Residence Urban 65.9 56.2 26.7 9.8 11.7 4.7 1.2 0.7 1.5 9.7 7.0 2.4 0.3 34.1 100.0 4,709 Rural 61.1 53.2 27.1 13.5 4.4 4.6 1.3 0.6 1.8 7.9 5.9 1.7 0.2 38.9 100.0 12,149 Division Barisal 63.3 54.6 27.2 17.2 4.4 3.1 0.7 0.2 1.9 8.7 6.8 1.7 0.2 36.7 100.0 1,051 Chittagong 55.0 47.2 24.1 12.0 4.8 3.6 0.7 0.7 1.2 7.8 5.6 2.0 0.1 45.0 100.0 3,121 Dhaka 63.0 54.2 27.5 10.8 8.5 4.0 1.2 0.6 1.8 8.7 6.4 1.8 0.6 37.0 100.0 5,857 Khulna 67.1 56.4 26.2 13.8 6.9 6.2 0.8 0.5 2.0 10.7 7.7 3.0 0.0 32.9 100.0 1,729 Rajshahi 69.4 60.7 27.9 15.9 7.4 5.6 1.2 0.7 1.9 8.7 6.6 2.0 0.1 30.6 100.0 2,007 Rangpur 69.8 63.0 33.2 14.2 3.9 5.2 3.2 1.1 2.2 6.7 5.1 1.5 0.2 30.2 100.0 1,946 Sylhet 47.8 40.9 21.4 6.5 4.0 6.7 1.2 0.3 0.8 6.9 5.7 1.3 0.0 52.2 100.0 1,147 Education No education 61.5 50.5 20.4 15.3 1.9 7.4 2.6 0.7 2.3 11.0 8.4 1.8 0.8 38.5 100.0 3,949 Primary incomplete 63.9 55.7 26.7 15.0 3.2 5.7 2.0 0.6 2.4 8.1 6.3 1.6 0.2 36.1 100.0 3,032 Primary complete1 62.0 54.3 28.7 15.3 3.0 4.1 0.9 0.8 1.4 7.7 6.1 1.5 0.0 38.0 100.0 1,884 Secondary incomplete 62.3 56.0 31.6 11.7 6.9 3.2 0.5 0.4 1.5 6.3 4.3 2.0 0.1 37.7 100.0 5,477 Secondary complete or higher2 63.0 53.2 26.3 4.0 19.1 2.2 0.1 0.9 0.6 9.7 7.1 2.6 0.1 37.0 100.0 2,516 Wealth quintile Lowest 62.6 55.1 25.6 17.6 1.2 5.7 2.2 0.3 2.5 7.4 5.5 1.7 0.3 37.4 100.0 3,097 Second 63.2 55.2 27.8 16.1 2.2 4.6 1.5 0.8 2.1 8.0 6.3 1.7 0.0 36.8 100.0 3,223 Middle 62.7 54.5 28.9 12.1 5.1 4.3 1.6 0.7 1.7 8.2 6.4 1.6 0.2 37.3 100.0 3,394 Fourth 61.1 52.8 27.6 11.5 6.6 4.5 0.6 0.6 1.5 8.2 5.8 1.7 0.7 38.9 100.0 3,556 Highest 62.8 52.9 25.0 5.9 15.8 4.0 0.5 0.7 0.8 9.9 7.0 2.8 0.1 37.2 100.0 3,587 Total 62.4 54.1 27.0 12.4 6.4 4.6 1.2 0.6 1.7 8.4 6.2 1.9 0.3 37.6 100.0 16,858 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 76 • Fertility Regulation Figure 7.1 Contraceptive use by background characteristics 7.3 TRENDS IN CURRENT USE OF FAMILY PLANNING Use of contraception among married women in Bangladesh has increased gradually, from 8 percent in 1975 to 62 percent in 2014 (Table 7.3 and Figure 7.2). In the last decade, contraceptive use has increased by 4 percentage points from 58 percent in 2004 to 62 percent in 2014, while use of modern contraceptive methods increased by 7 percentage points from 47 percent to 54 percent during the same period. In the last three years, contraceptive use increased by 1 percentage point and modern methods use by 2 percentage points, while traditional methods use fell by 1 percentage point. Between 1991 and 2011 use of female sterilization among currently married women declined from 9 to 5 percent. Use of oral pills peaked in 2007 (29 percent) and stayed at 27 percent in 2011 and 2014. Injectable use continued to increase from 7 percent in 2007, to 11 percent in 2011, and to 12 percent in 2014. The use of any long-acting and permanent methods of contraception increased by 1 percentage point between 2007 and 2011 and remained at 8 percent between 2011 and 2014 (NIPORT et al. 2009; NIPORT et al. 2013). Male sterilization and implant usage show signs of increase between 2007 and 2014, although the current levels of use are very low at 1 percent and 2 percent, respectively. Figure 7.3 shows that the use of modern methods has increased between 2011 and 2014 in all age groups except age 40 and over. This is due to the decline in the use of permanent methods among women age 45-49 from 14 percent in 2011 to 7 percent in 2014. An increase of 10 percentage points would be needed to occur in the next two years, or an average of 5 percentage points per year, in order to achieve the HPNSDP goal of overall use of contraception by 72 percent by 2016. The HPNSDP also focuses on reducing regional differences in contraceptive use, particularly in the low-performing divisions, Chittagong and Sylhet. For these divisions, the HPNSDP originally aimed to increase modern contraceptive use to 50 percent by 2016. In 2014 this indicator was reset to 40 percent for Sylhet division and 45 percent for Chittagong division (MOHFW 2014). Based on the 2014 BDHS data, with a current prevalence of modern contraceptive use of 41 percent and 47 percent, respectively, Sylhet and Chittagong divisions have successfully reached the revised target. Between 2011 and 2014, modern contraceptive method use in Chittagong increased by 2 percentage points and in Sylhet by 6 percentage points (Figure 7.4). 66 61 63 55 63 67 69 70 48 62 64 62 62 63 63 63 63 61 63 RESIDENCE Urban Rural DIVISION Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet EDUCATION No education Primary incomplete Primary complete* Secondary incomplete Secondary complete or higher** WEALTH QUINTILE Lowest Second Middle Fourth Highest Percentage of currently married women BDHS 2014 * Primary complete is defined as completing grade 5. ** Secondary complete is defined as completing grade 10. Fertility Regulation • 77 Table 7.3 Trends in current use of contraceptive methods Percentage of currently married women age 10-49 who are currently using specific family planning methods, selected sources, Bangladesh 1975-2014 Method 1975 BFS 1983 CPS 1985 CPS 1989 BFS 1991 CPS 1993-94 BDHS 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS1 2011 BDHS1 2014 BDHS1 Any method 7.7 19.1 25.3 30.8 39.9 44.6 49.2 53.8 58.1 55.8 61.2 62.4 Any modern method 5.0 13.8 18.4 23.2 31.2 36.2 41.5 43.4 47.3 47.5 52.1 54.1 Pill 2.7 3.3 5.1 9.6 13.9 17.4 20.8 23.0 26.2 28.5 27.2 27.0 Injectables u 0.2 0.5 0.6 2.6 4.5 6.2 7.2 9.7 7.0 11.2 12.4 Condom 0.7 1.5 1.8 1.8 2.5 3.0 3.9 4.3 4.2 4.5 5.5 6.4 Female sterilization 0.6 6.2 7.9 8.5 9.1 8.1 7.6 6.7 5.2 5.0 5.0 4.6 Male sterilization 0.5 1.2 1.5 1.2 1.2 1.1 1.1 0.5 0.6 0.7 1.2 1.2 IUD 0.5 1.0 1.4 1.4 1.8 2.2 1.8 1.2 0.6 0.9 0.7 0.6 Implants u u u u u u 0.1 0.5 0.8 0.7 1.1 1.7 Vaginal methods 0.0 0.3 0.2 0.1 u u u u u u u u Any traditional method 2.7 5.4 6.9 7.6 8.7 8.4 7.7 10.3 10.8 8.3 9.2 8.4 Periodic abstinence 0.9 2.4 3.8 4.0 4.7 4.8 5.0 5.4 6.5 4.9 6.9 6.2 Withdrawal 0.5 1.3 0.9 1.8 2.0 2.5 1.9 4.0 3.6 2.9 1.9 1.9 Other traditional methods 1.3 1.8 2.2 1.8 2.0 1.1 0.8 0.9 0.6 0.6 0.4 0.3 Number of women u 7,662 7,822 10,907 9,745 8,980 8,450 9,720 10,582 10,192 16,635 16,858 u = Unknown (not available) 1 Data from 2007, 2011, and 2014 are restricted to currently married women age 15-49. Other surveys refer to women age 10-49. Sources: 1975 Bangladesh Fertility Survey (BFS) (Islam and Islam, 1993:43); 1983 Contraceptive Prevalence Survey (CPS) (Mitra and Kamal 1985:159); 1985 CPS (Mitra 1987:147); 1989 BFS (Huq and Cleland 1990:64); 1991 CPS (Mitra et al. 1993:53); 1993-1994 Bangladesh Demographic and Health Survey (BDHS) (Mitra et al. 1994:45); 1996-1997 BDHS (Mitra et al. 1997:50); 1999-2000 BDHS (NIPORT et al. 2001:53); 2004 BDHS (NIPORT et al. 2005:67); 2007 BDHS (NIPORT et al. 2008: 52); ); and 2011 BDHS (NIPORT et al. 2013:84). Figure 7.2 Trends in contraceptive use among currently married women, 1975-2014 5 14 18 23 31 36 42 43 47 48 52 54 3 5 7 8 9 8 8 10 11 8 9 8 Any modern method Any traditional method Percent Note: Contraceptive use in 2007, 2011, and 2014 is for currently married women age 15-49; other surveys refer to women age 10-49. 8 19 25 31 40 44 50 53 58 56 61 62 78 • Fertility Regulation Figure 7.3 Trends in modern method use by age of currently married women, 2011-2014 Figure 7.4 Trends in use of modern contraceptives by division, 2007-2014 The method mix has also changed over the past two decades. Currently only 8 percent of married couples use a long-acting or permanent method (LAPM), namely sterilization, IUD, and implants, which account for 13 percent of all contraceptive use. Use of LAPM was 12 percent in 1991, accounting for 30 percent of contraceptive use. Use of LAPM started to decline in the early 1990s, stabilized in 2007, hinted at a slight increase in 2011, and remained the same in 2014 (NIPORT et al. 2009; NIPORT et al. 2013). Since 2004 there has been a slow increase in the use of male sterilization and implants, although the usage rate of these methods remains very low. The plateauing of LAPM methods should be of concern, as fertility is now so low that most childbearing is completed by the mid- to late-twenties, and women face two subsequent decades of reproductive life during which they must protect themselves from unwanted pregnancies. 42 53 60 61 57 46 30 52 47 55 63 65 61 45 25 54 15-19 20-24 25-29 30-34 35-39 40-44 45-49 All women 2011 BDHS 2014 BDHS 47 38 48 53 57 25 55 45 51 56 58 61 35 55 47 54 56 61 63 41 Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet 2007 BDHS 2011 BDHS 2014 BDHS Percent Note: Rajshahi includes Rangpur division in 2007 Fertility Regulation • 79 Figure 7.5 Trends in contraceptive method mix among currently married women, age 10-49, 1975-2014 7.4 TIMING OF STERILIZATION Table 7.4 shows the distribution of sterilized women by the age at which they were sterilized, according to the number of years preceding the survey that the procedure was done. Because data on age at sterilization are derived from a question on the month and year of the operation, it is possible that the data are distorted by recall errors in reporting either the date of the operation or the date of birth or age of the woman. Women who decide to get sterilized generally undergo the procedure early in their reproductive years. Six in ten sterilized women had the procedure done before age 30, and about three in ten women were sterilized before age 25. The median age of sterilization is 28 years in the 2011 and 2014 BDHS (NIPORT et al. 2013). Table 7.4 Timing of sterilization Percent distribution of sterilized women age 15-49 by age at the time of sterilization and median age at sterilization, according to the number of years since the operation, Bangladesh 2014 Years since operation Age at time of sterilization Total Number of women Median age1 <25 25-29 30-34 35-39 40-44 45-49 <2 7.8 40.5 24.8 18.5 2.8 5.7 100.0 129 29.9 2-3 15.8 36.6 29.4 13.9 4.2 0.0 100.0 128 28.9 4-5 19.2 25.8 29.0 18.8 7.2 0.0 100.0 129 30.2 6-7 27.1 31.2 17.3 13.5 10.8 0.0 100.0 103 27.4 8-9 26.1 28.6 38.4 4.7 2.3 0.0 100.0 61 29.0 10+ 49.8 31.9 13.8 4.5 0.0 0.0 100.0 226 a Total 27.3 32.7 23.1 11.9 4.0 0.9 100.0 775 28.3 a = Not calculated due to censoring 1 Median age at sterilization is calculated only for women sterilized before age 40 to avoid problems of censoring. 7.5 KNOWLEDGE AND USE OF MENSTRUAL REGULATION Menstrual regulation (MR) is a procedure used to bring on menses in women who have missed their menstrual cycle. Existing polices of GOB allow a woman to go through MR procedure within the eight weeks from the first day of the last menstrual period (LMP) by a paramedic (that is, a trained family welfare visitor) or within ten weeks from the first day of the LMP by a trained medical doctor. The 2014 BDHS asked women if they knew about or had ever used menstrual regulation (MR). Women who have used MR were asked their source of services. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pill Injectables Condom IUD Implants Sterilization Any traditional method Note: Contraceptive use in 2007, 2011, and 2014 is for women age 15-49; other surveys refer to women age 10-49. 80 • Fertility Regulation Table 7.5 shows that 45 percent of ever-married and 46 percent of currently married women know about MR. Among those who have ever heard of MR, 12 percent of ever-married and 13 percent of currently married women have ever used it. The use of MR increases among the ever-married and currently married women with the increase of age. Table 7.5 Knowledge and use of menstrual regulation Percentage of ever married and currently married women who know of menstrual regulation (MR) and the percentage who ever used MR, by age group, Bangladesh 2014 Ever-married women Currently married women Age Percent who have ever heard of MR Number of women Percent ever used MR among women who have ever heard of MR Number of women who have ever heard of MR Percent who have ever heard of MR Number of women Percent ever used MR among women who have ever heard of MR Number of women who have ever heard of MR 15-19 33.8 2,029 3.1 686 33.9 1,984 3.2 672 20-24 44.2 3,224 7.3 1,424 44.2 3,166 7.4 1,400 25-29 49.6 3,390 11.7 1,681 50.4 3,249 11.8 1,639 30-34 50.1 3,047 15.1 1,526 50.6 2,919 15.6 1,477 35-39 47.5 2,315 16.3 1,101 48.7 2,153 16.8 1,048 40-44 46.3 2,092 15.5 968 47.2 1,874 16.5 884 45-49 39.6 1,766 15.5 699 41.7 1,512 16.3 630 Total 45.3 17,863 12.3 8,084 46.0 16,858 12.5 7,749 The major source of MR among the ever-married women who have used MR in the last three years is public sector facilities (48 percent), followed by private medical sector (33 percent) and NGO sector (6 percent) facilities (Table 7.6). Private hospitals/ clinics and upazila health complexes are the major sources of MR (22 percent each) followed by medical college hospital/district hospital (13 percent) and qualified doctor’s chamber (9 percent). 7.6 KNOWLEDGE OF FERTILE PERIOD An elementary understanding of reproductive physiology, particularly knowledge of when in the ovulatory cycle a woman is most likely to become pregnant, is necessary in ensure success in the use of coitus-related methods such as the withdrawal, condom, and vaginal methods. Such knowledge is especially critical for the practice of periodic abstinence. To investigate women’s knowledge about their fertile period, the 2014 BDHS respondents were asked whether there are certain days a woman is more likely to become pregnant if she has sexual intercourse. Those who responded affirmatively to that question were asked whether this time is just before the period begins, during the period, right after the period ends, or halfway between two periods. Table 7.7 presents knowledge of the fertile period during the ovulatory cycle of currently-married women according to current use and nonuse of periodic abstinence method. Forty-six percent of users and 24 percent of nonusers of the abstinence method perceive halfway between two menstrual periods as the fertile period. Four in 10 of both users and nonusers of the abstinence method perceive the fertile period to be right after the menstrual period ends. However, about 3 in 10 women perceive the fertile period has no specific time (18 percent), or they do not know about the fertile period (11 percent). Table 7.6 Source of service for menstrual regulation in last three years Percent distribution of ever-married women age 15-49 who have used menstrual regulation in the last three years by source of service, Bangladesh 2014 Source of service Percent Public sector 47.5 Medical college hospital/ district hospital 12.9 Maternal and child welfare center 4.6 Upazila health complex 22.3 Family welfare center 6.3 Family welfare visitor 1.1 Other public sector 0.3 Private sector 33.0 Private hospital/clinic 22.3 Qualified doctor’s chamber 9.0 Non-qualified doctor’s chamber 1.1 Other private medical sector 0.6 NGO sector 5.6 NGO static clinic 5.6 Other 0.4 Don’t know 6.7 Missing 6.8 Total 100.0 Number of women 251 Fertility Regulation • 81 Table 7.7 Knowledge of fertile period Percent distribution of currently married women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Bangladesh 2014 Perceived fertile period Users of periodic abstinence method Nonusers of periodic abstinence method All women Just before her menstrual period begins 1.8 1.7 1.7 During her menstrual period 2.7 3.4 3.4 Right after her menstrual period end 39.7 41.2 41.1 Halfway between two menstrual periods 46.1 23.5 24.9 No specific time 6.6 18.7 18.0 Don’t know 3.0 11.4 10.9 Total 100.0 100.0 100.0 Number of women 1,050 15,808 16,858 7.7 KNOWLEDGE AND USE OF ECP The emergency contraceptive pill (ECP) is a form of contraception that women can use after unprotected intercourse. The 2014 BDHS asked women if they knew about or had ever used ECP. Fourteen percent of currently married women know about ECP (Table 7.8). Among those who have ever heard of ECP, 13 percent have ever used it and 6 percent used within the last 12 months. Awareness about ECP decreases with the increase of number of living children. Urban women are twice as likely as rural women to have heard of ECP. Awareness of ECP increases with increase in the woman’s education and wealth. Similar patterns are observed in the use of ECP. Table 7.8 Knowledge and use of ECP by background characteristics by background characteristics Percentage of currently married women age 15-49 who have heard of emergency contraceptive pill (ECP) and, among women who have heard of ECP, percentage who have ever used ECP and percentage who used ECP in the last 12 months, by background characteristics, Bangladesh 2014 Percent who have ever heard of ECP Number women Among those who heard of ECP, percent: Background characteristic Ever used ECP Used ECP in last 12 months Number of women who have heard of ECP Number of living children 0 15.4 1,707 15.2 11.9 262 1-2 16.3 8,948 13.3 5.6 1,461 3-4 10.8 4,901 14.0 5.4 530 5+ 8.3 1,302 8.2 2.6 108 Residence Urban 21.4 4,709 13.7 7.1 1,008 Rural 11.1 12,149 13.2 5.4 1,353 Division Barisal 17.5 1,051 10.6 5.0 183 Chittagong 12.5 3,121 16.0 6.9 389 Dhaka 16.2 5,857 12.0 5.8 949 Khulna 15.2 1,729 16.9 7.6 263 Rajshahi 12.2 2,007 16.7 7.2 244 Rangpur 10.1 1,946 9.0 4.4 197 Sylhet 11.9 1,147 13.8 5.7 137 Education No education 5.9 3,949 16.0 3.4 233 Primary incomplete 8.7 3,032 10.7 4.2 265 Primary complete1 8.5 1,884 12.6 6.3 159 Secondary incomplete 14.0 5,477 11.1 4.7 767 Secondary complete or higher2 37.2 2,516 15.6 8.5 937 Wealth quintile Lowest 5.4 3,097 8.2 2.6 166 Second 7.9 3,223 13.5 5.9 254 Middle 11.3 3,394 16.5 5.6 383 Fourth 16.4 3,556 10.0 4.7 585 Highest 27.1 3,587 15.2 7.9 972 Total 14.0 16,858 13.4 6.1 2,361 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 82 • Fertility Regulation 7.8 KNOWLEDGE AND PRACTICE OF LACTATIONAL AMENORRHEA METHOD The lactational amenorrhea method (LAM) is a short-term family planning method based on the natural effect of breastfeeding on fertility. The act of breastfeeding, particularly exclusive breastfeeding, suppresses the release of hormones that are necessary for ovulation. Nine percent of currently married women know about LAM (Table 7.9). Among those who have ever heard of LAM, 21 percent reported having used it1. Awareness of LAM is higher among urban women (11 percent) than rural women (8 percent). However, ever use of LAM is higher among rural women (23 percent) than urban women (16 percent). Ever use of LAM is higher in Sylhet (30 percent) and Chittagong (27 percent) divisions, and among women in the lowest wealth quintile (24 percent). Table 7.9 Knowledge and use of LAM by background characteristics by background characteristics Percentage of currently married women age 15-49 who have heard of LAM and among women who have heard of LAM, percentage who have ever used LAM, by background characteristics, Bangladesh 2014 Percent who have ever heard of LAM Number of women Among those who heard of LAM: Background characteristic Percent ever used LAM Number of women who have heard of LAM Number of living children 0 7.2 1,707 1.5 124 1-2 10.4 8,948 20.8 933 3-4 7.1 4,901 24.3 348 5+ 6.5 1,302 29.3 85 Residence Urban 11.2 4,709 15.5 527 Rural 7.9 12,149 23.2 962 Division Barisal 12.1 1,051 19.0 127 Chittagong 9.3 3,121 26.8 289 Dhaka 7.8 5,857 16.7 455 Khulna 9.0 1,729 16.3 155 Rajshahi 8.6 2,007 24.5 174 Rangpur 10.0 1,946 16.3 194 Sylhet 8.3 1,147 30.0 95 Education No education 4.3 3,949 19.1 171 Primary incomplete 7.6 3,032 22.3 230 Primary complete1 6.7 1,884 23.4 125 Secondary incomplete 9.9 5,477 22.0 545 Secondary complete or higher2 16.6 2,516 17.3 418 Wealth quintile Lowest 4.7 3,097 24.1 146 Second 7.0 3,223 21.3 225 Middle 9.9 3,394 22.1 336 Fourth 8.9 3,556 20.5 316 Highest 13.0 3,587 17.9 467 Total 8.8 16,858 20.5 1,489 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 7.9 SOURCES OF FAMILY PLANNING METHODS To ascertain the sources of family planning methods in Bangladesh, the 2014 BDHS asked women who were currently using a modern method of contraception where they obtained the method the last time they used it. Because women often do not know what category their source fits into (public hospital, upazila health complex, family welfare center, or private clinic), interviewers were instructed to write the name of the facility in the questionnaire. Team supervisors verified that the name and the type of source coded were correct and consistent. The sources of family planning methods are classified into four major categories: public-sector sources (including district hospital/medical college hospital, maternal and child welfare centers, upazila health complexes, family welfare centers, satellite/EPI clinics, community clinics, and government fieldworkers), private medical sources (including private hospitals and clinics, qualified or traditional 1 This is self-reported use of LAM, with no checks on whether the requirements for LAM use are fulfilled. Fertility Regulation • 83 doctors, and pharmacies), NGO-sector sources (including static clinics, satellite clinics, depot holders, and fieldworkers), and other private sources (including shops and friends or relatives). Table 7.10 and Figure 7.6 show the percentage of current users of modern methods who obtained their method from a specific source. The table shows that 49 percent of modern contraceptive users obtained the method from the public sector, with 20 percent receiving the method from a government fieldworker. Overall, 43 percent of modern contraceptive users get their supplies from a private medical sector facility, with pharmacies being the most important source, serving 38 percent of users. Four percent of modern contraceptive users obtain their methods from a private non-medical source, mainly a shop (3 percent). Nongovernmental organizations (NGOs) supply contraceptives to 4 percent of users of modern methods. The source of modern contraceptive methods varies largely by the specific method. Upazila health complex (32 percent), private hospitals/clinics (29 percent), and medical college hospitals/district hospitals (23 percent) are the key sources for female sterilization. Male sterilization, the IUD, and implants are almost exclusively obtained from a public sector facility, particularly at upazila health complexes, medical college hospitals/district hospitals and family welfare centers. The private sector, namely pharmacies, is the major supply source of pills (48 percent), injectables (22 percent), and condoms (75 percent). The government fieldworker is also an important source of pills (29 percent), as well as injectables (21 percent). The SMC distributes the injectable brand SOMA-JECT through a network of private sector health providers called the Blue Star Program. Although information on the brand of injectables among the users was not collected in the 2014 BDHS, information in Table 7.10 can be used as proxy indicators to estimate the use of social marketing brands because the Blue Star Program is the only formal source of injectables in the private sector in Bangladesh. Table 7.10 shows that more than one-fifth of married women age 15-49 who currently use injectables obtained the injection from either qualified doctor’s chambers or pharmacies, which are the sources of SOMA-JECT distribution. The supply source of injectables from pharmacies increased 8 percentage points during the last three years, which should be investigated by collecting the names of brands from respondents in the next BDHS. Table 7.10 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Bangladesh 2014 Source Female sterilization Male sterilization Pill IUD Injectables Implants Condom Total Public sector 68.7 84.5 42.3 92.1 61.0 93.1 14.9 48.7 Medical college hospital/district hospital 23.0 28.0 1.1 15.1 2.0 14.2 1.9 4.5 Maternal and child welfare center 10.7 8.7 0.4 10.4 2.1 18.1 0.5 2.6 Upazila health complex 31.6 39.2 1.7 34.7 6.5 47.7 1.3 8.0 Family welfare center 3.3 5.5 4.4 31.0 12.4 11.0 2.3 6.5 Satellite clinic or EPI outreach center 0.0 0.0 1.9 0.0 7.6 0.0 0.3 2.7 Community clinic 0.0 0.0 3.6 0.9 9.8 0.5 1.4 4.3 Government fieldworker 0.0 0.0 29.0 0.0 20.6 1.5 7.0 20.1 Other public 0.0 3.1 0.1 0.0 0.1 0.0 0.1 0.1 Private medical sector 28.8 7.5 49.1 6.6 28.8 2.2 76.0 43.0 Private hospital 28.8 7.5 0.1 6.6 0.7 1.9 0.4 3.0 Qualified doctor 0.0 0.0 0.1 0.0 0.8 0.0 0.2 0.3 Traditional doctor 0.0 0.0 0.7 0.0 5.0 0.0 0.7 1.6 Pharmacy 0.0 0.0 48.2 0.0 22.2 0.3 74.6 38.1 Other private 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NGO sector 2.0 3.0 3.1 1.3 9.6 4.8 2.0 4.4 Static clinic 2.0 3.0 1.2 1.3 6.3 4.5 1.3 2.6 Satellite clinic 0.0 0.0 0.0 0.0 0.4 0.3 0.2 0.2 Depot holder 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.1 Field worker 0.0 0.0 1.7 0.0 2.8 0.0 0.5 1.5 Other private 0.0 0.0 5.4 0.0 0.3 0.0 6.6 3.5 Shop 0.0 0.0 3.9 0.0 0.2 0.0 6.1 2.7 Friend/relative 0.0 0.0 1.5 0.0 0.1 0.0 0.5 0.8 Other 0.1 0.3 0.1 0.0 0.1 0.0 0.5 0.1 Don't know 0.0 4.7 0.0 0.0 0.0 0.0 0.0 0.1 Missing 0.5 0.0 0.1 0.0 0.2 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 775 210 4,549 107 2,094 288 1,086 9,110 84 • Fertility Regulation Figure 7.6 Distribution of current users of modern methods by source of supply Figure 7.7 shows that the contribution of the public sector in providing modern family planning methods declined from 57 percent in 2004 to 49 percent in 2014. The contribution of the public sector declined mainly due to increased participation of the private sector in the family planning program. Between 2004 and 2014, the contribution of the private sector as a source of contraceptive supply has increased 11 percentage points, from 36 to 47 percent. The NGO-sector supply of contraceptives has decreased from 6 percent in 2004 to 4 percent in 2014. Figure 7.7 Trends in source of contraceptive methods, 2004-2014 The 2014 BDHS asked women who have never used family planning whether they know a source of services for family planning. Table 7.11 shows that 64 percent of never users know a public sector source, 44 percent know a private medical sector source, and 12 percent know about an NGO source of family planning services. Twenty-six percent of never users do not know any source of family planning method. Public sector, 49% Private medical sector, 43% NGO sector, 4% Private nonmedical sector, 4% 57 50 52 49 36 45 44 47 6 5 4 4 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Public Private NGO Percent Fertility Regulation • 85 Table 7.11 Knowledge of source of specific source of family planning method services Percentage of currently married women age 15-49 who have never used family planning by known sources of family planning service, Bangladesh 2014 Known source known Percent Public sector 64.3 Medical college hospital/district hospital 13.0 Maternal and child welfare center 4.7 Upazila health complex 20.9 Family welfare center 17.8 Satellite clinic or EPI outreach center 5.3 Community clinic 9.3 Government fieldworker 33.1 Other public 0.1 Private medical sector 44.3 Private hospital/clinic 2.2 Qualified doctor’s chamber 1.8 Non-qualified doctor’s chamber 2.4 Pharmacy/drug store 41.2 NGO sector 12.2 Static clinic 5.6 Satellite clinic 0.7 Depot holder 0.2 Field worker 6.7 Other NGO 0.1 Other source 0.2 Friends/relatives 0.2 Don’t know 26.1 Missing 0.1 Any source 73.9 Number of women 2,709 7.10 USE OF SOCIAL MARKETING BRANDS Bangladesh has an active social marketing program that distributes family planning methods including pills, condoms, and injectables as well as other health and nutrition products such as oral rehydration salts (ORS), micronutrient powder, zinc tablets, sanitary napkins, and a safe delivery kit. These items are distributed through a network of retail outlets such as pharmacies, small shops, kiosks, a network of private health providers (Blue Star), and NGOs. The Social Marketing Company (SMC) currently carries several brands of oral contraceptives, including Femicon, Femipil, Noret-28, and the Progestin-only pill Minicon. Other oral pills, Combination-3 and Nordette-28, have been discontinued. Moreover, SMC is distributing IUDs and implants among a group of trained graduate physicians. To obtain information on the proportion of users purchasing the social marketing brands, the 2014 BDHS interviewers asked current pill users to show the packet of pills they were using. If the user could show the packet, the interviewer recorded the brand on the questionnaire. If not, the interviewer showed the woman a chart depicting all major pill brands and asked the user to identify which brand she was currently using. As shown in Table 7.12, 44 percent of pill users use social marketing brands compared with 52 percent who use Shuki, the government-supplied brand. Shuki is provided free of charge through government fieldworkers and clinics, and at a nominal charge through nongovernmental service providers. Three in ten pill users use Femicon, the most popular social marketing brand of pill. Femicon brand use is higher in urban (33 percent) than in rural (29 percent) areas. The next most widely used social marketing brand is Femipil (6 percent), with a small variation in the proportion of use between urban and rural areas. Minicon, a socially marketed progestin-only pill for lactating mothers, is used by 4 percent of pill users. 86 • Fertility Regulation Table 7.12 Use of pill brands by residence Percent distribution of currently married pill users by brand of pill used, according to urban-rural residence, Bangladesh 2014 Brand name Residence Total Urban Rural Social marketing 50.1 40.8 43.5 Nordette-28 3.3 1.0 1.7 Femicon 33.4 29.2 30.4 Minicon 6.3 3.5 4.3 Femipill 5.4 5.9 5.8 Noret-28 1.6 1.1 1.2 Combination 3 (C 3) 0.1 0.1 0.1 Government 42.3 55.1 51.6 Shuki 42.3 55.1 51.6 Private 7.6 4.1 4.9 Ovostat 3.0 2.4 2.5 Desolon 0.2 0.1 0.1 Bredicon 0.4 0.2 0.2 Lynes 0.5 0.2 0.3 Marvelon 2.5 0.8 1.2 Rosen 0.1 0.0 0.0 Other 0.9 0.4 0.6 Total 100.0 100.0 100.0 Number of women 1,253 3,282 4,535 Note: Pill users who do not know the brand are excluded from the table. The percentage of pill users using a social marketing brand increased consistently from 14 percent in 1993-94 to 45 percent in 2007, and then declined to 38 percent in 2011. SMC pill brand use increased to 44 percent in 2014. The use of Femicon increased by four percentage points from 26 percent in 2011 to 30 percent in 2014 (NIPORT et al. 2013). To assess the social marketing program’s reach in condom use, the 2014 BDHS gathered information on what type of condoms the couples used. Interviewers showed a chart depicting all major condom brands to women who reported that their husbands were currently using condoms. The women were asked to identify the brand used. Men would presumably be a more reliable source of data on condom brands; however, the data shown in Table 7.13 are derived from women. Three in five condom users buy social marketing brands; 23 percent use Panther, 17 percent use Sensation, 11 percent use Hero, and 5 percent use U & ME. The Raja, Panther, Sensation, and U & ME brands are more popular in urban than rural areas, while Hero brand is more popular in rural areas. The percentage of condom users who obtain their supplies from the SMC has increased over the past three years, from 60 percent in 2011 to 62 percent in 2014 (NIPORT et al. 2013). 7.11 CONTRACEPTIVE DISCONTINUATION A key concern for family planning programs is the rate at which users discontinue use of contraception and the reasons for such discontinuation. Life table contraceptive discontinuation rates are presented in Table 7.14. These rates are based on information collected in the 5-year, month-by-month Table 7.13 Use of condom brands by residence Percent distribution of currently married condom users by brand of condom used, according to urban-rural residence, Bangladesh 2014 Brand name Residence Total Urban Rural Social marketing 66.4 57.1 62.0 Raja 6.8 5.3 6.1 Panther 25.8 20.6 23.3 Hero 7.7 14.6 11.1 Sensation 19.2 13.9 16.6 U & ME 6.7 2.7 4.8 Xtreme 0.2 0.0 0.1 Government 8.1 13.2 10.6 Nirapad 8.1 13.2 10.6 Private 18.4 24.9 21.6 Moods 0.6 0.1 0.4 Gamy 0.5 0.8 0.6 Wonder life 0.1 0.1 0.1 Romantex 0.5 0.2 0.3 Durex 1.5 1.1 1.3 Love guard 1.3 0.0 0.7 Coral 6.0 5.6 5.8 Jippy 1.2 1.9 1.5 Green love 1.2 1.3 1.2 Carex 3.5 7.7 5.6 Deluxe Nirodh 1.3 3.1 2.2 Super Guard 0.7 3.0 1.9 Other 6.9 4.8 5.9 Total 100.0 100.0 100.0 Number of women 508 488 997 Note: Condom users who do not know the brand are excluded from the table. Fertility Regulation • 87 calendar of contraceptive use in the BDHS questionnaire. The analysis utilizes all episodes of contraceptive use from 3 to 62 months prior to the date of interview. The month of interview and the two preceding months are ignored to avoid the bias that might be introduced by an unrecognized pregnancy. The rates presented in Table 7.14 are cumulative one-year discontinuation rates and represent the proportion of users who discontinue using a method within 12 months of starting. The rates are calculated by dividing the number of discontinuations at each duration of use in single months, by the number of months of exposure for that duration. The single-month rates are then cumulated to produce a one-year rate. Table 7.14 First-year contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months, by reason for discontinuation and specific method, Bangladesh 2014 Method1 Method failure Desire to become pregnant Other fertility- related reasons2 Side effects/ health concerns Wanted more effective method Other method- related reasons3 Other reasons Any reason4 Switched to another method5 Number of episodes of use6 Pill 4.9 8.1 6.6 10.3 1.1 1.4 1.9 34.2 11.0 6,136 Injectables 1.0 3.2 3.1 13.7 0.8 1.7 1.3 24.9 12.5 2,369 Condoms 3.6 11.3 4.7 5.1 2.6 5.8 6.7 39.9 18.0 1,627 Female sterilization 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 350 Implants 0.0 2.1 0.8 3.6 0.0 0.0 0.0 6.5 2.7 305 Periodic abstinence 3.6 3.1 1.5 0.2 5.3 2.3 1.8 17.8 8.7 774 Withdrawal 4.0 5.7 1.2 0.0 4.6 6.2 3.7 25.5 13.9 308 All methods 3.5 6.6 4.8 8.8 1.5 2.1 2.4 29.7 11.5 12,120 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months prior to the survey. 1 Male sterilization, IUD, and other methods are not included due to small number of cases (fewer than 125 episodes of use). 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation 3 Includes lack of access/too far, costs too much, and inconvenient to use 4 Reasons for discontinuation are mutually exclusive and add to the total given in this column 5 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month following discontinuation or if she gave “wanted a more effective method” as the reason for discontinuation and started another method within two months of discontinuation. 6 Number of episodes of use includes both episodes of use that were discontinued during the period of observation and episodes of use that were not discontinued during the period of observation The results indicate that about one-third users of contraceptive methods stop using the method within 12 months of starting. Not surprisingly, discontinuation rates are much higher for temporary methods like condoms (40 percent), pills (34 percent), and injectables (25 percent) than for long-term methods like the implants (7 percent). FP 2020 has set a target to reduce the discontinuation rate to 20 percent by 2021 (Family Planning 2020). The all-method discontinuation rate has declined from 36 percent in 2011 to 30 percent in 2014. While the decline occurred for all methods in the past three years, it has been particularly large for withdrawal and periodic abstinence. Figure 7.8 shows that the all-method discontinuation rate has declined from 49 percent in 1993-94 to 30 percent in 2014. 88 • Fertility Regulation Figure 7.8 Trends in all method contraceptive discontinuation rates, 1993/94-2014 Further information on reasons for contraceptive discontinuation is presented in Table 7.15. This table shows the percent distribution of all discontinuations occurring during the five years preceding the survey, regardless of whether they occurred during the first 12 months of use or not. The most common reason for discontinuation is the desire to become pregnant (31 percent), followed by side effects and health concerns, accounting for 26 percent of all discontinuations. The category of accidental pregnancies was cited as a reason for 14 percent of discontinuations. Table 7.15 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the five years preceding the survey by main reason stated for discontinuation, according to specific method, Bangladesh 2014 Reason Pill IUD Injectables Implants Male condom Periodic abstinence Withdrawal All methods1 Became pregnant while using 16.5 0.0 5.6 1.1 12.8 19.1 17.8 13.8 Wanted to become pregnant 33.8 19.4 23.8 20.9 34.7 26.2 26.9 31.1 Husband disapproved 0.6 0.0 0.5 1.4 9.0 1.9 10.7 1.9 Wanted a more effective method 3.5 4.3 2.7 6.9 6.7 17.9 11.3 4.8 Side effects/health concerns 24.5 46.7 45.5 51.1 11.1 1.2 1.6 25.8 Lack of access/too far 0.4 1.4 2.8 0.3 0.2 0.0 0.0 0.8 Cost too much 0.1 0.0 0.2 0.0 0.1 0.0 0.0 0.1 Inconvenient to use 3.7 4.2 2.4 5.0 11.0 5.2 15.0 4.6 Up to God/fatalistic 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Difficult to get pregnant/ menopausal 2.4 2.8 4.8 0.0 1.3 14.1 4.8 3.4 Infrequent sex/husband away 9.4 0.0 5.1 0.4 7.8 4.9 7.1 7.8 Marital dissolution/separation 0.8 10.3 0.9 4.6 1.2 1.3 0.5 1.0 Other 0.6 9.6 1.2 8.4 0.3 0.8 0.2 0.9 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Missing 3.6 1.3 4.3 0.0 3.7 7.4 4.1 4.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 5,766 73 1,860 157 1,109 566 179 9,731 Note: Total includes 11 women who used other methods. There are variations in reasons for discontinuation by method. Side effects/health concerns is the most common reason for discontinuation of the injectables (46 percent), implant (51 percent), and IUD (47 percent). Desire to become pregnant is the most common reason for discontinuing use of the pill (34 percent) and male condom (35 percent). This reason is also cited for periodic abstinence (26 percent), withdrawal (27 percent), injectables (24 percent), implants (21 percent), and IUD (19 percent). Method failure (“became pregnant while using”) is the most common reason for discontinuation of periodic abstinence (19 percent), withdrawal (18 percent), and the pill (17 percent). 48 47 49 49 57 36 30 1993-94 BDHS 1996-97 BDHS 1990-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent Fertility Regulation • 89 7.12 FUTURE USE OF CONTRACEPTION An important indicator of the changing demand for family planning is the extent to which nonusers of contraception plan to use family planning in the future. Currently married women who were not using contraception at the time of the survey—defined as nonusers—were asked about their intention to use family planning in the future. The results are presented in Table 7.16, according to the number of living children the women had. Overall, 58 percent of nonusers said they intended to use family planning methods and 39 percent said that they did not intend to use contraceptives. Only a few nonusers (3 percent) said they were unsure of their intention. Intention to use varies with the number of children. The proportion of nonusers who say they intend to use family planning in the future peaks at 78 percent for women with one child and falls sharply to 27 percent among women with four or more children. Figure 7.9 shows the proportion of nonusers intending to use family planning in the future has been decreasing gradually from 73 percent in 2004 to 65 percent in 2011 and to 58 percent in 2014. A further investigation is crucial to understand the reasons for decreasing trend of future intention to use contraception by the nonusers. Table 7.16 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Bangladesh 2014 Number of living children1 Total Intention 0 1 2 3 4+ Intends to use 67.2 77.9 63.0 45.4 26.8 57.8 Unsure 6.3 3.4 1.7 1.9 1.3 2.7 Does not intend to use 26.4 18.5 35.1 52.6 71.9 39.3 Missing 0.0 0.1 0.2 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 790 1,767 1,510 1,053 1,210 6,330 1 Includes current pregnancy Figure 7.9 Trends in future intention to use contraception by currently married women who are not using a contraceptive method, age 15-49, from 2004-2014 73 70 65 58 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent Note: Intention to use contraception in 2007, 2011, and 2014 is for women age 15-49. In the 2004 BDHS it refers to women age 10-49. 90 • Fertility Regulation Another question assessed future demand for specific contraceptive methods among currently married women who were not using contraception but who said they intend to use a method in the future. They were asked which method they would prefer to use. The results are presented in Table 7.17. Close to half of the prospective users prefer the pill (49 percent) and 20 percent prefer injectables. One in five nonusers (21 percent) were unsure what method they wanted to use. 7.13 REASONS FOR NOT INTENDING TO USE CONTRACEPTION Table 7.18 presents the main reasons for not intending to use contraception in the future as reported by nonintenders (nonusers who do not intend to use family planning in the future). Approximately eight in ten of the nonintenders do not plan to use family planning for reasons related to fertility. The most common reason for nonuse is menopause/hysterectomy, cited by 33 percent of nonintenders, followed by those who are subfecund or infecund (27 percent). Sixteen percent of women do not intend to use a contraceptive method because of infrequent sex or no sex. Four percent of nonintenders, mostly women age 15-29, do not intend to use contraception because they want more children. Nine percent of married women do not intend to use because of method-related reasons, mainly health concerns and interfere with body’s normal process. Nine percent of nonintenders do not intend to use contraceptives because of opposition to family planning, either by themselves (6 percent), their husband (2 percent) or because of religious prohibitions (1 percent). Table 7.18 Reason for not intending to use contraception Percent distribution of currently married women age 15-49 who are not using contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, Bangladesh 2014 Age Total Reason 15-29 30-49 Fertility-related reasons 54.9 83.2 79.1 Infrequent sex/no sex 22.4 14.4 15.6 Menopausal/had hysterectomy 2.9 37.4 32.5 Subfecund/infecund 15.0 28.7 26.8 Wants as many children as possible 14.4 2.6 4.3 Opposition to use 21.7 6.7 8.9 Respondent opposed 9.9 5.0 5.7 Husband/partner opposed 7.7 1.0 1.9 Others opposed 0.5 0.0 0.1 Religious prohibition 3.5 0.8 1.2 Lack of knowledge 1.3 0.1 0.3 Knows no method 0.3 0.0 0.1 Knows no source 1.0 0.0 0.2 Method related reason 14.0 8.2 9.0 Health concerns 6.9 3.0 3.5 Fear of side effects 3.0 1.3 1.6 Lack of access/too far 0.0 0.2 0.2 Inconvenient to use 0.0 0.2 0.2 Interfere with body’s normal process 4.1 3.5 3.6 Other 5.5 1.6 2.2 Don’t know 1.2 0.1 0.2 Missing 1.5 0.1 0.3 Total 100.0 100.0 100.0 Number of women 357 2,134 2,490 Table 7.17 Preferred method of contraception for future use Percent distribution of currently-married women age 15-49 who are not using a contraceptive method but who intend to use in the future by preferred method, according to age, Bangladesh 2014 Age Total Method 15-29 30-49 Female sterilization 1.7 3.6 2.2 Male sterilization 0.0 0.0 0.0 Pill 49.7 47.4 49.2 IUD 0.2 0.1 0.2 Injection 20.1 19.6 20.0 Implants 0.9 1.1 1.0 Male condom 4.4 7.5 5.1 Periodic abstinence 0.6 3.2 1.2 Withdrawal 0.4 0.4 0.4 Other 0.1 0.4 0.2 Unsure 21.7 16.8 20.6 Total 100.0 100.0 100.0 Number of women 2,835 827 3,662 Fertility Regulation • 91 7.14 UNMET NEED FOR FAMILY PLANNING SERVICES This section provides information on the extent of need and potential demand for family planning services in Bangladesh. In the past, the definition of unmet need used information from the contraceptive calendar and other questions that were not included in every survey leading to calculate inconsistent unmet need for family planning. The revised definition (Bradley et al. 2012) uses only information that has been collected in every survey so that unmet need can be measured in the same way over time. Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone the next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have unmet need for spacing if they are: • At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years, or are unsure if or when they want to become pregnant. • Pregnant with a mistimed pregnancy. • Postpartum amenorrheic for up to two years following a mistimed birth and not using contraception. Women are considered to have unmet need for limiting if they are: • At risk of becoming pregnant, not using contraception, and want no (more) children. • Pregnant with an unwanted pregnancy. • Postpartum amenorrheic for up to two years following an unwanted birth and not using contraception. Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Women using contraception are considered to have met need. Women using contraception who say they want no (more) children are considered to have met need for limiting, and women who are using contraception and say they want to delay having a child, or are unsure if or when they want a/another child, are considered to have met need for spacing. Unmet need, total demand, and percentage of demand satisfied by modern methods are defined as follows: • Unmet need: the sum of unmet need for spacing plus unmet need for limiting • Total demand for family planning: the sum of unmet need plus total contraceptive use • Percentage of demand satisfied: total contraceptive use divided by the sum of unmet need plus total contraceptive use Overall, 12 percent of currently married women in Bangladesh have an unmet need for family planning services, 5 percent have need for spacing, and 7 percent have need for limiting births (Table 7.19). The total demand for family planning (the sum of total unmet need and total contraceptive use) in Bangladesh is 74 percent, of which 73 percent has been satisfied by the use of modern methods (modern contraceptive use divided by the sum of contraceptive use and total unmet need). Unmet need for family planning decreases with increasing age, from 17 percent among women age 15-19 to 7 percent among women age 45-49. Women in rural areas have a higher unmet need than urban women (13 compared with 10 percent). Across divisions, unmet need is highest in Sylhet (18 percent) and Chittagong (17 percent), and the lowest in Rangpur (7 percent). 92 • Fertility Regulation Unmet need for family planning in Bangladesh has decreased from 14 percent in 2011 to 12 percent in 2014 (Figure 7.10). The HPNSDP results framework has set a target to reduce unmet need for family planning services to 9 percent by 2016 (MOHFW 2011), and FP2020 has set a target to reach 7 percent by 2021 (Family Planning 2020). Table 7.19 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, the total demand for family planning, and the percentage of the demand for contraception that is satisfied, by background characteristics, Bangladesh 2014 Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Percentage of demand for modern methods satisfied3 Number of women Background characteristic For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 15.7 1.5 17.1 45.6 5.5 51.2 61.3 7.0 68.3 74.9 68.4 1,984 20-24 10.8 4.0 14.7 37.6 21.6 59.2 48.3 25.6 73.9 80.1 73.8 3,166 25-29 5.5 6.8 12.2 19.6 48.1 67.7 25.1 54.9 79.9 84.7 78.5 3,249 30-34 1.8 9.4 11.2 7.1 66.6 73.7 9.0 76.0 85.0 86.8 76.2 2,919 35-39 0.7 9.6 10.2 1.5 71.4 72.9 2.2 81.0 83.2 87.7 72.9 2,153 40-44 0.2 8.2 8.4 0.4 60.4 60.9 0.6 68.7 69.3 87.9 65.3 1,874 45-49 0.0 7.0 7.0 0.3 37.8 38.1 0.3 44.8 45.1 84.4 55.5 1,512 Residence Urban 4.1 5.5 9.6 21.0 44.9 65.9 25.1 50.4 75.5 87.3 74.5 4,709 Rural 5.8 7.0 12.9 16.4 44.7 61.1 22.3 51.7 74.0 82.6 71.9 12,149 Division Barisal 5.2 6.1 11.3 19.0 44.3 63.3 24.1 50.4 74.6 84.9 73.2 1,051 Chittagong 8.3 9.0 17.3 15.7 39.3 55.0 24.0 48.3 72.3 76.0 65.3 3,121 Dhaka 5.1 7.0 12.1 19.4 43.5 63.0 24.5 50.5 75.0 83.9 72.3 5,857 Khulna 3.6 5.8 9.4 16.4 50.6 67.1 20.0 56.5 76.5 87.7 73.7 1,729 Rajshahi 3.2 4.5 7.7 18.7 50.6 69.4 22.0 55.1 77.0 90.0 78.8 2,007 Rangpur 3.2 3.6 6.7 18.5 51.3 69.8 21.7 54.8 76.5 91.2 82.4 1,946 Sylhet 8.8 8.9 17.7 11.9 35.9 47.8 20.7 44.8 65.5 73.0 62.4 1,147 Education No education 2.0 8.3 10.3 6.0 55.5 61.5 8.0 63.8 71.8 85.7 70.4 3,949 Primary incomplete 3.7 7.7 11.4 12.0 51.8 63.9 15.7 59.6 75.2 84.9 74.1 3,032 Primary complete4 5.7 5.8 11.5 17.4 44.6 62.0 23.0 50.4 73.4 84.4 73.9 1,884 Secondary incomplete 7.9 5.8 13.7 24.6 37.7 62.3 32.5 43.5 76.0 82.0 73.7 5,477 Secondary complete or higher5 6.9 5.0 11.9 28.1 34.8 63.0 35.0 39.9 74.9 84.1 71.1 2,516 Wealth quintile Lowest 5.3 7.8 13.1 14.0 48.5 62.6 19.4 56.3 75.7 82.7 72.9 3,097 Second 4.5 6.0 10.6 16.2 47.0 63.2 20.7 53.0 73.7 85.7 74.8 3,223 Middle 5.8 6.1 11.9 17.8 44.9 62.7 23.6 50.9 74.6 84.0 73.1 3,394 Fourth 5.8 7.1 13.0 19.3 41.8 61.1 25.1 48.9 74.1 82.5 71.4 3,556 Highest 5.1 6.2 11.3 20.6 42.3 62.8 25.7 48.4 74.1 84.8 71.4 3,587 Total 5.3 6.6 12.0 17.7 44.7 62.4 23.0 51.4 74.4 83.9 72.6 16,858 1 Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrheic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrheic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. 2 Using for spacing is defined as women who are using some method of family planning and say they want to have another child or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Nonusers who are pregnant or amenorrheic and whose pregnancy was the result of a contraceptive failure are not included in the category of unmet need, but are included in total demand for contraception (since they would have been using had their method not failed). They are also considered as having their demand satisfied. 4 Primary complete is defined as completing grade 5. 5 Secondary complete is defined as completing grade 10. Fertility Regulation • 93 Figure 7.10 Trends in unmet need for family planning among currently married women age 15-49, 2011 and 2014 BDHS Figure 7.11 Trends in unmet need for family planning services among currently married women age 15-49, by division, 2011-2014 7.15 EXPOSURE TO FAMILY PLANNING MESSAGES The media play an important role in communicating messages about family planning. In assessing the reach of family planning messages, the 2014 BDHS asked women whether they had heard or seen a message about family planning on the radio, on television, in a newspaper or magazine, on a billboard, poster, or leaflet, or at a community event in the month before the survey. Table 7.20 presents the proportion of currently married women who had heard or seen such a message from a media source, by background characteristics. 14 61 75 82 12 62 74 84 Unmet need Current use Total demand Proportion of demand satisfied Percent 2011 BDHS 2014 BDHS 14 12 21 13 10 11 10 17 12 11 17 12 9 8 7 18 Bangladesh Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet 2011 BDHS 2014 BDHS Percent 94 • Fertility Regulation Table 7.20 Exposure to family planning messages Percentage of women age 15-49 who heard or saw a family planning message on radio, on television, or in a newspaper in the last month, according to background characteristics, Bangladesh 2014 Radio Television Newspaper/ magazine None of these three media sources Poster, billboard, or leaflet Community event Community health worker At least one of these sources Number of women Background characteristic Govern- ment Non- government Age 15-19 1.7 18.8 2.5 79.7 5.0 3.3 5.7 5.6 30.7 1,984 20-24 1.4 21.0 2.8 78.3 5.4 3.4 9.1 3.1 32.3 3,166 25-29 1.8 21.5 3.4 77.2 5.7 3.5 9.2 2.7 33.4 3,249 30-34 1.6 19.7 3.1 78.9 4.9 3.9 10.0 2.4 32.3 2,919 35-39 1.1 18.4 2.5 80.5 4.7 3.3 8.3 2.1 29.3 2,153 40-44 0.9 15.9 2.9 83.3 4.5 2.8 6.8 1.1 23.7 1,874 45-49 1.0 15.6 3.0 83.4 3.1 2.7 4.2 1.6 22.0 1,512 Residence Urban 1.1 29.8 6.1 69.0 8.1 3.5 4.9 2.9 37.6 4,709 Rural 1.6 15.1 1.7 83.8 3.7 3.3 9.3 2.6 27.1 12,149 Division Barisal 1.7 19.3 3.9 79.0 7.9 9.2 7.9 3.0 32.0 1,051 Chittagong 1.1 21.3 2.6 78.0 2.6 3.4 5.7 1.7 27.8 3,121 Dhaka 1.2 22.1 3.6 76.8 5.8 3.0 8.8 3.0 33.8 5,857 Khulna 2.0 18.6 2.3 80.2 6.8 2.5 8.5 1.9 30.0 1,729 Rajshahi 1.2 13.7 1.8 85.2 5.4 1.9 9.9 1.9 26.4 2,007 Rangpur 2.4 15.8 2.8 82.5 3.9 4.0 8.7 4.6 28.5 1,946 Sylhet 1.4 15.2 2.4 84.1 2.6 2.6 6.5 3.1 24.4 1,147 Education No education 0.4 8.6 0.1 91.1 1.1 2.0 6.6 1.8 17.6 3,949 Primary incomplete 1.3 11.4 0.2 87.8 1.6 1.9 8.3 3.1 22.2 3,032 Primary complete1 1.1 15.9 0.6 83.5 3.3 3.6 10.1 2.5 28.0 1,884 Secondary incomplete 1.6 23.1 2.2 75.9 5.5 3.6 8.7 3.4 34.5 5,477 Secondary complete or higher2 3.2 39.4 13.8 57.1 15.0 6.5 7.4 2.4 50.8 2,516 Wealth quintile Lowest 1.1 2.9 0.3 96.3 1.7 1.7 7.4 3.8 15.5 3,097 Second 1.4 6.7 0.7 91.9 1.8 2.4 10.3 2.2 20.2 3,223 Middle 2.0 17.5 1.1 81.3 3.6 3.1 10.9 2.9 30.4 3,394 Fourth 1.2 26.8 2.4 72.4 5.8 4.3 7.2 2.8 35.3 3,556 Highest 1.4 38.7 9.4 59.8 10.9 5.0 4.8 1.9 45.9 3,587 Total 1.4 19.2 2.9 79.6 4.9 3.4 8.1 2.7 30.0 16,858 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Television is the most popular source for family planning messages in Bangladesh with 19 percent of currently married women age 15-49 having seen a family planning message in this media. Five percent of women saw a family planning message in either a poster, billboard, or leaflet, and 3 percent of women read about family planning in a newspaper or magazine. Overall, 80 percent of women were not exposed to family planning messages in any of the three main media (radio, television, and print media). Not surprisingly, women residing in urban areas are much more likely to have been exposed to family planning messages in any media than their rural counterparts. This is especially true for messages on television and in print media. Women residing in rural areas are more exposed to family planning messages through community health workers and radio than those living in urban areas. Education has a positive influence on media exposure. For example, 9 percent of uneducated women are exposed to family planning information on television compared with 39 percent of women with a secondary or higher education. Exposure to family planning messages increases with the increase in wealth. Exposure to family planning messages in the mass media for women age 15-49 has declined over the last three years. Exposure to family planning messages on the radio declined from 3 percent in the 2011 BDHS to 1 percent in the 2014 BDHS, exposure through the television declined from 24 percent in 2011 to 19 percent in 2014, and exposure through poster, billboard, or leaflet declined slightly from 6 percent in 2011 to 5 percent in 2014 (NIPORT et al. 2013). Fertility Regulation • 95 7.16 FIELDWORKER VISITS In the 2014 BDHS, women were asked whether a family planning fieldworker had visited them in the six months prior to the survey. Table 7.21 shows that 20 percent of currently married women said they were visited by a fieldworker in the six months before the survey. This proportion is 5 percentage points higher than that recorded in the 2011 BDHS. One-fourth of women visited by a fieldworker received a family planning method from the worker. Table 7.21 Contact with family planning fieldworkers: Type of service Percentage of currently-married women age 15-49 who reported being visited by a fieldworker in the past six months, the percent distribution of various types of services provided by the fieldworker, by background characteristics, Bangladesh 2014 Percentage of women who reported being visited by fieldworker in the past 6 months Number of women Services provided by the fieldworker: Total Number of women Background characteristic Talked Gave family planning method Talked and gave family planning method Age 15-19 19.5 1,984 73.8 14.5 11.7 100.0 386 20-24 22.5 3,166 70.2 20.8 9.0 100.0 713 25-29 22.3 3,249 57.8 29.0 13.2 100.0 724 30-34 20.9 2,919 56.3 28.8 14.9 100.0 609 35-39 19.7 2,153 57.1 32.0 10.9 100.0 425 40-44 16.8 1,874 56.3 29.6 14.1 100.0 316 45-49 9.6 1,512 60.7 26.3 12.9 100.0 145 Residence Urban 15.7 4,709 68.5 20.6 10.9 100.0 737 Rural 21.2 12,149 60.1 27.3 12.6 100.0 2,581 Division Barisal 21.4 1,051 66.4 15.0 18.6 100.0 225 Chittagong 13.2 3,121 69.3 16.2 14.5 100.0 411 Dhaka 20.5 5,857 58.4 29.5 12.2 100.0 1,199 Khulna 21.0 1,729 64.4 21.5 14.1 100.0 363 Rajshahi 23.0 2,007 59.6 34.7 5.8 100.0 462 Rangpur 22.9 1,946 58.9 28.6 12.5 100.0 446 Sylhet 18.4 1,147 70.6 17.8 11.6 100.0 211 Education No education 16.2 3,949 56.6 29.6 13.8 100.0 641 Primary incomplete 20.8 3,032 56.7 28.7 14.6 100.0 631 Primary complete1 20.2 1,884 63.6 27.1 9.2 100.0 381 Secondary incomplete 21.9 5,477 63.0 24.9 12.1 100.0 1,199 Secondary complete or higher2 18.5 2,516 72.4 18.1 9.5 100.0 467 Wealth quintile Lowest 19.7 3,097 58.0 28.8 13.3 100.0 609 Second 22.6 3,223 57.8 29.4 12.8 100.0 727 Middle 24.4 3,394 58.5 27.4 14.1 100.0 829 Fourth 18.7 3,556 64.7 24.9 10.4 100.0 666 Highest 13.6 3,587 75.2 15.5 9.3 100.0 487 Total 19.7 16,858 62.0 25.8 12.2 100.0 3,318 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Eleven percent of currently-married women said they were visited by a government family planning fieldworker, while 4 percent were visited by a government health worker and 5 percent by an NGO fieldworker (Table 7.22). Married women who live in rural areas are twice as likely to be visited by a government fieldworker (both family planning and health workers) than women in urban areas. 96 • Fertility Regulation Table 7.22 Contact with family planning fieldworkers: Type of fieldworker Percentage of currently married women age 15-49 who reported being visited by a fieldworker in the past six months, by type of fieldworker, according to background characteristics, Bangladesh 2014 Visited in the last six months by a Background characteristic Government FP worker Government health worker NGO worker Other Missing Number of women Age 15-19 8.4 3.2 8.0 0.2 0.0 1,984 20-24 11.9 4.6 6.1 0.1 0.0 3,166 25-29 12.7 4.7 5.3 0.0 0.1 3,249 30-34 12.5 4.2 4.4 0.2 0.0 2,919 35-39 11.7 4.2 4.0 0.1 0.1 2,153 40-44 9.7 3.6 3.8 0.0 0.0 1,874 45-49 5.9 1.8 1.9 0.3 0.0 1,512 Residence Urban 7.0 2.9 5.7 0.1 0.0 4,709 Rural 12.5 4.4 4.7 0.1 0.0 12,149 Division Barisal 9.9 4.9 7.0 0.2 0.0 1,051 Chittagong 7.0 3.2 3.2 0.1 0.0 3,121 Dhaka 11.1 4.0 5.7 0.0 0.1 5,857 Khulna 13.3 3.6 3.9 0.3 0.0 1,729 Rajshahi 15.0 4.6 3.6 0.1 0.0 2,007 Rangpur 12.1 3.7 7.5 0.1 0.0 1,946 Sylhet 8.9 5.3 4.3 0.1 0.1 1,147 Education No education 9.0 3.4 4.0 0.1 0.0 3,949 Primary incomplete 11.4 4.7 4.7 0.2 0.0 3,032 Primary complete1 12.5 3.6 4.8 0.1 0.0 1,884 Secondary incomplete 12.3 4.3 5.6 0.1 0.0 5,477 Secondary complete or higher2 9.3 3.6 5.9 0.1 0.1 2,516 Wealth quintile Lowest 10.9 4.1 4.9 0.1 0.0 3,097 Second 12.7 5.8 4.5 0.0 0.0 3,223 Middle 14.3 4.7 5.7 0.2 0.0 3,394 Fourth 10.5 3.3 5.0 0.1 0.1 3,556 Highest 6.6 2.2 4.9 0.1 0.0 3,587 Total 10.9 4.0 5.0 0.1 0.0 16,858 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 7.17 SATELLITE CLINICS As shown in Table 7.23, 63 percent of ever-married women are aware of the existence of a satellite clinic in their community. Awareness of satellite clinics is lower among younger women, women in urban areas, women in Rajshahi, Rangpur and Sylhet divisions, women who completed secondary or higher education, and women in the highest wealth quintile. Seventeen percent of women who were aware of satellite clinics in their community reported visiting such a clinic in the three months before the 2011 BDHS. More than half of the women who visited a satellite clinic received immunization services for children, while one-fourth of women received family planning methods and 15 percent visited to obtain vitamin A for their children. Other reasons for visiting satellite clinics include receiving tetanus toxoid injections (5 percent), antenatal care services (3 percent), and child growth monitoring (3 percent). Fertility Regulation • 97 Table 7.23 Satellite clinics Percentage of ever-married women age 15-49 who reported a satellite clinic in their community, the percentage who visited a satellite clinic in the past three months, and the percentage who reported various types of services provided at the satellite clinic, by background characteristics, Bangladesh 2014 Percentage reporting a satellite clinic taking place in the community Number of women Of those who reported a satellite clinic in the community Of those who visited a satellite, clinic percentage receiving services in: Background characteristic Percent- age who visited satellite clinic in the past 3 months Number of women Family planning methods Immuni- zations Child growth monitor- ing Tetanus toxoid injections Antenatal care Vitamin A for children Others Don't know/ missing Number of women Age 15-19 57.5 2,029 24.6 1,166 8.6 76.0 0.9 7.8 3.7 9.4 2.9 0.0 287 20-24 63.0 3,224 24.4 2,030 16.5 64.5 1.9 4.9 3.4 16.5 2.5 0.3 495 25-29 63.2 3,390 20.3 2,141 26.3 55.2 4.7 4.4 1.3 15.5 3.9 0.6 435 30-34 65.3 3,047 15.9 1,989 32.5 48.8 3.9 3.0 2.8 18.9 5.0 1.2 315 35-39 63.1 2,315 11.5 1,460 41.5 37.2 2.4 7.0 3.3 14.1 8.1 0.5 169 40-44 65.1 2,092 7.6 1,362 34.1 45.8 2.0 8.3 5.5 16.0 8.3 0.0 103 45-49 61.2 1,766 6.6 1,081 33.9 48.7 0.6 0.9 1.2 16.8 5.3 0.6 71 Residence Urban 59.6 5,047 15.2 3,009 20.3 59.8 3.9 4.5 2.2 12.5 4.7 0.8 459 Rural 64.1 12,816 17.2 8,221 25.4 56.6 2.4 5.3 3.1 16.3 4.1 0.4 1,417 Division Barisal 62.6 1,111 15.2 695 32.5 51.5 2.0 6.6 3.5 12.8 2.1 0.7 106 Chittagong 66.6 3,301 17.7 2,197 21.0 64.9 2.9 5.5 2.0 13.8 1.5 0.6 390 Dhaka 64.6 6,223 16.2 4,018 20.6 59.2 1.8 3.9 2.8 16.2 3.7 0.3 652 Khulna 65.6 1,838 15.3 1,205 35.3 51.3 5.1 11.0 4.6 22.0 7.9 0.4 185 Rajshahi 57.4 2,103 17.7 1,206 26.7 51.9 2.3 4.1 2.3 11.0 7.2 0.8 214 Rangpur 59.7 2,056 16.9 1,227 32.9 48.3 4.2 3.0 1.3 10.4 6.1 0.8 208 Sylhet 55.1 1,232 18.0 679 9.4 62.7 2.8 5.7 6.7 23.9 3.7 0.0 122 Education No education 63.1 4,455 12.0 2,810 28.1 51.1 3.7 2.4 1.9 15.5 4.5 0.2 336 Primary incomplete 63.8 3,223 18.3 2,057 30.2 52.6 3.0 7.5 2.4 13.1 3.3 0.6 376 Primary complete1 66.7 1,986 19.6 1,325 31.1 51.2 1.4 4.7 5.0 13.7 4.0 0.7 260 Secondary incomplete 63.6 5,628 18.8 3,581 19.3 60.9 2.0 5.1 2.4 16.3 4.7 0.4 673 Secondary complete or higher2 56.6 2,571 15.9 1,456 14.8 70.9 4.7 5.6 3.9 17.9 4.2 0.7 231 Wealth quintile Lowest 62.7 3,359 18.3 2,107 27.9 53.8 1.9 4.0 2.2 16.7 3.1 0.2 385 Second 64.5 3,408 19.1 2,196 28.6 49.8 1.2 7.1 3.6 15.1 6.4 0.7 419 Middle 66.4 3,560 17.2 2,363 25.1 56.1 3.4 4.6 2.7 15.2 2.6 0.6 406 Fourth 66.0 3,758 15.5 2,479 18.4 66.2 3.5 3.1 2.4 14.0 5.0 0.3 385 Highest 55.2 3,778 13.5 2,084 18.8 63.3 4.3 7.2 3.7 15.9 3.8 0.6 281 Total 62.9 17,863 16.7 11,230 24.1 57.4 2.8 5.1 2.9 15.3 4.2 0.5 1,875 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 7.18 COMMUNITY CLINICS The government of Bangladesh has planned to establish 13,861 community clinics in the rural areas. Each clinic is expected to provide health care services to a community of 6,000 population. As of 2014, 12,527 community clinics are operating to provide health services (PMMU 2014). These clinics provide comprehensive primary health care, family planning services, and nutritional services from a single center. A question was asked of all ever-married women age 15-49 in the survey about whether their village or area has a community clinic, whether they visit that clinic, and if so, for what services. As shown in Table 7.24, 28 percent of ever-married women are aware of the community clinic in their locality. Awareness of community clinics is lower among women in Dhaka, Sylhet, and Chittagong divisions and women with high wealth status. 98 • Fertility Regulation Twenty-four percent of women who were aware of community clinics reported visiting such a clinic in the three months before the 2014 BDHS. Among these women, 62 percent visited the community clinic to obtain medicine for general health, 26 percent for family planning services, and 11 percent for immunization services for their children. Other reasons for visiting community clinics are insignificant: vitamin A for children (3 percent), tetanus toxoid injections (3 percent), antenatal care services (4 percent), and child growth monitoring (1 percent). Table 7.24 Community clinics Percentage of ever-married women age 15-49 who reported a community clinic in their community, the percentage who visited a community clinic in the past three months, and the percentage who reported various types of services provided at the clinic, by background characteristics, Bangladesh 2014 Percentage reporting a community clinic in the community Number of women Of those who reported a community clinic in the community Of those who visited a community clinic percentage receiving services in: Background characteristic Percentage who visited clinic in the past three months Number of women Family planning methods Immuni- zations Child growth monitor- ing Tetanus toxoid injec- tions Ante- natal care Vitamin A for children Medicine for general health Others Number of women Age 15-19 29.0 2,029 22.2 588 17.5 20.0 0.5 7.5 14.4 2.5 49.0 1.9 131 20-24 27.4 3,224 21.2 882 26.6 16.9 1.9 6.5 7.3 3.3 50.4 1.1 187 25-29 28.4 3,390 23.9 961 30.2 11.7 1.8 3.5 2.6 5.7 59.7 0.5 230 30-34 28.9 3,047 25.9 882 33.7 6.0 0.2 1.0 3.0 1.6 62.4 1.0 228 35-39 27.0 2,315 26.2 626 29.4 10.1 0.2 2.9 1.7 4.7 60.5 2.0 164 40-44 27.3 2,092 22.3 571 20.7 3.0 0.4 0.5 0.0 0.5 79.4 3.4 127 45-49 27.1 1,766 22.1 478 13.8 3.7 0.5 0.6 1.0 1.8 80.0 1.6 106 Residence Urban 15.3 5,047 14.8 774 14.4 19.3 1.1 4.4 5.6 2.2 56.0 0.6 115 Rural 32.9 12,816 25.1 4,214 27.6 9.5 0.8 3.2 4.0 3.2 62.2 1.6 1,057 Division Barisal 41.5 1,111 19.4 461 29.6 11.0 1.1 5.7 5.1 2.8 55.4 1.5 89 Chittagong 27.3 3,301 21.1 902 23.6 12.9 0.0 2.2 4.8 4.3 57.8 2.8 190 Dhaka 20.9 6,223 17.6 1,303 25.5 13.0 0.0 5.4 3.4 0.5 60.7 0.0 229 Khulna 31.5 1,838 29.5 578 34.2 13.2 3.4 6.4 3.3 9.8 57.3 3.4 170 Rajshahi 30.4 2,103 24.5 638 20.4 10.6 0.3 2.3 4.1 0.7 67.3 1.2 157 Rangpur 41.3 2,056 33.6 849 29.4 3.0 0.2 0.5 5.3 1.7 65.6 0.6 286 Sylhet 20.8 1,232 19.7 256 8.3 21.6 4.7 1.6 1.0 3.8 66.2 2.6 51 Education No education 24.3 4,455 24.1 1,084 27.8 4.3 0.4 1.1 0.8 2.0 69.6 0.4 261 Primary incomplete 27.8 3,223 24.3 897 23.5 8.8 1.6 3.8 1.3 3.2 64.7 2.0 218 Primary complete1 32.2 1,986 23.9 640 29.0 10.0 0.3 3.2 7.0 4.5 58.0 1.6 153 Secondary incomplete 29.9 5,628 24.7 1,682 26.6 12.6 0.5 4.0 6.1 2.2 58.9 1.6 416 Secondary complete or higher2 26.7 2,571 18.1 685 23.3 20.0 2.4 4.7 6.7 6.8 53.1 2.5 124 Wealth quintile Lowest 28.8 3,359 28.7 968 27.3 9.3 1.4 1.6 3.3 4.6 65.0 0.2 277 Second 33.0 3,408 26.3 1,125 30.9 7.8 0.5 4.9 5.0 3.4 59.6 0.6 296 Middle 31.7 3,560 27.0 1,127 26.8 7.6 0.8 1.6 3.9 1.6 62.4 2.0 304 Fourth 26.7 3,758 20.1 1,003 21.0 12.9 0.0 2.7 4.3 1.3 62.4 3.7 202 Highest 20.3 3,778 12.0 765 18.0 26.6 2.3 10.0 5.0 7.0 54.0 1.8 92 Total 27.9 17,863 23.5 4,988 26.3 10.5 0.9 3.3 4.2 3.1 61.6 1.5 1,172 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Infant and Child Mortality • 99 INFANT AND CHILD MORTALITY 8 nfant and child mortality rates reflect a country’s level of socioeconomic development and quality of life. The rates are also useful in identifying promising directions for health and nutrition programs in any country. Mortality levels are one of the main indicators of the standard of living or development of a population. Thus, identifying segments of the child population that are at greater risk of dying contributes to efforts to improve child survival and lower the exposure of young children to risk. This chapter presents information on levels, trends, and differences in mortality among children under age 5 in Bangladesh. Specifically, it presents information on neonatal, postneonatal, infant, child, and under-5 mortality. Information on perinatal mortality and patterns of fertility associated with mortality is also presented. Mortality estimates are disaggregated by socioeconomic characteristics, such as urban-rural residence, geographic division, mother’s level of education, and household wealth, as well as selected demographic characteristics, which may be used to identify segments of the population requiring special attention. The data for mortality estimates were collected in the birth history section of the Woman’s Questionnaire. The 2014 BDHS asked all ever-married women age 15-49 to provide a complete history of their live births, including the sex, month, and year of each birth, survival status, and age at the time of the survey or age at death. Age at death was recorded in days for children dying in the first month of life, in months for children dying before their second birthday, and in years for children dying at later ages. This information is used to directly estimate the infant and child mortality rates1. 1 A detailed description of the method for calculating the probabilities presented here is given in Rutstein (1984). I Key Findings • Under-5 mortality for the five-year period before the survey is 46 deaths per 1,000 live births. At this level, Bangladesh has achieved the Millennium Development Goal 4 target—48 deaths per 1,000 live births by 2015—ahead of time. • The infant mortality rate for the five years preceding the survey is 38 deaths per 1,000 live births. At this mortality level, 1 in 26 children in Bangladesh dies before reaching his or her first birthday. • Neonatal mortality, that is, deaths in the first month of life, is 28 per 1,000 live births, and these deaths comprise 61 percent of all under-5 deaths. The neonatal mortality rate is nearly three times greater than postneonatal mortality. • In the last two decades under-5 and infant mortality declined by 65 percent and 56 percent, respectively. Neonatal mortality declined by 46 percent while postneonatal mortality fell by 71 percent. • The perinatal mortality rate is 44 deaths per 1,000 pregnancies. • Sylhet division has the highest under-5 mortality rate among all the divisions. 100 • Infant and Child Mortality The mortality rates presented here are defined as follows: Neonatal mortality: the probability of dying within the first month of life Post-neonatal mortality: the difference between infant and neonatal mortality Infant mortality: the probability of dying before the first birthday Child mortality: the probability of dying between the first and fifth birthday Under-5 mortality: the probability of dying between birth and the fifth birthday All rates are expressed per 1,000 live births except for child mortality, which is expressed per 1,000 children surviving to their first birthday (12 months of age). 8.1 ASSESSMENT OF DATA QUALITY The reliability of mortality estimates calculated from retrospective birth histories depends upon the extent to which birth dates and ages at death are accurately reported and recorded. Omission of either births or deaths is a serious problem since they affect the level of the mortality estimates. Errors in reporting of birth dates may cause a distortion of trends over time, while errors in reporting of age at death can distort the age pattern of mortality. Estimated rates of infant and child mortality are subject to both sampling and nonsampling errors. Sampling errors for various mortality estimates are provided in Appendix B, and this section describes the results of various checks for nonsampling errors—in particular, underreporting of deaths in early childhood (which would result in an underestimate of mortality) and misreporting of the date of birth or age at death (which could distort the age pattern of under-5 mortality). Both problems are likely to be more pronounced for children born further in the past than for children born recently. Underreporting of infant deaths is usually most serious for deaths that occur very early in infancy. If deaths in the early neonatal period are selectively underreported, there will be an abnormally low ratio of deaths during the first seven days of life to all neonatal deaths and an abnormally low ratio of neonatal to infant mortality. Changes in these ratios over time can be examined to test the hypothesis that underreporting of early infant deaths is more common for births that occurred further in the past than for births that occurred more recently. Failure to report deaths will result in mortality figures that are low, and if underreporting is more severe for children born longer ago than for children born recently, any decrease in mortality will tend to be understated. Results from Appendix Table C.5 suggest that early neonatal deaths have not been seriously underreported in the 2014 BDHS because the ratios of deaths under seven days to all neonatal deaths are acceptable. For 0 to 19 years before the survey, the overall percentage of neonatal deaths occurring during the first week of life is 76 percent. A ratio of about 70 percent is often considered normal.2 This percentage decreases somewhat with increasing years before the survey, from 81 percent of neonatal deaths for the periods 0 to 4 years preceding the survey to 76 percent for the period 15 to 19 years preceding the survey. The ratios of neonatal to infant deaths (Appendix Table C.6) are also consistently high (between 65 percent and 75 percent) for the various periods preceding the survey. Another problem inherent in most retrospective surveys is heaping of age at death on certain digits (for example, 6, 12, and 18 months). If the net result of misreporting is the transference of deaths between age segments for which the rates are calculated, misreporting of the age at death will bias estimates of the age pattern of mortality. For instance, an overestimate of child mortality relative to infant mortality may result if children dying during the first year of life are reported as having died at age 1 or older. Thus, heaping at 12 months can bias the mortality estimates because a certain fraction of these deaths, which are reported to have occurred after infancy (i.e., at age 12-23 months), may have actually occurred during infancy (i.e., 2 There are no models for mortality patterns during the neonatal period. However, one review of data from developing countries concluded that at a neonatal mortality of 20 per 1,000 or higher, approximately 70 percent of neonatal deaths occur within the first six days of life (Boerma 1988). Infant and Child Mortality • 101 at age 0-11 months). In such cases, heaping would bias infant mortality (1q0) downward and child mortality (4q1) upward. In the 2014 BDHS, there appears to be a preference for reporting age at death at 3, 5, 7, 10, 15, 18, and 21 days (Appendix Table C.5). An examination of the distribution of deaths under age 2 during the 19 years preceding the survey by month of death (Appendix Table C.6) indicates some heaping of deaths at 3, 5, 8, 12, and 18 months of age. Some heaping on 12 months and recording of deaths at “1 year” is found despite the strong emphasis on this problem during the training of interviewers for the BDHS fieldwork.3 However, this brief assessment of the internal consistency of childhood mortality data suggests that the extent of digit preference is such that it will not substantially alter the rates. Appendix Table C.4 can be used to assess the quality of information recorded on date of birth. The results show that there was evidence of shifting in the reporting of births from calendar year 2009 to 2008. This shifting usually results from interviewers transferring births out of the five-year period for which child data are collected on maternal and child health indicators (January 2009 to date of interview for the 2014 BDHS) in an attempt to reduce the length of the interview. The data also show that transference is proportionately higher for dead children than for living children, which may underestimate the true level of childhood mortality rates for the five-year period before the survey. It is seldom possible to establish mortality levels with confidence for a period of more than 15 years before a survey. Even within the recent 15-year period considered here, apparent trends in mortality rates should be interpreted with caution for several reasons. First, there may be differences in the completeness of death reporting related to the length of time before the survey. Second, the accuracy of reports of age at death and of date of birth may deteriorate with time. Third, sampling variability of mortality rates tends to be high, especially for groups with relatively few births. Fourth, mortality rates are truncated as they go back in time because women currently age 50 or older who were bearing children during earlier periods were not included in the survey. This truncation affects mortality trends in particular. For example, for the period 10 to 14 years before the survey, the rates do not include any births to women age 40-49 because these women were over age 50 at the time of the survey and therefore not eligible to be interviewed. Because these older women were likely to have a somewhat greater risk of dying than younger women, the mortality rates for the period may be slightly underestimated. Estimates for more recent periods are less affected by truncation bias because fewer older women are excluded. However, the extent of this bias depends on the proportion of births omitted. 8.2 LEVELS AND TRENDS IN INFANT AND CHILD MORTALITY Mortality rates for children under age 5 are presented in Table 8.1 for the three five-year periods preceding the survey. Data from the 2014 BDHS shows that under-5 mortality in the five years preceding the survey (which corresponds approximately to the calendar years 2010-2014) is 46 deaths per 1,000 live births. This means Bangladesh already has achieved Millennium Development Goal 4, an under-5 mortality target of 48 deaths per 1,000 births. The infant mortality rate is 38 deaths per 1,000 live births, and the child mortality rate is 8 deaths per 1,000 children. During infancy, the risk of dying in the first month of life (28 deaths per 1,000 live births) is nearly three times greater than in the subsequent 11 months (10 deaths per 1,000 live births). It is also notable that deaths in the neonatal period account for 61 percent of all under-5 deaths. 3 Interviewers were trained to probe for the exact number of months lived by the child if the age at death was reported as “1 year.” 102 • Infant and Child Mortality Table 8.1 Early childhood mortality rates Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Bangladesh 2014 Years preceding the survey Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 28 10 38 8 46 5-9 36 14 49 13 61 10-14 36 21 57 16 72 1 Computed as the difference between the infant and neonatal mortality rates Trends in Childhood Mortality Another approach to looking at trends in mortality levels compares estimates from surveys conducted at different points in time. Since 1993-1994 the DHS surveys in Bangladesh have obtained childhood mortality rates for the five-year period preceding the survey. In examining the estimates, it is important to remember that the reporting of mortality events is generally better for the five-year period immediately before a survey since mothers are more likely to forget or fail to mention deaths further back in time. Thus the estimate for the five-year period immediately prior to each of the surveys in shown in Table 8.2 is likely to be the most accurate. Over the last two decades, the data confirm a steady downward trend in childhood mortality (Table 8.2 and Figure 8.1). A Bangladeshi child was around three times more likely to die before reaching his/her fifth birthday in the early-1990s than in 2014. As the overall rates have decreased, mortality has become increasingly concentrated in the earliest months of life. Between the 1989-1993 and 2010-2014 periods, infant mortality declined by 56 percent, from 87 to 38 deaths per 1,000 live births. An almost 20 percent further reduction in infant mortality is needed to achieve the Health, Population, and Nutrition Sector Development Program (HPNSDP) target of 31 deaths per 1,000 live births in 2016 (MOHFW 2011a). The corresponding decline in postneonatal mortality was even more impressive. There was a 71 percent decline from 35 deaths per 1,000 live births in 1989-1993 to 10 deaths per 1,000 live births in 2010- 2014 and a 65 percent decline in under-5 mortality from 133 to 46 deaths per 1,000 live births over the same period. Comparison of neonatal, infant, and under-5 mortality rates in Bangladesh over the last 20 years reveals that neonatal mortality declined at a slower pace than infant and child mortality, with the result that neonatal deaths have changed from 60 percent of all infant deaths in 1993-1994 to 74 percent in 2010-2014. The decline in childhood mortality continues, but at the current pace, it would be difficult to achieve the HPNSDP target of 21 neonatal deaths per 1,000 live births for the neonatal mortality rate by 2016 (MOHFW 2011b). Table 8.2 Trend in early childhood mortality Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the BDHS surveys Data source Approximate reference period Neonatal mortality (NN) Post-neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) BDHS 2014 2010-2014 28 10 38 8 46 BDHS 2011 2007-2011 32 10 43 11 53 BDHS 2007 2002-2006 37 15 52 14 65 BDHS 2004 1999-2003 41 24 65 24 88 BDHS 1999-2000 1995-1999 42 24 66 30 94 BDHS 1996-1997 1992-1996 48 34 82 37 116 BDHS 1993-1994 1989-1993 52 35 87 50 133 1 Computed as the difference between the infant and neonatal mortality rates Infant and Child Mortality • 103 Figure 8.1 Trends in childhood mortality rates, 1989-2014 8.3 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Selected socioeconomic and demographic differentials in early childhood mortality for the five years preceding the survey are presented in Table 8.3 and Figure 8.2. These findings must be interpreted with caution given the low precision of mortality estimates due to sampling error. Table 8.3 Early childhood mortality rates by socioeconomic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 5-year period preceding the survey, by background characteristics, Bangladesh 2014 Background characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 21 13 34 3 37 Rural 31 9 40 10 49 Division Barisal 21 5 26 9 35 Chittagong 24 12 36 14 50 Dhaka 25 10 35 5 41 Khulna 41 7 47 9 56 Rajshahi 31 7 38 5 43 Rangpur 27 7 34 5 39 Sylhet 39 16 55 12 67 Mother’s education No education 26 12 38 13 50 Primary incomplete 31 12 43 10 52 Primary complete2 31 12 42 3 45 Secondary incomplete 33 10 43 7 49 Secondary complete or higher3 13 4 18 9 27 Wealth quintile Lowest 35 8 43 10 53 Second 35 17 52 12 63 Middle 34 6 41 6 47 Fourth 23 8 31 7 37 Highest 14 10 24 6 30 1 Computed as the difference between the infant and neonatal mortality rates 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 52 87 133 48 82 116 42 66 94 41 65 88 37 52 65 32 43 53 28 38 46 Neonatal mortality Infant mortality Under-5 mortality Deaths per 1,000 live births BDHS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 104 • Infant and Child Mortality Table 8.3 shows that urban-rural differences in early childhood mortality favor urban children who have a lower probability of dying at any stage of early childhood than rural children. Under-5 mortality in urban areas is 37 per 1,000 live births, 24 percent lower than in rural areas (49 per 1,000). Between 2011 and 2014, mortality rates among children under age 5 have declined faster in urban areas than in rural areas. For example, the infant mortality rate has declined 21 percent in urban areas and 7 percent in rural areas (NIPORT et al. 2013), increasing the urban-rural gap in childhood mortality rates from 5 to 12 deaths per 1,000 live births. The 2014 BDHS data show wide variations in estimates of childhood mortality by division. In general, Sylhet has the highest rates and Barisal has the lowest rates. For instance, the under-5 mortality rate is 67 deaths per 1,000 births in Sylhet and 35 deaths per 1,000 births in Barisal. The infant mortality rate is 55 deaths per 1,000 live births in Sylhet and 26 deaths per 1,000 live births in Barisal. The child mortality rate, however, is highest in Chittagong (14 deaths per 1,000 births). Mother’s level of education is inversely related to her child’s risk of dying. Higher levels of educational attainment are generally associated with lower mortality risks because education exposes mothers to information about better nutrition, use of contraception to limit and space births, health care during pregnancy, and childhood illness, vaccinations, and treatments. The 2014 BDHS shows that children born to women who never attended school are almost twice as likely to die by the fifth birthday compared with children born to mothers with a secondary complete or higher education (50 and 27 deaths per 1,000 live births, respectively). Figure 8.2 Under-5 mortality rates by socioeconomic characteristics Similarly, a child’s risk of dying is associated with the economic status of the household. All childhood mortality rates, except the postneonatal mortality rate, are lowest for births to mothers in the highest wealth quintile. For instance, for mothers in the highest wealth quintile, the risk of a child dying by age 5 is 30 deaths per 1,000 live births. This compares with 53 deaths per 1,000 live births to mothers in the lowest quintile. For all childhood mortality, the rates are highest among children in the second wealth quintile. 8.4 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY This section examines the pattern of mortality rates by demographic variables, which correlate with levels of infant and child death. Table 8.4 and Figure 8.3 show the relationship between early childhood mortality and selected demographic variables, including the sex of the child, mother’s age at birth, birth order, length of previous birth intervals, and mother’s perception concerning the size of the child at birth. 37 49 35 50 41 56 43 39 67 50 52 45 49 27 53 63 47 37 30 RESIDENCE Urban Rural DIVISION Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet MOTHER'S EDUCATION No education Primary incomplete Primary complete Secondary incomplete Secondary complete or higher WEALTH QUINTILE Lowest Second Middle Fourth Highest Deaths per 1,000 live births Note: Rates are for the 5-year period preceding the survey. Infant and Child Mortality • 105 Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, infant, child, and under-5 mortality rates for the 5-year period preceding the survey, by demographic characteristics, Bangladesh 2014 Demographic characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 31 6 37 8 44 Female 26 14 39 9 48 Mother’s age at birth <20 31 11 42 6 48 20-29 27 8 34 8 42 30-39 28 13 40 15 55 40-49 * * (96) * (99) Birth order 1 33 10 43 7 50 2-3 25 10 35 7 41 4-6 24 11 34 16 50 7+ * (3) 40 4 44 Previous birth interval2 <2 years 22 8 30 16 46 2 years 27 10 36 14 50 3 years 24 9 33 4 37 4+ years 26 10 36 6 43 Birth size3 Small/very small 34 11 46 na na Average or larger 27 9 37 na na Notes: Figures in parentheses have 250-499 years of exposure for that group. An asterisk indicates that the exposure years for the group are fewer than 250. na = Not available 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births 3 Rates for the five-year period before the survey As expected, neonatal mortality is higher among boys than girls (31 deaths and 26 deaths per 1,000 live births, respectively) as by nature from the time of conception, boy babies are more vulnerable than girl babies. All other mortality rates, except neonatal mortality, are higher for girls than for boys. With the exception of the 2004 and 2007 BDHS, all BDHS surveys reported both higher postneonatal and child mortality for girls than for boys—a pattern that has been observed in other countries of South Asia where strong son preference is thought to result in relative nutritional and medical neglect of girl children (Das Gupta 1987; Basu 1989). The 2014 BDHS indicates that under-5 mortality is 9 percent higher in girls than boys (48 deaths and 44 deaths per 1,000 live births respectively). 106 • Infant and Child Mortality Figure 8.3 Under-5 mortality rates by demographic characteristics The relationship between mother’s age at birth and childhood mortality rates exhibits a U-shaped pattern—children of both the youngest and the oldest mothers experience the highest mortality risks. The 2014 BDHS shows a similar pattern for all mortality estimates except for child mortality rates. Neonatal and infant mortality rates also have a U-shaped relationship with birth order. The effect of older maternal age at birth on mortality is evident in Table 8.4. There is no clear relationship between birth order and childhood mortality. It seems to show a U- shaped pattern. But the relationship of birth order and child mortality shows an inverted U pattern; 16 deaths per 1,000 live births among children in the birth order category of 4-6 births and 4-7 deaths per 1,000 live births among other order births. The length of the previous birth interval is associated with mortality levels. Retherford and others (1989) observed increased mortality among births taking place fewer than two years after a previous birth, even after controlling for other demographic and socioeconomic variables. As shown in Table 8.4, all childhood mortality rates are lower at birth intervals of two years or more. The child mortality rate among children born fewer than two years after a previous birth is 16 deaths per 1,000 live births compared with 6 deaths among children born after an interval of four or more years. Studies have shown that children’s birth weight is an important determinant of their survival (UNICEF and WHO, 2004). Data on birth weight are not available in the 2014 BDHS. However, mothers in the 2014 BDHS were asked whether, according to their perception, their child was very large, larger than average, average, smaller than average, or very small at birth. This perception has been found to be a good proxy for a child’s weight. For example, infant mortality for children considered by their mothers to be small or very small is 46 deaths per 1,000 live births compared with 37 deaths per 1,000 live births for children regarded as average or larger size at birth. This gap appears to be due to higher infant mortality among small/very small children than among babies of average or larger size. 8.5 PERINATAL MORTALITY Perinatal deaths are those caused by pregnancy losses occurring after seven completed months of gestation (stillbirths) and those deaths within the first seven days of life (early neonatal deaths). The perinatal mortality rate is calculated by dividing the total number of perinatal deaths by the total number of pregnancies reaching seven months of gestation. The distinction between a stillbirth and an early neonatal 44 48 48 42 55 99 50 41 50 44 46 50 37 43 CHILD'S SEX Male Female MOTHER'S AGE AT BIRTH <20 20-29 30-39 40-49 BIRTH ORDER 1 2-3 4-6 7+ PREVIOUS BIRTH INTERVAL <2 years 2 years 3 years 4+ years Deaths per 1,000 live births Note: Rates are for the 5-year period preceding the survey. Previous birth interval excludes first-order births. a based on fewer than 500 unweighted cases a Infant and Child Mortality • 107 death is a delicate one, often depending on the observed presence or absence of some signs of life after delivery. The causes of stillbirths and early neonatal deaths overlap, and examining just one or the other can understate the true level of mortality around delivery. For these reasons, it is suggested that both events be combined and examined together. In the 2014 BDHS, information on stillbirths is available for the five years preceding the survey and is collected using the calendar at the end of the Woman’s Questionnaire. Table 8.5 Perinatal mortality Number of stillbirths and early neonatal deaths, and the perinatal mortality rate for the five-year period preceding the survey, by background characteristics, Bangladesh 2014 Background characteristic Number of stillbirths1 Number of early neonatal deaths2 Perinatal mortality rate3 Number of pregnancies of 7+ months duration Mother’s age at birth <20 50 65 44 2,621 20-29 93 94 41 4,511 30-39 30 24 51 1,066 40-49 4 1 71 71 Previous pregnancy interval in months4 First pregnancy 77 73 51 2,949 <15 25 14 50 770 15-26 11 25 45 802 27-38 9 10 25 788 39+ 55 61 39 2,960 Residence Urban 39 33 35 2,095 Rural 138 150 47 6,174 Division Barisal 8 10 38 465 Chittagong 35 33 38 1,783 Dhaka 59 58 41 2,891 Khulna 12 21 53 623 Rajshahi 18 20 45 848 Rangpur 14 19 41 811 Sylhet 30 23 63 848 Mother’s education No education 37 27 47 1,365 Primary incomplete 32 35 49 1,361 Primary complete5 33 18 53 968 Secondary incomplete 53 89 43 3,304 Secondary complete or higher6 22 14 29 1,271 Wealth quintile Lowest 45 49 50 1,883 Second 47 41 55 1,597 Middle 38 45 52 1,604 Fourth 24 30 33 1,626 Highest 23 18 26 1,559 Total 177 183 44 8,269 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0-6 days among live-born children. 3 The sum of the number of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1,000. 4 Categories correspond to birth intervals of <24 months, 24-35 months, 36-47 months, and 48+ months. 5 Primary complete is defined as completing grade 5. 6 Secondary complete is defined as completing grade 10. Table 8.5 presents the number of stillbirths, early neonatal deaths, and the perinatal mortality rate for the five-year period prior to the 2014 BDHS by selected background characteristics. The perinatal mortality rate in Bangladesh is 44 deaths per 1,000 pregnancies. Perinatal mortality is higher among mothers age 30 or older. Perinatal mortality in rural areas is 34 percent higher than in urban areas (47 and 35 per 1,000 pregnancies in rural and urban areas, respectively). Among divisions, Sylhet has the highest perinatal mortality rate. Perinatal mortality is highest in first pregnancy (51 deaths per 1,000 pregnancies). Overall, perinatal mortality has a negative association with the mother’s education and wealth status; that is, it is lowest for women who have completed secondary or higher education and for women in the highest wealth quintile. 108 • Infant and Child Mortality 8.6 HIGH-RISK FERTILITY BEHAVIOR Numerous studies have found a strong relationship between maternal fertility patterns and children’s survival risks. Typically, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short birth interval, or if they are born to mothers with high parity. Very young mothers may experience difficult pregnancies and deliveries because of their physical immaturity. To the contrary, older women may also experience age-related problems during pregnancy and delivery. For this analysis, a mother is classified as ‘too young’ if she is less than 18 and ‘too old’ if she is over age 34 at the time of delivery. A ‘short birth interval’ is defined as a birth occurring within 24 months of a previous birth. A child is of ‘high birth order’ if the mother had previously given birth to three or more children (i.e., the child is of birth order four or higher). Short succeeding birth intervals are not included, even though they can influence the survivorship of a child, because of the problem of reverse causal effect (i.e., a short succeeding birth interval can be the result of the death of a child rather than being the cause of the death of a child). A birth may have from zero to three high-risk characteristics. All risk categories are potentially avoidable except for first order births to mothers age 18-34. Table 8.6 High-risk fertility behavior Percent distribution of children born in the five years preceding the survey by category of elevated risk of mortality and the risk ratio, and percent distribution of currently married women by category of risk if they were to conceive a child at the time of the survey, Bangladesh 2014 Births in the 5 years preceding the survey Percentage of currently married women1 Risk category Percentage of births Risk ratio Not in any high risk category 39.1 1.00 35.3 Unavoidable risk category First order births between ages 18 and 34 years 24.4 1.07 7.1 Single high-risk category Mother’s age <18 15.3 1.14 2.4 Mother’s age >34 1.0 1.70 8.7 Birth interval <24 months 4.2 1.19 7.5 Birth order >3 10.7 1.07 11.7 Subtotal 31.3 1.14 30.3 Multiple high-risk category Age <18 and birth interval <24 months2 0.9 0.40 0.9 Age >34 and birth interval <24 months 0.0 * 0.1 Age >34 and birth order >3 2.6 1.11 23.2 Age >34 and birth interval <24 months and birth order >3 0.2 * 0.5 Birth interval <24 months and birth order >3 1.7 1.00 2.6 Subtotal 5.3 0.96 27.3 In any avoidable high-risk category 36.6 1.12 57.6 Total 100.0 na 100.0 Number of births/women 8,092 na 16,858 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that the exposure years for the group are fewer than 250. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 Table 8.6 shows the percent distribution of births in the five-year period before the survey and of currently married women at the time of the survey according to these elevated risk factors. The table also examines the relative risk of dying for children by comparing the proportion dead in each specified high- risk category with the proportion dead among children not in any high-risk category. First births, although often at increased risk, are included in the ‘not in any high-risk’ category in this analysis, because they are Infant and Child Mortality • 109 not considered an avoidable risk. The purpose of this table is to identify areas in which changes in reproductive behavior would be likely to reduce infant and child mortality. Mortality risk is represented by the proportion of children born during the five years preceding the survey who had died by the time of the survey. Among children born in the five years preceding the survey, 39 percent are not in any high-risk category, and 37 percent are in an avoidable high-risk category. Of those avoidable, 31 percent are in a single high-risk category, and 5 percent are in a multiple high-risk category. Births to women between ages 18 and 34 (24 percent) fall in the category of unavoidable risk. In the single risk category, 15 percent of births are associated with the mother’s young age (younger than 18 years) and 11 percent are a birth order of three or higher. Risk ratios, which describe the relationship between a particular risk category and a reference category, are used to compare mortality by risk category. A child who falls into any of the elevated mortality risk categories is 1.12 times more likely to die than a child who does not fall in any high-risk category. If the risk categories are viewed separately, children’s risk of dying is 1.7 times higher if the mother’s age is more than 34 years at the time of birth. The risk of dying is 1.19 times higher if the child is born within two years of a previous birth. However, only 4 percent of the births fall in this category. Children are 1.11 times more likely to die when their mother’s age at birth is over 34 years and the birth order is more than three. The last column in Table 8.6 presents the distribution of currently married women by category of increased risk if they were to conceive at the time of the survey. Although many women are protected from pregnancy due to use of family planning, postpartum insusceptibility, and prolonged abstinence, for the sake of simplicity, only those who have been sterilized are included in the ‘not in any high-risk’ category. The criteria for placing women into specific risk categories are adjusted to take into account the gestation time for an additional birth. The 2014 BDHS results indicate that 58 percent of currently married women in Bangladesh who have given birth in the five years preceding the survey have the potential of giving birth to a child who is in an avoidable high-risk category of mortality. Thirty percent are in a single high-risk category, and 27 percent have the potential for having a birth in a multiple high-risk category. Thirty-five percent of the women are not at any elevated risk of mortality. Maternal and Newborn Health • 111 MATERNAL AND NEWBORN HEALTH 9 health care system striving to reduce morbidity and mortality related to pregnancy must focus on maternal and newborn health. The health care that a woman receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and the child. The government of Bangladesh is committed to achieving the target for Millennium Development Goal (MDG) 4 and MDG 5. The BMMS 2010 (NIPORT et al., 2011) indicated a substantial reduction in the maternal mortality ratio (MMR), an annual rate of decrease of 5.6 percent. The MMR fell from 322 deaths per 100,000 live births (or between 253 and 391 at 95 percent confidence interval [CI]) in 1998-2001 to 194 deaths per 100,000 live births (149 to 238 at 95 percent CI) in 2007-2010, indicating a degree of success in the health sector. Moreover, Bangladesh has set targets to achieve the goal of the Health, Population and Nutrition Sector Development Program (HPNSDP) to reduce MMR to less than 143 deaths per 100,000 live births and to reduce the under-five mortality rate from 146 deaths per 1,000 live births in 1990 to 48 deaths per 1,000 live births by 2016. The Ministry of Health and Family Welfare (MOHFW) has A Key Findings • Sixty-four percent of women who gave birth in the three years preceding the survey received antenatal care from a medically trained provider, up from 55 percent in 2011. This increase is mainly due to an increase in ANC from a qualified doctor. • Thirty-one percent of women have four or more antenatal care visits during the course of pregnancy, an improvement from about one in every four (26 percent) in 2011. • Forty-two percent of births in the past three years were assisted by a medically trained provider. The percentage of births attended by a skilled provider has increased 2.6 times since 2004 due to the increase in deliveries at medical facilities. The national health sector program aims to have 50 percent of all deliveries made by a skilled birth attendant. • Thirty-seven percent of births in the past three years were delivered in a health facility. • Bangladesh aims to reduce inequity in the use of maternal health services. In 2014,15 percent of deliveries among women in the lowest wealth quintile occurred in a facility compared with 70 percent of deliveries among women in the highest wealth quintile. • Twenty-three percent of all births were delivered by C-section. Among births delivered in a health facility, 61 percent were delivered by C- section. • In the three years before the survey, 36 percent of women received postnatal care for their last birth from a medically trained provider within two days of their delivery, up from 27 percent in 2011. • Newborn care practices have improved considerably since 2007 in Bangladesh. Among non-institutional births in the three years preceding the survey, the use of boiled instruments to cut the umbilical cord has increased from 62 percent in 2007 to 83 percent in 2014. The practice of drying within five minutes of birth has also increased from 6 percent in 2007 to 67 percent in 2014. The practice of waiting at least 72 hours after birth to bathe the newborn is more common in 2014 than it was in 2007, having increased from 17 percent to 34 percent. 112 • Maternal and Newborn Health developed various policies and strategies to improve maternal and newborn health. With a strong emphasis on improving access and equity in the use of essential maternal and neonatal services, the MOHFW is implementing the program through two operational plans of HPNSDP under the Directorate General of Health Services and the Directorate General of Family Planning (MOHFW 2011). This chapter provides information from the 2014 BDHS on several aspects of maternal and newborn health, including antenatal care, delivery, postnatal care, and newborn care. In the 2014 BDHS, women who had given birth in the three years preceding the survey were asked a number of questions about maternal and child health care. For the last live birth in that period, mothers were asked whether they had received antenatal care during pregnancy and whether they had sought postnatal care for themselves and their children. Information was also collected on the place of delivery and on attendance at birth for all births in the three years preceding the survey. In addition, questions on newborn care, including cord cutting, drying, and bathing of the newborn following birth, were asked about the most recent live birth in the three years preceding the survey. Tables in this chapter present findings from the most recent pregnancies and births in the three years preceding the survey. To allow for comparison with data from previous surveys, data from the 2004, 2007, and 2011 BDHS reports have been re-tabulated to include births in the three years preceding the surveys. This information will assist planners and other collaborators in the health sector to formulate appropriate strategies and interventions to provide good-quality health services and a series of well-timed interventions that should further improve maternal and newborn health. 9.1 ANTENATAL CARE Antenatal care (ANC) from a medically trained provider is important to monitor the status of a pregnancy, identify the complications associated with the pregnancy, and prevent adverse pregnancy outcomes. To be most effective, there should be regular ANC throughout pregnancy. Information on ANC was assessed for women who gave birth in the three years preceding the survey. Among women with two or more live births during the three-year period, data refer to the most recent live birth only. 9.1.1 Antenatal Care Coverage Table 9.1 shows the percent distribution of mothers with a live birth, by source of antenatal care received during pregnancy. Women were asked to report on all persons they saw for ANC for their last birth. However, if a woman saw more than one provider, only the provider with the highest qualifications was considered in the tabulation of results. Seventy-eight percent of women with a birth in the three years preceding the survey received antenatal care at least once from a provider. About two-thirds of women (64 percent) received ANC from a medically trained provider, that is, a qualified doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendant (CSBA), or sub-assistant community medical officer (SACMO). Younger women, women with a lower birth order, and women who live in urban areas are more likely to receive ANC from a trained provider compared with other women. Women in Khulna are most likely to receive ANC from a medically trained provider (74 percent), while women in Sylhet are least likely (53 percent). The likelihood of receiving ANC from a medically trained provider increases with women’s education level and wealth status. For example, coverage of ANC from a trained provider ranges from 36 percent for women in the lowest wealth quintile to 90 percent for women in the highest quintile. In the last three years, the huge gap in use of ANC from a trained provider between the richest and the poorest women has declined only slightly, from 57 percentage points in 2011 to 54 percentage points in 2014 (NIPORT et al. 2013). Maternal and Newborn Health • 113 Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the three years preceding the survey, by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving ANC from a skilled provider for the most recent birth, according to background characteristics, Bangladesh 2014 Medically trained provider CHCP HA/ FWA Trained birth atten- dant Un- trained birth atten- dant Un- quali- fied pro- vider NGO worker Other No one Total Any ANC ANC from medi- cally trained provider1 Number of women Background characteristic Quali- fied doctor Nurse/ midwife/ para- medic FWV CSBA MA/ SACMO Mother’s age at birth <20 57.5 4.1 2.5 0.1 0.1 1.1 3.9 0.2 0.0 0.7 9.9 0.2 19.6 100.0 80.2 64.4 1,472 20-34 58.3 3.0 2.4 0.2 0.1 1.4 5.0 0.1 0.0 0.8 6.7 0.1 21.8 100.0 78.0 64.0 2,971 35-49 52.5 2.0 1.9 0.6 0.0 1.0 8.2 0.0 0.2 0.4 3.9 0.0 29.3 100.0 70.7 57.0 184 Birth order 1 64.9 4.0 2.0 0.0 0.1 1.0 3.9 0.1 0.0 0.7 7.8 0.1 15.3 100.0 84.5 71.0 1,857 2-3 56.7 3.1 2.9 0.2 0.1 1.8 5.3 0.1 0.0 0.7 7.5 0.2 21.3 100.0 78.5 63.0 2,133 4-5 45.6 2.7 2.3 0.2 0.3 0.6 5.0 0.0 0.1 1.3 7.9 0.0 34.2 100.0 65.8 51.0 484 6+ 27.4 1.3 0.4 0.7 0.0 1.1 6.3 0.0 0.0 0.8 5.8 0.0 56.2 100.0 43.8 29.8 154 Residence Urban 74.0 3.3 1.6 0.0 0.0 0.6 3.5 0.1 0.0 0.5 5.9 0.2 10.5 100.0 89.3 78.8 1,209 Rural 52.1 3.4 2.7 0.2 0.2 1.6 5.2 0.1 0.0 0.9 8.2 0.1 25.3 100.0 74.6 58.6 3,418 Division Barisal 50.6 2.7 3.9 0.4 0.5 2.2 8.1 0.0 0.0 1.0 3.6 0.3 26.8 100.0 72.8 58.0 268 Chittagong 60.1 4.0 2.1 0.0 0.0 1.3 2.4 0.1 0.0 1.1 3.3 0.2 25.4 100.0 74.4 66.3 1,011 Dhaka 61.0 2.1 1.1 0.1 0.0 0.8 5.9 0.0 0.0 0.7 12.2 0.0 16.1 100.0 83.9 64.3 1,634 Khulna 67.1 3.2 3.4 0.0 0.3 2.3 5.5 0.2 0.0 0.4 5.8 0.6 11.3 100.0 88.1 73.9 371 Rajshahi 55.0 5.0 3.5 0.4 0.0 1.1 6.2 0.2 0.0 0.6 3.5 0.3 24.2 100.0 75.5 63.9 464 Rangpur 51.9 5.5 4.6 0.0 0.4 2.5 3.5 0.2 0.0 0.0 12.7 0.0 18.7 100.0 81.3 62.4 450 Sylhet 46.6 3.0 2.5 0.6 0.4 0.7 2.9 0.3 0.1 1.6 3.8 0.1 37.5 100.0 62.4 53.1 428 Educational attainment No education 33.8 3.0 1.9 0.3 0.1 1.1 8.7 0.1 0.0 0.7 7.3 0.1 42.9 100.0 57.0 39.0 655 Primary incomplete 41.5 3.9 2.9 0.4 0.2 1.2 6.5 0.1 0.0 1.0 9.2 0.3 32.9 100.0 66.9 48.8 749 Primary complete2 48.9 3.7 2.8 0.0 0.1 1.1 4.4 0.1 0.0 0.9 10.8 0.0 27.2 100.0 72.8 55.4 544 Secondary incomplete 64.6 3.0 2.5 0.1 0.1 1.8 3.7 0.1 0.0 0.9 8.6 0.2 14.5 100.0 85.3 70.2 1,892 Secondary complete or higher3 83.6 3.7 2.0 0.1 0.0 0.5 2.6 0.1 0.0 0.2 1.9 0.1 5.3 100.0 94.6 89.4 787 Wealth quintile Lowest 28.7 3.0 3.7 0.0 0.2 1.1 8.6 0.1 0.0 1.0 11.0 0.1 42.5 100.0 57.4 35.6 1,003 Second 48.5 3.8 3.3 0.1 0.2 1.4 4.9 0.1 0.0 0.6 7.0 0.2 29.8 100.0 69.9 55.9 876 Middle 58.1 3.4 2.6 0.4 0.2 2.7 4.0 0.2 0.0 0.7 9.2 0.1 18.6 100.0 81.4 64.6 882 Fourth 69.3 3.9 1.6 0.3 0.1 1.2 3.5 0.1 0.0 1.5 8.2 0.0 10.3 100.0 89.7 75.2 955 Highest 86.7 2.6 0.7 0.0 0.0 0.3 2.4 0.0 0.0 0.1 2.3 0.3 4.5 100.0 95.2 90.0 912 Total 57.9 3.3 2.4 0.2 0.1 1.3 4.7 0.1 0.0 0.8 7.6 0.1 21.4 100.0 78.4 63.9 4,627 Note: If more than one source of antenatal care was mentioned, only the provider with the highest qualifications is considered in this tabulation. FWV = family welfare visitor, CSBA = community skilled birth assistant, SACMO = sub-assistant community medical officer, HA = health assistant, FWA = family welfare assistant, CHCP = community health care provider 1 Medically trained providers include: qualified doctor, nurse/midwife/paramedic, FWV, CSBA, and SACMO 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Figure 9.1 shows that coverage of antenatal care for births in the three years preceding the surveys has increased substantially from 58 percent in 2004 to 78 percent in 2014. During the same period, ANC from a medically trained provider increased from 51 percent to 64 percent. Between 2011 and 2014, ANC from any provider increased by 10 percentage points, from 68 percent to 78 percent, and ANC from a medically trained provider increased by 9 percentage points, from 55 to 64 percent. The sharp increase in ANC in the three years between BDHS 2011 and BDHS 2014 is mostly due to an increase in ANC from medically trained providers, mainly qualified doctors, whose role in ANC increased from 43 percent in 2011 to 58 percent in 2014. This is a positive trend because there has been a concern that between 2004 and 2011 ANC from a medically trained provider had changed very little (4 percentage points, from 51 percent to 55 percent). 114 • Maternal and Newborn Health Figure 9.1 Trend in use of antenatal care, 2004-2014 9.1.2 Place of Antenatal Care The place where a woman receives antenatal care influences the frequency and quality of care received. Information on the source of ANC also assists policymakers with decisions on how to allocate resources. Table 9.2 shows the percentage of women with a live birth in the three years preceding the survey who received ANC for the most recent birth, according to the place where they received that care. Because women may visit more than one type of facility for ANC during the same pregnancy, the categories are not mutually exclusive and do not sum to 100 percent. The private sector is the leading source for ANC (52 percent), followed by the public sector (36 percent), and the nongovernmental organizations (NGO) sector (11 percent). Sixteen percent of women received ANC at home. The place where a woman receives antenatal care does not vary much by age. In contrast, women with fewer than four live births (i.e., birth order of 1 to 3), women in urban areas, women who have completed secondary or higher education, and women in the highest wealth quintile are more likely to receive ANC from the private sector. For example, 69 percent of women who completed secondary or higher education received ANC from the private sector compared with 38 percent of women with no education. Women in the lower two wealth quintiles are more likely to seek ANC from the public sector than from the private sector. 51 53 55 64 7 10 13 14 58 63 68 78 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent Medically untrained providers only Medically trained providers Maternal and Newborn Health • 115 Table 9.2 Place of antenatal care Among women age 15-49 who had a live birth in the three years preceding the survey, the percentage who received antenatal care (ANC) during the pregnancy of the most recent birth by place of ANC care, according to background characteristics, Bangladesh 2014 Place of antenatal care Number of women Background characteristic Home Public sector Private sector NGO sector Other Mother’s age at birth <20 18.1 37.6 48.2 11.6 0.5 1,183 20-34 15.3 35.5 53.6 11.5 0.5 2,322 35-49 14.4 37.0 53.1 6.6 0.0 130 Birth order 1 14.7 35.1 54.4 11.8 0.5 1,572 2-3 16.2 37.4 50.8 11.7 0.5 1,678 4-5 20.8 37.0 46.4 8.7 0.0 318 6+ 31.3 32.1 42.3 5.1 0.0 67 Residence Urban 10.4 31.6 56.5 14.9 0.3 1,083 Rural 18.7 38.2 49.8 9.8 0.5 2,553 Division Barisal 14.1 49.3 38.9 7.5 0.0 196 Chittagong 7.6 35.2 58.8 10.0 0.7 754 Dhaka 19.3 26.3 57.3 13.8 0.2 1,371 Khulna 18.7 47.0 44.0 11.8 1.6 329 Rajshahi 17.6 43.7 50.1 5.0 0.4 352 Rangpur 22.8 53.6 33.1 11.3 0.4 366 Sylhet 12.1 33.6 50.7 13.6 0.2 267 Educational attainment No education 24.7 38.0 38.0 13.9 0.3 374 Primary incomplete 23.9 40.9 37.0 10.7 1.1 503 Primary complete1 18.2 37.4 45.8 17.2 0.0 396 Secondary incomplete 14.9 37.0 53.3 11.0 0.4 1,618 Secondary complete or higher2 8.6 29.9 68.7 8.2 0.4 745 Wealth quintile Lowest 30.0 41.3 33.0 7.9 0.2 577 Second 21.9 44.0 43.1 9.6 0.7 614 Middle 15.1 41.3 45.8 13.0 0.1 718 Fourth 13.1 35.6 56.0 13.8 0.8 856 Highest 7.1 23.9 71.2 11.1 0.4 870 Total 16.2 36.2 51.8 11.3 0.4 3,635 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Comparable data from the 2011 and 2014 BDHS surveys show a decrease in the proportion of women who received ANC from the public sector (from 41 percent in 2011 to 36 percent in 2014) and an increase of 9 and 2 percentage points in the private and NGO sector, respectively (Figure 9.2). 116 • Maternal and Newborn Health Figure 9.2 Trend in place of antenatal care, 2011-2014 9.1.3 Number of Antenatal Visits Under normal circumstances, the World Health Organization (WHO) recommends that a pregnant woman should have at least four antenatal care visits (WHO 2007). Table 9.3 presents information on the number of antenatal visits for the most recent live birth in the three years preceding the survey. Thirty-one percent of women with a live birth in the three years before the survey made four or more ANC visits during their pregnancy. Urban women were more likely than rural women to have made four or more antenatal visits (46 percent compared with 26 percent). For urban women this percentage has hardly changed between 2011 and 2014 (from 45 to 46 percent), while in rural areas the percentage of women who made four or more antenatal care visits increased from 20 percent to 26 percent between surveys. The HPNSDP results framework sets a target of 50 percent of pregnant women making at least four antenatal care visits to be achieved by 2016 (MOHFW 2011). Data from the 2014 BDHS show that Bangladesh lags far behind in reaching this target. A comparison of the 2014 BDHS with the 2004, 2007, and 2011 BDHS surveys shows that the percentage of women who had no ANC visit has declined from 42 percent in 2004 to 21 percent in 2014. At the same time, the percentage of pregnant women who made four or more antenatal visits has increased, from 17 percent in 2004 to the current level of 31 percent (Figure 9.3). 16 41 43 9 16 36 52 11 Home Public sector Private sector NGO sector Percent 2011 BDHS 2014 BDHS Table 9.3 Number of antenatal care visits Percent distribution of women age 15-49 who had a live birth in the three years preceding the survey by number of antenatal care (ANC) visits for the most recent live birth, according to residence, Bangladesh 2014 Residence Total Number of ANC visits Urban Rural None 10.5 25.3 21.4 1 12.2 19.9 17.9 2 16.8 15.9 16.2 3 14.7 12.7 13.2 4 or more 45.5 26.1 31.2 Don’t know/missing 0.2 0.1 0.1 Median number of visits (for those with ANC) 4.1 3.1 3.4 Total 100.0 100.0 100.0 Number of women 1,209 3,418 4,627 Maternal and Newborn Health • 117 Figure 9.3 Trend in number of antenatal care visits, 2004-2014 9.1.4 Components of Antenatal Care The content of antenatal care is an essential component of ANC service quality. Focused ANC hinges on the principle that every pregnancy is at risk of complications. Therefore, apart from receiving basic care, every pregnant woman should be monitored for complications. Ensuring that pregnant women receive information and undergo screening for complications should be a routine part of all ANC visits. To assess ANC services, mothers in the 2014 BDHS were asked a number of questions about the care they received. These included measurement of weight and blood pressure, assessment of urine and blood samples and an ultrasonogram. In addition, women were asked if they had been informed of signs of pregnancy complications. The proportion of pregnant women who sought antenatal care and had their weight and blood pressure measured was found to be high (84 and 88 percent, respectively) (Table 9.4). Overall, 65 and 55 percent of women reported that they had urine and blood taken for testing, respectively. More than half (57 percent) of mothers who received ANC reported that they were informed about pregnancy complications during the ANC visit. Remarkably, an ultrasonogram was done on 71 percent of women. The quality of antenatal care was closely related to mother’s education, wealth, residence, and birth order. Women with a birth order of one, women who had completed secondary or higher education, and women in the highest wealth quintile were more likely to receive most of the services. For example, 93 percent of women with secondary or higher education had their weight measured compared with 78 percent of women with no education. Women in the lowest wealth quintile were less often provided information about pregnancy complications (48 percent) compared with women in the highest wealth quintile (64 percent). Urban women (62 percent) were more likely to be informed of signs of pregnancy complications compared with rural women (55 percent). The overall quality of antenatal care has improved since 2007. The percentage who had their urine samples taken, blood samples taken, and ultrasonogram performed increased by 10, 17, and 34 percentage points respectively. Also, the percentage of pregnant women who were informed of complications during pregnancy increased by 18 percentage points. In contrast, the percentage of pregnant women whose weight and blood pressure were measured has remained high and almost the same. Measuring weight and blood pressure are the most common components of ANC. 42 37 32 21 17 22 26 31 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent No ANC visits 4+ ANC visits 118 • Maternal and Newborn Health Table 9.4 Components of antenatal care Percentage of women age 15-49 with a live birth in the three years preceding the survey, for which mother received specific antenatal care services for the most recent birth, according to background characteristics, Bangladesh 2014 Among women who received antenatal care for their most recent birth in the past three years, the percentage with selected services Background characteristic Weighed Blood pressure measured Urine sample taken Blood sample taken Ultra- sonogram Informed of signs of pregnancy complications Number of women with ANC for their most recent birth Mother’s age at birth <20 83.2 88.3 62.8 53.0 69.5 57.0 1,183 20-34 84.2 88.3 66.5 56.0 71.6 57.1 2,322 35-49 84.2 85.3 48.0 43.1 68.8 53.6 130 Birth order 1 84.9 90.0 67.3 60.2 74.7 59.6 1,572 2-3 84.8 87.7 65.1 52.4 69.4 53.9 1,678 4-5 76.0 83.1 52.1 40.9 62.7 58.3 318 6+ 72.6 83.6 47.9 40.7 55.9 62.6 67 Residence Urban 88.9 92.8 74.2 65.6 78.6 62.3 1,083 Rural 81.7 86.3 60.6 49.9 67.5 54.6 2,553 Division Barisal 86.5 92.5 63.6 55.1 64.1 62.4 196 Chittagong 84.9 88.2 69.3 61.8 74.0 59.0 754 Dhaka 81.8 88.6 65.5 55.8 75.7 60.2 1,371 Khulna 90.3 88.3 61.5 55.4 73.6 48.8 329 Rajshahi 81.5 82.6 55.3 45.1 73.3 49.0 352 Rangpur 87.7 91.7 57.6 41.0 51.4 51.3 366 Sylhet 79.7 85.7 73.3 57.5 61.6 58.6 267 Education No education 78.3 81.1 50.1 33.4 49.3 55.9 374 Primary incomplete 78.6 85.2 52.2 38.1 53.2 52.5 503 Primary complete1 81.7 86.9 63.6 45.2 63.9 62.2 396 Secondary incomplete 83.1 88.2 64.8 56.4 74.6 55.0 1,618 Secondary complete or higher2 93.0 94.5 80.5 77.3 88.9 61.7 745 Wealth quintile Lowest 74.5 79.0 45.5 27.5 41.6 48.4 577 Second 81.2 85.1 54.1 42.5 62.1 54.2 614 Middle 81.1 87.8 60.4 46.4 71.2 56.1 718 Fourth 85.1 90.0 70.9 62.5 75.5 58.3 856 Highest 93.0 95.1 82.1 79.9 91.5 63.9 870 Total 83.9 88.2 64.6 54.6 70.8 56.9 3,635 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 9.2 DELIVERY CARE Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause death or serious illness for the mother or the newborn. Hence, it is important to increase the proportion of births delivered in a safe, clean environment and under the supervision of health professionals. The Bangladesh Maternal Health Strategy, which encourages women to deliver under the care of medically trained birth attendants, promotes safe motherhood through various activities, especially delivery by a skilled birth attendant (SBA). Women interviewed in the 2014 BDHS reported on the place and type of assistance during delivery of all children born in the three years before the survey. The tables presented in this report on delivery-related services are based on all live births in the three years preceding the survey. 9.2.1 Place of Delivery Table 9.5 presents the percent distribution of live births in the three years preceding the survey by place of delivery, according to background characteristics. Thirty-seven percent of births in the three years before the survey were delivered at a health facility. Overall, 22 percent of the births were delivered in a private facility, 13 percent were delivered in a public facility, and 2 percent in an NGO facility. Sixty-two percent of births were delivered at home. The likelihood of delivering in a health facility is lower for women Maternal and Newborn Health • 119 age 35 or older compared with younger women. Facility delivery decreases sharply as birth order increases. Women’s number of antenatal care visits, education level, and wealth status have a positive relationship with the likelihood of delivering in a health facility. Across divisions, Khulna has the highest proportion of births delivered at a health facility (55 percent), while Sylhet has the lowest (23 percent). Table 9.5 Place of delivery Percent distribution of live births in the three years preceding the survey by place of delivery, percentage delivered in a health facility, and percentage delivered by C-section, according to background characteristics, Bangladesh 2014 Health facility Home Other/ missing Total Percentage delivered in a health facility Percentage delivered by C-section Number of births Background characteristic Public sector Private sector NGO Birthing hut Mother’s age at birth <20 12.2 21.8 2.2 0.0 63.7 0.2 100.0 36.1 21.3 1,562 20-34 13.3 22.9 2.2 0.2 60.9 0.4 100.0 38.5 24.0 3,144 35-49 9.5 17.9 3.4 0.0 69.3 0.0 100.0 30.7 17.4 198 Birth order 1 14.5 29.7 2.3 0.0 53.2 0.3 100.0 46.4 29.7 1,990 2-3 13.1 20.4 2.1 0.2 63.9 0.4 100.0 35.6 21.3 2,247 4-5 8.1 8.5 2.6 0.3 80.4 0.0 100.0 19.3 9.1 502 6+ 3.3 3.2 2.5 0.0 91.0 0.0 100.0 9.0 3.7 166 Antenatal care visits1 None 5.4 5.2 0.3 0.0 89.1 0.1 100.0 10.8 4.5 992 1-3 13.8 21.7 2.1 0.2 62.0 0.1 100.0 37.7 22.1 2,187 4+ 17.1 37.2 4.1 0.2 41.1 0.3 100.0 58.4 41.1 1,442 Residence Urban 15.8 35.6 5.4 0.6 42.3 0.3 100.0 56.8 38.1 1,267 Rural 11.8 17.7 1.1 0.0 69.1 0.3 100.0 30.6 17.6 3,637 Division Barisal 10.9 17.2 1.8 0.0 69.0 1.1 100.0 29.9 17.7 279 Chittagong 11.9 20.0 3.3 0.3 64.4 0.1 100.0 35.2 18.3 1,074 Dhaka 11.4 27.0 2.1 0.2 59.1 0.1 100.0 40.5 29.1 1,740 Khulna 19.2 31.9 3.4 0.1 45.0 0.4 100.0 54.6 33.0 387 Rajshahi 15.3 22.9 0.9 0.0 60.7 0.2 100.0 39.2 22.3 488 Rangpur 16.5 16.1 1.7 0.0 65.3 0.3 100.0 34.3 17.5 461 Sylhet 9.9 11.3 1.4 0.0 76.6 0.8 100.0 22.6 10.9 474 Education No education 8.0 6.3 1.3 0.1 83.8 0.4 100.0 15.7 7.0 704 Primary incomplete 11.1 9.4 2.5 0.0 76.5 0.4 100.0 23.0 10.1 801 Primary complete2 12.5 15.5 1.7 0.1 69.6 0.6 100.0 29.6 13.8 579 Secondary incomplete 14.2 23.7 2.4 0.3 59.3 0.2 100.0 40.3 24.6 1,999 Secondary complete or higher3 15.5 50.3 2.7 0.0 31.3 0.2 100.0 68.6 51.2 821 Wealth quintile Lowest 8.4 6.1 0.4 0.0 84.8 0.3 100.0 14.9 6.7 1,084 Second 11.9 11.3 0.9 0.0 75.6 0.3 100.0 24.1 10.4 932 Middle 14.6 17.4 2.0 0.0 65.5 0.5 100.0 34.0 18.4 942 Fourth 15.1 27.6 3.5 0.0 53.6 0.1 100.0 46.3 29.2 995 Highest 14.6 51.1 4.5 0.8 28.8 0.3 100.0 70.2 51.4 950 Total 12.8 22.4 2.2 0.2 62.2 0.3 100.0 37.4 22.9 4,904 Note: Total include six births with missing information on number of antenatal care visits. 1 Includes only the most recent birth in the three years preceding the survey 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Although still low, the proportion of births delivered at health facilities has continued to increase from 12 percent in 2004 to 17 percent in 2007, 29 percent in 2011, and to the current level of 37 percent in 2014 (Figure 9.4) The increase since 2007 is mostly due to a sharp increase in delivery at private facilities (from 8 percent in 2007 to 15 percent in 2011 and to 22 percent in 2014), and to a less significant increase in deliveries in public facilities (from 8 percent in 2007 to 12 percent in 2011 and to 13 percent in 2014). 120 • Maternal and Newborn Health Figure 9.4 Trend in facility births, 2004-2014 Bangladesh has been making progress in reducing the gap between the poorest and the richest women in the use of facilities for delivery. In the 2014 BDHS, 15 percent of births to women in the lowest wealth quintile were delivered in a health facility compared with 70 percent of births in the highest wealth quintile (Figure 9.5). This translates to a ratio of about 1 to 5. In the effort to achieve equity in delivery in a health facility, the HPNSDP sets a ratio of less than 1 to 4 between women in the lowest and the highest quintiles (MOHFW 2011). The corresponding ratios in the 2007 BDHS and 2011 BDHS among births in the three years before the survey are 1 to 8 and 1 to 6, respectively. Figure 9.5 Health facility delivery by wealth quintile, 2011 and 2014 9.2.2 Caesarean Section Table 9.5 also shows the percentage of live births delivered by Caesarean section during the three years preceding the survey. The percentage of C-section births is sometimes considered to be a proxy indicator of women’s access to skilled care for complicated deliveries. In 2014, 23 percent of live births in 12 17 29 37 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent of deliveries in the past 3 years 10 1518 2424 34 39 46 60 70 2011 BDHS 2014 BDHS Percent of deliveries in the past 3 years Lowest Second Middle Fourth Highest Maternal and Newborn Health • 121 the three years preceding the survey were delivered by C-section, which implies that 6 in every 10 births in a health facility are delivered by C-section. Urban women are twice as likely as rural women to deliver by C-section (38 percent in urban areas and 18 percent in rural areas). Among women with secondary or higher education and women in the highest wealth quintile, half of births were delivered by C-section. The percentage of births delivered by C-section has been increasing over time, from 4 percent in 2004, to 9 percent in 2007, to 17 percent in 2011, and to the current level of 23 percent (Figure 9.6). Figure 9.6 Trend in births delivered by C-section, 2004-2014 Table 9.6 presents the percent distribution of women who gave birth in a health facility in the three years preceding the survey by duration of stay in the facility and type of delivery. Among women who gave birth by C-section, 97 percent stayed at the hospital for more than three days compared with 13 percent of women who had a vaginal birth. Among women who had a vaginal birth in a health facility, 38 percent were discharged less than 11 hours after delivery, and about 44 percent were discharged one to two days after delivery. Table 9.6 Length of stay in the health facility after delivery Among women with a birth in the three years preceding the survey who delivered their last birth in a health facility, the percent distribution by duration of stay in the health facility following their last live birth, according to type of delivery, Bangladesh 2014 Type of delivery <11 hours 12-23 hours 1-2 days 3+ days Missing Total Number of women Vaginal birth 38.4 4.1 44.4 12.7 0.4 100.0 656 Caesarean section 0.8 0.1 2.5 96.7 0.0 100.0 1,121 4 9 17 23 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent of deliveries in the past 3 years 122 • Maternal and Newborn Health The 2014 BDHS collected information on the reasons for which a doctor proposed to have the birth delivered by C-section. Table 9.7 shows the findings for the most recent live births in the three years preceding the survey. The most common reasons cited include mal-presentation of the baby (42 percent) and failure to progress in labor (21 percent). 9.2.3 Assistance during Delivery Obstetric care from a trained provider during delivery is critical for the reduction of maternal and neonatal mortality. Table 9.8 shows the percent distribution of all live births in the three years preceding the survey by type of assistance during delivery, according to background characteristics. Forty-two percent of births in Bangladesh were attended by medically trained personnel, that is, a qualified doctor, nurse, midwife, family welfare visitor (FWV), or community skilled birth attendant (CSBA)1. Additionally, trained traditional birth attendants assisted in 10 percent of deliveries. However, more than one-third of births in Bangladesh were assisted by dais or untrained traditional birth attendants (37 percent), and 6 percent of deliveries were assisted by relatives and friends. 1 In Bangladesh, although medical assistants (MAs) and sub-assistant community medical officers (SACMOs) are considered medically trained providers for antenatal care and postnatal care, they are not considered medically trained providers for childbirth. Table 9.7 Reasons for C-section Percentage of most recent live births in the three years preceding the survey proposed by doctor for delivery by C-section by reasons for C- section, Bangladesh 2014 Reasons for C-section Percentage of births by C-section Avoid labor pain 3.2 Mal presentation 41.5 Premature baby 1.7 Cord prolapsed 2.6 Multiple births 0.2 Failure to progress in labor 21.1 Pre-eclampsia 2.9 Diabetes 0.5 Less pressure on baby’s brain 9.7 Convenience 5.8 Other complications 38.6 Number of births by C-section 627 Note: 274 births delivered by C-section had a previous birth by C-section and have not been included in the table. M at er na l a nd N ew bo rn H ea lth • 1 23 Ta ble 9. 8 As sis tan ce du rin g d eli ve ry Pe rce nt dis trib uti on of liv e b irth s i n t he th ree ye ars pr ec ed ing th e s urv ey b y p ers on pr ov idi ng as sis tan ce du rin g d eli ve ry, pe rce nta ge of bi rth as sis ted by a me dic all y t rai ne d p rov ide r, ac co rdi ng to ba ck gro un d ch ara cte ris tic s, Ba ng lad es h 2 01 4 Me dic all y t rai ne d p rov ide r CH CP HA /FW A NG O wo rke r Tr ain ed tra dit ion al bir th att en da nt Un - tra ine d tra dit ion al bir th att en da nt Un - qu ali fie d do cto r Re lat ive s/ frie nd s/ oth ers No on e Mi ss ing To tal Pe rce nta ge de liv ere d b y a m ed ica lly tra ine d pro vid er1 Nu mb er of bir ths Ba ck gro un d ch ara cte ris tic Qu ali fie d do cto r Nu rse / mi dw ife / pa ra- me dic FW V CS BA Mo th er ’s ag e a t b irt h <2 0 30 .0 11 .2 0.4 0.1 0.2 1.3 0.9 10 .2 37 .9 2.1 5.4 0.0 0.2 10 0.0 41 .8 1,5 62 20 -34 31 .7 10 .7 0.3 0.0 0.1 1.2 0.6 10 .1 36 .6 1.7 6.5 0.1 0.2 10 0.0 42 .8 3,1 44 35 -49 24 .8 7.3 0.0 0.0 0.0 0.4 0.0 10 .7 46 .1 0.0 10 .3 0.5 0.0 10 0.0 32 .0 19 8 Bi rth or de r 1 39 .7 11 .8 0.4 0.1 0.1 1.1 0.8 9.5 29 .8 2.0 4.5 0.0 0.2 10 0.0 52 .0 1,9 90 2-3 28 .9 10 .9 0.3 0.1 0.1 1.0 0.5 10 .6 38 .2 1.8 7.3 0.0 0.2 10 0.0 40 .2 2,2 47 4-5 13 .0 8.5 0.1 0.0 0.2 2.1 1.1 10 .8 55 .0 1.0 8.0 0.3 0.0 10 0.0 21 .5 50 2 6+ 6.8 3.2 0.0 0.0 0.0 1.4 0.0 10 .0 65 .9 1.2 9.6 1.9 0.0 10 0.0 10 .0 16 6 An ten ata l c ar e v isi ts1 No ne 8.0 6.2 0.2 0.1 0.0 0.6 0.4 9.2 63 .2 1.8 10 .4 0.2 0.0 10 0.0 14 .4 99 2 1-3 30 .3 11 .9 0.2 0.1 0.2 1.2 0.8 11 .3 35 .6 2.4 5.7 0.1 0.0 10 0.0 42 .6 2,1 87 4+ 50 .3 12 .3 0.5 0.0 0.1 1.7 0.9 8.3 21 .7 1.1 3.0 0.0 0.0 10 0.0 63 .2 1,4 42 Pl ac e o f d eli ve ry Pu bli c s ec to r 67 .5 29 .0 1.3 0.0 0.2 0.0 0.6 0.4 0.1 0.0 0.8 0.0 0.0 10 0.0 97 .9 62 8 Pr iva te se cto r 90 .8 9.1 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 10 0.0 99 .9 1,0 96 NG O se cto r 47 .5 36 .7 0.0 0.0 0.6 10 .2 0.0 4.7 0.0 0.0 0.3 0.0 0.0 10 0.0 84 .2 11 0 Ho me 1.2 6.7 0.2 0.1 0.2 1.4 0.9 16 .1 60 .2 2.9 9.9 0.1 0.1 10 0.0 8.2 3,0 48 Re sid en ce Ur ba n 48 .9 11 .2 0.4 0.0 0.0 1.9 0.7 6.7 25 .3 1.3 3.7 0.0 0.0 10 0.0 60 .5 1,2 67 Ru ral 24 .6 10 .6 0.3 0.1 0.2 0.9 0.7 11 .4 41 .7 2.0 7.2 0.1 0.3 10 0.0 35 .6 3,6 37 Di vis ion Ba ris al 24 .0 12 .1 0.2 0.3 0.2 0.3 0.2 12 .7 42 .7 2.3 3.8 0.2 0.8 10 0.0 36 .7 27 9 Ch itta go ng 28 .7 14 .5 0.6 0.0 0.1 0.7 0.6 6.7 41 .6 1.7 4.5 0.0 0.2 10 0.0 43 .9 1,0 74 Dh ak a 37 .1 6.2 0.0 0.1 0.2 1.0 0.6 10 .6 34 .6 1.4 8.0 0.1 0.0 10 0.0 43 .5 1,7 40 Kh uln a 42 .2 15 .8 0.2 0.0 0.0 1.3 0.6 8.9 24 .3 1.2 5.4 0.0 0.2 10 0.0 58 .2 38 7 Ra jsh ah i 29 .2 11 .5 0.7 0.2 0.0 0.0 0.5 6.4 44 .1 2.8 4.3 0.1 0.2 10 0.0 41 .6 48 8 Ra ng pu r 24 .7 12 .9 0.3 0.0 0.2 5.5 1.5 16 .8 29 .1 2.9 5.7 0.3 0.1 10 0.0 37 .9 46 1 Sy lhe t 15 .7 11 .1 0.3 0.1 0.0 0.2 0.9 13 .4 47 .2 1.4 8.9 0.0 0.7 10 0.0 27 .1 47 4 Ed uc ati on No ed uc ati on 10 .6 6.5 0.1 0.0 0.0 1.0 0.8 11 .5 57 .8 2.1 9.1 0.2 0.4 10 0.0 17 .1 70 4 Pr im ary in co mp let e 16 .1 10 .4 0.2 0.0 0.4 2.0 0.5 12 .3 48 .5 1.5 7.9 0.1 0.3 10 0.0 26 .6 80 1 Pr im ary co mp let e2 22 .2 10 .5 0.7 0.1 0.3 0.3 0.0 11 .5 45 .4 1.4 6.9 0.4 0.3 10 0.0 33 .5 57 9 Se co nd ary in co mp let e 33 .3 12 .4 0.2 0.1 0.1 1.2 0.9 9.9 33 .0 2.5 6.5 0.0 0.1 10 0.0 46 .0 1,9 99 Se co nd ary co mp let e or hig he r3 63 .2 11 .2 0.6 0.0 0.0 1.1 0.8 6.8 14 .4 0.4 1.4 0.0 0.1 10 0.0 75 .0 82 1 W ea lth qu int ile Lo we st 10 .9 6.8 0.2 0.0 0.0 1.1 0.7 13 .3 54 .6 2.5 9.5 0.1 0.4 10 0.0 17 .9 1,0 84 Se co nd 17 .9 11 .7 0.2 0.1 0.6 1.3 0.8 10 .7 47 .0 2.3 7.2 0.1 0.2 10 0.0 29 .9 93 2 Mi dd le 26 .3 12 .0 0.5 0.0 0.1 0.9 0.6 9.2 37 .7 2.3 9.8 0.2 0.3 10 0.0 38 .8 94 2 Fo urt h 38 .0 13 .3 0.4 0.2 0.0 1.2 0.6 11 .8 30 .0 1.3 3.1 0.0 0.1 10 0.0 52 .0 99 5 Hi gh es t 63 .7 10 .3 0.3 0.0 0.0 1.4 0.7 5.3 16 .0 0.5 1.6 0.0 0.0 10 0.0 74 .4 95 0 To tal 30 .9 10 .8 0.3 0.1 0.1 1.2 0.7 10 .2 37 .4 1.8 6.3 0.1 0.2 10 0.0 42 .1 4,9 04 No te: If the re sp on de nt me nti on ed m ore th an on e p ers on at ten din g d uri ng de liv ery , o nly th e m os t q ua lifi ed pe rso n i s c on sid ere d i n t his ta bu lat ion . T ota l in clu de s 6 bi rth s w ith m iss ing in for ma tio n o n A NC vi sit s an d 2 2 b irth s d eli ve red in a de liv ery hu t. FW V = f am ily w elf are vi sit or, C SB A = c om mu nit y s kil led bi rth at ten da nt, C HC P = c om mu nit y h ea lth ca re pro vid er, H A = h ea lth as sis tan t, F W A = f am ily w elf are as sis tan t 1 M ed ica lly tra ine d p rov ide r in clu de s d oc tor , n urs e, mi dw ife , p ara me dic , F W V, an d C SB A. 2 P rim ary co mp let e i s d efi ne d a s c om ple tin g g rad e 5 . 3 S ec on da ry co mp let e i s d efi ne d a s c om ple tin g g rad e 1 0. 124 • Maternal and Newborn Health First-order births are more likely to be assisted by a medically trained provider (52 percent). Medically assisted births are more common among women in urban areas (61 percent), women who have completed secondary or higher education (75 percent), and women in the highest wealth quintile (74 percent). Among divisions, Khulna has the highest proportion of births assisted by medically trained providers (58 percent), while Sylhet has the lowest (27 percent). The HPNSDP target for delivery by a medically trained provider is set at 50 percent by 2016 (MOHFW, 2011). Over the past 10 years, the proportion of deliveries by medically trained providers has increased 2.6 times, from 16 percent in 2004 to the current level of 42 percent (Figure 9.7). This is almost solely due to an increase in institutional delivery, given that the great majority of births delivered at home are delivered by unskilled individuals (92 percent in 2014) (Table 9.8). Figure 9.7 Trend in skilled attendance at deliveries, 2004-2014 9.3 POSTNATAL CARE FOR MOTHERS AND CHILDREN Postnatal care is a crucial component of safe motherhood and neonatal health. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their newborn infant. A large proportion of maternal and neonatal deaths occur during the 24 hours following delivery (UNICEF 2012). In addition, the first two days following delivery are critical for monitoring complications for both mothers and their newborns. To assess the extent to which mothers receive postnatal care, the 2014 BDHS asked the respondent whether she and her child had received a health checkup after the delivery, the timing of the first check, and the type of health provider for the last birth in the three years preceding the survey. 9.3.1 Postnatal Checkup for Mother The 2014 BDHS data show that 39 percent of mothers and 36 percent of children in Bangladesh received postnatal care from a medically trained provider within 42 days after delivery, the vast majority within the crucial first two days of delivery (36 percent of women and 32 percent of children) (Table 9.9). On the other hand, 61 percent of mothers and 64 percent of children did not receive a postnatal checkup from a medically trained provider. Occurrence of a postnatal checkup from a medically trained provider within two days of delivery has increased from 20 percent of mothers in 2007 to 27 percent in 2011 to the current level of 36 percent 16 21 32 42 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent of deliveries in the past 3 years Maternal and Newborn Health • 125 (Figure 9.8). This demonstrates that the revised target of HPNSDP 2011-2016 for postnatal checkup for mothers from a medically trained provider within two days of delivery (35 percent) has already been achieved in 2014. For children, a postnatal checkup from a medically trained provider within the first two days increased from 20 percent in 2007 to the current level of 32 percent. Table 9.9 Postnatal care for mothers and children Percent distribution of last births in the three years preceding the survey for which the mother and/or children received postnatal care from any provider and a medically trained provider1, by timing of postnatal care, Bangladesh 2014 Women Children Timing Any provider Medically trained provider1 Any provider Medically trained provider1 Within 2 days of delivery 59.1 36.4 54.3 31.5 3-6 days after delivery 2.5 1.3 2.2 1.2 7-41 days after delivery 1.9 1.1 5.5 3.3 Did not receive postnatal check up 35.8 60.6 37.5 63.5 Don’t know/missing 0.7 0.6 0.5 0.5 Total 100.0 100.0 100.0 100.0 Number 4,627 4,627 4,627 4,627 Note: Women and children who received a checkup after 41 days are assumed to have not received postnatal care. 1 Medically trained provider includes qualified doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendants (CSBA) and SACMO. Figure 9.8 Trend in use of postnatal care for women and children from a medically trained provider within two days of delivery, 2004-2014 Table 9.10 shows the percent distribution of women age 15-49 who give birth in the three years preceding the survey by time after delivery of the mother’s first postnatal check-up for the last live birth from a medically trained provider, according to background characteristics. Twenty-eight percent of women received a postnatal checkup within the first four hours after delivery, 4 percent received a checkup between 4 and 23 hours, and 5 percent were seen one to two days following delivery. 16 13 20 20 27 30 36 32 Mothers Newborn infants Percent 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS 126 • Maternal and Newborn Health Table 9.10 Timing of first postnatal checkup for the mother Percent distribution of women age 15-49 who give birth in the three years preceding the survey by time after delivery of the mother’s first postnatal check-up for the last live birth from a medically trained provider; and percentage of women age 15-49 with no postnatal checkup, according to background characteristics, Bangladesh 2014 Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Number of women Background characteristic Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 28.1 4.5 3.2 0.8 1.4 0.9 61.1 100.0 1,472 20-34 27.8 4.3 5.1 1.6 0.9 0.5 59.8 100.0 2,971 35-49 20.7 1.6 6.7 1.3 0.5 0.0 69.1 100.0 184 Birth order 1 34.4 5.7 5.1 1.2 1.6 0.9 51.1 100.0 1,857 2-3 25.9 3.7 4.8 1.7 0.9 0.5 62.5 100.0 2,133 4-5 15.6 2.3 2.6 0.4 0.3 0.0 78.8 100.0 484 6+ 7.5 0.2 1.1 0.0 0.0 0.0 91.2 100.0 154 Place of delivery Health facility 64.6 10.3 10.8 2.0 1.9 1.2 9.1 100.0 1,784 Elsewhere 4.4 0.4 0.6 0.9 0.5 0.2 92.9 100.0 2,841 Residence Urban 42.8 6.1 7.0 1.7 1.8 0.4 40.2 100.0 1,209 Rural 22.3 3.6 3.7 1.2 0.8 0.7 67.8 100.0 3,418 Division Barisal 25.5 3.8 5.0 1.1 0.9 0.1 63.6 100.0 268 Chittagong 27.7 4.0 4.6 1.4 0.9 0.3 61.0 100.0 1,011 Dhaka 27.9 4.1 4.7 1.5 1.1 0.9 59.7 100.0 1,634 Khulna 37.1 7.9 5.8 0.8 1.8 0.9 45.6 100.0 371 Rajshahi 29.6 5.0 5.1 1.4 1.4 1.0 56.6 100.0 464 Rangpur 28.4 3.1 2.5 2.0 0.5 0.2 63.4 100.0 450 Sylhet 16.9 2.7 3.8 0.4 1.1 0.0 75.1 100.0 428 Education No education 12.5 1.4 2.1 0.6 1.0 0.0 82.5 100.0 655 Primary incomplete 18.4 2.6 2.5 0.5 0.5 0.4 75.1 100.0 749 Primary complete2 22.3 1.7 2.5 0.6 0.5 0.9 71.6 100.0 544 Secondary incomplete 29.6 4.5 5.0 1.7 0.9 0.7 57.6 100.0 1,892 Secondary complete or higher3 48.1 9.3 8.8 2.3 2.6 1.0 27.9 100.0 787 Wealth quintile Lowest 11.1 1.4 2.6 0.7 0.6 0.5 83.1 100.0 1,003 Second 15.9 3.1 3.8 0.3 0.6 0.1 76.2 100.0 876 Middle 26.4 2.8 3.7 1.3 1.1 0.9 63.9 100.0 882 Fourth 34.0 6.2 3.8 1.8 1.0 0.5 52.9 100.0 955 Highest 51.7 7.7 9.1 2.6 2.2 1.1 25.7 100.0 912 Total 27.6 4.2 4.5 1.3 1.1 0.6 60.6 100.0 4,627 Note: Total includes 2 children with missing information on place of delivery. Medically trained provider includes qualified doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendants (CSBA), and MA/SACMO. 1 Includes women who received a checkup after 41 days and women who received a checkup from non-medically trained providers 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. The skill of the provider who performs the first postnatal checkup has important implications for maternal and neonatal health. Table 9.11 shows that among women who gave birth in the last three years, 25 percent of women received care from a qualified doctor, and 12 percent received care from a nurse, midwife, paramedic, or family welfare visitor (FWV) within two days after birth. Forty-one percent of women who gave birth received no postnatal checkup within two days of birth. The likelihood of receiving postnatal care from a medically trained provider within two days of delivery differs substantially by mother’s age, birth order, place of delivery, residence, education, and wealth quintile. Women younger than age 35 at the time of birth (36-37 percent), women having their first child (45 percent), urban women (56 percent), women who have completed a secondary education or higher (66 percent), and women in the highest wealth quintile (69 percent) are much more likely to receive the first postnatal checkup from a medically-trained provider in the first two days after delivery compared with other women. Receiving the first postnatal checkup from a trained provider within two days of delivery is most common in Khulna (51 percent) and least common in Sylhet (23 percent). Maternal and Newborn Health • 127 Table 9.11 Type of provider of first postnatal checkup for the mother Percent distribution of women age 15-49 who give birth in the three years preceding the survey by type of provider of the mother’s first postnatal health check in the two days after the last live birth, and the percentage of women with a live birth in the three years preceding the survey who received a postnatal checkup from a medically-trained provider in the first two days after giving birth, according to background characteristics, Bangladesh 2014 Background characteristic Type of provider Percentage receiving checkup within 2 days of delivery from a medically trained provider Number of women Qualified doctor Nurse/midwife/ paramedic/ FWV CSBA/SACMO Non-medically trained provider No postnatal checkup in the first two days after birth1 Total Mother’s age at birth <20 24.0 11.9 0.0 23.5 40.7 100.0 35.8 1,472 20-34 25.7 11.5 0.0 22.2 40.7 100.0 37.2 2,971 35-49 20.8 8.3 0.0 24.5 46.5 100.0 29.0 184 Birth order 1 32.0 13.2 0.0 19.1 35.7 100.0 45.2 1,857 2-3 23.1 11.3 0.0 22.4 43.2 100.0 34.4 2,133 4-5 12.2 8.3 0.0 33.0 46.6 100.0 20.5 484 6+ 6.2 2.6 0.0 38.0 53.2 100.0 8.8 154 Place of delivery Health facility 61.0 24.8 0.0 1.5 12.7 100.0 85.8 1,784 Elsewhere 2.3 3.1 0.0 36.0 58.6 100.0 5.4 2,841 Residence Urban 40.8 15.1 0.0 18.8 25.3 100.0 55.9 1,209 Rural 19.3 10.2 0.0 24.0 46.4 100.0 29.5 3,418 Division Barisal 22.0 12.2 0.2 22.3 43.4 100.0 34.3 268 Chittagong 24.2 12.1 0.0 23.7 40.0 100.0 36.3 1,011 Dhaka 27.8 9.0 0.0 24.0 39.2 100.0 36.8 1,634 Khulna 32.2 18.7 0.0 12.5 36.6 100.0 50.9 371 Rajshahi 24.6 15.1 0.0 24.1 36.1 100.0 39.7 464 Rangpur 22.7 11.2 0.0 24.0 42.0 100.0 33.9 450 Sylhet 14.3 9.0 0.1 21.1 55.5 100.0 23.4 428 Education No education 9.3 6.6 0.1 28.8 55.3 100.0 16.0 655 Primary incomplete 13.1 10.4 0.0 30.2 46.2 100.0 23.6 749 Primary complete2 15.3 11.2 0.0 29.4 44.1 100.0 26.5 544 Secondary incomplete 26.6 12.5 0.0 20.2 40.7 100.0 39.1 1,892 Secondary complete or higher3 52.0 14.3 0.0 11.8 22.0 100.0 66.2 787 Wealth quintile Lowest 9.7 5.4 0.0 28.3 56.6 100.0 15.1 1,003 Second 13.0 9.8 0.1 27.6 49.6 100.0 22.8 876 Middle 20.9 12.0 0.0 21.2 45.9 100.0 32.9 882 Fourth 28.1 15.9 0.0 22.1 33.9 100.0 43.9 955 Highest 53.9 14.5 0.0 13.8 17.7 100.0 68.5 912 Total 24.9 11.5 0.0 22.7 40.9 100.0 36.4 4,627 Note: Total includes 2 children with missing information on place of delivery. Medically trained provider includes doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendants (CSBA) and SACMO. 1 Includes women who received a checkup after 41 days 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. The content of postnatal care is an essential component of service quality. Focused postnatal care hinges on the principle that the first few days after birth are very crucial for both mother and child. The 2014 BDHS is the first DHS survey in Bangladesh to collect information on components of postnatal care for both mother and child. Among mothers who sought postnatal care, 43 percent had their breasts examined, 41 percent were assessed for any vaginal discharge, 84 percent had their temperature measured, and over half (56 percent) received counseling on the danger signs (Table 9.12). These examinations are more likely to be conducted by a medically trained provider than a non-medically trained provider. Table 9.12 Components of postnatal care for the mother Among women age 15-49 who give birth in three years preceding the survey and received postnatal care (PNC) services within two days of delivery, percentage receiving specific components of PNC and type of PNC provider, Bangladesh 2014 Component of PNC PNC provider Medically trained Non- medically trained Any provider Breast examination 45.5 39.0 43.0 Check vaginal discharge 42.4 38.2 40.8 Check temperature 84.7 83.2 84.2 Counsel on danger signs 56.7 54.3 55.8 Number of women 1,685 1,052 2,737 128 • Maternal and Newborn Health 9.3.2 Postnatal Checkup for the Newborn Table 9.13 shows that 26 percent of the newborns had a postnatal checkup within 4 hours after birth, and 28 percent of newborns had a postnatal checkup within 24 hours after birth from a medically trained provider. Differences by mother’s age, birth order, place of birth, residence, education, and wealth quintile are pronounced and are similar to patterns for mothers’ timing of postnatal checkups. Table 9.13 Timing of first postnatal checkup for the children Percent distribution of last births in the three years preceding the survey by time after birth of first postnatal checkup from a medically-trained provider, according to background characteristics, Bangladesh 2014 Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Number of births Background characteristic Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 13.2 12.5 3.0 2.2 0.8 2.9 0.6 64.7 100.0 1,472 20-34 13.6 12.5 2.6 3.8 1.4 3.4 0.3 62.3 100.0 2,971 35-49 8.4 7.6 1.7 1.4 1.9 3.6 1.8 73.5 100.0 184 Birth order 1 16.0 16.1 3.8 3.4 1.1 3.0 0.7 55.8 100.0 1,857 2-3 13.2 11.2 2.1 3.8 1.5 3.8 0.2 64.2 100.0 2,133 4-5 6.6 6.1 1.8 0.7 0.6 2.3 0.8 81.1 100.0 484 6+ 3.3 2.5 0.2 0.8 0.3 1.6 0.0 91.2 100.0 154 Place of delivery Health facility 31.0 28.7 6.7 7.0 1.3 3.0 1.1 21.3 100.0 1,784 Elsewhere 2.2 2.0 0.2 0.8 1.2 3.4 0.1 90.1 100.0 2,841 Residence Urban 23.1 18.8 4.4 4.7 1.2 2.7 0.6 44.5 100.0 1,209 Rural 9.8 10.0 2.1 2.7 1.3 3.5 0.4 70.2 100.0 3,418 Division Barisal 14.4 9.9 3.3 3.0 1.6 4.6 0.0 63.2 100.0 268 Chittagong 16.5 10.7 2.2 3.6 1.6 4.5 0.6 60.3 100.0 1,011 Dhaka 14.0 11.2 2.6 2.7 0.9 3.2 0.3 65.2 100.0 1,634 Khulna 13.3 19.2 4.6 4.5 1.0 3.5 1.8 52.2 100.0 371 Rajshahi 12.7 15.1 3.9 4.5 1.0 1.3 0.2 61.2 100.0 464 Rangpur 9.4 15.6 2.2 2.2 2.4 2.1 0.9 65.2 100.0 450 Sylhet 7.3 9.3 1.3 2.9 0.8 3.1 0.0 75.4 100.0 428 Education No education 4.8 5.6 0.9 1.1 0.7 1.8 0.4 84.7 100.0 655 Primary incomplete 9.5 6.4 1.5 1.6 0.6 1.8 0.2 78.3 100.0 749 Primary complete2 10.8 9.5 1.0 2.8 0.2 5.0 0.6 70.1 100.0 544 Secondary incomplete 13.9 13.4 3.4 3.3 1.4 3.6 0.5 60.6 100.0 1,892 Secondary complete or higher3 24.3 22.8 4.8 6.7 2.6 3.9 0.7 34.3 100.0 787 Wealth quintile Lowest 3.5 6.1 1.1 2.5 1.0 2.7 0.1 83.1 100.0 1,003 Second 6.9 7.9 0.9 1.5 1.0 4.5 0.2 77.2 100.0 876 Middle 11.6 9.8 1.9 3.4 0.7 3.4 0.4 68.9 100.0 882 Fourth 17.1 14.3 4.1 2.6 1.5 3.7 0.7 56.0 100.0 955 Highest 27.7 23.8 5.4 6.2 1.9 2.2 1.1 31.7 100.0 912 Total 13.3 12.3 2.7 3.2 1.2 3.3 0.5 63.5 100.0 4,627 Note: Total includes two children with missing information on place of delivery. Medically trained provider includes doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendant (CSBA), and SACMO. 1 Includes women who received a checkup after 41 days and women who received checkup from non-medically trained providers 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Table 9.14 presents the percent distribution of last births in the three years preceding the survey by type of provider of postnatal checkup for the newborn during the first two days after delivery, according to background characteristics. Among all newborns, 23 percent received their checkup from a qualified doctor, and 9 percent received a checkup from a nurse, midwife, paramedic, or FWV within the first two days after birth. Twenty-three percent of newborns received their first postnatal checkup from a non-medically trained provider within the first two days after birth. Forty-six percent of newborns received no postnatal checkup in the first two days after birth. Maternal and Newborn Health • 129 Table 9.14 Type of provider of first postnatal checkup for the newborn Percent distribution of last births in the three years preceding the survey by type of provider of the child’s first postnatal health check during the two days after birth and the percentage of births with postnatal checkup in the first two days after birth from medically-trained provider, according to background characteristics, Bangladesh 2014 Background characteristic Type of provider Percentage receiving checkup within 2 days of delivery from a medically trained provider Number of women Qualified doctor Nurse/ midwife/ paramedic/ FWV CSBA/ SACMO Non-medically trained provider No postnatal checkup in the first two days after birth1 Total Mother’s age at birth <20 21.7 9.2 0.0 24.1 45.1 100.0 30.9 1,472 20-34 24.0 8.5 0.0 21.9 45.6 100.0 32.6 2,971 35-49 14.1 5.0 0.0 28.6 52.2 100.0 19.1 184 Birth order 1 29.4 9.9 0.0 20.0 40.7 100.0 39.3 1,857 2-3 21.6 8.6 0.0 21.3 48.5 100.0 30.2 2,133 4-5 9.0 6.2 0.0 33.6 51.3 100.0 15.2 484 6+ 5.5 1.5 0.0 44.1 49.0 100.0 6.9 154 Place of delivery Health facility 55.3 18.0 0.0 1.4 25.3 100.0 73.3 1,784 Elsewhere 2.5 2.7 0.0 36.3 58.5 100.0 5.2 2,841 Residence Urban 39.0 11.9 0.0 19.3 29.8 100.0 50.9 1,209 Rural 17.2 7.4 0.0 24.1 51.3 100.0 24.6 3,418 Division Barisal 18.8 11.6 0.2 23.4 45.9 100.0 30.6 268 Chittagong 23.6 9.5 0.0 22.5 44.4 100.0 33.0 1,011 Dhaka 24.6 5.9 0.0 24.4 45.1 100.0 30.5 1,634 Khulna 27.3 14.2 0.0 10.9 47.5 100.0 41.6 371 Rajshahi 24.9 11.3 0.0 24.1 39.7 100.0 36.2 464 Rangpur 20.2 9.2 0.0 26.2 44.4 100.0 29.4 450 Sylhet 14.0 6.7 0.0 22.4 56.9 100.0 20.7 428 Education No education 7.5 4.9 0.0 30.5 57.1 100.0 12.4 655 Primary incomplete 11.2 7.8 0.0 29.4 51.5 100.0 19.0 749 Primary complete2 15.6 8.5 0.0 28.0 48.0 100.0 24.1 544 Secondary incomplete 24.9 9.1 0.0 21.1 44.9 100.0 33.9 1,892 Secondary complete or higher3 47.1 11.5 0.0 10.6 30.8 100.0 58.6 787 Wealth quintile Lowest 9.2 4.0 0.0 27.6 59.3 100.0 13.1 1,003 Second 11.2 6.0 0.1 26.2 56.6 100.0 17.2 876 Middle 17.3 9.4 0.0 23.9 49.4 100.0 26.7 882 Fourth 25.7 12.5 0.0 22.6 39.2 100.0 38.1 955 Highest 51.8 11.4 0.0 13.5 23.4 100.0 63.1 912 Total 22.9 8.6 0.0 22.8 45.7 100.0 31.5 4,627 Note: Total includes two children with missing information on place of delivery. Medically trained provider includes doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendant (CSBA), and SACMO. 1 Includes women who received a checkup after 41 days 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Among the newborns who received a postnatal checkup, there was not much difference in the percentages receiving services from a medically trained provider compared with a non-medically trained provider, except in measurement of weight. Within two days of birth, those who received PNC from a medically trained provider (74 percent) were more likely to have their weight measured compared to those who received PNC from a non-medically trained provider (18 percent) (Table 9.15). Table 9.15 Components of postnatal checkup for the newborn Among last births in the three years preceding the survey who received postnatal care (PNC) within two days after birth, percentage receiving specific components of PNC, according to PNC provider, Bangladesh 2014 Postnatal care provider Specific PNC services received Medically trained provider Non- medically trained provider Any provider Examined the cord 80.9 81.0 80.9 Counseled on danger signs 54.9 47.4 51.7 Assessed temperature 88.0 78.7 84.1 Counseled mother on breastfeeding 76.6 74.7 75.8 Observed breastfeeding 39.2 33.2 36.7 Assessed weight 74.2 18.1 50.6 Number of children 1,458 1,061 2,519 130 • Maternal and Newborn Health 9.4 NEWBORN CARE Newborn primary care focuses on the use of clean instruments to cut the umbilical cord, cord care, bathing delays, prevention of hypothermia, and keeping the newborn warm. The 2014 BDHS is the third DHS survey in Bangladesh to collect information on newborn care. Women who gave birth in the past three years, but who did not deliver their last-born child in a health facility, were asked about newborn care practices, including cord cutting, drying, and bathing of the newborn following birth. 9.4.1 Care of the Umbilical Cord According to the 2014 BDHS, a blade is the most common instrument used to cut the umbilical cord (97 percent); 19 percent of the births used a blade from the delivery kit and 78 percent used a blade from other sources (Table 9.16). The instrument used to cut the cord was boiled before use in 83 percent of non-institutional births. The use of a boiled instrument to cut the umbilical cord varies slightly by background characteristics. For example, a boiled instrument was used in 85 percent of the births to women residing in urban areas compared with 83 percent in rural areas. Similarly, the use of a boiled instrument ranges from a low of 81 percent of births to mothers in the lowest wealth quintile to a high of 85 percent in the highest quintile. Table 9.16 Type of instrument used to cut the umbilical cord Percent distribution of non-institutional births which were women’s most recent live birth in the three years preceding the survey by type of instrument used to cut the umbilical cord, and the percentage of instruments boiled before the cord was cut, according to background characteristics, Bangladesh 2014 Instrument used to cut the umbilical cord Percentage of instruments boiled before the cord was cut Number of births Background characteristic Blade from delivery kit Blade from other source Bamboo strips Scissors Other Don’t know Total Mother’s age at birth <20 21.6 74.5 1.1 1.2 0.1 1.5 100.0 76.7 920 20-34 18.0 79.9 0.8 0.6 0.1 0.6 100.0 86.0 1,793 35-49 14.1 79.7 4.4 0.6 0.0 1.2 100.0 87.9 123 Birth order 1 22.9 73.2 1.0 1.2 0.1 1.5 100.0 76.2 959 2-3 19.0 78.8 0.8 0.6 0.1 0.7 100.0 85.8 1,349 4-5 14.1 83.6 1.5 0.8 0.0 0.0 100.0 88.1 387 6+ 6.0 90.4 2.6 0.0 0.0 1.1 100.0 89.8 141 Residence Urban 20.7 76.5 0.1 0.9 0.0 1.8 100.0 84.9 501 Rural 18.6 78.5 1.3 0.8 0.1 0.7 100.0 82.7 2,335 Division Barisal 25.8 72.0 1.6 0.2 0.0 0.3 100.0 78.5 186 Chittagong 12.2 83.9 2.3 0.4 0.0 1.1 100.0 85.6 648 Dhaka 16.4 81.6 0.5 0.7 0.0 0.8 100.0 83.1 941 Khulna 15.7 79.7 0.5 3.7 0.0 0.3 100.0 88.9 166 Rajshahi 17.1 78.1 0.7 1.0 0.8 2.3 100.0 69.6 278 Rangpur 44.3 53.5 0.2 1.3 0.0 0.8 100.0 84.6 292 Sylhet 16.7 81.7 1.1 0.4 0.0 0.1 100.0 87.9 326 Education No education 9.3 88.4 1.7 0.0 0.0 0.7 100.0 83.9 549 Primary incomplete 15.6 81.5 1.6 0.9 0.2 0.2 100.0 79.4 570 Primary complete1 16.5 80.9 1.2 0.7 0.2 0.4 100.0 85.6 376 Secondary incomplete 23.0 73.9 0.5 1.2 0.0 1.4 100.0 82.8 1,100 Secondary complete or higher2 34.8 62.1 0.7 1.0 0.0 1.4 100.0 87.1 241 Wealth quintile Lowest 14.1 83.3 1.3 0.3 0.2 0.7 100.0 81.4 848 Second 17.6 78.8 2.2 0.7 0.0 0.7 100.0 83.5 660 Middle 21.5 76.4 0.6 0.9 0.0 0.7 100.0 81.8 573 Fourth 21.3 76.3 0.2 1.4 0.0 0.8 100.0 86.2 500 Highest 28.7 67.0 0.0 1.6 0.0 2.7 100.0 84.6 255 Total 19.0 78.2 1.1 0.8 0.1 0.9 100.0 83.1 2,836 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Maternal and Newborn Health • 131 The use of a blade from a delivery kit has increased substantially between surveys, from 6 percent in 2007 to 14 percent in 2011 and to 19 percent in 2014, while the use of boiled instruments has increased only slightly, from 62 percent in 2007 to 84 percent in 2011 and then dropped 83 percent in 2014 (Figure 9.9). Figure 9.9 Trend in use of appropriate cord care, 2007-2014 Table 9.17 shows what material was applied to the cord immediately after cutting it, according to the mother’s background characteristics. In over a half of the cases (52 percent), nothing was applied to the cord after it was cut. When something was applied to the cord, mustard oil with garlic and antibiotics were the most common materials (19 and 17 percent, respectively), followed by antiseptics (9 percent), and Boric powder (4 percent). Other materials used were turmeric juice or powder, chewed rice, shidur (vermillion), gention violet, and ginger juice, but their use is not widespread, about 1 percent or less. The practice of applying nothing to the umbilical cord was applicable till July 2013, when the National Core Committee approved of the recommended practice of applying chlorhexidine to the umbilical cord. Although the recommendation was approved before the 2014 BDHS survey fieldwork, the practice did not start until July 2015. The question regarding the application of chlorhexidine was asked in the survey, but did not have any significant number of responses, and hence the results are not included in Table 9.17. The practice of applying nothing to the umbilical cord increased slightly from 56 percent in 2007 to 59 percent in 2011, but dropped to 52 percent in 2014 (Figure 9.9). 6 62 56 14 84 59 19 83 52 Blade from kit Boiled instrument to cut cord Nothing applied to cord Percent 2007 BDHS 2011 BDHS 2014 BDHS 132 • Maternal and Newborn Health Table 9.17 Application of material after the umbilical cord was cut Percentage of non-institutional births which were the mother’s most recent live birth in the three years preceding the survey by material applied to the cord immediately after cutting and tying it, according to background characteristics, Bangladesh 2014 Material applied to the cord Num- ber of births Background characteristic Anti- biotics Anti- septic Spirit/ alcohol Mustard oil with garlic Chewed rice Turmeric juice/ powder Ginger juice Shidur Boric powder Gentian violet (blue ink) Talcum powder Other1 Don’t know Nothing applied to the cord Mother’s age at birth <20 15.7 7.8 0.7 19.1 0.1 0.6 0.2 0.0 3.1 1.0 0.1 1.3 1.6 53.4 920 20-34 17.1 9.6 0.1 18.4 0.2 1.1 0.3 1.6 3.7 1.3 0.2 0.7 0.3 52.2 1,793 35-49 18.2 10.7 0.0 22.8 0.0 2.2 0.3 0.0 3.7 0.0 0.0 0.3 0.6 48.2 123 Birth order 1 15.6 8.9 0.7 19.3 0.1 1.0 0.2 0.2 3.5 1.5 0.2 1.3 1.6 50.8 959 2-3 17.4 9.0 0.1 18.5 0.3 0.5 0.3 1.8 2.6 0.9 0.1 0.8 0.2 54.0 1,349 4-5 16.2 8.4 0.0 17.9 0.1 2.6 0.2 0.5 7.7 0.8 0.3 0.3 0.2 51.2 387 6+ 18.5 11.5 0.0 19.9 0.0 1.0 0.5 0.5 0.0 2.5 0.0 0.2 1.2 51.1 141 Residence Urban 21.3 11.1 0.0 18.0 0.0 0.3 0.6 0.5 4.2 1.1 0.3 0.8 1.2 47.0 501 Rural 15.7 8.6 0.4 18.9 0.2 1.1 0.2 1.2 3.3 1.2 0.1 0.9 0.7 53.6 2,335 Division Barisal 13.1 8.9 0.2 41.2 0.0 1.0 0.0 0.0 2.0 1.0 0.0 1.1 1.5 35.0 186 Chittagong 14.1 8.5 0.2 27.7 0.2 1.6 0.0 0.6 1.3 1.0 0.0 0.2 0.2 51.3 648 Dhaka 15.6 9.1 0.4 11.5 0.0 0.8 0.1 0.6 5.9 2.0 0.1 1.3 0.6 56.6 941 Khulna 28.7 12.8 1.8 15.1 0.1 0.4 0.0 2.9 2.5 1.3 0.0 1.3 0.5 42.6 166 Rajshahi 18.1 13.2 0.0 17.3 0.7 0.5 0.0 0.7 0.8 0.0 0.3 0.3 0.2 53.9 278 Rangpur 19.1 5.5 0.0 13.8 0.0 0.3 0.0 0.7 2.4 0.0 0.0 0.4 1.9 59.1 292 Sylhet 17.8 7.7 0.3 16.7 0.6 1.6 1.9 3.4 5.5 1.2 0.5 1.2 1.4 50.2 326 Education No education 14.6 7.8 0.0 19.7 0.1 1.8 0.6 0.9 4.8 1.0 0.0 0.2 0.5 53.7 549 Primary incomplete 15.6 8.4 0.8 20.7 0.3 2.3 0.3 1.4 3.3 1.5 0.0 1.4 0.3 50.6 570 Primary complete1 15.1 6.6 0.0 19.5 0.4 0.5 0.2 1.0 4.5 2.2 0.2 1.0 0.5 54.7 376 Secondary incomplete 17.7 9.5 0.4 18.0 0.2 0.2 0.1 1.1 3.0 0.9 0.3 1.0 0.3 52.8 1,100 Secondary complete or higher2 22.4 15.3 0.0 14.1 0.0 0.0 0.0 0.0 1.8 0.0 0.0 0.2 4.8 48.5 241 Wealth quintile Lowest 11.0 7.8 0.1 19.6 0.0 1.3 0.4 1.5 4.3 1.4 0.2 1.0 0.6 57.0 848 Second 19.2 8.0 0.2 18.2 0.5 0.8 0.2 1.2 2.8 1.0 0.1 0.5 0.1 54.0 660 Middle 18.2 9.5 0.9 15.9 0.2 1.6 0.3 0.9 2.4 0.6 0.0 0.4 0.5 53.4 573 Fourth 18.6 9.5 0.4 20.1 0.3 0.2 0.3 0.6 3.7 1.3 0.0 2.1 0.9 47.6 500 Highest 22.0 14.1 0.0 21.4 0.0 0.4 0.0 0.0 4.5 1.5 0.6 0.0 3.2 40.1 255 Total 16.7 9.0 0.3 18.8 0.2 1.0 0.3 1.0 3.5 1.2 0.1 0.9 0.8 52.4 2,836 Note: Total includes 10 births with information missing on mothers’ educational attainment 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 9.4.2 Drying and Bathing the Newborn Newborns should be dried within minutes after birth, placed on the mother’s bare chest after birth, and should not be bathed in the first 24 hours in order to reduce the risk of hypothermia (WHO 2012). The 2014 BDHS asked mothers with non-institutional deliveries in the past three years about all three components of thermal care of newborn: when the newborn was first dried, whether the newborn was given skin-to-skin care, and when the newborn was first bathed. The tables are based on births in the past three years. Table 9.18 shows that one in four (25 percent) of the newborns was put on the chest to allow for skin-to-skin contact. This practice is more common among births to younger mothers, low parity births, and births in Dhaka and Khulna. The skin-to-skin practice has no clear relationship with the mother’s education or wealth status. Table 9.18 shows that 67 percent of the newborns were dried within the recommended 5 minutes of birth, 83 percent of the newborns were dried within 10 minutes, and 9 percent after 10 minutes. Seven percent of newborns were not dried. Maternal and Newborn Health • 133 There is little variation in early drying of newborns by background characteristics. Among divisions, newborns in Rajshahi and Rangpur are more likely to be dried within five minutes of birth (75 and 74 percent, respectively) compared with newborns in other divisions (70 percent and lower). Early drying does not vary significantly with mother’s education. However, early drying of newborns is more prevalent among newborns in the highest wealth quintile (75 percent). The practice of immediate drying after birth has improved considerably since 2007, when only 6 percent of newborns were dried within five minutes, compared with 51 percent in 2011 and 67 percent in 2014. Table 9.18 Newborn care practices: timing of drying Percent distribution of non-institutional births which were women’s most recent live birth in the three years preceding the survey by timing of drying the newborn, according to background characteristics, Bangladesh 2014 Percentage of births that have skin-to- skin contact Timing of drying after delivery Number of births Background characteristic 0-4 minutes 5-9 minutes 10+ minutes Newborn not dried before washing Don’t know/ missing Total Mother’s age at birth <20 25.2 66.1 16.3 10.0 5.4 2.1 100.0 920 20-34 25.0 67.5 15.8 8.7 6.4 1.5 100.0 1,793 35-49 17.5 65.5 13.2 3.9 16.3 1.1 100.0 123 Birth order 1 24.5 67.1 15.8 10.7 4.4 2.0 100.0 959 2-3 26.5 66.0 17.4 7.9 6.9 1.8 100.0 1,349 4-5 23.0 71.3 12.4 9.6 6.3 0.4 100.0 387 6+ 13.5 62.9 10.4 5.6 18.7 2.4 100.0 141 Residence Urban 22.4 68.1 19.0 6.0 5.1 1.8 100.0 501 Rural 25.2 66.7 15.2 9.6 6.9 1.7 100.0 2,335 Division Barisal 25.6 56.2 30.3 9.6 2.5 1.4 100.0 186 Chittagong 19.8 65.6 14.9 10.9 6.9 1.8 100.0 648 Dhaka 28.6 63.7 17.5 9.1 8.4 1.4 100.0 941 Khulna 29.5 71.7 14.6 8.7 2.0 3.0 100.0 166 Rajshahi 21.2 74.6 11.9 8.0 2.7 2.9 100.0 278 Rangpur 23.5 73.9 14.8 9.2 0.8 1.3 100.0 292 Sylhet 24.5 70.3 9.6 4.9 13.7 1.5 100.0 326 Education No education 20.1 65.0 14.8 7.4 11.6 1.2 100.0 549 Primary incomplete 25.4 67.3 14.0 9.7 6.9 2.2 100.0 570 Primary complete1 23.5 69.4 12.6 6.4 10.2 1.4 100.0 376 Secondary incomplete 27.5 66.4 17.5 10.8 3.4 1.8 100.0 1,100 Secondary complete or higher2 23.3 69.5 20.3 6.1 2.6 1.5 100.0 241 Wealth quintile Lowest 25.7 66.3 12.9 10.1 9.5 1.3 100.0 848 Second 22.0 65.4 14.1 8.5 9.2 2.8 100.0 660 Middle 27.5 61.3 20.5 12.3 4.0 1.9 100.0 573 Fourth 25.9 72.5 17.2 6.1 3.1 1.1 100.0 500 Highest 20.1 75.1 17.1 4.4 2.3 1.1 100.0 255 Total 24.7 67.0 15.9 8.9 6.5 1.7 100.0 2,836 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. The 2014 BDHS assessed the timing of a newborn’s first bath. Table 9.19 shows that 34 percent of newborns were first bathed 72 hours or more following birth, which is the recommended practice in Bangladesh. Thirty-two percent of the newborns were bathed within the first 6 hours of birth, while 39 percent were bathed in the first 24 hours. Bathing 72 hours or more after birth is most common among children born to women younger than age 20 and for birth order 2-3. Among divisions, Rangpur (51 percent) has the highest proportion of newborns bathed after 72 hours of delivery, while Chittagong and Khulna (28 to 31 percent) have the lowest proportions. Waiting to give a newborn the first bath is also associated with the mother’s education. Twenty- three percent of newborns to women with no education are bathed at least 72 hours after birth compared with 45 percent of newborns whose mothers have completed secondary or higher education. 134 • Maternal and Newborn Health Table 9.19 Newborn care practices: Timing of first bath Percent distribution of non-institutional births which were women’s most recent live birth in the three years preceding the survey by timing of first bath, according to background characteristics, Bangladesh 2014 Timing of first bath after delivery Number of births Background characteristic 0-5 hours 6-11 hours 12-23 hours 24-71 hours 72+ hours Baby not bathed1 Don’t know/ missing Total Mother’s age at birth <20 31.2 3.8 2.2 24.1 36.6 1.6 0.5 100.0 920 20-34 31.8 4.6 1.9 25.9 34.1 1.4 0.3 100.0 1,793 35-49 48.2 4.0 2.4 21.3 22.0 1.3 0.7 100.0 123 Birth order 1 30.4 4.1 2.2 25.6 35.4 1.9 0.5 100.0 959 2-3 29.7 5.2 1.8 25.1 36.6 1.1 0.5 100.0 1,349 4-5 35.9 2.8 2.0 29.3 28.1 1.8 0.1 100.0 387 6+ 61.2 2.2 3.1 10.7 22.7 0.2 0.0 100.0 141 Residence Urban 33.9 5.4 0.8 28.8 30.0 0.6 0.5 100.0 501 Rural 32.0 4.1 2.3 24.3 35.3 1.6 0.4 100.0 2,335 Division Barisal 26.9 3.4 1.6 31.0 33.2 1.9 1.9 100.0 186 Chittagong 39.6 3.3 1.6 26.3 28.2 0.8 0.2 100.0 648 Dhaka 32.0 6.4 1.8 24.6 33.8 1.3 0.1 100.0 941 Khulna 24.0 3.9 2.2 36.5 31.1 1.4 0.8 100.0 166 Rajshahi 26.4 5.5 1.7 27.5 35.9 2.3 0.6 100.0 278 Rangpur 12.8 2.5 5.8 27.1 50.7 0.5 0.6 100.0 292 Sylhet 48.6 1.9 0.5 11.2 34.6 3.2 0.1 100.0 326 Education No education 42.8 7.9 3.3 21.7 23.2 0.9 0.3 100.0 549 Primary incomplete 37.3 4.3 0.5 26.2 29.4 1.7 0.7 100.0 570 Primary complete2 33.3 3.2 0.8 21.7 38.6 2.0 0.5 100.0 376 Secondary incomplete 26.3 3.4 2.3 27.5 38.8 1.5 0.2 100.0 1,100 Secondary complete or higher3 22.7 2.4 3.6 24.9 44.6 1.3 0.4 100.0 241 Wealth quintile Lowest 38.5 3.9 2.5 24.4 28.7 1.6 0.3 100.0 848 Second 33.4 3.4 2.2 22.6 35.7 2.1 0.6 100.0 660 Middle 31.6 3.9 1.4 22.8 38.9 1.1 0.4 100.0 573 Fourth 24.3 7.6 1.2 28.7 37.0 1.1 0.1 100.0 500 Highest 26.3 3.0 3.1 32.0 34.4 0.7 0.6 100.0 255 Total 32.3 4.3 2.0 25.1 34.4 1.5 0.4 100.0 2,836 Note: Total includes 10 births with information missing on mothers’ educational attainment. 1 Majority of cases accounted for by early neonatal deaths 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 9.4.3 Essential Newborn Care The National Neonatal Health Strategy and Guidelines for Bangladesh recommend a set of essential newborn care practices (MOHFW 2009). Essential newborn care focuses on the use of clean instruments to cut the umbilical cord, applying nothing to the cord, immediate drying (within five minutes) keeping the baby warm, delaying bathing to 72 hours after birth, and initiating breastfeeding within 1 hour of delivery. To assess the extent to which newborn care practices have been followed, Table 9.20 summarizes the essential newborn care practices among non-institutional last live births in the three years preceding the survey. Overall, only 6 percent of newborns receive all the essential newborn care practices. This proportion was 5 percent in 2011 (Figure 9.10). A comparison of the 2011 and 2014 BDHS findings shows considerable improvement in newborn bathing practices in Bangladesh (Figure 9.10). Using a clean delivery kit/bag or boiling the blade to cut the cord has increased slightly from 86 percent in 2011 to 88 percent in 2014. The recommended practice of applying nothing to Table 9.20 Essential newborn care Percent distribution of non-institutional births which were their mother’s most recent live birth in the three years preceding the survey by essential newborn care received, according to background characteristics, Bangladesh 2014 Essential newborn care practices Percentage of non-institutional births with newborn care practices Instrument boiled before the cord was cut 83.1 Nothing applied to the umbilical cord after it was cut and tied 52.4 Dried within 0-4 minutes of birth 66.9 Delayed bathing (bathed 72+ hours after delivery) 34.3 Immediate breastfeeding (breastfed within 1 hour after birth) 57.2 All the essential newborn care practices 6.1 Number of births 2,836 Maternal and Newborn Health • 135 the umbilical cord of the newborn has declined from 59 to 52 percent. In contrast, use of the recommended practice of drying the newborns within 5 minutes of birth has increased substantially, from 51 to 67 percent. Adherence to recommended practices regarding initiation of breastfeeding within one hour of birth and delayed bathing of the newborn has increased in the last three years. The recommended practice of first bathing babies at least 72 hours after birth has increased from 17 percent in 2007 to 28 percent in 2011 and further increased to 34 percent in 2014. Initiation of breastfeeding within one hour of birth increased from 50 percent in 2011 to 57 percent in 2014. Figure 9.10 Trend in use of essential newborn care practices, 2011-2014 86 59 51 28 50 5 88 52 67 34 57 6 Used safe delivery kit or boiled instrument used for cutting cord Nothing applied to cord Dried within 5 minutes of birth 1st bath delayed >72hours Immediate breastfeeding All ENC practices Percentage 2011 BDHS 2014 BDHS Child Health • 137 CHILD HEALTH 10 his chapter presents findings from several areas of importance to child health; characteristics of the neonate (birth weight and size at birth), vaccination status of children, and important childhood illnesses and their treatment. The information on birth weight and neonate’s size assists in monitoring programs to decrease neonatal and infant mortality by reducing the incidence of low birth weight. The presentation of information on vaccination coverage focuses on the age group 12-23 months. Overall coverage levels at the time of the survey and by age 12 months are shown for this age group. Additionally, the source of the vaccination information (whether based on a written vaccination card or on the mother’s recall) is shown. Differences in vaccination coverage between different subgroups of the population are an aid in program planning. Examining treatment practices and the contact with health services for children with the three most important childhood illnesses—diarrhea, acute respiratory infection (ARI), and fever—can help in the assessment of national programs aimed at reducing mortality from these illnesses. Information is provided on the prevalence and treatment of ARI and its treatment with antibiotics and the prevalence of fever and its treatment with antimalarial drugs and antibiotics. The treatment of diarrheal disease with oral rehydration therapy (including increased fluids) aids in the assessment of programs that recommend such treatment. Because the appropriate use of zinc can help reduce the severity and duration of diarrheal disease, information is also provided on this treatment. 10.1 CHILD’S SIZE AT BIRTH A child’s birth weight or size at birth is an important indicator of the child’s vulnerability to the risk of childhood illnesses and chances of survival. Children whose birth weight is less than 2.5 kilograms, i.e., low birth weight (LBW), have a higher than average risk of early childhood death. Because birth weight was T Key Findings • Among children age 12-23 months in 2014, 78 percent are fully vaccinated by 12 months of age. • Six percent of children under age 5 had diarrhea in the two weeks preceding the survey. Of these children, 36 percent were taken for treatment to a health facility or health provider. Among children with diarrhea, 77 percent received ORS, 84 percent received oral rehydration therapy (ORT), which is ORS or recommended home fluid, and 38 percent received both ORT and zinc. • The use of ORT and zinc to treat children with diarrhea increased from 20 percent in 2007 to 38 percent in 2014; ORT use increased from 81 to 84 percent, but ORS use remained at 77 percent. • Five percent of children under age 5 had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey. For 42 percent of these children, treatment was sought from a health facility or health provider, and 34 percent were given antibiotics to treat the illness. • Thirty-seven percent of children under age 5 had a fever in the two weeks preceding the survey. Of these children, 55 percent were taken to a health facility or health provider for treatment. Among those who received treatment, 9 percent received antibiotic drugs. Over half (55 percent) of the drugs were prescribed by a health professional/worker. 138 • Child Health not collected in the 2014 BDHS, the mother’s perception of the baby’s birth size was obtained. A mother’s report of a child being “very small” or “smaller than average,” even though subjective, is considered as a useful proxy for LBW. Table 10.1 presents the information on child’s size at birth according to their mothers’ estimate. Overall, 7 percent of children were considered by their mothers to be very small at birth, 13 percent smaller than average, and 80 percent average or larger in size. There are small differences in mother’s perception of their children’s size at birth by mother’s age at birth and by birth order. Across divisions of the country, mothers in Sylhet are more likely than mothers in other divisions to think that their children are smaller than average. Mothers in Rangpur, on the other hand, are more likely than mothers in other divisions to consider their babies as average or larger than average. In general, a mother’s perception that her child’s size at birth is average or larger increases with her education and wealth status. For instance, 73 percent of children whose mothers have no education are considered average or larger compared with 86 percent of children whose mothers have completed secondary or higher education. Table 10.1 Child’s size and weight at birth Percent distribution of live births in the three years preceding the survey by mother’s estimate of baby’s size at birth, according to background characteristics, Bangladesh 2014 Percent distribution of all live births by size of child at birth Total Number of births Background characteristic Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 6.7 14.4 78.9 0.0 100.0 1,562 20-34 6.6 12.3 80.9 0.2 100.0 3,144 35-49 10.6 18.2 71.2 0.0 100.0 198 Birth order 1 6.5 14.5 78.9 0.1 100.0 1,979 2-3 6.9 10.9 82.0 0.3 100.0 2,256 4-5 7.8 15.1 77.0 0.0 100.0 503 6+ 4.9 22.3 72.8 0.0 100.0 167 Residence Urban 5.2 13.5 81.2 0.1 100.0 1,267 Rural 7.3 13.1 79.5 0.1 100.0 3,637 Division Barisal 6.3 10.9 82.2 0.6 100.0 279 Chittagong 5.9 15.9 78.1 0.1 100.0 1,074 Dhaka 7.8 13.2 78.9 0.1 100.0 1,740 Khulna 6.9 11.3 81.8 0.0 100.0 387 Rajshahi 5.7 9.6 84.7 0.0 100.0 488 Rangpur 4.0 9.6 86.5 0.0 100.0 461 Sylhet 8.9 17.1 73.4 0.6 100.0 474 Mother’s education No education 7.9 18.6 73.1 0.4 100.0 704 Primary incomplete 7.6 15.3 76.8 0.4 100.0 801 Primary complete1 5.8 12.6 81.5 0.0 100.0 579 Secondary incomplete 7.1 12.1 80.8 0.1 100.0 1,999 Secondary complete or higher2 5.0 9.6 85.5 0.0 100.0 821 Wealth quintile Lowest 8.1 15.7 76.1 0.1 100.0 1,084 Second 6.6 13.8 79.4 0.1 100.0 932 Middle 8.6 11.1 80.0 0.3 100.0 942 Fourth 5.8 13.0 81.1 0.0 100.0 995 Highest 4.6 11.9 83.4 0.2 100.0 950 Total 6.8 13.2 79.9 0.1 100.0 4,904 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 10.2 VACCINATION OF CHILDREN In 1979, the government of Bangladesh initiated the Expanded Program on Immunization (EPI) against six preventable diseases (tuberculosis; diphtheria, pertussis, and tetanus; polio; and measles). Efforts intensified after 1985, when Bangladesh committed itself to reaching universal child immunization by 1990 (Jamil et al. 1999). Universal immunization of children against the major vaccine-preventable diseases Child Health • 139 (tuberculosis, diphtheria, pertussis, tetanus, hepatitis, haemophilus influenzae type B, poliomyelitis, pneumonia, measles, and rubella) is globally recognized as one of the most cost-effective programs to reduce infant and child morbidity and mortality. The EPI incorporated the hepatitis B (HepB) vaccine in 2003 (EPI 2004). The hepatitis B vaccine was initially distributed in seven districts and one City Corporation, and then gradually expanded to all districts of Bangladesh by October 2005. Haemophilus influenzae type B (Hib) vaccine was introduced in Bangladesh in 2009. This was done in the form of pentavalent vaccine that included diphtheria, pertussis, and tetanus (DPT), HepB, and the new Hib vaccine. Measles and rubella vaccine were introduced in the EPI in 2012 (EPI 2013). The EPI is a priority program for the government of Bangladesh. It follows the international guidelines recommended by the World Health Organization (WHO). According to the Bangladesh immunization guidelines, children are considered fully vaccinated when they have received doses of the “standard eight” antigens—one dose of the vaccine against tuberculosis (BCG), three doses of pentavalent (DPT, Hib, and HepB), three doses of polio vaccine (excluding polio vaccine given at birth), and one dose of measles and rubella vaccine. One dose of BCG is given at birth or at first contact with health workers; the pentavalent and polio vaccines require three doses at approximately 6, 10, and 14 weeks; and the measles and rubella vaccine is given soon after 9 months. WHO recommends giving children all of these vaccines before their first birthday and recording the vaccinations on a vaccination card given to the parents. The 2014 BDHS collected data on childhood vaccinations for all surviving children born during the five-year period before the survey. In Bangladesh, immunizations are routinely recorded on a vaccination card. For each child, mothers were asked whether they had the vaccination card and, if so, to show the card to the interviewer. If the mother was able to show the vaccination card, the dates of vaccinations were transferred from the card to the survey questionnaire. If the vaccination card was not available, mothers were asked to recall whether the child had received each vaccine. 10.2.1 Vaccination Coverage Table 10.2 presents information on vaccination coverage according to the source of information. The data are for children age 12-23 months, thereby including only those children who have reached the age by which they should be fully vaccinated. According to information from both vaccination cards and mother’s reports, 84 percent of children age 12-23 months are fully vaccinated. The level of coverage for BCG, three doses of pentavalent vaccine, and three doses of polio vaccine is 91 percent or higher. Coverage for measles vaccine is slightly lower (86 percent). Coverage for the pentavalent and polio vaccines declines with the dosage, from 97 percent each for the first dose to 91 percent each for the third dose. Only 2 percent of children age 12-23 months have not received any vaccinations. Table 10.2 Vaccinations by source of information Percentage of children age 12-23 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother’s report), and percentage vaccinated by age12 months, Bangladesh 2014 Source of information BCG Penta- valent 1 Penta- valent 2 Penta- valent 3 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions1 No vaccina- tions Number of children Vaccinated at any time before survey Vaccination card 73.8 73.8 72.8 70.8 73.7 72.7 70.4 65.8 65.2 0.0 1,207 Mother’s report 24.1 23.2 22.6 20.5 23.7 22.8 21.0 20.3 18.6 2.0 426 Either source 97.9 97.0 95.4 91.3 97.4 95.5 91.4 86.1 83.8 2.0 1,633 Vaccinated by 12 months of age2 97.8 97.0 95.3 90.9 97.4 95.4 91.1 79.9 78.0 2.0 1,633 Note: Data for polio vaccination were adjusted for a likely misreporting. It appears that, for some children, mothers may have reported that the first polio dose took place “soon after birth”, when in fact the dose was polio 1 and not polio 0. To correct for any such errors, the total number of doses of pentavalent and polio was checked, because the two vaccinations are usually given at the same time. For children reported as having received the same or fewer pentavalent doses than polio doses, the first dose of polio was assumed to be polio 1, not polio 0. For example, children who were reported by the mother to have received all three doses of pentavalent and polio 0, polio 1, and polio 2 only, it was assumed that polio 0 was in fact polio 1, polio 1 was in fact polio 2, and polio 2 was in fact polio 3. 1 BCG, measles, and three doses each of pentavalent and polio vaccine (excluding polio vaccine given at birth and polio 4) 2 For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life is assumed to be the same as for children with a written record of vaccination. 140 • Child Health Vaccinations are most effective when given at the proper age. Therefore, in line with the WHO guidelines, it is recommended that children complete the schedule of immunizations during their first year of life (i.e., by age 12 months). Overall, 78 percent of children age 12-23 months had received all the recommended vaccinations before their first birthday. The Health, Population and Nutrition Sector Development Program (HPNSDP) 2011-2016 sets a target of 90 percent coverage for measles vaccine by age 12 months by 2016 (MOHFW 2011). The 2014 BDHS shows that 80 percent of children have received the measles vaccine by age 12 months. 10.2.2 Differentials in Vaccination Coverage Table 10.3 shows differences in vaccination coverage by background characteristics. Vaccination coverage does not vary by the sex of the child. Birth order is negatively related to the likelihood of being fully vaccinated—as birth order increases, vaccination coverage declines. Among administrative divisions, the highest level of coverage is seen in Rangpur (90 percent) and the lowest in Sylhet (61 percent). As expected, mother’s education and wealth status are positively associated with children’s likelihood of being fully vaccinated. For instance, 95 percent of children whose mothers completed secondary or higher education are fully vaccinated compared with 74 percent of children whose mothers have no education. Table 10.3 also shows that vaccination cards were seen for 74 percent of children age 12-23 months. Table 10.3 Vaccinations by background characteristics Percentage of children age 12-23 months who received specific vaccines at any time before the survey (according to a vaccination card or the mother’s report), and percentage with a vaccination card seen, by background characteristics, Bangladesh 2014 Background characteristic BCG Penta- valent 1 Penta- valent 2 Penta- valent 3 Polio 1 Polio 2 Polio 3 Measles All basic vaccina- tions1 No vaccina- tions Percent- age with a vaccination card seen Number of children Sex Male 98.3 96.9 95.4 90.4 97.5 95.4 90.9 85.9 83.6 1.5 74.0 862 Female 97.5 97.1 95.5 92.3 97.4 95.6 92.0 86.4 84.1 2.5 73.8 772 Birth order 1 98.9 97.7 96.3 92.2 98.5 96.5 92.0 88.5 85.9 1.0 70.4 660 2-3 97.8 97.4 95.8 92.8 97.5 95.8 92.7 86.7 84.8 2.1 76.4 767 4-5 97.9 95.9 92.7 88.0 95.7 92.5 89.2 79.0 76.6 2.1 76.3 151 6+ 87.8 87.1 87.1 67.3 87.1 87.1 71.6 69.1 64.9 12.2 75.0 55 Residence Urban 98.9 98.5 97.2 93.6 98.6 97.5 93.0 90.0 87.6 1.0 74.3 423 Rural 97.6 96.5 94.8 90.4 97.0 94.8 90.8 84.8 82.5 2.3 73.8 1,210 Division Barisal 97.8 97.0 95.1 91.6 97.5 95.6 88.2 87.5 81.5 1.8 78.7 92 Chittagong 96.9 96.3 92.7 88.3 96.7 92.7 88.9 87.6 83.3 2.9 69.1 349 Dhaka 99.1 98.4 98.2 93.9 98.7 98.2 93.9 88.4 87.4 0.9 72.6 624 Khulna 98.9 98.1 95.1 92.0 98.1 95.7 92.6 86.2 85.5 1.1 78.2 129 Rajshahi 98.3 97.8 95.1 93.0 97.7 95.0 92.9 86.0 83.6 1.7 77.5 163 Rangpur 100.0 99.5 99.0 97.9 100.0 99.0 97.9 90.3 90.0 0.0 85.6 146 Sylhet 91.3 87.5 86.0 76.0 89.0 86.6 77.9 65.6 61.1 8.3 67.7 129 Mother’s education No education 93.9 92.7 87.1 80.1 92.9 87.3 80.8 75.6 73.8 6.1 74.2 209 Primary incomplete 97.8 96.8 95.2 87.7 97.1 95.0 87.5 78.5 75.2 2.2 79.9 234 Primary complete2 96.4 95.1 93.9 88.4 95.5 94.2 89.7 79.1 76.2 3.2 71.5 225 Secondary incomplete 99.1 98.1 97.1 94.2 98.8 97.3 94.5 89.7 87.9 0.8 72.8 701 Secondary complete or higher3 99.4 99.4 99.0 97.9 99.2 98.9 96.4 97.5 94.8 0.6 73.4 264 Wealth quintile Lowest 96.5 94.0 90.1 81.3 94.3 90.2 81.6 73.4 69.4 3.5 74.7 376 Second 97.3 97.4 97.4 93.0 97.5 97.5 93.3 85.7 83.4 2.4 73.8 292 Middle 98.1 97.2 94.7 93.2 98.1 95.0 94.1 88.8 87.2 1.8 71.2 323 Fourth 98.2 97.6 96.7 93.9 98.1 96.9 94.0 91.0 89.7 1.7 74.2 336 Highest 99.8 99.6 99.3 97.0 99.6 99.3 95.8 93.9 91.9 0.2 75.6 307 Total 97.9 97.0 95.4 91.3 97.4 95.5 91.4 86.1 83.8 2.0 73.9 1,633 Note: Data for polio vaccination were adjusted for a likely misreporting. It appears that, for some children, mothers may have reported that the first polio dose took place “soon after birth,” when in fact the dose was polio 1 and not polio 0. To correct for any such errors, the total number of doses of pentavalent and polio was checked, since the two vaccinations are usually given at the same time. For children reported as having received the same or fewer pentavalent doses than polio doses, the first dose of polio was assumed to be polio 1, not polio 0. For example, children who were reported by the mother to have received all three doses of pentavalent and polio 0, polio 1, and polio 2 only, it was assumed that polio 0 was in fact polio 1, polio 1 was in fact polio 2, and polio 2 was in fact polio 3. 1 BCG, measles, and three doses each of pentavalent and polio vaccine (excluding polio vaccine given at birth and polio 4) 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Child Health • 141 10.2.3 Trends in Vaccination Coverage Figure 10.1 shows that the proportion of children receiving all basic vaccinations by age 12 months increased between surveys in 2004 and 2011. Between 2011 and 2014, coverage of measles vaccination decreased by 4 percentage points and coverage of all basic vaccinations decreased by 5 percentage points (NIPORT et al. 2013). This decline in immunization coverage is of concern. It cannot be ruled out completely that the vaccination coverage rate in the 2014 BDHS may be underestimated. Whenever a vaccination card was available, this served as the source of information. If there was no written vaccination record, or if the vaccination was not recorded on the card, mothers were specifically asked whether the child had received BCG, measles, pentavalent, and polio vaccine, including the number of doses of polio and pentavalent vaccines. In BDHS 2014, for 26 percent of children age 12-23 months a vaccination card was not shown to the interviewer, and information on their vaccination was based on mother’s recall. Probing guidelines used by the interviewers lacked some clarity and that may have affected vaccination rates derived through recall. Research has shown that both of the existing sources of vaccination information (vaccination card and mothers’ recall) are inadequate in terms of completeness and accuracy (Islam et. al. 2009). Figure 10.1 Trend in vaccination coverage by age 12 months, 2004-2014 10.3 CHILDHOOD ILLNESS AND TREATMENT This section discusses three illnesses that are major contributors to childhood morbidity and mortality in Bangladesh: diarrhea, acute respiratory infection (ARI), and fever. Estimates of the prevalence of these illnesses are presented, as well as data concerning types of treatment and feeding practices during diarrhea. 10.3.1 Childhood Diarrhea Diarrhea remains a leading cause of childhood morbidity and mortality in developing countries. Dehydration from diarrhea has been an important contributing cause of childhood mortality. The administration of oral rehydration therapy (ORT) is a simple means of countering the effects of dehydration. During diarrhea, the child is given a solution prepared either by mixing water with the salts in a commercially prepared oral rehydration packet (ORS)—also called khabar or packet saline in Bangladesh—or by making a homemade solution of sugar, salt, and water, also called labon gur. Oral rehydration therapy has a long 70 68 77 76 84 8380 78 Measles vaccine All basic vaccinations Percent 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS 142 • Child Health history of use in Bangladesh because it was developed more than four decades ago by the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B). Currently, ORS packets are available through health facilities and at shops and pharmacies, many of which are marketed by the Social Marketing Company and other pharmaceutical companies. Research has shown that zinc provides a very effective treatment for diarrhea among children under age 5. Zinc treatment reduces the severity and duration of diarrhea as well as the likelihood of future episodes of diarrhea and the need for hospitalization. Studies conducted at the ICDDR,B have helped to build an evidence base for integrating zinc treatment into current child health practice and policies (ICDDR,B 2008). In the 2014 BDHS, respondents were asked if their children under age 5 had experienced an episode of diarrhea in the two weeks before the survey. Table 10.4 shows that 6 percent of children under age 5 were reported to have had diarrhea, including 1 percent with blood in the stools. The prevalence of diarrhea is highest at age 6-23 months, a period during which solid foods are first introduced into the child’s diet. This pattern is believed to be associated with increased exposure to illness as a result of both weaning and the greater mobility of the child, as well as the immature immune system of children in this age group. The prevalence of diarrhea is slightly higher among children living in households with non-improved toilet facilities. Diarrhea prevalence is higher for children in Barisal, Chittagong, and Dhaka, while children in Rangpur have the lowest reported diarrhea prevalence compared with children in other divisions. The relationship between diarrhea prevalence and mother’s education and wealth is not linear, but prevalence is lowest among children of mothers who have completed secondary or higher education, and also lowest among children living in households in the fourth wealth quintile. 10.3.2 Treatment of Childhood Diarrhea For children with diarrhea in the two weeks before the survey, the mother was asked what she did to treat the diarrhea. Because the prevalence of diarrhea varies seasonally, the survey results pertain only to the period from June to October, when the fieldwork took place. Table 10.5 shows that 36 percent of children under age 5 with diarrhea were taken to a health facility or provider for treatment. Overall, 84 percent of children with diarrhea were given oral rehydration therapy (ORT)—either a solution made from oral rehydration salt (ORS packets) (77 percent) or a homemade sugar-salt solution (20 percent)—while 9 percent received no treatment at all for diarrhea. Figure10.2 shows that use of ORT increased from 81 percent in 2011 to 84 percent in 2014. Table 10.4 Prevalence of diarrhea Percentage of children under age 5 who had diarrhea in the two weeks preceding the survey, by background characteristics, Bangladesh 2014 Diarrhea in the two weeks preceding the survey Number of children Background characteristic All diarrhea Diarrhea with blood Age in months <6 6.0 0.9 657 6-11 6.7 1.0 857 12-23 8.5 0.9 1,633 24-35 5.1 0.8 1,563 36-47 4.0 0.8 1,535 48-59 4.3 1.4 1,515 Sex Male 5.7 0.7 4,051 Female 5.6 1.3 3,710 Source of drinking water1 Improved 5.7 1.0 7,564 Not improved 5.3 1.7 190 Toilet facility2 Improved, not shared 4.9 0.8 3,413 Shared3 5.5 0.7 1,766 Non-improved 6.8 1.4 2,581 Residence Urban 5.7 0.6 1,984 Rural 5.7 1.1 5,777 Division Barisal 6.5 1.3 444 Chittagong 6.7 0.8 1,668 Dhaka 6.5 1.3 2,733 Khulna 3.6 0.7 580 Rajshahi 4.3 0.8 797 Rangpur 2.7 1.0 768 Sylhet 6.1 0.6 771 Mother’s education No education 5.9 2.4 1,270 Primary incomplete 6.3 1.3 1,269 Primary complete4 6.1 0.9 896 Secondary incomplete 5.9 0.6 3,102 Secondary complete or higher5 3.8 0.2 1,223 Wealth quintile Lowest 6.1 1.6 1,754 Second 6.4 2.0 1,462 Middle 5.9 0.5 1,500 Fourth 4.6 0.5 1,551 Highest 5.2 0.3 1,493 Total 5.7 1.0 7,760 Note: Total includes children with missing information on source of drinking water and toilet facility. 1 See Table 2.1 for definition of categories. 2 See Table 2.2 for definition of categories. 3 Shared facilities of an otherwise improved type 4 Primary complete is defined as completing grade 5. 5 Secondary complete is defined as completing grade 10. Child Health • 143 Table 10.5 Diarrhea treatment Among children under age 5 who had diarrhea in the two weeks preceding the survey, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage given oral rehydration therapy (ORT), the percentage given increased fluids, the percentage given ORT or increased fluids, and the percentage who were given other treatments, by background characteristics, Bangladesh 2014 Percentage of children with diarrhea for whom advice or treatment was sought from a health facility or provider1 Oral rehydration therapy (ORT) Increased fluids ORT or increased fluids Other treatments No treatment Number of children with diarrhea Background characteristic ORS packets Recom- mended home fluids (RHF) Either ORS or RHF1 Zinc syrup Zinc tablets Age in months <6 * * * * * * * * * 39 6-11 39.5 62.5 19.2 72.3 15.3 72.3 39.9 11.1 17.2 57 12-23 42.1 82.8 18.3 90.0 27.4 90.9 46.3 10.1 5.7 138 24-35 41.1 89.6 23.8 92.9 23.6 92.9 45.6 18.8 5.6 79 36-47 25.0 75.1 19.2 82.7 24.2 85.1 33.0 18.9 4.4 61 48-59 (35.1) (81.7) (26.8) (93.4) (22.4) (94.1) (11.1) (15.3) (5.1) 65 Sex Male 37.2 80.8 20.5 87.9 25.0 88.9 39.1 10.7 7.4 232 Female 35.2 72.9 18.4 80.2 20.6 83.7 32.0 15.3 10.8 208 Type of diarrhea Non-bloody 39.4 77.2 17.2 82.4 25.1 84.7 38.1 11.4 10.1 367 Bloody 21.1 75.6 31.6 93.2 12.3 94.9 24.5 20.7 3.8 72 Residence Urban 53.4 83.4 17.3 88.5 24.4 89.6 36.0 10.5 9.7 112 Rural 30.4 74.8 20.2 82.8 22.4 85.3 35.7 13.7 8.8 328 Division Barisal (32.5) (85.8) (19.2) (88.5) (17.6) (88.5) (46.4) (14.6) (11.5) 29 Chittagong 40.5 79.5 29.2 83.8 14.1 83.8 33.8 15.1 12.1 111 Dhaka 37.2 81.8 12.8 88.9 25.3 89.6 37.7 12.4 3.9 177 Khulna (34.9) (70.0) (25.9) (84.3) (38.5) (88.9) (32.5) (12.2) (11.1) 21 Rajshahi (34.3) (72.3) (23.3) (82.4) (27.5) (82.4) (17.8) (6.1) (14.6) 34 Rangpur * * * * * * * * * 21 Sylhet (32.7) (66.7) (15.8) (79.2) (23.0) (83.2) (39.0) (12.3) (13.1) 47 Mother’s education No education 36.8 85.9 15.3 87.9 21.0 87.9 35.3 14.7 9.4 74 Primary incomplete 27.1 66.5 21.8 73.6 21.8 82.5 35.1 16.9 13.9 80 Primary complete2 22.4 69.5 16.7 80.3 8.3 81.2 22.2 6.5 6.1 55 Secondary incomplete 39.5 80.3 19.4 89.1 28.9 90.0 43.5 11.6 8.3 184 Secondary complete or higher3 (54.8) (76.9) (25.7) (82.5) (21.3) (82.5) (23.0) (15.7) (6.1) 46 Wealth quintile Lowest 29.9 71.8 26.1 84.2 37.0 89.5 44.1 12.9 9.2 107 Second 30.6 74.5 20.8 84.0 14.8 84.0 26.4 16.1 9.3 94 Middle 32.1 77.7 15.4 81.9 9.9 83.5 34.4 6.8 10.2 89 Fourth 31.1 82.7 19.9 84.2 25.9 84.2 31.2 12.3 9.8 72 Highest 61.3 81.3 13.1 87.5 25.5 90.3 41.2 16.6 6.4 78 Total 36.3 77.0 19.5 84.3 22.9 86.4 35.7 12.9 9.0 440 Note: ORT includes fluid prepared from oral rehydration salt (ORS) packets, pre-packaged ORS fluid, and recommended home fluids (RHF). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes pharmacy, shop, and traditional practitioner 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. In 2014, 20 percent of children under age 5 with recent diarrhea were given recommended home fluids (RHF), double the percentage in 2011, at 10 percent. The use of commercially available ORS packets has remained virtually unchanged in recent surveys, at 77 percent in 2007, 78 percent in 2011, and 77 percent in 2014 (NIPORT et al. 2009). The percentage of children receiving increased fluids has decreased slightly, from 25 percent in 2011 to 23 percent in 2014 (NIPORT et al. 2013). Zinc is another diarrheal treatment, available in the market in the form of tablets and syrup. Zinc is not a substitute for ORT, but when taken in addition to ORT, it can reduce the severity and duration of diarrhea. Table 10.6 shows that, overall, 46 percent of children under age 5 with diarrhea received ORT only, 6 percent received zinc only, and 38 percent received both ORT and zinc. Figure 10.2 shows that the use of ORT and zinc to treat children with diarrhea has been increasing, from 20 percent in 2007 and 34 percent in 2011 to the level of 38 percent in the 2014 BDHS. The combined treatment of ORT and zinc varies little by child’s age after age 6 months. Male children are more likely than female children to receive ORT and zinc 144 • Child Health (40 and 36 percent, respectively). Children living in urban areas are more likely to receive ORT and zinc (40 percent) compared with children living in rural areas (37 percent). Treatment of diarrhea with ORT and zinc ranges from 21 percent among children in Rajshahi and Rangpur to 52 percent in Barisal. Figure 10.2 Trend in use of ORT and zinc for treatment of diarrhea in children under age 5, 2007-2014 81 20 81 34 84 38 ORT ORT and zinc Percent 2007 BDHS 2011 BDHS 2014 BDHS Child Health • 145 Table 10.6 Diarrhea treatment with ORT and zinc Among children under age 5 who had diarrhea in the two weeks preceding the survey, percentage who received oral rehydration therapy (ORT) but not zinc syrup or tablets, percentage who received zinc but not ORT, and percentage who received both ORT and zinc, by background characteristics, Bangladesh 2014 Background characteristic ORT but not zinc Zinc syrup/ tablets but not ORT ORT and zinc Number of children with diarrhea Age in months <6 * * * 39 6-11 36.5 10.5 35.8 57 12-23 43.2 4.3 46.8 138 24-35 33.7 1.4 59.3 79 36-47 49.4 10.5 33.3 61 48-59 (70.9) (0.8) (22.5) 65 Sex Male 47.8 4.3 40.1 232 Female 44.5 8.0 35.8 208 Type of diarrhea Non-bloody 46.0 4.7 38.5 363 Bloody 46.0 12.9 36.7 76 Residence Urban 48.1 1.8 40.4 112 Rural 45.6 7.5 37.3 328 Division Barisal (36.1) (0.0) (52.3) 29 Chittagong 45.0 4.2 38.7 111 Dhaka 49.2 7.2 39.7 177 Khulna (48.5) (0.0) (35.7) 21 Rajshahi (61.5) (3.1) (20.8) 34 Rangpur * * * 21 Sylhet (36.5) (3.7) (42.7) 47 Mother’s education No education 45.0 2.7 43.0 74 Primary incomplete 38.1 10.1 35.4 80 Primary complete1 64.2 12.7 16.0 55 Secondary incomplete 41.8 2.3 47.3 184 Secondary complete or higher2 (58.4) (11.3) (24.2) 46 Wealth quintile Lowest 36.8 6.2 47.4 107 Second 54.0 6.7 30.0 94 Middle 50.7 6.3 31.2 89 Fourth 47.6 6.0 36.6 72 Highest 43.4 4.9 44.1 78 Total 46.2 6.0 38.1 440 Note: ORT includes fluid prepared from oral rehydration salt (ORS) packets, pre-packaged ORS fluid, and recommended home fluids (RHF). Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate 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. 10.3.3 Feeding Practices during Diarrhea Mothers are encouraged to continue feeding children normally when they have diarrhea and to increase the amount of fluids they offer. The 2014 BDHS asked mothers who had a child under age 5 with a recent episode of diarrhea how much they gave the child to drink and eat during the diarrheal episode compared with their usual practice. Table 10.7 shows that 23 percent of children with diarrhea received more fluids than usual, while 42 percent received the usual amount. About one-third of mothers (35 percent) still engage in the dangerous practice of curtailing fluid intake when a child has diarrhea. The percentage of children with diarrhea receiving more liquids than usual has declined from 25 percent in 2011 to 23 percent in 2014 (NIPORT et al. 2013). Table 10.7 also shows that 34 percent of children with diarrhea were given the same amount of food as usual, and 58 percent were given less food. 14 6 • C hi ld H ea lth Ta ble 10 .7 Fe ed ing pr ac tic es du rin g d iar rhe a Pe rce nt dis trib uti on of ch ild ren un de r a ge 5 wh o h ad di arr he a i n t he tw o w ee ks pr ec ed ing th e s urv ey by am ou nt of liq uid s a nd fo od of fer ed co mp are d w ith no rm al pra cti ce , th e p erc en tag e o f c hil dre n g ive n i nc rea se d f lui ds an d c on tin ue d f ee din g du rin g t he di arr he a e pis od e, an d t he pe rce nta ge of ch ild ren w ho co nti nu ed fe ed ing an d w ere gi ve n O RT an d/o r in cre as ed flu ids du rin g t he ep iso de of di arr he a, by ba ck gro un d c ha rac ter ist ics , B an gla de sh 20 14 Am ou nt of liq uid s g ive n Am ou nt of foo d g ive n Pe rce nta ge giv en inc rea se d flu ids an d co nti nu ed fee din g1 Pe rce nta ge wh o c on tin ue d fee din g a nd we re giv en OR T a nd /or in - cre as ed flu ids 1 Nu mb er of ch ild ren w ith dia rrh ea Ba ck gro un d ch ara cte ris tic Mo re Sa me as us ua l So me - wh at les s Mu ch le ss No ne Do n’t kn ow / mi ss ing To tal Mo re Sa me as us ua l So me - wh at les s Mu ch le ss No ne Ne ve r ga ve fo od Do n’t kn ow / mi ss ing To tal Ag e i n m on th s <6 * * * * * * 10 0.0 * * * * * * * 10 0.0 * * 39 6-1 1 15 .3 52 .4 19 .5 12 .8 0.0 0.0 10 0.0 2.3 56 .9 18 .5 14 .8 2.0 5.5 0.0 10 0.0 13 .7 56 .2 57 12 -23 27 .4 39 .5 21 .1 12 .0 0.0 0.0 10 0.0 2.8 29 .2 49 .1 15 .1 3.7 0.0 0.0 10 0.0 25 .2 73 .3 13 8 24 -35 23 .6 39 .5 26 .2 8.5 0.0 2.1 10 0.0 3.1 35 .4 44 .7 13 .0 1.7 0.0 2.1 10 0.0 20 .4 77 .0 79 36 -47 24 .2 36 .0 18 .8 20 .9 0.0 0.0 10 0.0 0.0 32 .6 39 .8 27 .6 0.0 0.0 0.0 10 0.0 19 .1 63 .2 61 48 -59 (22 .4) (48 .4) (18 .1) (11 .1) (0. 0) (0. 0) 10 0.0 (12 .3) (19 .7) (49 .5) (16 .5) (2. 0) (0. 0) (0. 0) 10 0.0 21 .2 75 .7 65 Se x Ma le 25 .0 36 .0 21 .2 17 .1 0.0 0.7 10 0.0 2.9 26 .2 42 .0 22 .1 2.2 3.6 1.0 10 0.0 23 .3 64 .9 23 2 Fe ma le 20 .6 47 .8 18 .6 12 .6 0.4 0.0 10 0.0 4.4 41 .7 36 .2 14 .6 2.1 1.0 0.0 10 0.0 17 .1 67 .3 20 8 Ty pe of di ar rh ea No n-b loo dy 19 .9 42 .3 22 .2 15 .0 0.2 0.5 10 0.0 2.6 33 .8 38 .6 18 .9 2.6 2.9 0.7 10 0.0 17 .1 62 .8 36 3 Blo od y 35 .8 39 .0 9.9 15 .3 0.0 0.0 10 0.0 8.7 33 .1 41 .0 17 .2 0.0 0.0 0.0 10 0.0 33 .9 80 .6 76 Re sid en ce Ur ba n 24 .4 49 .3 13 .5 11 .3 0.0 1.5 10 0.0 3.8 47 .1 27 .5 15 .9 1.5 2.7 1.5 10 0.0 22 .8 69 .4 11 2 Ru ral 22 .4 38 .9 22 .2 16 .3 0.2 0.0 10 0.0 3.6 28 .9 43 .3 19 .4 2.4 2.3 0.2 10 0.0 19 .5 64 .9 32 8 Di vis ion Ba ris al (17 .6) (23 .4) (28 .3) (30 .6) (0. 0) (0. 0) 10 0.0 (0. 0) (32 .8) (40 .5) (26 .7) (0. 0) (0. 0) (0. 0) 10 0.0 (16 .3) (61 .8) 29 Ch itta go ng 14 .1 52 .0 24 .9 9.1 0.0 0.0 10 0.0 4.7 37 .1 40 .2 13 .7 3.4 0.9 0.0 10 0.0 11 .6 67 .9 11 1 Dh ak a 25 .3 38 .6 15 .1 20 .1 0.0 0.9 10 0.0 3.6 24 .9 46 .7 20 .9 2.3 0.7 0.9 10 0.0 25 .3 66 .7 17 7 Kh uln a (38 .5) (28 .9) (5. 6) (23 .6) (3. 5) (0. 0) 10 0.0 (3. 4) (50 .6) (18 .0) (24 .5) (0. 0) (3. 5) (0. 0) 10 0.0 (34 .7) (67 .6) 21 Ra jsh ah i (27 .5) (36 .5) (30 .6) (5. 4) (0. 0) (0. 0) 10 0.0 (3. 9) (24 .3) (36 .6) (23 .6) (2. 8) (8. 9) (0. 0) 10 0.0 (16 .7) (54 .1) 34 Ra ng pu r * * * * * * 10 0.0 * * * * * * * 10 0.0 * * 21 Sy lhe t (23 .0) (46 .2) (23 .0) (7. 7) (0. 0) (0. 0) (10 0.0 ) (4. 9) (41 .0) (28 .1) (15 .2) (1. 4) (9. 3) (0. 0) (10 0.0 ) (16 .7) (66 .0) 47 Mo th er ’s ed uc ati on No ed uc ati on 21 .0 48 .7 25 .9 4.4 0.0 0.0 10 0.0 4.9 35 .7 50 .1 7.6 1.3 0.5 0.0 10 0.0 19 .1 79 .1 74 Pr im ary in co mp let e 21 .8 38 .3 21 .8 18 .0 0.0 0.0 10 0.0 2.0 33 .6 31 .5 21 .3 3.1 8.4 0.0 10 0.0 20 .7 55 .5 80 Pr im ary co mp let e2 8.3 51 .9 26 .7 10 .0 0.0 3.1 10 0.0 0.0 50 .3 29 .5 17 .1 0.0 0.0 3.1 10 0.0 6.6 67 .4 55 Se co nd ary in co mp let e 28 .9 35 .0 14 .6 21 .0 0.4 0.0 10 0.0 4.8 25 .8 41 .6 23 .0 2.9 1.5 0.4 10 0.0 25 .2 63 .9 18 4 Se co nd ary co mp let e or hig he r3 (21 .3) (49 .4) (20 .7) (8. 6) (0. 0) (0. 0) 10 0.0 (4. 3) (40 .5) (37 .5) (15 .4) (1. 4) (0. 9) (0. 0) 10 0.0 (18 .8) (70 .3) 46 W ea lth qu int ile Lo we st 37 .0 27 .1 21 .9 14 .0 0.0 0.0 10 0.0 3.6 34 .6 45 .1 12 .7 0.9 2.5 0.6 10 0.0 35 .7 75 .6 10 7 Se co nd 14 .8 43 .7 21 .2 19 .5 0.8 0.0 10 0.0 0.7 25 .8 42 .2 21 .5 6.5 3.2 0.0 10 0.0 12 .6 61 .1 94 Mi dd le 9.9 49 .5 20 .4 20 .2 0.0 0.0 10 0.0 2.1 31 .7 42 .8 21 .2 0.0 2.2 0.0 10 0.0 8.8 62 .0 89 Fo urt h 25 .9 45 .6 19 .9 6.3 0.0 2.4 10 0.0 9.4 29 .0 38 .4 19 .9 0.9 0.0 2.4 10 0.0 18 .8 62 .0 72 Hi gh es t 25 .5 46 .1 15 .4 12 .9 0.0 0.0 10 0.0 3.8 47 .8 24 .3 18 .5 2.2 3.4 0.0 10 0.0 23 .2 67 .3 78 To tal 22 .9 41 .6 20 .0 15 .0 0.2 0.4 10 0.0 3.6 33 .5 39 .3 18 .5 2.2 2.4 0.5 10 0.0 20 .3 66 .1 44 0 No te: It is rec om me nd ed th at ch ild ren sh ou ld be gi ve n m ore liq uid s t o d rin k d uri ng di arr he a a nd fo od sh ou ld no t b e r ed uc ed . F igu res in pa ren the se s a re ba se d o n 2 5-4 9 u nw eig hte d c as es . A n a ste ris k i nd ica tes th at an es tim ate is ba se d o n few er tha n 2 5 u nw eig hte d c as es an d h as be en su pp res se d. 1 C on tin ue d f ee din g i nc lud es ch ild ren w ho w ere gi ve n m ore , s am e a s u su al, or so me wh at les s f oo d d uri ng th e d iar rhe a e pis od e. 2 P rim ary co mp let e i s d efi ne d a s c om ple tin g g rad e 5 . 3 S ec on da ry co mp let e i s d efi ne d a s c om ple tin g g rad e 1 0. Child Health • 147 10.3.4 Acute Respiratory Infections Acute respiratory infection (ARI) is a leading cause of childhood illness and death. Early diagnosis and treatment with antibiotics can reduce the number of deaths caused by ARI, particularly deaths resulting from pneumonia. Respondents in the 2014 BDHS were asked if their children under age 5 had experienced symptoms of ARI in the two weeks before the survey. Table 10.8 shows that, overall, 5 percent of children under age 5 had symptoms of ARI in the two weeks preceding the survey. The prevalence of ARI decreases slightly with the increasing age of the child. Children living in rural areas are more likely to suffer from ARI than children living in urban areas. A higher proportion of children living in Rajshahi and Sylhet have symptoms of ARI compared with other divisions. Table 10.8 Prevalence and treatment of symptoms of ARI Among children under age 5, the percentage who had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey and among children with symptoms of ARI, the percentage for whom advice or treatment was sought from a health facility or provider and the percentage who received antibiotics as treatment, according to background characteristics, Bangladesh 2014 Among children under age 5: Among children under age 5 with symptoms of ARI: Background characteristic Percentage with symptoms of ARI1 Number of children Percentage for whom advice or treatment was sought from a health facility or provider2 Pharmacy Traditional doctor Other No one Percentage who received antibiotics Number of children Age in months <6 6.7 657 (43.5) (21.5) (22.4) (6.7) (12.3) (33.1) 44 6-11 8.5 857 42.1 34.1 28.3 4.8 4.3 41.0 73 12-23 6.5 1,633 50.0 25.5 18.4 1.4 10.2 33.3 106 24-35 5.6 1,563 45.1 14.4 19.2 2.8 16.6 27.5 88 36-47 3.9 1,535 25.9 39.7 26.3 1.6 8.0 39.8 59 48-59 3.1 1,515 (36.8) (18.6) (42.2) (0.0) (11.5) (32.1) 47 Sex Male 6.1 4,051 38.8 25.7 24.8 3.0 12.4 33.2 248 Female 4.5 3,710 46.7 25.2 24.1 2.3 7.9 35.6 169 Residence Urban 4.3 1,984 52.1 22.8 12.2 3.1 11.8 33.2 86 Rural 5.7 5,777 39.3 26.2 27.7 2.6 10.2 35.6 331 Division Barisal 4.1 444 (38.6) (22.5) (31.4) (0.0) (17.6) (45.3) 18 Chittagong 4.9 1,668 46.3 22.9 20.7 2.8 12.6 38.7 81 Dhaka 5.2 2,733 43.2 31.4 19.3 0.0 8.7 33.9 141 Khulna 6.0 580 (44.8) (15.2) (46.0) (4.3) (5.4) (32.3) 35 Rajshahi 6.6 797 37.3 28.7 20.5 5.7 12.3 31.9 53 Rangpur 5.2 768 (30.1) (22.4) (41.6) (9.2) (4.2) (47.5) 40 Sylhet 6.3 771 45.0 20.3 18.6 1.9 16.8 16.5 49 Mother’s education No education 4.5 1,270 31.2 37.9 14.6 3.9 15.0 21.2 57 Primary incomplete 5.8 1,269 37.5 26.9 26.6 2.9 14.0 37.7 74 Primary complete3 9.2 896 44.3 23.7 25.0 3.4 6.2 22.3 82 Secondary incomplete 5.3 3,102 45.1 22.1 30.1 2.6 6.9 43.1 163 Secondary complete or higher4 3.3 1,223 (48.0) (22.8) (11.5) (0.0) (21.6) (34.3) 40 Wealth quintile Lowest 6.8 1,679 37.6 27.3 26.4 1.2 14.3 22.8 114 Second 6.3 1,405 43.5 28.3 27.5 1.1 6.0 35.2 89 Middle 5.3 1,419 37.0 26.8 27.3 6.7 5.6 43.5 75 Fourth 5.1 1,557 39.3 25.3 26.1 2.2 11.9 33.8 80 Highest 3.5 1,701 57.8 16.5 10.8 3.9 14.9 44.7 59 Total 5.4 7,760 42.0 25.5 24.5 2.7 10.6 34.2 417 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Symptoms of ARI (cough accompanied by short, rapid breathing that was chest-related and/or by difficult breathing that was chest-related) is considered a proxy for pneumonia. 2 Excludes pharmacy and traditional practitioner 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. 148 • Child Health Forty-two percent of children with symptoms of ARI were taken to a health facility or a medically trained provider for treatment. This is a slightly higher percentage than that recorded in the 2011 BDHS (35 percent) (NIPORT et al. 2013). Female children are more likely than male children to be taken to a health facility or trained provider when ill with ARI (47 percent versus 39 percent), a reverse of the findings in the 2011 BDHS (29 percent of female children versus 40 percent of male children). Urban children are more likely than rural children to receive treatment at a health facility or from a medically trained provider (52 percent versus 39 percent). In addition, treatment was sought from a pharmacy for 26 percent of children, and 25 percent were treated by a traditional doctor. In the 2014 BDHS, the interviewing teams were provided with a list of drug names to facilitate identifying whether the drug given to a child reported to have ARI symptoms is an antibiotic or not. About one-third of children (34 percent) were given antibiotics. This proportion is much lower than the target of 50 percent of children age 0-59 months that was set in the HPNSDP 2011-16 (MOHFW 2011). While it may seem that the use of antibiotics to treat ARI has decreased, from 71 percent in 2011 to 34 percent in 2014, the estimates are not comparable because the methodology for obtaining the information in the two surveys differs. In the 2011 BDHS, respondents were asked which drugs children with ARI symptoms took. The responses were recorded and checked against a precoded list of antimalarial drugs, two types of antibiotics, and other drugs. This likely resulted in an overestimation of the use of antibiotics. In an attempt to obtain a more accurate estimate on the use of antibiotics to treat ARI in children, interviewers in the 2014 BDHS were instructed to ask the name of the drug(s) used. If the woman did not know the name of the drug, the respondent was asked to show the drug or the packaging of the drug. As in the 2011 BDHS, multiple responses were allowed to account for multiple drugs taken for the illness in the past two weeks. In the 2014 BDHS, the list consisted of six types of antimalarial drugs, seven types of antibiotics, and other drugs. The interviewers were also given a detailed list of various drugs that are commonly given to children with ARI and are available in the market. Table 10.8 shows that children age 6-11 months, female children, children living in rural areas, and children living in households in the highest wealth quintile are more likely than other children to receive antibiotics for symptoms of ARI. 10.4 FEVER Fever is a major manifestation of malaria and other acute infections in children. Malaria and fever contribute to high levels of malnutrition and morbidity. Table 10.9 shows the percentage of children under age 5 who had a fever during the two weeks preceding the survey and their treatments. Among children under age 5, 37 percent had a fever in the two weeks before the survey. Children age 6-23 months are more likely to have fever than either younger or older children. The prevalence of fever is highest among children in Sylhet division (43 percent) and lowest in Khulna (31 percent). Fifty-five percent of the children with fever were taken to a health facility or trained medical provider for treatment. The percentage of children with fever for whom medical care is sought from a health facility or medical provider has increased from 27 percent in 2011 (NIPORT et al. 2013). Table 10.9 shows that urban children and children in Khulna division are more likely than rural children and children in other divisions to receive this kind of treatment. The likelihood of being taken to a health facility or medical provider for treatment increases with a mother’s education and wealth. For example, 49 percent of children in the lowest wealth quintile were taken to a health facility or a medical provider for treatment of their fever compared with 60 percent of children in the highest wealth quintile. Table 10.9 also shows that 9 percent of children with fever received antibiotics. Children age 48-59 months, male children, and children in Barisal division are more likely than other children to receive antibiotic treatment. Five percent of children received antimalarial drugs. Child Health • 149 Table 10.9 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the two weeks preceding the survey; and among children with fever, the percentage for whom advice or treatment was sought from a health facility or provider, the percentage who took antimalarial drugs, and the percentage who received antibiotics as treatment, and among children with fever who were treated with antibiotic drugs, the percentage for whom the drug was prescribed by a health professional, by background characteristics, Bangladesh 2014 Among children under age 5: Among children under age 5 with fever: Among children under age 5 with fever who were treated with antibiotic drugs: Background characteristic Percentage with fever Number of children Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage who took antimalarial drugs Percentage who took antibiotic drugs Number of children with fever Percentage prescribed by a health professional/ worker Number of children who took antibiotic drugs Age in months <6 34.7 657 55.3 2.7 10.3 228 * 24 6-11 46.6 857 65.7 5.1 8.2 399 (53.0) 33 12-23 39.3 1,633 55.6 3.6 7.9 643 49.3 51 24-35 35.9 1,563 53.3 5.3 8.3 562 (64.2) 46 36-47 34.6 1,535 48.6 4.0 7.6 531 (32.8) 41 48-59 32.3 1,515 56.3 8.7 11.9 490 (74.5) 58 Sex Male 37.0 4,051 56.6 6.1 10.1 1,498 59.9 151 Female 36.5 3,710 54.0 3.8 7.5 1,354 47.7 101 Residence Urban 33.8 1,984 59.1 3.5 6.3 670 (67.0) 42 Rural 37.8 5,777 54.2 5.5 9.6 2,182 52.6 210 Division Barisal 37.9 444 51.2 3.3 17.0 168 (40.3) 29 Chittagong 38.4 1,668 59.2 8.3 7.7 641 (51.9) 49 Dhaka 34.0 2,733 51.1 4.7 8.0 930 (72.1) 75 Khulna 31.3 580 63.3 4.2 4.7 182 * 9 Rajshahi 37.1 797 53.3 1.1 10.0 296 (41.6) 30 Rangpur 40.0 768 59.2 3.3 11.1 307 (53.8) 34 Sylhet 42.6 771 56.0 6.2 8.4 328 (50.7) 27 Mother’s education No education 36.0 1,270 51.1 4.5 10.4 457 (58.7) 48 Primary incomplete 38.4 1,269 51.4 6.9 8.4 487 (69.6) 41 Primary complete2 38.7 896 50.1 2.6 6.2 347 (38.2) 21 Secondary incomplete 37.3 3,102 56.7 5.2 8.8 1,156 42.9 102 Secondary complete or higher3 33.1 1,223 65.5 5.1 10.0 405 (75.4) 40 Wealth quintile Lowest 36.6 1,754 48.7 4.6 6.5 642 28.9 42 Second 35.8 1,462 54.3 4.5 9.3 524 (41.6) 49 Middle 42.4 1,500 58.4 4.9 11.1 635 72.5 70 Fourth 36.8 1,551 56.4 6.7 9.1 571 52.2 52 Highest 32.1 1,493 60.2 4.4 8.1 480 (72.0) 39 Total 36.8 7,760 55.4 5.0 8.8 2,852 55.0 252 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Excludes pharmacy, shop, market, and traditional practitioner 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Among children under age 5 with fever who were treated with antibiotics, 55 percent were prescribed by health professionals, an increase of 22 percentage points from 33 percent in 2011. Male children, urban children, and children in Dhaka division are more likely than other children to receive prescribed medication. Children whose mothers have secondary or higher education and children living in households in the highest wealth quintile are most likely to receive a prescribed antibiotic drug compared with children whose mothers have less education and children living in households in the lowest wealth quintile. In the 2014 BDHS, mothers of children with fever in the two weeks preceding the survey were asked to report in chronological order where they sought advice or treatment for their child. Table 10.10 shows the first source of treatment. Among children with fever, 69 percent were taken first to a private medical sector, a level 4 percentage points higher than in the 2011 BDHS. Ten percent of children with fever received their first treatment from the public sector, 2 percentage points more than in the 2011 BDHS. The proportion of children with fever who were not treated has declined substantially, from 24 percent in 2011 to 16 percent in 2014 (NIPORT et al. 2013). 150 • Child Health Table 10.10 First source of treatment of fever Percent distribution of children under age 5 who had fever in the two weeks preceding the survey by the first source of treatment, according to background characteristics, Bangladesh 2014 Background characteristic Public sector NGO sector Private medical sector Other source No treatment sought Total Number of children with fever Age in months <6 13.4 0.6 54.0 12.2 19.8 100.0 228 6-11 9.7 0.5 72.8 3.7 13.3 100.0 399 12-23 9.4 0.5 70.9 3.6 15.5 100.0 643 24-35 13.1 1.2 64.9 2.7 18.2 100.0 562 36-47 6.7 0.2 70.1 5.1 17.9 100.0 531 48-59 9.4 1.5 72.1 2.3 14.7 100.0 490 Sex Male 9.0 0.7 70.8 3.5 16.1 100.0 1,498 Female 11.1 0.9 66.3 5.0 16.7 100.0 1,354 Residence Urban 12.3 0.8 69.6 4.8 12.5 100.0 670 Rural 9.3 0.7 68.4 4.0 17.6 100.0 2,182 Division Barisal 15.5 0.0 60.9 0.8 22.8 100.0 168 Chittagong 9.7 1.3 69.0 3.4 16.6 100.0 641 Dhaka 9.5 0.2 70.9 2.9 16.6 100.0 930 Khulna 16.1 0.6 63.0 3.4 17.0 100.0 182 Rajshahi 8.4 1.0 65.9 7.1 17.6 100.0 296 Rangpur 8.8 0.3 66.6 11.0 13.4 100.0 307 Sylhet 8.2 2.0 73.5 2.7 13.6 100.0 328 Mother’s education No education 10.4 0.2 66.1 4.2 19.0 100.0 457 Primary incomplete 9.3 0.9 66.9 5.7 17.1 100.0 487 Primary complete1 8.6 1.2 71.2 2.7 16.4 100.0 347 Secondary incomplete 9.5 0.7 70.1 4.1 15.6 100.0 1,156 Secondary complete or higher2 12.9 1.0 67.4 4.0 14.7 100.0 405 Wealth quintile Lowest 10.4 0.4 65.9 5.7 17.6 100.0 642 Second 9.1 0.3 66.7 4.5 19.5 100.0 524 Middle 11.6 0.9 68.4 4.1 14.9 100.0 635 Fourth 11.4 1.0 68.8 2.6 16.1 100.0 571 Highest 6.6 1.2 74.8 3.8 13.7 100.0 480 Total 10.0 0.8 68.7 4.2 16.4 100.0 2,852 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Nutrition of Children and Women • 151 NUTRITION OF CHILDREN AND WOMEN 11 utritional status is the result of complex interactions between food consumption, overall health status, and care practices. Adequate nutrition is a prerequisite for attaining good health, quality of life, and national productivity. Although problems related to poor nutrition affect the entire population, women and children are especially vulnerable because of their unique physiology and socioeconomic characteristics. The period from birth to age 2 is crucial for optimal growth, health, and development. Unfortunately, this period is often marked by protein-energy and micronutrient deficiencies that interfere with optimal physical growth and cognitive development. Malnourished children have lower resistance to infection and are more likely to die from common childhood ailments, such as diarrheal diseases N Key Findings • Thirty-six percent of children under age 5 are stunted, 14 percent are wasted, and 33 percent are underweight. The HPNSDP 2011-16 targets for 2016 for stunting and underweight have been achieved. • Breastfeeding is almost universal in Bangladesh; 96 percent of children are breastfed during the first year of life and 87 percent of children are breastfed until age 2. Fifty-one percent of children are breastfed within one hour after birth, and 89 percent are breastfed within one day after delivery. • Fifty-five percent of children under age 6 months are exclusively breastfed. Median duration of exclusive breastfeeding is 2.8 months. • Twenty-seven percent of Bangladeshi children receive a prelacteal feed. The likelihood of receiving a prelacteal feed is higher for births assisted by a health professional and for births delivered at a health facility. • Bottle feeding is common in Bangladesh; 22 percent of infants 6-9 months are fed with a bottle with a nipple. Bottle feeding is most common among children age 4-5 months (26 percent). • Complementary foods are not introduced in a timely fashion for all children. Seventy percent of breastfed children age 6-9 months receive complementary foods. • Overall, only 23 percent of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices. • Sixty two percent of children received vitamin A supplementation in the 6 months preceding the survey. The HPNSDP 2011-16 target for 2016 is 90 percent. • Thirty-one percent of ever-married women age 15-19 are undernourished (BMI <18.5). However, women’s nutritional status has improved considerably in the last 10 years. The percentage of women undernourished (BMI<18.5) has declined from 34 to 19 percent between 2004 and 2014. • On the other hand, overweight or obesity (BMI ≥25) among ever-married women age 15-49 has been increasing over the past decade from 9 percent in 2004 to 24 percent in 2014. • Using a lower cutoff point, with BMI ≥23 as a measure of overweight or obesity among ever-married women age 15-49, the proportion has increased from 17 percent in 2004 to 39 percent in 2014. 152 • Nutrition of Children and Women and respiratory infections (Black et al. 2008). Malnutrition in adults results in reduced productivity, increased susceptibility to infections, slow recovery from illness, and for women, increased risk of adverse pregnancy outcomes (Victor et al. 2008). A woman of poor nutritional status—indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiencies—has a heightened risk of obstructed labor, having a baby with low birth weight, producing low-quality breast milk, and dying from postpartum hemorrhage. Morbidity, in general, is also high for both the woman and her baby. Effects of undernutrition are passed from one generation to the next, as undernourished girls tend to become short adults and thus are more likely to have small children (Victor et al. 2008). Poor nutritional status is one of the most important health and welfare problems in Bangladesh. Young children and women of reproductive age are especially vulnerable to nutritional deficits and micronutrient deficiencies. At the individual level, inadequate or inappropriate feeding patterns lead to malnutrition. Numerous socioeconomic and cultural factors influence patterns of feeding and nutritional status. Overweight and obesity is also a growing concern in Bangladesh. Overweight individuals are predisposed to a wide range of health problems such as diabetes and heart disease as well as poor birth outcomes for women. Maternal overweight and obesity at the time of pregnancy increases the risk for childhood obesity that continues into adolescence and early adulthood, with the potential to transmit obesity to the next generation (Black et al. 2013). The 2014 BDHS survey measured height and weight of children under age 5 and of ever-married women of reproductive age. The survey also collected data on feeding practices for infants and young children, including breastfeeding, the feeding of solid and semi-solid foods, diversity of foods, and frequency of feeding. Information was also collected on the feeding of micronutrients—vitamin A and iron—and vitamin A supplementation among children and women. 11.1 NUTRITIONAL STATUS OF CHILDREN The 2014 BDHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5 in the selected households. The nutritional status assessment helps to identify subgroups of the child population that face increased risk of faltered growth and provides data for comparison with previous surveys in trend analyses. 11.1.1 Measurement of Nutritional Status among Young Children The nutritional status of children in the survey population is compared with the World Health Organization (WHO) Child Growth Standards, which are based on an international sample of ethnically, culturally, and genetically diverse healthy children living under optimum conditions that are conducive to achieve a child’s full genetic growth potential (WHO 2006). The WHO Child Growth Standards identify breastfed children as the normative model for growth and development and document how children should grow under optimum conditions and with optimum infant feeding and child health practices. Use of the WHO Child Growth Standards is based on the finding that well-nourished children in all population groups for which data exist follow very similar growth patterns before puberty. These standards can therefore be used to assess the nutritional status of children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. Three standard indices of physical growth that describe the nutritional status of children are: • Height-for-age (stunting) • Weight-for-height (wasting) • Weight-for-age (underweight) Each of these indices provides different information about growth and body composition that can be used to assess nutritional status. Nutrition of Children and Women • 153 Height-for-age measures linear growth. A child who is more than two standard deviations below the median (-2 SD) of the WHO reference population in terms of height-for-age is considered short for his or her age, or stunted. This condition reflects the cumulative effect of chronic malnutrition. If a child is below three standard deviations (-3 SD) from the reference median, then the child is considered severely stunted. Stunting reflects a failure to receive adequate nutrition over a long period of time and is worsened by recurrent and chronic illness. Height-for-age, therefore, reflects the long-term effects of malnutrition in a population and does not vary appreciably according to recent dietary intake. Weight-for-height describes current nutritional status. A child who is more than two standard deviations below (-2 SD) the reference median for weight-for-height is considered to be too thin for his or her height, or wasted. This condition reflects acute or recent nutritional deficit. As with stunting, wasting is considered severe if the child is more than three standard deviations below the reference median. Severe wasting is closely linked to mortality risk. Weight-for-age is a composite index of weight-for-height and height-for-age. Thus, it does not distinguish between acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be underweight for his or her age because the child is stunted, is wasted, or both. Children whose weight-for- age is below two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age is below three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. Weight-for-age is an overall indicator of a population’s nutritional health. Z-score means are also calculated as summary statistics representing the nutritional status of children in a population. These mean scores describe the nutritional status of the entire population without the use of a cut-off. A mean Z-score of less than 0 (i.e., a negative mean value for stunting, wasting, or underweight) suggests that the distribution of an index has shifted downward and that most if not all children in the population suffer from undernutrition relative to the reference population. 11.1.2 Data Collection In the survey, all children under age 6 listed in the selected households were eligible for height and weight measurement, although the data analysis is restricted to children under age 5. Each interviewing team carried two weighing scales and two height boards. Weight was measured using lightweight SECA scales with digital screens, designed and manufactured under the authority of the United Nations Children’s Fund (UNICEF). The height/length boards were specially produced by Shorr Productions for use in survey settings. Recumbent length was recorded for children under age 2 or shorter than 85 centimeters. Standing height was measured for all other children. 11.1.3 Levels of Child Malnutrition Table 11.1 shows the percentage of children under age 5 classified as malnourished according to height-for-age, weight-for-height, and weight-for-age indices, by various background characteristics. A total of 8,325 children under age 5 (unweighted) in the BDHS sample households were eligible for anthropometric measurements. The following analysis focuses on the 7,318 children (88 percent) for whom complete and credible anthropometric and age data are available. Height-for-age (stunting) The data show that 36 percent of children under 5 are considered to be short for their age or stunted and 12 percent are severely stunted (below -3 SD). The prevalence of stunting increases with age, from 14 percent of children under age 6 months to 46 percent of children 18-23 months, and then decreases to 38 percent among children age 48-59 months. Severe stunting shows a similar pattern, with children age 18-23 months having the highest proportion of severe stunting (17 percent). Stunting is slightly higher among male children (37 percent) than among female children (35 percent). Stunting is more prevalent among children who were born less than 24 months after a preceding birth (47 percent). 154 • Nutrition of Children and Women Table 11.1 Nutritional status of children Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Bangladesh 2014 Height-for-age1 Weight-for-height Weight-for-age Number of children Background characteristic Percent- age below -3 SD Percent- age below -2 SD2 Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Percent- age below -3 SD Percent- age below -2 SD2 Percent- age above +2 SD Mean Z-score (SD) Age in months <6 3.8 14.0 (0.6) 4.9 19.9 4.3 (0.8) 3.6 19.0 0.0 (1.0) 583 6-8 3.1 16.2 (0.7) 4.8 16.2 2.4 (0.7) 2.9 16.1 1.7 (1.0) 389 9-11 6.5 22.6 (1.1) 5.8 20.1 1.5 (0.8) 6.3 24.8 1.0 (1.2) 437 12-17 10.6 30.6 (1.5) 6.0 17.6 1.3 (0.9) 8.5 29.4 0.3 (1.4) 809 18-23 16.5 46.3 (1.8) 2.0 12.4 1.4 (0.8) 8.9 34.7 0.3 (1.5) 744 24-35 13.4 41.4 (1.8) 2.2 12.6 1.1 (0.9) 9.0 36.7 0.6 (1.6) 1,446 36-47 14.2 44.5 (1.8) 1.7 11.4 1.0 (0.9) 8.2 36.6 0.0 (1.7) 1,457 48-59 12.3 38.4 (1.7) 2.4 13.7 0.9 (1.0) 8.4 37.6 0.3 (1.7) 1,452 Sex Male 11.8 36.7 (1.5) 3.7 15.0 1.5 (0.9) 7.5 32.2 0.4 (1.5) 3,801 Female 11.4 35.4 (1.5) 2.4 13.6 1.4 (0.9) 7.9 33.1 0.4 (1.5) 3,516 Birth interval in months3 First birth4 8.4 31.6 (1.4) 2.8 14.0 2.1 (0.8) 5.9 28.8 0.6 (1.4) 2,749 <24 15.9 47.4 (1.8) 1.4 15.9 0.3 (1.0) 10.5 43.8 0.0 (1.7) 485 24-47 16.4 43.6 (1.8) 4.3 16.1 1.2 (1.0) 10.7 39.1 0.2 (1.7) 1,461 48+ 11.2 34.8 (1.5) 3.1 13.4 1.1 (0.9) 7.3 31.0 0.4 (1.4) 2,429 Size at birth3 Very small 18.1 43.1 (1.8) 7.5 26.4 1.0 (1.3) 13.3 51.2 0.0 (2.0) 282 Small 18.7 43.3 (1.8) 4.8 20.6 1.2 (1.1) 15.7 43.1 0.5 (1.8) 562 Average or larger 8.4 29.9 (1.3) 3.3 13.9 1.9 (0.7) 5.4 25.7 0.6 (1.2) 3,497 Mother’s interview status Interviewed 11.5 36.2 (1.5) 3.1 14.4 1.4 (0.9) 7.7 32.7 0.4 (1.5) 7,123 Not interviewed5 17.3 32.4 (1.5) 3.6 13.7 0.7 (0.9) 9.2 31.8 0.0 (1.5) 195 Residence Urban 9.8 30.8 (1.3) 3.1 12.2 1.8 (0.7) 6.6 26.1 0.9 (1.3) 1,828 Rural 12.3 37.9 (1.6) 3.1 15.1 1.3 (0.9) 8.1 34.8 0.2 (1.6) 5,490 Division Barisal 10.4 39.9 (1.5) 3.9 17.7 1.4 (1.0) 7.5 36.9 0.8 (1.5) 424 Chittagong 14.1 38.0 (1.6) 3.8 15.6 1.4 (0.9) 8.7 36.0 0.4 (1.5) 1,541 Dhaka 10.1 33.9 (1.5) 2.1 11.9 2.1 (0.8) 7.0 28.5 0.5 (1.4) 2,546 Khulna 7.3 28.1 (1.4) 3.0 13.5 0.4 (0.9) 5.2 25.5 0.1 (1.4) 565 Rajshahi 9.8 31.1 (1.4) 3.7 17.3 0.9 (1.0) 6.6 32.1 0.1 (1.5) 780 Rangpur 9.8 36.0 (1.5) 5.0 17.7 1.3 (1.1) 8.0 36.8 0.3 (1.6) 762 Sylhet 19.8 49.6 (1.9) 2.2 12.1 0.8 (0.9) 11.5 39.8 0.1 (1.7) 700 Mother’s education6 No education 18.4 47.4 (1.9) 3.0 14.7 0.6 (1.0) 12.1 41.9 0.2 (1.8) 1,161 Primary incomplete 16.6 44.3 (1.8) 3.5 14.6 0.9 (1.0) 10.1 38.5 0.1 (1.7) 1,165 Primary complete7 13.4 43.2 (1.8) 3.6 16.6 0.6 (1.1) 10.3 40.1 0.0 (1.7) 828 Secondary incomplete 8.8 33.2 (1.5) 2.8 13.9 1.9 (0.9) 5.9 30.1 0.4 (1.4) 2,868 Secondary complete or higher8 4.1 18.4 (0.9) 3.3 13.2 2.4 (0.7) 3.1 17.9 1.3 (1.0) 1,101 Wealth quintile Lowest 18.8 49.2 (1.9) 3.7 17.1 0.5 (1.1) 12.8 45.1 0.1 (1.9) 1,661 Second 13.3 42.2 (1.7) 3.6 16.5 0.9 (1.0) 8.8 38.7 0.0 (1.7) 1,383 Middle 10.8 35.9 (1.6) 2.8 12.8 2.2 (0.9) 7.1 32.1 0.1 (1.5) 1,464 Fourth 8.5 31.0 (1.4) 2.7 13.1 0.7 (0.8) 5.4 27.3 0.3 (1.3) 1,465 Highest 5.4 19.4 (1.0) 2.8 11.7 3.0 (0.6) 3.5 17.4 1.5 (1.0) 1,345 Total 11.6 36.1 (1.5) 3.1 14.3 1.4 (0.9) 7.7 32.6 0.4 (1.5) 7,318 Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. 1 Recumbent length is measured for children under age 2, or in the few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children. 2 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth Standards population median 3 Excludes children whose mothers were not interviewed 4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval. 5 Includes children whose mothers are deceased and those not in the household 6 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire 7 Primary complete is defined as completing grade 5. 8 Secondary complete is defined as completing grade 10. Nutrition of Children and Women • 155 The 2014 BDHS asked mothers their perception of their child’s birth size: average or larger, small, or very small. Perceived birth size is used as a proxy for birth weight because the majority of deliveries in Bangladesh occur at home and newborns are not weighed at birth. Table 11.1 shows that among children who are perceived by their mothers to be very small or small, 43 percent are stunted. A previous study in Bangladesh showed a similar result; children’s birth weight is an important determinant of their nutritional status (Rahman and Chowdhury 2007). Rural children are more likely to be stunted than urban children (38 percent compared with 31 percent). Stunting is most prevalent in Sylhet (50 percent) and lowest in Khulna (28 percent). Children of mothers with no education are much more likely to be stunted (47 percent) than children whose mothers have completed secondary and higher education (18 percent). The differentials in stunting across wealth quintiles are larger, at 49 percent of children whose mothers are in the lowest wealth quintile compared with 19 percent of children whose mothers are in the wealthiest quintile. Weight-for-height (wasting) Overall, 14 percent of children are considered wasted or too thin for their height, and 3 percent are severely wasted. Moderate wasting peaks at age 9-11 months (20 percent) and severe wasting at age 12-17 months (6 percent). Wasting among male children is similar to that among female children (15 percent and 14 percent, respectively). Wasting is not strongly correlated with the length of the preceding birth interval. Children who are very small at birth are almost twice as likely to be wasted as children who are of average size or larger at birth (26 percent and 14 percent, respectively). Children living in urban areas are less likely to be wasted (12 percent) than children living in rural areas (15 percent). By division, wasting among children ranges from 12 percent in Dhaka to 18 percent in Rangpur and Barisal. The prevalence of wasting does not show a linear relationship with mother’s education and wealth quintile, as indicated by the highest prevalence of wasting among children of women with completed primary education (17 percent) and among children of women from the lowest wealth quintiles (17 percent). Weight-for-age (underweight) Table 11.1 shows that 33 percent of children under age 5 are underweight (low weight-for-age), and 8 percent are severely underweight. Under Millennium Development Goal 1, Bangladesh has set a target to halve the rate of underweight children between 1990 and 2015. Using the WHO standard, the MDG1 target is 31 percent, whereas using the NCHS reference, the target is 33 percent. Using the WHO standard, therefore, according to the 2014 BDHS data Bangladesh is 2 percentage points short of reaching the MDG1 target for underweight. Nineteen percent of children under age 6 months are underweight. At 6-8 months, 16 percent of children are underweight. The rate of underweight continues to increase with age, peaking at 38 percent at age 48-59 months (Figure 11.1). Female children are only slightly more likely to be underweight (33 percent) compared with male children (32 percent). The data show a strong correlation between underweight children and their perceived birth size. Babies perceived by mothers as very small at birth are much more likely to be underweight (51 percent) than those perceived as average or larger at birth (26 percent). Rural children are more likely to be underweight (35 percent) than urban children (26 percent). Sylhet has the highest proportion of underweight children (40 percent), while among the other divisions the proportion ranges from 26 percent in Khulna to 40 percent in Sylhet. As with wasting and stunting, mother’s education is associated with underweight; the percentage of children who are underweight is lowest among children of mothers with a secondary and higher education (18 percent) and highest among children of mothers with no education (42 percent). A similar negative relationship is observed between household wealth and the percentage of underweight children; children in the poorest households are more likely to be underweight (45 percent) compared with children in the wealthiest households (17 percent). 156 • Nutrition of Children and Women Figure 11.1 Nutritional status of children by age 11.1.4 Trends in Children’s Nutritional Status There has been some improvement in child nutritional status over the past decade (Figure 11.2). The level of stunting among children under age 5 has declined from 51 percent in 2004 to 36 percent in 2014. In the last three years it declined by 5 percentage points. Wasting increased to 17 percent in 2007 from 15 percent in 2004 and has gradually declined since then, to 14 percent in 2014. The level of underweight has declined from 43 percent in 2004 to 33 percent in 2014. The HPNSDP 2011-16 targets for 2016 are 38 percent for stunting and 33 percent for underweight. The 2014 BDHS data show that these targets have been achieved. Figure 11.2 Trends in nutritional status of children under age 5, 2004-2014 0 10 20 30 40 50 60 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Percent Age in months Stunted Wasted Underweight BDHS 2014 51 15 4343 17 4141 16 3636 14 33 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age) Percent 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Nutrition of Children and Women • 157 11.2 BREASTFEEDING AND COMPLEMENTARY FEEDING Feeding practices play a pivotal role in determining the optimal growth and development of infants. Poor breastfeeding and infant feeding practices have adverse consequences for the health and nutritional status of children. These consequences, in turn, affect their mental and physical development. Breastfeeding also affects mothers by physiologically suppressing the return of fertility, thereby lengthening the interval between pregnancies. UNICEF and WHO recommend that children be exclusively breastfed (that is, given no other liquid or solid food or plain water) for the first six months and then should be given solid or semi-solid complementary foods beginning in the seventh month of life. The standard indicator of exclusive breastfeeding is the percentage of children under age 6 months who are exclusively breastfeeding. The standard indicator of timely complementary feeding is the percentage of children age 6-8 months who receive solid, semi-solid, or soft foods. WHO recommends that breastfeeding should continue through the second year of life. Use of bottles with nipples is not recommended for feeding at any age (WHO 2008). 11.2.1 Initiation of Breastfeeding Early initiation of breastfeeding is important for both the mother and the child. There are a number of reasons to encourage early breastfeeding. Mothers benefit from early suckling because it stimulates production of breast milk and facilitates the release of oxytocin, which helps to contract the uterus and reduce postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also encourages bonding between the mother and her newborn. The 2014 BDHS collected data on infant feeding for the youngest children under age 2 who were living with their mother, using a 24-hour recall period. Table 11.2 presents the breastfeeding status of all last-born children born in the two years preceding the survey, by background characteristics. The table shows the percentage of children according to whether they were ever breastfed, when they started breastfeeding, and whether they were fed anything other than breast milk before beginning breastfeeding. Breastfeeding is almost universal in Bangladesh; 98 percent of last-born children who were born in the two years preceding the survey were breastfed at some point in their life. There are no marked differences by background characteristics in the proportion of children ever breastfed. Overall, 51 percent of children are breastfed within one hour after birth, and 89 percent are breastfed within one day. These results are for last-born children born in the two years preceding the survey. Table 11.2 indicates no marked differences in the timing of initial breastfeeding within one hour of birth by the sex of the child. Rural children are more likely to be breastfed within one hour of birth compared with urban children (53 percent and 45 percent, respectively). Notable variations can be seen by geographic division. The proportion of children breastfed within one hour of birth is highest in Rangpur (60 percent) and lowest in Khulna (39 percent). The timing of initiation of breastfeeding varies by other background characteristics. Less likely to begin breastfeeding within one hour of birth are children born in a health facility (38 percent), children attended by a health professional at delivery (40 percent), children of mothers who completed secondary or higher education (45 percent), and children from households in the highest wealth quintile (44 percent). Similar patterns were also reported in the 2011 BDHS. 11.2.2 Prelacteal Breastfeeding Prelacteal feeding is the practice of giving other liquids to a child during the first three days of life. The practice of prelacteal feeding is discouraged because it limits the frequency of suckling by the infant and exposes the child to the risk of gastrointestinal infection. Twenty-seven percent of Bangladeshi children 158 • Nutrition of Children and Women receive a prelacteal feed. The likelihood of receiving a prelacteal feed is higher for births assisted by a health professional and for births delivered at a health facility. Prelacteal feeding is more common in Rajshahi (37 percent), Dhaka (34 percent) and Khulna (33 percent) than in other divisions. Children of mothers with limited education and less wealth are less likely to receive prelacteal feeds. The 2014 BDHS did not collect information on whether the child received the first milk (colostrum). However, the 2007 BDHS reported that 92 percent of last-born children in the five years preceding the survey who were ever breastfed received colostrum (NIPORT et al. 2009). Table 11.2 Initial breastfeeding Among last-born children who were born in the two years preceding the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within one hour and within one day of birth; and among last-born children born in the two years preceding the survey who were ever breastfed, the percentage who received a prelacteal feed, by background characteristics, Bangladesh 2014 Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Background characteristic Percentage ever breastfed Percentage who started breastfeeding within one hour of birth Percentage who started breastfeeding within one day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last- born children ever breastfed Sex Male 98.3 50.7 89.4 1,705 28.8 1,676 Female 98.0 50.9 88.7 1,500 25.6 1,470 Assistance at delivery Health professional3 97.9 40.1 86.1 1,421 30.1 1,392 Traditional birth attendant 97.8 67.1 94.3 344 24.1 337 Other 98.4 57.5 90.8 1,419 25.3 1,397 Place of delivery Health facility 97.5 37.7 84.5 1,187 32.5 1,158 At home 98.5 58.9 91.8 1,927 24.6 1,897 Other 99.6 50.3 91.5 89 18.4 89 Residence Urban 98.6 45.2 87.0 835 31.9 824 Rural 98.0 52.7 89.8 2,370 25.7 2,322 Division Barisal 98.4 52.0 89.0 185 22.9 182 Chittagong 98.8 45.8 91.1 682 19.4 674 Dhaka 98.5 51.8 90.3 1,182 33.6 1,165 Khulna 96.0 39.1 81.7 250 33.1 239 Rajshahi 98.0 52.5 84.8 323 37.0 316 Rangpur 98.6 59.6 92.5 292 16.9 288 Sylhet 96.3 56.5 86.9 292 18.0 281 Mother’s education No education 98.6 55.6 87.6 433 24.2 427 Primary incomplete 98.8 54.6 89.8 509 26.5 503 Primary complete4 98.3 54.0 88.4 396 25.0 389 Secondary incomplete 97.6 49.0 89.1 1,317 28.8 1,285 Secondary complete or higher5 98.3 45.4 90.0 550 28.8 541 Wealth quintile Lowest 98.4 56.9 89.9 699 24.1 688 Second 97.5 50.2 86.2 618 27.4 602 Middle 98.4 50.1 91.5 641 25.7 631 Fourth 98.3 51.9 90.6 631 25.9 620 Highest 98.2 44.0 86.9 616 34.0 605 Total 98.1 50.8 89.1 3,205 27.3 3,146 Note: Table is based on last-born children born in the two years preceding the survey regardless of whether the children are living or dead at the time of interview. Total includes missing cases. 1 Includes children who started breastfeeding within one hour of birth 2 Children given something other than breast milk during the first three days of life 3 Doctor, nurse, midwife, paramedic, FWV, and CSBA 4 Primary complete is defined as completing grade 5. 5 Secondary complete is defined as completing grade 10. Nutrition of Children and Women • 159 11.3 BREASTFEEDING STATUS BY AGE Breast milk contains all the nutrients needed by children in the first six months of life. Supplementing breast milk before age 6 months is discouraged because it increases the likelihood of contamination, and hence risk of diarrhea. It is recommended that complementary feeding (giving solid or semi-solid foods to infants in addition to breast milk) start at the beginning of the seventh month of life, because at this age breast milk is no longer sufficient to maintain the child’s growth (WHO 2008). Children should be fed small quantities of solid and semi-solid foods while continuing to breastfeed. The amount of food is increased gradually from 6 to 23 months, which is the period of transition to eating the regular family diet. The 2014 BDHS collected data on infant feeding for the youngest children under age 2 who were living with their mother, using a 24-hour recall period. Table 11.3 and Figure 11.3 show that almost all Bangladeshi babies are breastfed for the first year of life. Children are breastfed for an extended time; at age 20-23 months, 87 percent of children are still being breastfed. Complementary foods are introduced at an early age. Among infants under age 2 months, 80 percent are exclusively breastfed, while other infants are given water (7 percent), other milk (9 percent), and complementary foods (2 percent) in addition to breast milk. Table 11.3 Breastfeeding status by age Percent distribution of youngest children under age 2 who are living with their mother by breastfeeding status and the percentage currently breastfeeding; and the percentage of all children under age 2 using a bottle with a nipple, according to age in months, Bangladesh 2014 Not breast- feeding Breastfeeding status Total Percentage currently breast- feeding Number of youngest child under two years living with their mother Percentage using a bottle with a nipple Number of all children under age 2 Age in months Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming non milk liquids1 Breast- feeding and consuming other milk Breast- feeding and consuming comple- mentary foods 0-1 2.2 80.3 6.8 0.0 8.9 1.7 100.0 97.8 173 7.9 174 2-3 0.4 61.8 12.1 1.1 17.5 7.1 100.0 99.6 230 19.4 232 4-5 0.5 31.7 16.4 2.8 19.3 29.3 100.0 99.5 248 25.9 251 6-8 2.7 6.1 12.5 1.8 12.3 64.5 100.0 97.3 401 20.4 403 9-11 4.4 0.9 4.3 0.7 2.8 86.9 100.0 95.6 452 21.6 454 12-17 5.2 0.3 2.2 0.4 1.8 90.1 100.0 94.8 834 14.8 849 18-23 11.2 0.7 1.5 0.1 0.1 86.4 100.0 88.8 755 13.5 784 0-3 1.2 69.8 9.8 0.6 13.8 4.8 100.0 98.8 403 14.5 406 0-5 0.9 55.3 12.3 1.4 15.9 14.1 100.0 99.1 651 18.9 657 6-9 3.1 4.5 10.9 1.3 10.2 70.0 100.0 96.9 551 22.0 554 12-15 4.0 0.3 1.9 0.5 2.0 91.2 100.0 96.0 570 14.6 582 12-23 8.0 0.5 1.9 0.3 1.0 88.3 100.0 92.0 1,589 14.1 1,633 20-23 12.7 0.3 0.7 0.1 0.2 86.1 100.0 87.3 511 12.1 531 Note: Breastfeeding status refers to a “24-hour” period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and non-milk liquids and who do not receive other milk and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. 1 Non-milk liquids include juice, juice drinks, clear broth or other liquids Table 11.3 presents the percentage of children using a bottle with a nipple. Bottle feeding is common in Bangladesh; 22 percent of infants age 6-9 months are fed with a bottle with a nipple. Bottle feeding is most common among children age 4-5 months (26 percent). At age 6-8 months, 20 percent of children are bottle fed, and 12 percent of children age 20-23 months use bottles with nipple. 160 • Nutrition of Children and Women Figure 11.3 Infant feeding practices by age Fifty-five percent of infants under age 6 months are exclusively breastfed. This proportion is lower than that reported in the 2011 BDHS (64 percent) (Figure 11.4). Between the 2007 BDHS and the 2011 BDHS there was a sharp increase in exclusive breastfeeding, from 43 percent to 64 percent. Intensive mass media campaigns for several years preceding the 2011 survey could have impacted the status of mothers reporting on breastfeeding in 2011. The 2011 BDHS report and results dissemination discussed the increased level of breastfeeding. It was not clear whether the increase was the result of reporting bias or actual change, and if the latter, whether this higher level would be sustained. The 2013 Utilization of Essential Service Delivery Survey and the 2012-13 Multiple Indicator Cluster Survey reported lower exclusive breastfeeding rates of 60 percent (Sultana et al. 2014) and 56 percent (BBS and UNICEF 2014), respectively. In spite of the decline in exclusive breastfeeding between 2011 and 2014, the prevalence of exclusive breastfeeding of infants up to age 6 months in 2014 is 5 percentage points higher than the HPNSDP target of 50 percent exclusive breastfeeding by 2016 (MOHFW 2011). 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months Not breastfeeding Complementary foods Other milk Non-milk liquids/juice Plain water only Exclusively breastfed BDHS 2014 Nutrition of Children and Women • 161 Figure 11.4 Trends in exclusive breastfeeding practices among children age 0-5 months, 2004-2014 Figure 11.5 shows the 2011 BDHS results for key infant and young child feeding (IYCF) practices on breastfeeding for youngest children under age 2 who are living with their mother. Although 55 percent of all children under age 6 months are exclusively breastfed, only 32 percent of those age 4-5 months are exclusively breastfed. Almost all children (96 percent) continue breastfeeding at age 1, and 87 percent continue to breastfeed until age 2. Sixty-five percent of children are introduced to complementary foods at an appropriate age. Seventy-seven percent of children age 0-23 months are breastfed appropriately for their age, i.e., exclusive breastfeeding for children age 0-5 months and continued breastfeeding along with complementary foods for children age 6-23 months. Predominant breastfeeding (receiving breast milk and only plain water or non-milk liquids such as juice, clear broth, and other liquids) is prevalent in 70 percent of the children. Seventeen 17 percent of children under age 2 are bottle-fed. Figure 11.5 IYCF indicators on breastfeeding status 42 43 64 55 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent 55 32 96 65 87 77 70 17 IYCF 2: Exclusive breastfeeding (0-5 months) Exclusive breastfeeding (4-5 months) IYCF 3: Continued breastfeeding at 1 year (12-15 months) IYCF 4: Introduction of solid, semi-solid or soft foods (6-8 months) IYCF 10: Continued breastfeeding at 2 years (20-23 months) IYCF 11: Age-appropriate breastfeeding (0-23 months) IYCF 12: Predominant breastfeeding (0-5 months) IYCF 14: Bottle feeding (0-23 months) Percentage BDHS 2014 162 • Nutrition of Children and Women 11.4 DURATION OF BREASTFEEDING Table 11.4 shows the median duration and frequency of breastfeeding by selected background characteristics. The estimates of median and mean duration of breastfeeding are based on current status data, that is, the proportion of children born in the three years preceding the survey who were being breastfed at the time of the survey. The median duration of any breastfeeding among Bangladeshi children in 2014 is 31 months. The median duration of exclusive breastfeeding is 2.8 months, while the median duration of predominant breastfeeding is 4.4 months. The mean duration of any breastfeeding is 28.6 months, while the mean duration of exclusive breastfeeding is 4 months and of predominant breastfeeding 5.6 months. The median duration of exclusive breastfeeding and predominant breastfeeding has decreased since 2011. The median duration of exclusive breastfeeding decreased from 3.5 months to 2.8 months, and the median duration of predominant breastfeeding decreased from 4.9 months to 4.4 months. The median durations of any, exclusive, and predominant breastfeeding do not vary much across background characteristics. The median duration of any breastfeeding is one month shorter in urban areas than in rural areas (30 months versus 31 months). Duration of exclusive breastfeeding increases slightly with mother’s education. In contrast, the median duration of exclusive breastfeeding generally decreases as household wealth increases. Differentials in exclusive breastfeeding and predominant breastfeeding across subgroups of children are smaller than for any breastfeeding. 11.5 TYPES OF COMPLEMENTARY FOODS In the 2014 BDHS, women who had at least one child living with them who was born in 2012 or later were asked questions about the types of liquids and foods the child had consumed during the day or night preceding the interview. Mothers who had more than one child born in 2012 or later were asked questions about the youngest child living with them. Specifically, mothers were asked about the number of times the child had eaten solid or semi-solid food during the period. The results are subject to a number of limitations. The dietary data on children are subject to recall errors on the mother’s part. In addition, a mother may not be able to report fully on a child’s intake of food and liquids if the child was fed by other individuals during the period. The information in Table 11.5 is restricted to the youngest children under age 2 living with the mother at the time of the survey. Information on type of foods and liquids consumed by young children is useful in assessing timely and appropriate complementary feeding. Table 11.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the three years preceding the survey, by background characteristics, Bangladesh 2014 Median duration (months) of breastfeeding among children born in the past three years1 Background characteristic Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 31.2 2.8 4.2 Female 30.8 2.8 4.6 Residence Urban 29.6 2.7 4.6 Rural 31.4 2.8 4.3 Division Barisal 33.1 * 3.7 Chittagong 26.2 3.4 5.7 Dhaka 31.2 * 3.1 Khulna na 3.6 4.5 Rajshahi 33.9 2.7 3.9 Rangpur na 4.0 4.9 Sylhet 30.5 3.9 5.3 Education No education 32.6 2.9 4.7 Primary incomplete 32.3 (2.4) 3.5 Primary complete3 31.4 3.0 4.2 Secondary incomplete 30.2 2.6 4.2 Secondary complete or higher4 28.8 3.5 5.1 Wealth quintile Lowest 31.6 (2.2) 4.2 Second 0.0 3.6 4.5 Middle 31.4 2.6 4.3 Fourth 30.7 2.9 4.1 Highest 28.1 2.8 4.8 Total 31.0 2.8 4.4 Mean for all children 28.6 4.0 5.6 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey na = Median duration of more than 36 months * = Median is based on fewer than 25 unweighted cases. 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. Nutrition of Children and Women • 163 For many breastfeeding children, liquids other than breast milk are introduced earlier than the recommended age of 6 months. Six percent of breastfeeding children under age 2 months are given infant formula and 3 percent receive other milk in addition to breast milk. Two percent of breastfeeding children under age 2 months are given solid or semi-solid food. Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with the mother by type of foods consumed in the day or night preceding the interview, according to breastfeeding status and age, Bangladesh 2014 Liquids Solid or semi-solid foods Any solid or semi- solid food Number of children Age in months Infant formula Other milk1 Other liquids2 Fortified baby foods Food made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 6.4 2.9 0.7 0.0 1.8 0.0 0.0 1.8 0.0 0.0 1.8 0.0 1.8 169 2-3 8.4 9.9 5.1 1.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.7 5.7 229 4-5 14.3 10.5 14.9 3.1 7.7 14.4 0.7 6.5 0.2 0.4 0.6 3.1 27.7 246 6-8 10.8 26.4 20.5 6.3 35.5 18.5 5.7 12.9 2.4 10.8 13.4 4.8 64.3 390 9-11 8.8 26.9 24.1 9.0 69.8 29.5 19.0 34.8 6.5 32.7 19.8 3.6 88.3 432 12-17 5.2 28.8 23.1 6.5 83.0 44.4 17.2 44.0 6.4 46.9 31.1 6.8 94.8 790 18-23 2.4 30.4 26.6 4.3 88.4 52.7 27.9 53.1 11.5 63.0 37.0 8.2 95.1 670 6-23 6.0 28.5 23.8 6.3 74.0 39.6 18.7 39.6 7.2 42.8 27.7 6.3 88.4 2,283 Total 6.9 24.0 20.3 5.3 58.5 32.1 14.7 31.6 5.6 33.4 21.7 5.3 71.8 2,928 NONBREASTFEEDING CHILDREN 12-17 (29.6) (52.5) (28.4) (9.4) (84.1) (64.0) (25.6) (52.2) (9.7) (54.8) (37.7) (7.1) (100.0) 43 18-23 14.0 49.0 32.9 6.1 91.1 54.5 38.8 60.6 11.4 65.3 50.3 12.6 98.8 84 6-23 20.1 48.3 29.3 8.4 81.6 53.6 31.8 51.8 11.4 58.3 41.9 13.1 96.5 158 Total 19.4 47.4 29.0 8.1 78.5 52.4 30.7 49.8 11.0 56.2 40.3 12.6 93.7 164 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). 1 Other milk includes fresh, tinned and powdered cow or other animal milk. 2 Doesn’t include plain water. Includes juice, juice drinks, clear broth, or other non-milk liquids 3 Includes fortified baby food 4 Includes pumpkin, red or yellow sweet potatoes, squash, carrots, dark green leafy vegetables like spinach, poi sag, methi, kolmi, kochu, palak, ripe mangoes, papayas, ripe kathal, bangi or other Vitamin A rich fruits and other locally grown fruits and vegetables that are rich in vitamin A By age 9 months, every child is expected to be receiving at least one daily feeding of solid or semi- solid foods. Table 11.5, however, indicates that 12 percent of breastfeeding children age 9-11 months did not receive any solid or semi-solid food on the day before the interview. Overall, 74 percent of breastfeeding children age 6-23 months consume foods made from grains (including fortified baby foods), 40 percent consume vitamin A-rich fruits and vegetables, 43 percent have meat, fish, or poultry, and 28 percent consume eggs. In addition to being breastfed, 6 percent of these children receive infant formula, 29 percent receive other milk, and 6 percent receive cheese, yogurt, or other milk products. As expected, non-breastfed children age 6-23 months are more likely than breastfed children to receive the different types of liquids and solid and semi-solid foods. The difference in the consumption of solid and semi-solid food between breastfed and non-breastfed children is especially marked in the consumption of fortified baby foods, meat, fish or poultry, and cheese, yogurt, or other milk products. However, caution should be exercised when interpreting these results because the number of non-breastfed children is small compared with the number of breastfed children. Figure 11.6 presents trends in the consumption of solid and semi-solid or soft foods by children age 6-9 months since 1993-94. The trends in complementary feeding indicate an increase in the timely introduction of solid or semi-solid foods, with a slight decrease since 2007. 164 • Nutrition of Children and Women Figure 11.6 Trends in complementary feeding for breastfeeding children age 6-9 months 11.6 INFANT AND YOUNG CHILD FEEDING PRACTICES Infant and young child feeding (IYCF) practices include initiating timely feeding of solid or semi- solid foods at age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older, while maintaining frequent breastfeeding. Guidelines have been established for IYCF practices for children age 0-23 months (PAHO/WHO 2003; WHO 2005; WHO 2008). Although breastfeeding is recommended for infants up to age 2, some infants have stopped breastfeeding before reaching age 2 because their mothers are HIV-positive, have died, or for some other reason do not breastfeed (WHO 2005). Minimum dietary diversity means feeding the child food from at least four food groups. This cut- off was selected because it is associated with better-quality diets for both breastfed and non-breastfed children. Studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO and UNICEF1998). Therefore it is recommended that meat, poultry, fish, or eggs be eaten daily or as often as possible. Vegetarian diets may not meet children’s nutrient requirements unless supplements or fortified products are used. Vitamin A-rich fruits and vegetables should be consumed daily. Children’s diets should include an adequate fat content, because fat provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A), and enhances dietary energy density and palatability. Consumption of food from at least four food groups means that the child has a high likelihood of consuming at least one animal source of food and at least one fruit or vegetable in addition to a staple food (grains, roots, or tubers) (WHO 2008). The four food groups should come from a list of seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry, and liver/organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. The minimum dietary diversity may be reported separately for breastfed and non-breastfed children. However, diversity scores for breastfed and non-breastfed children should not be directly compared, because breast milk is not counted in any of the above stated food groups. The recommended number of feedings is as follows: 29 28 59 62 74 67 70 1993-94 BDHS 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 BDHS Percent Nutrition of Children and Women • 165 • Breastfed infants age 6-8 months should be fed meals of complementary foods two to three times per day, with one or two snacks as desired; breastfed children 9-23 months should be fed meals three to four times per day, with one or two snacks. • Non-breastfed children age 6-23 months should receive milk products at least twice a day to ensure their calcium needs are met. In addition, they need animal-source foods and vitamin A- rich fruits and vegetables. Therefore, four food groups are considered a minimum acceptable number of food groups for non-breastfed young children. Non-breastfed children should be fed meals four to five times per day, with one or two snacks as desired (WHO 2005). • Meal frequency is considered a proxy for energy intake from foods other than breast milk; therefore, the feeding frequency indicator for non-breastfed children includes both milk feeds and solid/semi-solid feeds (WHO 2008). The minimum feeding frequencies are based on the energy needs from complementary foods estimated from age-specific total daily energy requirements. • Infants with low intake of breast milk would need to be fed more frequently. However, overly frequent feeding may lead to the displacement of breast milk (PAHO and WHO 2003). Table 11.6 shows infant and young child feeding (IYCF) practices for the youngest children age 6- 23 months living with their mother. The percentage of children who are fed with appropriate feeding practices is calculated by taking into account current guidelines on the number of food groups and the number of times a child should eat during the day or night preceding the survey. Overall, 23 percent of children age 6-23 months are fed appropriately according to recommended IYCF practices; that is, they are given milk or milk products and foods from the recommended number of food groups and are fed at least the recommended minimum number of times. Infant and child feeding practices have changed very little between 2011 and 2014 BDHS (an increase of 2 percentage points), and are far below the revised HNPSDP target of 45 percent for 2016 (MOHFW 2014). The results in Table 11.6 show that 26 percent of breastfed children age 6-23 months are fed foods from four or more food groups, and 63 percent are fed the minimum number of times. Nearly all breastfed and non-breastfed children age 6-23 months are given breast milk or other milk products (97 percent). Overall, 28 percent of children receive the appropriately diverse diet, and 64 percent of children are fed the recommended number of times with solid or semi-solid foods. Because 98 percent of children age 6-23 months are ever breastfed, the number of non-breastfed children is too small to come to any meaningful conclusions. Feeding according to IYCF recommendations is uncommon among children age 6-8 months (7 percent), increasing to 34 percent among children age 18-23 months. Male children and female children are equally likely to be fed according to appropriate IYCF practices. Adherence to IYCF practices is better in urban areas than in rural areas (29 percent compared with 21 percent). The recommended IYCF practices are least common in Sylhet (17 percent) and most common in Khulna (31 percent). IYCF practices improve as mother’s education levels and wealth status increase. Overall the level of IYCF practice is low among all subgroups. Even in the highest wealth quintile, only 1 in 3 children receive appropriate feeding. These findings indicate, among other things, a lack of knowledge on appropriate feeding practices for infant and young children. 166 • Nutrition of Children and Women Table 11.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night preceding the survey, by background characteristics, Bangladesh 2014 Among breastfed children age 6-23 months, percentage fed: Among non-breastfed children age 6-23 months, percentage fed: Among all children age 6-23 months, percentage fed: Background characteristic 4+ food groups1 Minimum meal fre- quency2 Both 4+ food groups and minimum meal fre- quency Number of breast- fed children age 6-23 months Milk or milk products3 4+ food groups1 Minimum meal fre- quency4 With 3 IYCF prac- tices5 Number of non- breast- fed children age 6-23 months Breast milk, milk, or milk products6 4+ food groups1 Minimum meal fre- quency7 With 3 IYCF practices Number of all children 6-23 months Age in months 6-8 7.6 50.3 7.1 390 * * * * 11 98.6 7.5 50.5 6.9 401 9-11 17.1 51.1 14.4 432 * * * * 20 99.4 18.6 52.5 15.1 452 12-17 27.5 67.7 25.1 790 (70.0) (42.8) (77.1) (19.1) 43 98.4 28.3 68.2 24.8 834 18-23 42.0 71.2 35.5 670 50.1 51.3 79.4 19.7 84 94.4 43.1 72.2 33.7 755 Sex Male 26.1 63.3 23.3 1,202 62.1 39.5 83.8 13.6 79 97.7 26.9 64.6 22.7 1,280 Female 26.7 61.8 22.8 1,082 57.8 52.3 72.2 25.6 80 97.1 28.4 62.5 23.0 1,161 Residence Urban 32.1 65.9 28.2 571 73.2 46.7 82.4 31.7 61 97.4 33.5 67.5 28.6 632 Rural 24.5 61.5 21.3 1,712 51.6 45.5 75.1 12.0 97 97.4 25.6 62.3 20.8 1,809 Division Barisal 29.7 61.4 25.3 131 * * * * 5 98.4 29.2 62.1 24.3 136 Chittagong 22.4 55.1 18.2 471 (46.7) (42.4) (73.6) (16.5) 51 94.7 24.4 56.9 18.0 522 Dhaka 25.6 60.4 23.3 843 (71.9) (53.0) (77.5) (25.3) 75 97.7 27.9 61.8 23.5 919 Khulna 34.5 80.0 31.2 183 * * * * 8 98.0 35.1 80.1 31.0 191 Rajshahi 28.2 73.4 27.1 244 * * * * 6 99.6 28.0 73.9 27.0 250 Rangpur 28.8 67.0 24.2 212 * * * * 1 99.7 29.3 67.2 24.1 214 Sylhet 24.4 57.0 18.2 199 * * * * 11 96.5 24.8 58.5 17.2 210 Mother’s education No education 14.3 52.5 10.6 316 * * * * 15 97.5 15.5 54.5 10.5 331 Primary incomplete 15.9 55.5 14.4 346 * * * * 19 97.4 17.2 57.1 14.3 365 Primary complete8 21.1 58.7 18.0 288 * * * * 16 98.5 20.7 59.4 17.1 303 Secondary incomplete 29.0 66.9 25.4 965 53.3 48.1 64.9 17.3 70 96.8 30.2 66.8 24.8 1,035 Secondary complete or higher9 43.9 69.9 39.6 369 (78.1) (60.8) (92.5) (40.4) 39 97.9 45.5 72.1 39.7 408 Wealth quintile Lowest 17.2 53.9 14.6 509 * * * * 23 97.4 17.9 55.2 14.3 532 Second 22.4 61.8 18.0 448 * * * * 17 97.4 22.6 61.8 17.8 466 Middle 26.8 65.0 22.8 451 (62.7) (51.3) (68.9) (16.7) 35 97.3 28.6 65.3 22.3 486 Fourth 31.9 66.1 28.7 460 (72.3) (45.2) (91.8) (12.0) 32 98.2 32.7 67.8 27.7 492 Highest 35.4 67.8 32.9 415 (69.1) (53.8) (77.7) (32.8) 51 96.6 37.4 68.9 32.9 466 Total 26.4 62.6 23.0 2,283 59.9 45.9 77.9 19.6 158 97.4 27.6 63.6 22.8 2,442 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases and has been suppressed. 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables (and red palm oil); d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts 2 At least twice a day for breastfed infants 6-8 months and at least three times a day for breastfed children 9-23 months 3 Includes two or more feedings of commercial infant formula, fresh, tinned, and powdered animal milk, and yogurt 4, Minimum meal frequency is receiving solid or semisolid food or milk feeds at least four times a day 5 Fed with other milk or milk products at least twice a day, receive solid or semisolid foods from at least four food groups not including the milk or milk products food group, and receive the minimum meal frequency 6 Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula, fresh, tinned, and powdered animal milk, and yogurt 7 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in footnotes 2 and 4 8 Primary complete is defined as completing grade 5. 9 Secondary complete is defined as completing grade 10. Figure 11.7 shows IYCF practices according to minimum standard of acceptable feeding practices. In terms of dietary diversity, a higher proportion of non-breastfed children meet the minimum requirements (46 percent) than breastfed children (26 percent). Minimum meal frequency is also higher among non- breastfed children. (78 percent compared with 63 percent among breastfed children). There are smaller differences between breastfed and non-breastfed children in meeting the minimum acceptable diet criteria. Nutrition of Children and Women • 167 Figure 11.7 Percentage fed according to minimum standard of acceptable feeding practices 11.7 MICRONUTRIENT INTAKE AMONG CHILDREN Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, fortified food, and direct supplementation. The 2014 BDHS collected information on consumption of foods rich in vitamin A and iron, vitamin A and iron supplementation, and deworming status for children age 6-59 months. Table 11.7 presents data regarding the intake of key micronutrients among children age 6-59 months. The table shows, by background characteristics, the percentage of youngest children age 6-23 months who are living with their mother and who consumed foods rich in vitamin A and iron in the day or night preceding the survey. In addition, the table shows the proportion of all children age 6-59 months who were given vitamin A supplements or deworming medication in the six months preceding the survey and the proportion who were given iron supplements in the week before the survey. 11.7.1 Consumption of Micronutrient-rich Foods Table 11.7 shows that 67 percent of youngest children age 6-23 months who were living with their mother consumed foods rich in vitamin A in the day or night preceding the survey. The proportion of children consuming vitamin A-rich foods increases with age, from 31 percent among children age 6-8 months to 85 percent among children age 18-23 months. Consumption of vitamin A-rich foods is similar among male and female children. A higher proportion of non-breastfed children consume vitamin A rich foods than breastfed children (83 percent compared with 66 percent). Urban children are more likely to consume vitamin A-rich foods (68 percent) compared with children in rural areas (66 percent). The proportion of children consuming vitamin A-rich foods is highest in Khulna division (79 percent) and lowest in Sylhet and Chittagong divisions (63 percent). Mother’s educational status and household wealth correlate positively with the consumption of vitamin A-rich foods. Seventy-six percent of children of mothers with secondary or higher education consumed vitamin A-rich foods compared with 59 percent of children whose mothers are not educated. Similarly, 70 percent of children in the highest wealth quintile consumed vitamin A-rich foods compared with 63 percent of children in the lowest wealth quintile. Overall, 55 percent of children age 6-23 months consumed foods rich in iron (Table 11.7). Differences in the intake of iron-rich foods by background characteristics are largely similar to the differences in consumption of vitamin A-rich foods. Breastfed children consume less food rich in iron (54 percent) compared with non-breastfed children (71 percent). Intake of iron-rich foods among children has slightly increased, from 54 percent in 2011 to 55 percent in the 2014 BDHS. 26 63 23 46 78 20 28 64 23 Minimum dietary diversity Minimum meal frequency Minimum acceptable diet Percent Among breastfed children Among non-breastfed children Among all children 6-23 months BDHS 2014 168 • Nutrition of Children and Women Table 11.7 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the day or night preceding the survey, and among all children age 6-59 months, the percentages who were given vitamin A supplements in the six months preceding the survey, who were given iron supplements in the past seven days, and who were given deworming medication in the six months preceding the survey, by background characteristics, Bangladesh 2014 Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Background characteristic Percentage who consumed foods rich in vitamin A in last 24 hours1 Percentage who consumed foods rich in iron in last 24 hours2 Number of children Percentage given vitamin A supplements in last 6 months Percentage given iron supplements in last 7 days Percentage given deworming medication in last 6 months3 Number of children Age in months 6-8 31.1 21.4 401 42.6 3.2 2.4 403 9-11 54.0 42.3 452 56.9 4.9 7.0 454 12-17 74.9 60.7 834 61.9 5.2 18.2 849 18-23 84.9 75.2 755 62.5 5.0 34.5 784 24-35 na na 0 65.4 5.1 47.0 1,563 36-47 na na 0 65.2 3.2 53.8 1,535 48-59 na na 0 62.1 4.0 52.8 1,515 Sex Male 66.0 54.2 1,280 61.7 4.5 39.3 3,682 Female 67.9 56.6 1,161 62.5 4.2 40.3 3,421 Breastfeeding status Breastfeeding 65.8 54.3 2,283 59.8 4.7 25.0 3,200 Not breastfeeding 82.8 70.6 156 63.9 4.1 51.9 3,889 Mother’s age at birth 15-19 65.2 53.9 536 55.7 4.8 28.3 913 20-29 67.8 55.6 1,475 62.2 4.2 40.6 4,443 30-39 66.0 55.7 406 65.6 4.6 44.7 1,615 40-49 * * 24 57.6 4.2 32.1 133 Residence Urban 68.3 59.8 632 65.3 6.1 44.5 1,813 Rural 66.4 53.7 1,809 61.0 3.8 38.2 5,291 Division Barisal 70.6 57.9 136 64.1 4.6 38.5 399 Chittagong 63.1 54.0 522 65.0 4.2 47.1 1,524 Dhaka 64.6 52.6 919 62.0 4.6 40.9 2,509 Khulna 78.9 63.9 191 64.5 4.6 34.0 532 Rajshahi 68.9 55.4 250 56.6 2.8 32.0 737 Rangpur 74.8 66.1 214 65.5 4.6 38.3 697 Sylhet 63.0 49.7 210 55.5 4.9 34.7 706 Education No education 58.8 44.3 331 57.5 3.4 36.2 1,189 Primary incomplete 60.5 44.5 365 55.7 3.7 37.9 1,146 Primary complete4 65.2 54.3 303 55.1 3.5 40.9 820 Secondary incomplete 68.6 58.3 1,035 64.8 4.2 40.1 2,859 Secondary complete or higher5 76.2 67.1 408 71.9 7.1 43.9 1,090 Wealth quintile Lowest 62.5 46.4 532 56.0 3.0 36.5 1,612 Second 63.6 48.8 466 60.9 3.0 39.5 1,338 Middle 68.5 59.3 486 62.8 4.1 36.0 1,358 Fourth 70.0 59.8 492 62.0 4.9 40.8 1,436 Highest 70.3 63.0 466 69.8 6.8 46.6 1,359 Total 66.9 55.3 2,442 62.1 4.3 39.8 7,103 Note: Information on vitamin A is based on both mother’s recall and the immunization card (where available). Information on iron supplements and deworming medication is based on the mother’s recall. An asterisk indicates that an estimate is based on fewer than 25 unweighted cases. na = Not applicable 1 Includes meat (and organ meat), fish, poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mango, papaya, and other locally grown fruits and vegetables that are rich in vitamin A, and red palm oil [if data are collected] 2 Includes meat (including organ meat), fish, poultry and eggs 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 4 Primary complete is defined as completing grade 5. 5 Secondary complete is defined as completing grade 10. Nutrition of Children and Women • 169 11.7.2 Micronutrient Supplementation Vitamin A is an essential micronutrient for the immune system. Severe vitamin A deficiency (VAD) can result in childhood blindness. VAD can also increase the severity of infections such as measles and diarrheal diseases in children and can slow recovery from illness. An important strategy in overcoming vitamin A deficiency in Bangladesh has been the distribution of vitamin A capsules to children age 6-59 months. Children under age 6 months are not covered, primarily because most children in this age group are expected to be exclusively breastfed and should receive adequate vitamin A through breast milk. Children age 6-59 months receive supplementation once in every six months during the National Immunization Days and vitamin A campaigns. Since February 2011, children age 9-11 months are no longer provided vitamin A supplementation at the time they receive the measles vaccination. In the 2014 BDHS, mothers were asked if their children under age 5 had taken a vitamin A capsule in the six months preceding the survey. Table 11.7 shows that 62 percent of children age 6-59 months had received vitamin A supplementation in the six months before the survey. The level of vitamin A supplementation varies across subgroups of children. Children age 24-35 months are most likely to have received vitamin A supplements (65 percent). Across divisions, the proportion of children who received vitamin A supplements ranges from 56 percent in Sylhet to 66 percent in Rangpur. The likelihood of children receiving vitamin A increases with mother’s education level and wealth status. The coverage of vitamin A supplementation among children age 6-59 months has increased from 60 percent in 2011 to 62 percent in 2014, which seems insufficient to attain HPNSDP target of 90 percent by 2016. In the 2014 BDHS, mothers were asked if their children under age 5 had taken an iron tablet in the seven days preceding the survey. Table 11.7 shows that only 4 percent of children age 6-59 months received iron supplements in this period. Iron supplementation varies little by children’s background characteristics. 11.7.3 Deworming Certain types of intestinal parasites can cause anemia. Periodic deworming for organisms such as helminthes can improve children’s micronutrient status. The 2014 BDHS asked mothers if their children under age 5 had taken deworming medication in the six months preceding the survey. Overall, 40 percent of children age 6-59 months received deworming medication in this period (Table 11.7). Recently, the Ministry of Health and Family Welfare decided not to distribute deworming tablets during the National Vitamin A Plus campaign, which might explain why deworming has become less common since the 2011 BDHS, which found a level of 50 percent. However, decisions have been made to run vitamin A supplementation and deworming programs separately. The percentage of children who received deworming medication increases with age, from 2 percent of children age 6-8 months to 54 percent of children age 36-47 months. Breastfed children are less likely than non-breastfed children to receive deworming medication (25 percent versus 52 percent). Children in urban areas are more likely to receive deworming medication compared with rural children (45 percent versus 38 percent). Coverage also varies across divisions, from 32 percent in Rajshahi to 47 percent in Chittagong. Mother’s levels of education and household wealth have positive associations with children’s likelihood of receiving deworming medication. 11.8 NUTRITIONAL STATUS OF WOMEN Malnutrition in women, encompassing both undernutrition and overweight, is a major problem with important consequences for survival and healthy development. Body mass index (BMI) is used to measure thinness or obesity. It is defined as weight in kilograms divided by height in meters squared (kg/m2). A BMI of less than 18.5 is used to define thinness or acute under nutrition. A BMI of 25 or above usually indicates overweight, and a BMI of 30 or above indicates obesity. 170 • Nutrition of Children and Women In many countries chronic energy deficiency, characterized by a BMI of less than 18.5 among women, remains the predominant problem, leading to low work productivity and less resistance to illness. Low pre-pregnancy BMI and short stature of women are known risk factors for poor maternal and birth outcomes. Overweight and obese women are also predisposed to a wide range of health problems. Maternal obesity can lead to several adverse maternal and fetal complications during pregnancy, delivery, and postpartum (Van Lieshout et al. 2011). It increases the risk for childhood obesity that continues into adolescence and adulthood, potentiating transgenerational transmission of obesity (Black et al. 2013). The 2014 BDHS measured the height and weight of ever-married women age 15-49. The data are used to derive two measures of nutritional status: height and body mass index (BMI). Given the relationship between maternal stature and pelvic size, women’s height can be useful in predicting the risk of difficulties in delivery. The risk of giving birth to low-weight babies is also higher among women of small stature. The cut-off point at which mothers are considered at risk because of short stature normally falls between 140 and 150 centimeters. Table 11.8 presents nutritional indicators for women by various background characteristics. The analysis excludes women for whom there was no information on height and/or weight and women for whom a BMI could not be estimated because they were pregnant or had given birth in the preceding two months. The height analysis is based on 17,710 ever-married women age 15-49, while the analysis of BMI is based on 16,478 women. Table 11.8 Nutritional status of ever-married women Among ever-married women age 15-49, the percentage with height under 145 cm, mean body mass index (BMI), and the percentage with specific BMI levels, by background characteristics, Bangladesh 2014 Height Body mass index1 Percent- age below 145 cm Number of women Mean body mass index (BMI) 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Moderate- ly and severely thin) Total overweight or obese 25.0-29.9 (Over- weight) ≥30.0 (Obese) Number of women Background characteristic ≥23.0 ≥25.0 Age 15-19 13.4 2,012 20.2 62.0 31.0 19.8 11.1 16.8 7.1 5.8 1.3 1,618 20-29 12.1 6,560 21.9 60.3 19.5 12.7 6.8 35.1 20.2 17.5 2.7 5,886 30-39 12.2 5,324 23.1 56.1 13.5 8.0 5.4 47.6 30.4 24.3 6.2 5,165 40-49 13.9 3,814 22.7 53.8 18.7 10.4 8.3 43.6 27.5 21.6 5.9 3,808 Residence Urban 11.8 4,992 23.7 51.4 12.2 7.4 4.8 53.2 36.4 27.6 8.8 4,685 Rural 13.0 12,717 21.7 60.1 21.1 13.0 8.1 33.6 18.8 16.2 2.6 11,793 Division Barisal 12.7 1,099 22.0 57.9 20.5 11.4 9.0 35.5 21.7 17.1 4.5 1,016 Chittagong 11.7 3,264 22.7 56.7 15.7 10.6 5.1 42.5 27.6 22.0 5.6 3,007 Dhaka 13.3 6,170 22.4 56.6 18.2 11.3 6.9 41.4 25.1 20.6 4.5 5,778 Khulna 10.0 1,830 22.8 58.4 13.7 8.4 5.3 44.9 27.9 23.0 4.9 1,734 Rajshahi 12.7 2,087 22.1 57.5 19.6 11.9 7.7 38.6 22.9 18.8 4.1 1,966 Rangpur 12.8 2,042 21.6 62.7 20.3 12.5 7.9 31.4 16.9 14.2 2.7 1,913 Sylhet 15.7 1,217 21.0 55.0 29.8 16.6 13.2 27.4 15.2 12.4 2.8 1,063 Education No education 17.5 4,414 21.4 60.1 24.1 13.5 10.6 30.0 15.8 13.2 2.6 4,255 Primary incomplete 14.8 3,201 21.7 58.9 21.7 13.8 7.8 34.2 19.4 16.2 3.2 2,989 Primary complete2 13.7 1,969 22.1 58.1 19.0 11.3 7.7 37.0 22.9 18.6 4.4 1,821 Secondary incomplete 9.7 5,594 22.6 58.0 16.0 10.6 5.4 42.4 26.0 21.2 4.8 5,093 Secondary complete or higher3 7.2 2,531 24.0 50.2 9.8 6.4 3.3 57.2 40.0 31.6 8.4 2,319 Wealth quintile Lowest 15.9 3,339 20.3 59.5 32.2 18.9 13.3 17.8 8.4 7.4 1.0 3,057 Second 15.2 3,380 21.1 61.8 24.9 15.5 9.4 27.3 13.3 12.1 1.2 3,116 Middle 11.8 3,530 21.9 60.8 19.0 11.7 7.3 34.7 20.2 17.4 2.7 3,300 Fourth 11.6 3,733 22.9 60.6 12.3 7.6 4.7 47.2 27.1 22.4 4.6 3,496 Highest 9.2 3,728 24.8 46.4 7.0 4.9 2.1 64.7 46.7 35.1 11.5 3,509 Total 12.6 17,710 22.3 57.6 18.6 11.4 7.2 39.2 23.8 19.4 4.4 16,478 Note: The body mass index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). 1 Excludes pregnant women and women with a birth in the preceding 2 months 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Nutrition of Children and Women • 171 Overall, 13 percent of ever-married women are below the cut-off of 145 centimeters in height. The proportion below the cut-off for women’s height does not vary much by age group. Urban women and women in Khulna division tend to be taller than other women. Woman’s educational status and household wealth are positively associated with height. For example, 18 percent of uneducated women and 16 percent of women in the lowest wealth quintile are below 145 centimeters in height compared with 7 percent of women who have completed secondary or higher education and 9 percent of women in the highest wealth quintile. The mean BMI for ever-married women age 15-49 is 22.3 (Table 11.8), which falls in the normal BMI classification. About 6 in 10 ever-married women (58 percent) have a normal BMI, and 19 percent are undernourished or thin (BMI less than 18.5). Despite much discussion, the global nutrition community has retained the international classification of BMI ≥25 kg/m2 cut-off for overweight and obesity for adults. Based on this classification, 24 percent of women are overweight or obese (BMI 25 or higher). Variations are apparent by background characteristics. Ever-married women age 15-19 are more likely to be thin or undernourished compared with women in other age cohorts (Figure 11.8). The proportion of overweight women increases with age. Rural women are more likely than urban women to be undernourished (21 percent and 12 percent, respectively), whereas urban women are twice as likely to be overweight or obese compared with rural women (36 percent and 19 percent, respectively). Among the divisions, the proportion of undernourished women ranges from 14 percent in Khulna to 30 percent in Sylhet. As educational attainment and household wealth increase, the proportion of women who are undernourished declines sharply, while the proportion of overweight or obese women increases. Bangladeshi women in the highest wealth quintile are six times more likely to be overweight or obese compared with women in the lowest wealth quintile. However, the World Health Organization (WHO Expert Consultation 2004) also noted that the cut- off points of 23, 27.5, 32.5 and 37.5 kg/m2 are to be added as points for public health action. Based on this, Table 11.8 includes a column showing BMI ≥23 kg/m2 as a measure of overweight and obesity by background characteristics. Based on this classification, 39 percent of women are overweight or obese, 15 percentage points higher than the measure based on BMI ≥25 kg/m2. Variations across subgroups of population are similar to that measured by BMI ≥25 kg/m2. Using this classification, women in urban areas are 19 percentage points more likely than rural women to be overweight or obese (53 percent and 34 percent, respectively). Figure 11.8 Percentage of undernourishment (BMI <18.5) among ever-married women age 15-49 years 31 20 14 19 15-19 years 20-29 years 30-39 years 40-49 years Percentage Age group BDHS 2014 172 • Nutrition of Children and Women Comparison of anthropometric measurements of ever-married women age 15-49 collected in the 2004, 2007, 2011, and 2014 BDHS indicate a slight improvement in the proportion of women whose height is less than 145 cm, from 16 percent in 2004 to 13 percent in 2014. At the same time, the mean BMI has increased from 20.2 in 2004 to 22.3 in 2014. Consequently, the proportion of women with a BMI below 18.5 has decreased, from 34 percent in 2004 to 19 percent in 2014 (Figure 11.9). Figure 11.9 Trends in nutritional status of ever-married women, 2004-2014 Figure 11.10 shows that the proportion of underweight among ever-married women 15-49 (BMI <18.5) has decreased markedly from 52 percent in 1996 to 19 percent in 2014. At the same time, the proportion of overweight women (BMI ≥25) has increased from 3 percent to 24 percent. If BMI ≥23 is considered, the increase in the proportion of overweight women is from 7 percent in 1996 to 39 percent in 2014. Figure 11.10 Trend in BMI among ever-married women age 15-49, 1996/97-2014 BDHS 16 20.2 34 9 15 20.6 30 1213 21.4 24 17 13 22.3 19 24 Height <145 cm Mean BMI BMI <18.5 BMI ≥25.0 Percent BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 52 45 34 30 24 19 7 9 17 21 29 39 3 5 9 12 17 24 BDHS 1996-97 BDHS 1999-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 Percent BMI <18.5 BMI ≥23 BMI ≥25 Nutrition of Children and Women • 173 11.9 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both the women and their children. Breastfeeding children benefit from the micronutrient supplementation that mothers receive, especially vitamin A. In Bangladesh, micronutrient deficiency among women is a common public health problem. Maternal vitamin A deficiency can cause visual impairment and possibly other health consequences. Maternal night blindness due to vitamin A deficiency (VAD) has been associated with increased low birth weight (Tielsch et al. 2008) and infant mortality (Christian et al. 2001). VAD can be prevented through provision of a high dose (200,000 IU) vitamin A capsule in the first six to eight weeks after delivery (when women are considered not at risk of being pregnant). Due to possible adverse effects (birth defects) resulting from high doses of vitamin A, pregnant women should not be given a high dose vitamin A supplement. The 2014 BDHS collected data on use of vitamin A supplements among women age 15- 49 with a child born in the past three years. Table 11.9 presents information on the percentage of women who received a dose of vitamin A during the first two months after the birth of their most recent child. Overall, 46 percent of women age 15-49 with a child born in the past three years received a postpartum vitamin A dose. This proportion varies by urban-rural residence, division, educational attainment, and household wealth. There is no discernible pattern with respect to women’s age. Women in urban areas are more likely to receive vitamin A supplements compared with women in rural areas (53 percent versus 43 percent). Among divisions, the percentage of women who received a postpartum vitamin A dose is highest in Rangpur (50 percent) and lowest in Sylhet (30 percent). Postpartum vitamin A supplementation does not show a linear relationship with mother’s education or wealth. Postpartum vitamin A supplementation is highest among women who have completed secondary or higher education (55 percent) and lowest among women who have completed primary education (37 percent). It is lowest among mothers in the second wealth quintile (40 percent) and highest among mothers in the highest quintile (57 percent). Figure 11.11 shows that postpartum vitamin A supplementation has increased remarkably in the past decade, from 15 percent in 2004, 21 percent in 2007, and 29 percent in 2011 to its current level of 46 percent. Table 11.9 Micronutrient intake among mothers Among women age 15-49 with a child born in the past three years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, by background characteristics, Bangladesh 2014 Background characteristic Percentage who received vitamin A dose postpartum1 Number of women Age 15-19 44.7 971 20-29 46.4 2,743 30-39 45.3 851 40-49 (51.5) 62 Residence Urban 52.9 1,209 Rural 43.4 3,418 Division Barisal 49.0 268 Chittagong 46.0 1,011 Dhaka 48.4 1,634 Khulna 47.9 371 Rajshahi 44.8 464 Rangpur 50.1 450 Sylhet 29.6 428 Education No education 39.8 655 Primary incomplete 40.3 749 Primary complete2 36.7 544 Secondary incomplete 49.0 1,892 Secondary complete or higher3 55.4 787 Wealth quintile Lowest 40.6 1,003 Second 39.6 876 Middle 44.4 882 Fourth 48.1 955 Highest 57.0 912 Total 45.9 4,627 1 In the first two months after delivery of last birth 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 174 • Nutrition of Children and Women Figure 11.11 Trends in postpartum vitamin A supplementation among mothers, 2004-2014 15 21 29 46 BDHS 2004 BDHS 2007 BDHS 2011 BDHS 2014 Percentage HIV/AIDS-related Knowledge, Attitudes, and Behavior • 175 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 12 cquired immune deficiency syndrome (AIDS) is an illness caused by the human immunodeficiency virus (HIV). AIDS was first recognized internationally in 1981. Epidemiological studies have since identified the main routes of transmission of HIV to be unsafe sexual intercourse, intravenous injections with contaminated needles, unscreened or contaminated blood transfusions, and transmission from an infected mother to her child during pregnancy, delivery, or breastfeeding. HIV cannot be transmitted through food, water, insect vectors, or casual contact. HIV infection weakens the immune system and makes the body susceptible to and unable to recover from other opportunistic diseases. Secondary infections, if not adequately treated, can lead to death. In Bangladesh, the first case of HIV was detected in 1989. In 2014, a total of 433 new cases of HIV infection, 251 new AIDS cases, and 91 deaths due to AIDS were reported. The reported number of HIV- positive people in Bangladesh increased from 1,207 in 2007 to 3,674 in 2014, a more than three-fold increase in seven years (Bdnews24.com 2014). The estimated number of HIV/AIDS cases remains at 8,900, however, indicating both the likelihood of incomplete reporting and the potential for growth of the AIDS epidemic in Bangladesh (UNAIDS 2014). Although, Bangladesh is still considered a low-prevalence country for HIV/AIDS, it remains vulnerable to an HIV epidemic because of the high prevalence in neighboring countries and the high mobility of people within and beyond the country (DGHS 2015). The HIV/AIDS prevention program in Bangladesh started in 1985. In response to HIV/AIDS prevention efforts, the government of Bangladesh formed the National AIDS Committee (NAC) under the patronage of the president of Bangladesh. In 2010 the membership of NAC was expanded to include other stakeholders. The MOHFW plays the leading role in the prevention of HIV and control of the AIDS epidemic. In 1995, the Directorate General of Health Services (DGHS) of the Ministry of Health and Family Welfare (MOHFW) formed a task force. The task force was convened by the Technical Committee of the National AIDS Council (TC-NAC). The TC-NAC was composed of national experts from various A Key Findings • Seventy percent of ever-married women age 15-49 have heard of HIV/AIDS, similar to that documented in the 2011 BDHS. • Between 2011 and 2014 the proportion of ever-married women who know two HIV prevention methods decreased from 37 to 34 percent. • Only 11 percent of ever-married women age 15-49 have comprehensive knowledge about AIDS. • More than half of ever-married women (56 percent) know that HIV can be transmitted during pregnancy and through breastfeeding, while less than half (44 percent) know that HIV can be transmitted during delivery. • Fifty-nine percent of ever-married women know that HIV can be transmitted both by using an unsterilized needle or syringe and by blood transfusion. • The great majority of ever-married women (91 percent) think that if a woman knows her husband has a sexually transmitted infection (STI), she is justified in refusing to have sexual intercourse with him. • Fourteen percent of ever-married women report having had an STI and/or symptoms of an STI in the 12 months preceding the survey. The proportion of women who sought advice or treatment for an STI from a clinic, hospital, or health professional increased from 31 percent in 2011 to 46 percent in 2014. 176 • HIV/AIDS-related Knowledge, Attitudes, and Behavior disciplines relevant to the prevention and control of HIV and sexually transmitted diseases (STDs). With political support from the National AIDS Committee and technical support from the TC-NAC, the task force led the process of developing a national policy on HIV and AIDS, which was endorsed by the Cabinet in 1997 (NASP and MOHFW 2008). In 1997, the protocol for safe blood transfusion was formulated. Today there are 211 blood screening centers established for screening HIV, syphilis, malaria, hepatitis B virus (HBV), and hepatitis C virus (HCV). With support from the government of Bangladesh, non-governmental organizations (NGOs) have set up an STD/AIDS network with more than 250 members working in the field of HIV/AIDS. As the nodal body for HIV/AIDS activities, the National AIDS/STD Program (NASP) was formed under the DGHS, and has functioned since 1998. The major role of the NASP is to formulate policies, coordinate information, and regulate the implementation of the HIV/AIDS prevention efforts in the country. The NASP is implementing HIV/AIDS prevention activities through a coalition of three functionaries, the NAC, MOHFW, and DGHS. The NASP is also responsible for coordinating activities of all stakeholders and development partners involved in HIV and AIDS program. Bangladesh has adopted its third National Strategic Plan (2011-2015), with the following objectives: to implement services to prevent new HIV infections; to provide universal access to treatment, care, and support services for people infected and affected by HIV; to strengthen coordination mechanisms and management capacity at different levels to ensure an effective multi-sector HIV/AIDS response; and to strengthen the strategic information systems and research for an evidence-based response (MOHFW 2012). Most HIV-related activities are based on prevention among most-at-risk populations, because Bangladesh is a country with low prevalence of HIV. HIV intervention programs targeting the vulnerable population in Bangladesh evolved over a period of more than 10 years, from 1997-2008. Initially, programs were started and led by NGOs, and a strong partnership developed with the government, civil society, and donors, who worked to facilitate comprehensive interventions for the most vulnerable groups. These groups included female sex workers and their male clients, injecting drug users (IDUs), men who have sex with men, transgendered persons (hijras), and transport workers. In general, intervention packages included condom promotion, STI management, needle/syringe exchange, detoxification, peer education, health education and counseling, resting/recreation facilities, community awareness, and local level advocacy. In addition, the Government of Bangladesh, under the direct supervision of NASP, has taken the initiative to provide optimum care and management to people living with HIV through care, support, and treatment services at government and NGO facilities. An AIDS Epidemic Model analysis conducted to examine the impact of interventions concluded that early response to HIV/AIDS helped to maintain a low prevalence in Bangladesh. The analysis demonstrated that up to 2014 the ongoing interventions have averted a total of 141,225 HIV infections and saved 3,841,000 Disability Adjusted Life Years (DALYs) and 19,545 lives (MIS 2015). Bangladesh has been conducting serological surveillance and behavioral surveys since 1999. These surveys provide data to better understand and address the HIV situation at both the national and sub-national levels. They thereby aid in the design of prevention, treatment, care, and support programs. Since 1998, serological surveillance surveys of most-at-risk groups have been conducted approximately every two years. According to the latest Serological Surveillance (NASP 2012) in Bangladesh, HIV prevalence among persons who use drugs, female sex workers, male sex workers, men who have sex with men, and hijras is 0.7 percent with IDUs in Dhaka city have the highest prevalence (5.3 percent). A recent study also observed that the number of HIV cases among IDUs in Dhaka city is increasing rapidly (NASP et al. 2014). Bangladesh has been implementing HIV prevention programs through awareness-raising activities since 1987, a time when there were no identified cases of HIV in the country. Over the years, the HIV program has grown in size and quality and has involved a wider network of stakeholders. The program has increased its coverage of most-at-risk populations, which now include young people. There have been various efforts to prevent HIV transmission, such as public health education through the media and program activities by both government and NGOs, particularly with groups considered to be at high risk for transmission of HIV/AIDS. In addition, adolescent and young people age 11-24 have been targeted through providing life-skills training to peer leaders. Integrating life-skills based education in secondary school curriculums is a major accomplishment to reach adolescents with messages on HIV/AIDS prevention. HIV/AIDS-related Knowledge, Attitudes, and Behavior • 177 Because Bangladesh is a low-prevalence country, with HIV not posing an immediate threat, no special focus has been placed on the general population. Instead, the focus continues to be mainly on high- risk groups. This chapter presents current levels of knowledge and attitudes regarding HIV/AIDS prevention and transmission in the general population of women of reproductive age. This chapter also discusses self- reported prevalence of sexually transmitted infections (STIs) and symptoms including care-seeking behaviors. 12.1 KNOWLEDGE OF HIV/AIDS AND TRANSMISSION AND PREVENTION METHODS 12.1.1 Knowledge of HIV/AIDS The 2014 BDHS included a series of questions to gauge respondent’s knowledge and attitudes concerning HIV/AIDS. All ever-married women age 15-49 were first asked if they had ever heard of AIDS. Those who had heard of AIDS were then questioned on their knowledge of HIV transmission and prevention. Table 12.1 shows that 70 percent of ever-married women age 15-49 have heard of HIV/AIDS, the same level as documented in the 2011 BDHS. Awareness of HIV/AIDS varies by age, with women under age 30 being more aware of the disease than older women. Knowledge of HIV/AIDS is higher among urban than rural women (85 compared with 64 percent). Awareness of HIV/AIDS ranges from a high of 77 percent among women in Khulna to 60 percent in Sylhet. Nearly all women who have completed secondary education (99 percent) have heard of HIV/AIDS compared with 40 percent of women with no education. The proportion of ever-married women who have ever heard of AIDS increases steadily as women’s wealth status increases. 12.1.2 Knowledge of HIV Prevention Methods HIV/AIDS prevention programs focus their messages and efforts on two important aspects of sexual behavior: limiting the number of partners and staying faithful to one uninfected partner; and using condoms. To ascertain whether programs have effectively communicated these messages, the 2014 BDHS asked respondents specific questions about whether it is possible to reduce the chances of getting the AIDS virus by using a condom at every sexual encounter and by limiting sexual intercourse to one uninfected partner. Table 12.2 shows that 51 percent of ever-married women say that HIV infection can be reduced by limiting sex to one uninfected partner who has no other partners, while 42 percent cite using condoms at every sexual encounter, and 34 percent are aware of both means of reducing the risk of HIV infection. However, there has been a slight decline in knowledge of HIV prevention methods; the proportion of ever- married women who know about both methods of HIV prevention decreased from 37 percent in 2011 to 34 percent in 2014. Knowledge of the various methods of HIV/AIDS prevention varies by respondent’s age; women age 20-24 and women age 25-29 are more knowledgeable than older women. Knowledge of HIV/AIDS prevention methods is higher among urban women than rural women, and higher among women in Dhaka compared with other districts. Knowledge of HIV/AIDS prevention methods increases with women’s education and wealth status. Table 12.1 Knowledge of AIDS Percentage of ever-married women age 15-49 who have heard of AIDS, by background characteristics, Bangladesh 2014 Background characteristic Has heard of AIDS Number of women Age 15-24 75.4 5,253 15-19 72.0 2,029 20-24 77.5 3,224 25-29 76.8 3,390 30-39 67.9 5,362 40-49 57.4 3,859 Marital status Married/living together 70.4 16,858 Divorced/separated/ widowed 54.8 1,005 Residence Urban 84.8 5,047 Rural 63.5 12,816 Division Barisal 71.4 1,111 Chittagong 68.9 3,301 Dhaka 74.0 6,223 Khulna 76.9 1,838 Rajshahi 63.1 2,103 Rangpur 62.0 2,056 Sylhet 59.5 1,232 Education No education 40.3 4,455 Primary incomplete 58.7 3,223 Primary complete1 70.9 1,986 Secondary incomplete 85.2 5,628 Secondary complete or higher2 98.5 2,571 Wealth quintile Lowest 42.9 3,359 Second 55.4 3,408 Middle 71.4 3,560 Fourth 80.9 3,758 Highest 92.8 3,778 Total 69.5 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 178 • HIV/AIDS-related Knowledge, Attitudes, and Behavior Table 12.2 Knowledge of HIV prevention methods Percentage of ever-married women age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting the AIDS virus by using condoms every time they have sexual intercourse, and by having one sex partner who is not infected and has no other partners, by background characteristics, Bangladesh 2014 Percentage who say HIV can be prevented by Number of women Background characteristic Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Age 15-24 45.0 55.4 37.3 5,253 15-19 42.1 51.8 34.4 2,029 20-24 46.9 57.7 39.1 3,224 25-29 46.3 57.5 38.6 3,390 30-39 41.2 49.2 33.5 5,362 40-49 32.9 41.2 27.3 3,859 Marital status Married/living together 42.3 51.6 34.9 16,858 Divorced/separated/ widowed 28.8 38.1 23.7 1,005 Residence Urban 54.4 64.0 45.7 5,047 Rural 36.5 45.7 29.8 12,816 Division Barisal 40.7 52.5 33.4 1,111 Chittagong 37.0 44.9 28.2 3,301 Dhaka 47.4 57.2 40.6 6,223 Khulna 46.5 54.8 36.5 1,838 Rajshahi 37.7 47.7 32.1 2,103 Rangpur 39.1 47.2 32.8 2,056 Sylhet 27.7 38.7 22.3 1,232 Education No education 21.9 27.2 17.7 4,455 Primary incomplete 30.5 40.1 24.5 3,223 Primary complete3 38.4 49.4 30.4 1,986 Secondary incomplete 51.1 63.3 41.9 5,628 Secondary complete or higher4 70.7 79.5 61.4 2,571 Wealth quintile Lowest 22.7 29.3 18.8 3,359 Second 30.2 39.7 24.8 3,408 Middle 41.1 51.1 32.7 3,560 Fourth 48.4 58.9 39.5 3,758 Highest 62.1 72.1 52.8 3,778 Total 41.5 50.9 34.3 17,863 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. 12.1.3 Comprehensive Knowledge about AIDS Comprehensive knowledge about HIV/AIDS is a useful composite measure, combining understanding on HIV prevention methods and local misconceptions. The 2014 BDHS collected information on common misconceptions about HIV transmission. Respondents were asked whether they think it is possible for a healthy-looking person to have HIV, and also whether they believe HIV can be transmitted through mosquito bites, or by sharing food with a person who has HIV or AIDS. Comprehensive knowledge about AIDS is defined as knowing that consistent condom use and having just one faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about HIV transmission in Bangladesh: that HIV can be transmitted by mosquito bites and that HIV can be transmitted by sharing food with a person who has AIDS. The data presented in Table 12.3 indicate that many ever-married women age 15-49 in Bangladesh lack accurate knowledge about the ways in which the AIDS virus can and cannot be transmitted. Less than half of ever-married women (47 percent) know that a healthy-looking person can have HIV, and 38 percent HIV/AIDS-related Knowledge, Attitudes, and Behavior • 179 know that HIV cannot be transmitted by mosquito bites. Thirty-six percent of women correctly believe that a person cannot become infected by sharing food with a person who has AIDS. Overall, only 11 percent of ever-married women have comprehensive knowledge about AIDS. Comprehensive knowledge about AIDS is higher among married women and urban residents than among other women. Among administrative divisions, comprehensive AIDS knowledge is the highest in Dhaka (14 percent) and the lowest in Sylhet (6 percent). Comprehensive knowledge about AIDS increases with education, from 4 percent among women with no education to 27 percent among women who have completed secondary or higher education. Comprehensive knowledge about AIDS also increases with household wealth. The proportion of ever- married women who have comprehensive knowledge about AIDS remained unchanged between surveys in 2011 and 2014. The proportion of women who correctly reject local misconceptions also remained unchanged between the two surveys, except for the proportion of ever-married women who correctly believe that HIV cannot be transmitted by mosquito bites, which increased from 32 to 38 percent. Table 12.3 Comprehensive knowledge about AIDS Percentage of ever-married women age 15-49 who say that a healthy-looking person can have the AIDS virus and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention and the percentage with a comprehensive knowledge about AIDS, by background characteristics, Bangladesh 2014 Percentage of respondents who say that: Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local misconceptions1 Percentage with a comprehensive knowledge about AIDS2 Number of women Background characteristic A healthy-looking person can have the AIDS virus The AIDS virus cannot be transmitted by mosquito bites A person cannot become infected by sharing food with a person who has the AIDS virus Age 15-24 49.9 41.9 40.4 19.6 12.7 5,253 15-19 47.0 38.0 37.8 17.7 12.0 2,029 20-24 51.7 44.3 42.0 20.9 13.2 3,224 25-29 51.3 42.2 41.3 19.2 12.1 3,390 30-39 47.1 37.4 34.4 16.9 10.8 5,362 40-49 39.2 28.3 27.0 11.5 7.5 3,859 Marital status Married/living together 47.6 38.2 36.5 17.3 11.2 16,858 Divorced/separated/ widowed 36.9 28.5 25.2 11.0 6.2 1,005 Residence Urban 58.4 52.6 50.8 26.2 17.5 5,047 Rural 42.5 31.7 30.0 13.4 8.3 12,816 Division Barisal 52.9 35.7 30.7 14.1 7.8 1,111 Chittagong 43.4 42.0 36.4 16.5 8.7 3,301 Dhaka 50.5 40.2 40.0 19.5 13.8 6,223 Khulna 58.1 42.6 39.9 20.0 12.7 1,838 Rajshahi 43.0 31.9 31.3 16.0 10.1 2,103 Rangpur 38.5 31.3 31.5 13.7 9.5 2,056 Sylhet 38.6 28.0 27.6 11.0 6.0 1,232 Education No education 25.5 17.9 15.7 5.9 3.5 4,455 Primary incomplete 38.9 25.5 23.4 9.1 4.8 3,223 Primary complete3 45.0 36.1 32.9 13.3 8.1 1,986 Secondary incomplete 58.2 46.6 43.6 20.9 13.8 5,628 Secondary complete or higher4 71.6 68.7 71.9 40.4 27.2 2,571 Wealth quintile Lowest 28.1 19.8 18.0 7.5 4.6 3,359 Second 35.1 24.7 21.8 8.1 4.7 3,408 Middle 48.7 35.2 32.1 15.0 9.1 3,560 Fourth 55.5 43.9 42.9 20.0 13.0 3,758 Highest 64.6 61.2 61.0 32.4 21.8 3,778 Total 47.0 37.6 35.9 17.0 10.9 17,863 1 Two most common local misconceptions: AIDS can be transmitted by mosquito bites and by sharing food with a person who has AIDS 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about AIDS transmission or prevention. 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. 180 • HIV/AIDS-related Knowledge, Attitudes, and Behavior Figure 12.1 Comprehensive knowledge about AIDS among ever-married women age 15-49 12.2 KNOWLEDGE ABOUT MOTHER-TO-CHILD TRANSMISSION OF HIV To assess the level of knowledge about mother-to-child transmission (MTCT) of HIV, the 2014 BDHS asked ever-married women age 15-49 whether HIV can be transmitted from a mother to a child during pregnancy, during delivery, or through breastfeeding. Table 12.4 shows that 56 percent of ever-married women know that HIV can be transmitted during pregnancy, while 44 percent of women know that HIV can be transmitted during delivery, and 55 percent of women know that HIV can be transmitted through breastfeeding. Knowledge about MTCT of HIV during pregnancy and delivery has decreased slightly since 2011, when 59 percent of women knew that HIV can be transmitted during pregnancy and 48 percent knew about MTCT during delivery. However, the proportion of ever-married women who know that HIV can be transmitted through breastfeeding has remained almost unchanged between BDHS 2011 and BDHS 2014. Knowledge of MTCT of HIV is highest among women age 20-24, women living in Khulna, currently married women, pregnant women, and women living in urban areas. Like other aspects of HIV/AIDS knowledge, women’s knowledge about MTCT increases with their educational level and wealth status. 47 38 36 17 11 49 32 38 17 11 A healthy-looking person can have the AIDS virus AIDS cannot be transmitted by mosquito bites A person cannot become infected by sharing food with a person who has the AIDS virus Percentage who say that a healthy looking person can have the AIDS virus and who reject the two most common local misconceptions Percentage with a comprehensive knowledge about AIDS Percent BDHS 2011 BDHS 2014 HIV/AIDS-related Knowledge, Attitudes, and Behavior • 181 Table 12.4 Knowledge of prevention of mother to child transmission of HIV Percentage of ever-married women age 15-49 who know that HIV can be transmitted from mother to child by breastfeeding and that the risk of mother-to-child transmission (MTCT) can be reduced by mother taking special drugs during pregnancy, by background characteristics, Bangladesh 2014 Percentage who know that HIV can be transmitted: Number of women Background characteristic During pregnancy During delivery By breastfeeding Age 15-24 59.8 47.6 59.7 5,253 15-19 57.0 45.0 56.9 2,029 20-24 61.6 49.2 61.5 3,224 25-29 61.4 47.2 60.4 3,390 30-39 54.8 43.1 54.3 5,362 40-49 45.2 36.0 45.2 3,859 Marital status Married/living together 56.2 44.3 55.7 16,858 Divorced/separated/ widowed 43.5 33.4 44.6 1,005 Currently pregnant Pregnant 58.6 47.0 56.4 1,070 Not pregnant or not sure 55.3 43.5 55.0 16,793 Residence Urban 68.5 53.6 68.0 5,047 Rural 50.4 39.8 50.0 12,816 Division Barisal 58.6 45.3 55.6 1,111 Chittagong 57.2 47.2 56.2 3,301 Dhaka 58.8 47.1 59.2 6,223 Khulna 62.9 46.3 61.4 1,838 Rajshahi 50.2 36.1 51.0 2,103 Rangpur 46.0 36.4 45.4 2,056 Sylhet 44.9 36.5 44.0 1,232 Education No education 30.8 24.4 30.9 4,455 Primary incomplete 46.3 37.5 46.7 3,223 Primary complete1 55.5 44.8 57.0 1,986 Secondary incomplete 68.9 54.2 68.0 5,628 Secondary complete or higher2 80.3 60.9 77.5 2,571 Wealth quintile Lowest 34.1 27.1 32.5 3,359 Second 42.7 35.1 44.0 3,408 Middle 57.5 45.6 57.1 3,560 Fourth 65.6 51.0 65.7 3,758 Highest 74.1 57.0 72.5 3,778 Total 55.5 43.7 55.1 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 12.3 KNOWLEDGE OF MEANS OF TRANSMISSION OF HIV To ascertain women’s knowledge about nonsexual means of transmission of HIV, the survey asked respondents whether it is possible to get the AIDS virus by using an unsterilized needle or syringe or by receiving an unsafe blood transfusion. Table 12.5 shows that 63 percent of ever-married women age 15-49 know that the AIDS virus can be transmitted by using an unsterilized needle or syringe, while 61 percent of women know that the AIDS virus can be transmitted through blood transfusion. Fifty-nine percent of ever- married women know both of these means of HIV transmission. The proportion of women who know both means of HIV transmission decreased slightly between 2011 and 2014, from 61 to 59 percent. There are considerable variations in knowledge of HIV transmission by women’s background characteristics. Knowledge is higher among younger women, married women, urban women, women living in Khulna, women who have completed secondary or higher education, and women in the highest wealth quintile. 182 • HIV/AIDS-related Knowledge, Attitudes, and Behavior Table 12.5 Knowledge of transmission of HIV through unclean needles and unsafe blood transfusions Percentage of ever-married women age 15-49 who, in response to prompted questions, say that people can get the AIDS virus by using an unsterilized needle or syringe and through blood transfusion, by background characteristics, Bangladesh 2014 Background characteristic Using an unsterilized needle or syringe Via blood transfusion Both Number of women Age 15-24 68.3 66.5 63.5 5,253 15-19 64.5 64.1 60.8 2,029 20-24 70.6 68.1 65.1 3,224 25-29 69.3 67.7 64.9 3,390 30-39 61.7 61.0 58.2 5,362 40-49 50.3 49.8 46.7 3,859 Marital status Married/living together 63.5 62.3 59.4 16,858 Divorced/separated/ widowed 47.7 48.0 44.9 1,005 Residence Urban 77.1 76.8 73.4 5,047 Rural 56.9 55.4 52.7 12,816 Division Barisal 63.1 62.9 58.8 1,111 Chittagong 61.1 60.8 57.6 3,301 Dhaka 67.0 66.0 63.3 6,223 Khulna 72.1 69.8 67.4 1,838 Rajshahi 57.4 56.7 53.8 2,103 Rangpur 55.6 52.9 49.8 2,056 Sylhet 50.4 48.8 46.5 1,232 Education No education 34.5 33.5 31.3 4,455 Primary incomplete 50.9 49.6 46.7 3,223 Primary complete1 62.5 61.0 58.0 1,986 Secondary incomplete 77.2 76.0 72.5 5,628 Secondary complete or higher2 94.0 93.1 90.6 2,571 Wealth quintile Lowest 37.2 35.4 33.3 3,359 Second 49.1 46.9 44.4 3,408 Middle 62.8 62.6 58.8 3,560 Fourth 73.6 73.3 69.7 3,758 Highest 86.2 84.9 82.4 3,778 Total 62.6 61.4 58.5 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 12.4 ATTITUDE TOWARD NEGOTIATING SAFE SEXUAL RELATIONS WITH HUSBANDS An important determinant of practicing safer sexual relations is control over one’s sexual rights and preferences. Knowledge about HIV transmission and ways to prevent it are of little use if women feel powerless to negotiate safer sex practices with their husbands. To assess a woman’s ability to negotiate safer sex, the 2014 BDHS asked respondents if they think that a wife is justified in refusing to have sex with her husband when she knows he has a disease that can be transmitted through sexual contact. Table 12.6 shows that the great majority of ever-married women (91 percent) think that if a woman knows her husband has a sexually transmitted infection (STI), she is justified in refusing to have sex with him. This percentage remains the same as in the 2011 BDHS. There are small variations in women’s attitudes toward negotiating safer sex with their husbands by background characteristics. Among administrative divisions, the proportion of women who support a woman’s right to refuse sex ranges from 87 percent in Sylhet and Rangpur to 95 percent in Rajshahi. It is important to note that among ever-married women with no education 87 percent say that a woman is justified in refusing to have sex with her husband if she knows he has an STI, nearly as high as the 93 percent of women with a secondary or higher level of education. Similarly, 90 percent of women in the lowest wealth quintile support women’s right to refuse sex, only 5 percentage points lower than for women in the highest wealth quintile (95 percent). HIV/AIDS-related Knowledge, Attitudes, and Behavior • 183 Table 12.6 Attitudes toward negotiating safer sexual relations with husband Percentage of ever-married women age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has a sexually transmitted infection (STI), by background characteristics, Bangladesh 2014 Background characteristic Woman is justified in refusing to have sexual intercourse with her husband if she knows that her husband has an STI Number of women Age 15-24 90.8 5,253 15-19 91.7 2,029 20-24 90.2 3,224 25-29 91.8 3,390 30-39 90.5 5,362 40-49 89.7 3,859 Marital status Married/living together 90.7 16,858 Divorced/separated/ widowed 89.1 1,005 Residence Urban 94.2 5,047 Rural 89.3 12,816 Division Barisal 88.7 1,111 Chittagong 89.7 3,301 Dhaka 91.4 6,223 Khulna 92.7 1,838 Rajshahi 95.0 2,103 Rangpur 87.1 2,056 Sylhet 86.7 1,232 Education No education 87.3 4,455 Primary incomplete 91.2 3,223 Primary complete1 91.5 1,986 Secondary incomplete 91.5 5,628 Secondary complete or higher2 93.1 2,571 Wealth quintile Lowest 89.5 3,359 Second 87.3 3,408 Middle 90.5 3,560 Fourth 90.9 3,758 Highest 94.6 3,778 Total 90.7 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 12.5 SELF-REPORTED PREVALENCE OF SEXUALLY TRANSMITTED INFECTIONS (STIS) AND STI SYMPTOMS In the 2014 BDHS, respondents who ever had sex were asked if they had gotten a disease through sexual contact in the previous 12 months or if they had experienced either of two symptoms associated with sexually transmitted infections (STIs), that is, a bad-smelling or abnormal genital discharge, or a genital sore or ulcer. Table 12.7 shows the self-reported prevalence of STIs and STI symptoms among ever-married women age 15-49. Overall, only 0.5 percent of ever-married women age 15-49 responded that they had an STI in the 12 months preceding the survey. It is likely that this figure underestimates the actual prevalence of STIs among sexually active women in Bangladesh, as many STI symptoms are not easily recognized and many STIs do not have visible symptoms. 184 • HIV/AIDS-related Knowledge, Attitudes, and Behavior Table 12.7 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms Among ever-married women age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, by background characteristics, Bangladesh 2014 Background characteristic STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/sore or ulcer Number of women who ever had sexual intercourse Age 15-24 0.4 10.7 5.1 13.5 5,242 15-19 0.2 8.8 2.9 10.4 2,020 20-24 0.5 11.9 6.5 15.5 3,222 25-29 0.5 11.6 6.1 14.4 3,386 30-39 0.5 11.5 5.8 14.6 5,362 40-49 0.7 8.8 4.8 11.6 3,857 Marital status Married/living together 0.5 10.8 5.6 13.8 16,848 Divorced/separated/ widowed 0.3 8.1 2.6 9.7 998 Residence Urban 0.5 9.5 4.9 12.5 5,040 Rural 0.5 11.1 5.6 14.0 12,806 Division Barisal 1.1 12.2 8.4 17.0 1,109 Chittagong 0.4 9.9 7.2 13.9 3,298 Dhaka 0.6 10.1 3.9 12.2 6,219 Khulna 0.8 13.5 6.1 16.5 1,837 Rajshahi 0.2 12.2 6.1 15.4 2,100 Rangpur 0.3 9.5 4.2 11.9 2,053 Sylhet 0.4 9.6 5.3 12.5 1,231 Education No education 0.5 9.9 4.7 12.2 4,454 Primary incomplete 0.4 12.3 6.2 15.3 3,219 Primary complete1 0.6 12.7 6.1 15.8 1,986 Secondary incomplete 0.5 10.9 5.7 13.9 5,620 Secondary complete or higher2 0.7 8.0 4.7 11.5 2,568 Wealth quintile Lowest 0.7 10.9 4.9 13.6 3,358 Second 0.5 12.2 6.6 15.3 3,405 Middle 0.5 12.1 5.9 15.3 3,554 Fourth 0.4 10.1 4.9 12.7 3,753 Highest 0.5 8.4 4.9 11.4 3,777 Total 0.5 10.7 5.4 13.6 17,846 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Self-reported prevalence of STIs and/or STI symptoms among women has decreased by 1 percentage point since 2011. In the 2014 BDHS, 14 percent of ever-married women report having had an STI and/or symptoms of an STI in the 12 months before the survey. Women who report STI symptoms are somewhat more likely to say they have had a bad-smelling or abnormal genital discharge (11 percent) than a genital ulcer or sore (5 percent). The proportion of women having a genital sore or ulcer in the 12 months before the survey decreased by 2 percentage points during the last three years. There is a small variation in the prevalence of STIs and/or STI symptoms by women’s background characteristics. Among divisions, the percentage of women reporting an STI and/or STI symptoms is highest in Barisal and Khulna (17 percent) and lowest in Rangpur and Dhaka (12 percent). When women reported having an STI, STI symptoms, or both in the past 12 months, the 2014 BDHS interviewer asked whether they sought any advice or treatment for it. Figure 12.2 shows that care seeking for treatment of STIs improved between 2011 and 2014. The proportion of women who sought advice or treatment from a clinic, hospital, private doctor, or other health professional increased from 31 percent in 2011 to 46 percent in 2014. The proportion of women who sought advice or medicine from a pharmacy increased from 8 to 11 percent between two surveys. In contrast, care seeking from other sources for treatment of STIs decreased substantially, from 18 to 7 percent. The proportion of women who sought no advice or treatment for STIs also decreased between surveys, from 45 to 39 percent. HIV/AIDS-related Knowledge, Attitudes, and Behavior • 185 Figure 12.2 Care seeking for STIs of women, 2011 and 2014 46 11 7 39 31 8 18 45 Advice or treatment from clinic/hospital/qualified doctor/other health professional Advice or medicine from pharmacy Advice or treatment from any other source No advice or treatment Percent BDHS 2011 BDHS 2014 Women’s Empowerment and Health Seeking Behavior • 187 WOMEN’S EMPOWERMENT AND HEALTH SEEKING BEHAVIOR 13 he issue of women’s empowerment has a long history, but many say that gender equity is not yet established throughout the world (Bhasin 1993; Begum et al. 1990). Achieving gender equity is not a straightforward goal that can be attained readily. Against this backdrop, the 1994 International Conference on Population and Development declared, “advancing gender equality and equity and the empowerment of women and the elimination of all kinds of violence against women, and ensuring women’s ability to control their own fertility are cornerstones of population and development-related programs” (UNFPA 1994). Women’s empowerment has been defined to encompass women having a sense of self- worth, access to opportunities and resources, choices and the ability to exercise them, control over their own lives, and influence over the direction of social change (United Nations Population Information Network 1995). According to the United Nations Development Program’s (UNDP) Human Development Report for 2013, Bangladesh ranks 115 out of 187 countries on the Gender Inequality Index, which is defined in the report as “a composite measure reflecting inequality in achievements between women and men in three dimensions: reproductive health, empowerment, and the labor market” (UNDP 2013). The 2014 Global Gender Gap Index, developed by the World Economic Forum, ranks Bangladesh 68 out of 142 countries in terms of gender equality (World Economic Forum 2014). Thus, Bangladesh ranks among the bottom half of countries included in each gender-related index. Women make up half of the total population and women’s labor force participation is increasing more than ever compared with men’s (BBS 2013). Women need much attention from all concerned if they are to achieve the desired levels of empowerment, even though women’s right to equality is considered as one of the fundamental themes of the Constitution of Bangladesh (Ministry of Women and Children Affairs 2010). Empowerment and autonomy of women are essential for the achievement of sustainable development. The full participation and partnership of both women and men is required in productive and reproductive life, including sharing responsibilities for the care and nurture of children as well as for the maintenance of households. In Bangladesh, women’s empowerment is high on the list of priority improvements sought in the social and economic conditions of its people. As of today, the government of Bangladesh has formulated four statements of the National Women’s Policy (1997, 2004, 2008, and 2011) T Key Findings • Thirty-two percent of currently married employed women who earn cash make decisions mainly by themselves on how to use their own earnings. • Seventy percent of currently married women go alone or with children to the health center or hospital, an increase from 56 percent in 2011. • Forty-four percent of currently married women participate in all four types of decisions regarding their own health care, their child’s health care, major household purchases, and visits to their family or relatives. • Twenty-eight percent of women agree with one or more reasons justifying wife beating. One in five women thinks wife beating is justified if she argues with her husband. • Active involvement in household decision-making has a positive bearing on a woman’s use of contraceptives. • Access to antenatal care, postnatal care, and delivery assistance from a medically trained provider increases with a higher score on the women’s empowerment indices. 188 • Women’s Empowerment and Health Seeking Behavior to empower women at all stages (Ministry of Women and Children Affairs 2011). These policies have successfully identified the crux of the problems related to socioeconomic, administrative, political, and legal empowerment of women. In addition, Bangladesh ratified the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) in 1984, for all four sections, and has committed to all optional protocols of this charter to ensure women’s empowerment, after the United Nations adopted this charter in 1979. The main idea is to eliminate all discrimination against women that exists at institutional levels (Ministry of Women and Children Affairs 2010). A number of studies show that women lag behind men in educational attainment, literacy, employment, and exposure to mass media (Ahmed and Khatun 2008; Khatun and Cornwell 2009; Khatun 2009). Achievements in these areas are crucial contributors to women’s empowerment. At the individual level, education, employment, and exposure to mass media all exert considerable influence on the development of a woman’s opportunities and sense of self-worth can help strengthen her position in the household and in the society. This chapter discusses indicators of women’s empowerment including employed women’s control over their own earnings, women’s freedom of movement, women’s participation in household decisions, and women’s acceptance of wife beating. In addition, two summary indicators of women’s empowerment are defined: an index of the number of household decisions (0-4) in which the respondent participates and an index of the number of reasons (0-5) the respondent accepts as justifying wife beating. The ranking of women on these two indices is then related to selected demographic and health outcomes including contraceptive use, ideal family size, unmet need for family planning, and receipt of health care services during pregnancy, at delivery, and in the postnatal period. 13.1 EMPLOYMENT AND FORM OF EARNINGS Employment, particularly employment for cash, and control over how earnings are used are important indicators of women’s empowerment. In the 2014 BDHS, currently married women were asked whether they were employed at the time of the survey and, if not, whether they were employed at any time during the 12 months preceding the survey. Table 13.1 shows the percentage of currently married women age 15-49 who were employed at any time in the 12 months preceding the survey, and the percent distribution of employed women by the type of earnings they received (cash, in-kind, cash and in-kind, or neither). Thirty-four percent of currently married women age 15-49 reported some forms of employment in the past 12 months. By age, employment increases from 17 percent among women age 15-19 to 42 percent among women age 40-44, before declining to 39 percent in the oldest group (age 45-49). As age increases, the difference in employment between age group decreases, from 10 percentage points between women age 15-19 and women age 20-24, to 8 percentage points between women age 20-24 and women age 25-29. Then this difference decreases to 1 or 2 percentage points among the older age groups. The popular assumption is that employment and payment for work come together, but not all women receive earnings for the work they do. Even among women who receive earnings, not all are paid in cash. Eighty-five percent of employed women are paid in cash, 6 percent receive both cash and in-kind earnings, 1 percent have in-kind earnings only, and 8 percent are not paid at all for their work. Older women are more likely to report cash and in-kind earnings compared with younger employed women, while younger women are more likely to report earning cash only. For instance, 9 percent of women age 45-49 reported that they receive cash and in-kind earnings compared with 2 percent of women age 15-19. On the other hand, 89 percent of women age 15-19 reported receiving cash only compared with 79 percent of women age 45-49. Women’s Empowerment and Health Seeking Behavior • 189 Table 13.1 Employment and cash earnings of currently married women Percentage of currently married women age 15-49 who were employed at any time in the past 12 months and the percent distribution of currently married women employed in the past 12 months by type of earnings, according to age, Bangladesh 2014 Among currently married women: Percent distribution of currently married women employed in the past 12 months, by type of earnings Total Number of employed women Age Percentage employed Number of women Cash only Cash and in-kind In-kind only Not paid Missing/ don’t know 15-19 17.1 1,984 89.1 2.4 0.3 8.0 0.3 100.0 338 20-24 27.7 3,166 84.3 6.4 0.3 9.0 0.0 100.0 877 25-29 35.3 3,249 86.4 4.6 1.2 7.7 0.1 100.0 1,149 30-34 40.6 2,919 84.8 6.2 1.5 7.4 0.1 100.0 1,185 35-39 40.2 2,153 85.0 5.1 1.9 7.8 0.3 100.0 867 40-44 41.6 1,874 84.0 7.8 1.9 6.1 0.3 100.0 779 45-49 38.9 1,512 78.7 9.1 1.3 10.9 0.0 100.0 589 Total 34.3 16,858 84.6 6.0 1.3 8.0 0.1 100.0 5,784 13.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS One main component of measuring women’s empowerment is whether women have control over their earnings. To assess control over earnings, the survey asked currently married women with cash earnings in the past 12 months about who makes the main decision about the use of their earnings. If women are able to control how their own cash earnings are used, they are more likely to have a greater say in using other household resources. Table 13.2 shows the percent distribution of currently married women who received cash earnings in the past 12 months, according to the person who mainly decides about the use of their earnings. Thirty- two percent of currently married women who earn cash reported that they themselves mainly decide how their cash earnings are used; 54 percent reported that they decide jointly with their husbands, and 13 percent reported that their husbands alone decide how their earnings are used. A very low percentage of women reported that other people participate in the decision on how their earnings are used. Women age 45-49 are less likely to make their own decisions about how to use their earnings than their younger counterparts (28 percent compared with 34 percent of women age 15-19). However, as age increases, women are more likely to make decisions jointly with their husbands. Women with lower parity are more likely to make decisions about their earnings alone compared with women with higher parity, while women with higher parity are more likely to make decisions jointly with their husbands. Urban women are more likely than rural women to make decisions themselves about spending their earnings (39 percent versus 29 percent). As expected, rural women are more likely than urban women to report that their husbands alone make decisions about the use of their earnings (14 percent versus 10 percent). A substantial variation in who makes decisions on how women’s earnings is observed across administrative divisions in the 2014 BDHS. The proportion of employed women who mainly decide by themselves about the use of their earnings ranges from 45 percent in Barisal to 20 percent in Rangpur, and joint decision-making ranges from 41 percent in Barisal to 61 percent in Rangpur. The 2014 BDHS data provide consistent findings about women of Barisal and Rangpur. If a woman decides alone about her earnings, she is less likely to report joint decision-making, and vice versa. The proportion of women who reported that decisions about their earnings are made mainly by their husbands ranges from 10 percent in Dhaka to 17 percent in Rajshahi. Women’s decision-making power about their earnings increases with their level of education and household wealth. Forty-three percent of women who have completed secondary or higher education mainly make the decision by themselves on how to use the money they earn compared with 28 percent of women with no education. Women with no education and those who completed primary school are more likely than other women to decide jointly with their husbands (56 percent and 58 percent, respectively) about the use of their earnings. Forty-one percent of women in the highest wealth quintile mainly decide by themselves about the use of their earnings compared with 23 percent of women in the lowest wealth quintile. 190 • Women’s Empowerment and Health Seeking Behavior Table 13.2 Control over women’s cash earnings Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife’s cash earnings are used, according to background characteristics, Bangladesh 2014 Person who decides how the wife’s cash earnings are used: Total Number of employed women with cash earnings Background characteristic Mainly wife Wife and husband jointly Mainly husband Other Missing Age 15-19 34.1 44.0 18.9 2.9 0.2 100.0 310 20-24 29.9 53.2 14.8 1.6 0.6 100.0 796 25-29 33.6 52.3 12.2 1.4 0.5 100.0 1,045 30-34 33.2 54.1 12.1 0.0 0.7 100.0 1,079 35-39 31.9 54.9 12.5 0.0 0.6 100.0 781 40-44 31.4 55.7 12.0 0.1 0.9 100.0 715 45-49 27.5 58.7 12.9 0.0 0.8 100.0 517 Number of living children 0 33.8 51.0 12.0 3.1 0.0 100.0 360 1-2 32.4 52.6 13.5 0.9 0.6 100.0 2,753 3-4 31.8 54.6 12.6 0.0 0.9 100.0 1,702 5+ 26.8 60.4 12.9 0.0 0.0 100.0 427 Residence Urban 39.1 50.1 10.1 0.3 0.4 100.0 1,426 Rural 29.1 55.2 14.1 0.9 0.7 100.0 3,815 Division Barisal 44.9 40.8 13.3 0.5 0.4 100.0 282 Chittagong 34.8 50.5 12.7 1.0 0.9 100.0 749 Dhaka 32.7 56.4 9.8 0.9 0.2 100.0 2,014 Khulna 36.5 46.3 16.0 0.6 0.5 100.0 532 Rajshahi 27.8 54.4 16.8 0.5 0.4 100.0 796 Rangpur 20.3 61.3 15.8 0.4 2.1 100.0 689 Sylhet 37.2 48.5 14.1 0.0 0.2 100.0 179 Education No education 27.8 56.3 15.3 0.2 0.4 100.0 1,514 Primary incomplete 30.4 53.3 14.1 0.8 1.4 100.0 1,101 Primary complete1 29.7 58.4 10.9 0.6 0.5 100.0 632 Secondary incomplete 33.4 50.5 14.7 1.1 0.3 100.0 1,384 Secondary complete or higher2 43.3 51.1 4.0 1.1 0.5 100.0 610 Wealth quintile Lowest 23.1 58.7 16.7 0.8 0.7 100.0 1,127 Second 25.8 57.8 15.7 0.1 0.6 100.0 1,146 Middle 33.2 53.5 12.1 0.7 0.4 100.0 1,050 Fourth 39.1 47.9 11.0 1.0 0.9 100.0 1,078 Highest 40.6 49.7 8.3 0.9 0.5 100.0 841 Total 31.8 53.8 13.1 0.7 0.6 100.0 5,242 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 13.3 FREEDOM OF MOVEMENT Freedom of movement outside the home is an important indicator of women’s autonomy and empowerment. Bangladesh embraces a traditional culture with patriarchal values secluding women from the outside world and from men, popularly known as “purdah.” This is particularly true in rural areas. The 2014 BDHS asked currently married women whether they go to a health center or hospital or, if they do not go, whether they can go alone or with their young children to a health center or hospital. Table 13.3 shows that 70 percent of women said that they go alone or with their young children to a health center or hospital, and 10 percent of women who do not go to a health center or hospital said that they can go to these health facilities alone or with their children. Comparison of data from the 2007 BDHS, 2011 BDHS, and 2014 BDHS shows that in 2014 a higher proportion of women reported going alone or with children to a health center or a hospital. Consequently, fewer women now report constraints in going to a health center or hospital, either alone or with their children (NIPORT et al. 2009, 2013). The proportion of women who go to a health center or a hospital alone or with children increases with age, from 43 percent of women age 15-19 to 80 percent of women age 35-39, while the proportion of women who cannot go alone or accompanied by their children decreases with age, from 41 percent among women age 15-19 to 16 percent among women age 45-49. Urban women, women with three or four children, Women’s Empowerment and Health Seeking Behavior • 191 women who have completed a secondary or higher level of education, and women in the highest wealth quintile are more likely than their counterparts to go to a health facility, either alone or with their children. Rural women and women in Sylhet are more likely to be among those who cannot go to a health facility alone or accompanied by their young children. Table 13.3 Freedom of movement Percent distribution of currently married women age 15-49 by freedom of movement to go to a hospital or health center, according to background characteristics, Bangladesh 2014 Go alone or with children to health center or hospital Do not go to health center or hospital Other Total Number of women Background characteristic Can go alone or with children Cannot go alone or with children Age 15-19 43.1 14.5 40.6 1.6 100.0 1,984 20-24 64.4 11.7 23.0 0.8 100.0 3,166 25-29 73.8 8.8 16.9 0.5 100.0 3,249 30-34 77.5 9.4 12.7 0.4 100.0 2,919 35-39 79.6 7.6 12.5 0.2 100.0 2,153 40-44 78.2 9.4 12.3 0.1 100.0 1,874 45-49 75.1 8.1 16.4 0.4 100.0 1,512 Number of living children 0 38.2 15.1 44.0 2.5 100.0 1,707 1-2 72.6 10.4 16.7 0.4 100.0 8,948 3-4 76.5 8.4 14.7 0.3 100.0 4,901 5+ 74.5 6.6 18.6 0.3 100.0 1,302 Residence Urban 74.7 9.0 15.7 0.6 100.0 4,709 Rural 68.7 10.4 20.3 0.6 100.0 12,149 Division Barisal 76.4 7.8 14.8 0.9 100.0 1,051 Chittagong 68.0 9.9 21.3 0.7 100.0 3,121 Dhaka 70.9 9.1 19.7 0.3 100.0 5,857 Khulna 72.1 9.6 17.9 0.3 100.0 1,729 Rajshahi 69.5 12.8 17.0 0.8 100.0 2,007 Rangpur 72.6 11.3 15.7 0.5 100.0 1,946 Sylhet 64.3 10.3 23.9 1.6 100.0 1,147 Education No education 73.3 8.0 18.3 0.3 100.0 3,949 Primary incomplete 70.2 8.5 21.0 0.3 100.0 3,032 Primary complete1 70.4 10.2 18.6 0.8 100.0 1,884 Secondary incomplete 68.2 10.8 20.2 0.7 100.0 5,477 Secondary complete or higher2 70.7 13.0 15.5 0.7 100.0 2,516 Wealth quintile Lowest 68.8 8.3 22.4 0.5 100.0 3,097 Second 68.7 10.7 20.1 0.5 100.0 3,223 Middle 70.1 10.7 18.4 0.8 100.0 3,394 Fourth 70.9 10.4 18.1 0.6 100.0 3,556 Highest 73.1 9.8 16.7 0.5 100.0 3,587 Total 70.4 10.0 19.0 0.6 100.0 16,858 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 13.4 WOMEN’S EMPOWERMENT The 2014 BDHS collected information from women on other measures of women’s autonomy and status. In particular, the survey asked women about their participation in household decisions and their attitudes toward gender roles. Such information provides insight into women’s control over household resources and environment, factors that are relevant to understanding women’s demographic and health behavior. The ability of women to make decisions that affect the personal circumstances of their own lives is an essential aspect of empowerment and serves as an important contributor to women’s overall welfare. To assess currently married women’s decision-making autonomy, the 2014 BDHS collected information on women’s participation in four types of decisions: their own health care, major household purchases, their child’s health care, and visits to their family or relatives. Table 13.4 shows the percent distribution of 192 • Women’s Empowerment and Health Seeking Behavior currently married women age 15-49 by the person in the household who usually makes decisions concerning these matters. Table 13.4 shows that just over half of women make each of the four types of decisions jointly with their husbands. About three in ten currently married women reported that their husbands are the main decision-makers about their health care, major household purchases, and visits to family or relatives. Women have more say in decisions related to their children’s health care; 16 percent reported that they mainly make these decisions, and 17 percent reported that their husbands mainly make these decisions. Few women (8 percent) make decisions about major household purchases alone compared with 28 percent whose husbands mainly make purchasing decisions. Ten percent of women reported that someone else makes such decisions—a higher percentage than for women’s own decision-making about household purchases. Overall, women’s decision-making power for all four specified issues has increased since 2007 (NIPORT et al. 2009; NIPORT et al. 2013). Table 13.4 Participation in decision-making Percent distribution of currently married women age 15-49 by person who usually makes decisions about various issues, Bangladesh 2014 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 14.1 50.7 29.2 5.7 0.2 0.0 100.0 16,858 Major household purchases 8.3 53.0 28.3 10.2 0.2 0.0 100.0 16,858 Child health care 16.2 53.7 17.4 4.3 7.6 0.9 100.0 16,858 Visits to her family or relatives 9.8 52.9 29.0 8.1 0.2 0.0 100.0 16,858 Table 13.5 shows how currently married women’s participation (alone or jointly) in decision- making varies by background characteristics. The table presents results for the four specific types of decisions, namely women’s own health care, making major household purchases, child’s health care, and visits to the woman’s family or relatives. In addition, the table includes two summary indicators: the proportion of women involved in making all four decisions and the proportion not involved in making any of the four decisions. About three in five currently married women participate in each of the four types of decision, either alone or jointly with their husbands. Forty-four percent participate in all four decisions, and 16 percent do not participate in any of the decisions. Women’s participation in all four decisions varies by background characteristics. Participation in decision-making in general increases with age. Women age 15-19 reported the least involvement in making all four decisions compared with women in all other age groups. As expected, employed women who have cash earnings are more likely to participate in all four decisions than women who are not employed (48 percent versus 42 percent). Compared with women who have children, women with no children are less likely to participate in all four household decisions (10 percent compared with 46 percent or higher). Urban women are more likely to participate in all four decisions than rural women (47 percent versus 42 percent). Among administrative divisions, Sylhet has the lowest proportion of women who participate in all four decisions (33 percent) and the highest percentage of women who do not participate in any of the four types of decisions (24 percent). Women’s participation in decision-making does not vary greatly by education or wealth, although women who have completed secondary or higher education (46 percent) and women in the highest wealth quintile (47 percent) are most likely to participate in all four decisions. Women’s Empowerment and Health Seeking Behavior • 193 Table 13.5 Women’s participation in decision-making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either by themselves or jointly with their husband, by background characteristics, Bangladesh 2014 Specific decisions All four decisions None of the four decisions Number of women Background characteristic Woman’s own health care Making major household purchases Child health care Visits to her family or relatives Age 15-19 48.9 40.9 39.9 43.6 21.4 33.3 1,984 20-24 60.7 53.5 62.3 55.9 36.7 20.5 3,166 25-29 66.9 63.5 73.7 64.1 45.8 14.3 3,249 30-34 69.9 68.4 78.0 69.4 50.6 10.8 2,919 35-39 72.0 70.5 81.4 70.4 53.6 9.7 2,153 40-44 69.2 67.3 77.2 68.6 50.0 11.8 1,874 45-49 64.7 65.2 76.2 67.7 46.5 12.9 1,512 Employment (last 12 months) Not employed 62.6 57.9 67.6 60.7 41.5 18.2 11,072 Employed for cash 70.1 68.6 74.9 67.2 48.2 11.4 5,242 Employed not for cash 60.7 59.3 68.9 59.0 39.9 17.3 535 Number of living children 0 49.8 41.0 13.7 44.2 9.8 35.6 1,707 1-2 66.0 61.9 74.9 63.0 46.0 15.0 8,948 3-4 67.9 67.7 78.7 68.8 50.1 11.3 4,901 5+ 64.8 59.6 76.2 61.9 46.7 16.1 1,302 Residence Urban 68.6 67.3 72.7 68.9 46.8 12.5 4,709 Rural 63.4 58.9 68.8 60.3 42.3 17.5 12,149 Division Barisal 56.3 53.1 66.4 58.4 36.3 20.4 1,051 Chittagong 68.4 61.8 70.8 62.9 48.2 17.8 3,121 Dhaka 69.1 66.4 74.5 68.8 49.3 12.4 5,857 Khulna 59.5 57.0 64.0 58.1 37.1 19.1 1,729 Rajshahi 64.0 60.1 68.8 61.6 39.8 15.1 2,007 Rangpur 62.7 62.3 68.4 58.7 39.1 15.6 1,946 Sylhet 54.5 47.8 60.6 50.7 32.7 24.2 1,147 Education No education 65.5 63.9 73.9 66.0 47.1 14.5 3,949 Primary incomplete 63.4 62.6 72.0 61.5 43.2 15.3 3,032 Primary complete1 65.9 62.2 69.6 62.9 44.1 15.0 1,884 Secondary incomplete 62.8 57.3 66.8 59.4 40.2 18.6 5,477 Secondary complete or higher2 69.1 63.5 68.2 66.0 45.6 15.0 2,516 Wealth quintile Lowest 60.8 58.2 69.7 60.2 41.5 18.1 3,097 Second 63.3 60.8 68.7 61.1 43.5 16.8 3,223 Middle 64.4 61.5 70.0 61.9 43.4 16.7 3,394 Fourth 65.8 60.3 68.2 61.7 41.9 16.1 3,556 Highest 69.2 65.1 72.8 68.1 47.3 13.2 3,587 Total 64.8 61.3 69.9 62.7 43.6 16.1 16,858 Note: Total includes 15 women with missing information on employment in the past 12 months. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Women may have a say in some, but not all decisions. The number of decisions that a woman makes by herself or jointly with her husband is positively related to women’s empowerment and reflects the degree of control women are able to exercise in areas that affect their lives and environments. Figure 13.1 shows the percent distribution of currently married women according to the number of decisions in which they participate. Forty-four percent of currently married women participate in all four household decisions, and 16 percent participate in none. 194 • Women’s Empowerment and Health Seeking Behavior Figure 13.1 Number of decisions in which currently married women participate, Bangladesh 2014 13.5 ATTITUDES TOWARD WIFE BEATING The critical problems that women face are many and diverse. One of the most serious is violence, and Bangladesh is no exception in this regard. The nature and extent of violence makes it as an internationally recognized issue for women’s disempowerment (Akand and Shamim 1995; Ameen 2005). In Bangladesh, an estimated three in every five women experience violence including physical or sexual violence (Naved and Amin, ed. 2013). One of the most common forms of violence against women worldwide is abuse by the husband or partner (Heise et al. 1999). The 2014 BDHS obtained information on women’s attitudes toward wife beating by asking women about their opinion on whether a husband is justified in hitting or beating his wife under a series of circumstances: if she burns the food, if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual intercourse with him. A woman’s attitude toward wife beating is considered a proxy for her perception of women’s status. A lower score on the “number of reasons wife beating is justified” indicates a woman’s greater sense of entitlement, self-esteem, and status and reflects positively on her sense of empowerment. Agreement with wife beating as justified indicates that a woman generally accepts the right of a man to control her behavior even by means of violence. Such a perception could act as a barrier to accessing health care for her children and herself, affect her attitude toward contraceptive use, and have an impact on her general well-being. Table 13.6 shows the percentage of ever-married women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics. Twenty-eight percent of women agree that a husband is justified in beating his wife for at least one of the reasons listed. The most widely accepted reason for wife beating among women in Bangladesh is arguing with her husband (20 percent), followed by neglecting the children (15 percent). Fourteen percent of women agree that going out without telling her husband is a justifiable reason for a husband to beat his wife. Seven percent of women agree that refusing to have sexual intercourse is an acceptable reason for a husband to beat his wife, and 4 percent of women agree that a husband is justified in beating his wife if she burns the food. Agreement with at least one reason for wife beating varies little by age or marital status. Women who are employed and are paid in cash (29 percent), reside in urban areas (25 percent), reside in Dhaka (24 percent), have completed secondary or higher education (16 percent), and are in households in the highest wealth quintile (19 percent) are less likely than most other women to agree with at least one reason for wife 16 12 13 16 44 0 1 2 3 4 Percent of women Number of household decisions BDHS 2014 Women’s Empowerment and Health Seeking Behavior • 195 beating. This result is supported by the 2007 BDHS results, which found that having little education, living in rural areas, having multiple marriages, and having limited access to wealth are strongly and positively associated with experiencing all kinds of domestic violence on the part of women (NIPORT et al. 2009; Naved and Amin, ed. 2013). Table 13.6 Women’s attitude toward wife beating Percentage of ever-married women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Bangladesh 2014 Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number Background characteristic Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 4.0 20.3 15.2 14.1 5.6 28.8 2,029 20-24 3.4 19.4 13.0 14.9 6.1 27.3 3,224 25-29 4.1 19.9 12.7 14.5 6.9 28.1 3,390 30-34 4.1 18.7 14.8 15.0 7.8 27.4 3,047 35-39 5.0 21.0 15.6 15.1 8.2 29.0 2,315 40-44 4.6 20.5 15.5 14.7 8.0 29.1 2,092 45-49 5.9 20.7 15.8 16.6 8.3 29.6 1,766 Employment (last 12 months) Not employed 4.1 19.5 14.2 14.5 6.7 28.0 11,506 Employed for cash 4.7 20.6 14.9 15.6 8.0 28.8 5,781 Employed not for cash 5.3 21.4 15.3 16.5 8.2 29.2 565 Number of living children 0 3.0 18.0 13.2 12.4 5.8 26.3 1,814 1-2 3.8 19.0 13.5 14.5 6.6 27.1 9,478 3-4 5.3 20.9 15.4 15.5 8.1 29.6 5,180 5+ 6.2 25.3 18.5 18.9 9.8 33.9 1,391 Marital status Married or living together 4.2 19.8 14.1 14.7 7.0 28.1 16,858 Divorced/separated/widowed 6.7 21.8 20.3 18.8 10.9 32.2 1,005 Residence Urban 2.8 17.1 12.2 13.1 5.8 24.8 5,047 Rural 4.9 21.1 15.3 15.6 7.8 29.6 12,816 Division Barisal 7.7 22.8 21.1 21.7 10.4 35.9 1,111 Chittagong 4.7 21.6 13.8 16.4 8.2 29.6 3,301 Dhaka 3.7 16.0 12.8 12.1 5.3 23.8 6,223 Khulna 4.0 21.2 14.5 15.7 8.0 29.5 1,838 Rajshahi 3.5 25.5 17.5 15.4 8.7 33.6 2,103 Rangpur 4.3 17.8 12.5 15.8 6.7 25.9 2,056 Sylhet 5.6 24.7 16.3 15.3 8.2 33.8 1,232 Education No education 6.8 24.4 17.5 16.9 10.2 33.0 4,455 Primary incomplete 6.0 22.8 17.6 17.8 9.5 32.5 3,223 Primary complete1 4.4 21.5 16.7 16.3 8.0 30.5 1,986 Secondary incomplete 2.9 19.0 12.7 14.2 5.5 26.9 5,628 Secondary complete or higher2 1.0 9.4 7.1 8.4 2.2 16.1 2,571 Wealth quintile Lowest 7.4 24.2 18.9 18.0 11.3 34.3 3,359 Second 5.4 24.3 17.6 17.1 9.4 33.1 3,408 Middle 4.4 20.0 14.2 14.7 6.5 28.0 3,560 Fourth 3.4 20.1 13.9 15.4 6.2 28.2 3,758 Highest 1.5 12.0 8.3 9.9 3.2 18.9 3,778 Total 4.3 19.9 14.4 14.9 7.2 28.3 17,863 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 13.6 INDICATORS OF WOMEN’S EMPOWERMENT Women’s empowerment has important implications for demographic and health outcomes, including women’s use of family planning and maternal health care services. To examine how selected demographic and health outcomes vary by women’s empowerment, information on women’s participation in household decision-making and their attitudes toward wife beating are summarized in two separate indices. 196 • Women’s Empowerment and Health Seeking Behavior The first index is the number of decisions (0-4) women participate in, alone or jointly with their husbands (see Table 13.4 for the list of decisions). This index is positively related to women’s empowerment and reflects the degree of control that women are able to exercise through making decisions in areas that affect their own lives and environments. The second index is the number of reasons (0-5) for which women justify a husband beating his wife (see Table 13.6 for the list of reasons). A lower score on this index is interpreted as reflecting a greater sense of entitlement, higher self-esteem, and a higher status of women. In general, it is expected that women who participate in making household decisions are also more likely to have gender-egalitarian beliefs and to reject wife beating. Accordingly, Table 13.7 provides an overview on how these two basic empowerment indices—number of decisions in which women participate and number of reasons for which wife beating is justified—relate to one another. Women’s rejection of all the reasons for wife beating varies only somewhat by the number of decisions they participate in. Specifically, 67-70 percent of women who participate in 0-3 decisions reject all the reasons for wife beating compared with 76 percent of women who participate in all four decisions. However, the proportion of women who participate in all four decisions does not vary uniformly with the number of reasons for which wife beating is justified. The percentage of women who participate in all four decisions is highest (46 percent) for women who do not agree with any reason for wife beating and falls to 36 percent for women who agree with 3-4 reasons for wife beating, and to 32 percent for women who agree with all five reasons for wife beating. Table 13.7 Indicators of women’s empowerment Percentage of currently married women age 15-49 who participate in all four decisions and the percentage who disagree with all of the reasons justifying wife beating, by value on each of the indicators of women’s empowerment, Bangladesh 2014 Empowerment indicator Percentage who participate in all decision-making Percentage who disagree with all the reasons justifying wife beating Number of currently married women Number of decisions in which women participate1 0 na 67.0 2,715 1-2 na 69.2 4,150 3 na 70.4 2,647 4 na 75.9 7,346 Number of reasons for which wife beating is justified2 0 46.0 na 12,129 1-2 38.6 na 3,202 3-4 35.7 na 1,226 5 32.2 na 301 na = not applicable 1 See Table 13.4 for the list of decisions. 2 See Table 13.6 for the list of reasons. 13.7 CURRENT USE OF CONTRACEPTION BY WOMEN’S EMPOWERMENT The 2014 BDHS asked whether women were using contraception or not at the time of the survey. Three in every five currently married women use contraceptive methods (See Chapter 7, Fertility Regulation, Table 7.1). A woman’s desire and ability to control her fertility and the contraceptive method she chooses are likely to be affected by her status in the household, her self-image, and her own sense of empowerment. A woman who feels that she is unable to control other aspects of her life may be less likely to feel that she can make and carry out decisions about her fertility. She may also feel the need to choose methods that can be hidden from others or that do not depend on her husband’s cooperation. Table 13.8 shows the distribution of married women age 15-49 by the type of contraceptive method used, by the two indicators of women’s empowerment. Women’s Empowerment and Health Seeking Behavior • 197 Women’s participation in household decision-making has a positive bearing on contraceptive use. The more decisions a woman participates in, the more likely she is to use a contraceptive method. Both use of any method and use of any modern method are higher among women who participate in all four decisions (67 percent and 57 percent, respectively) compared with women who participate in no decisions (53 percent and 47 percent, respectively). Nonetheless, one-third of women who participate in all four types of decision- making do not use any contraceptive method, implying that participation in making household decisions does not necessarily translate into taking action on a major choice like contraceptive use. The relationship between attitudes about wife beating and use of contraception is not clear. These two issues seem to be related to each other, but the variations in contraceptive use by number of reasons women agree with for justifying wife beating are small. Table 13.8 Current use of contraception by women’s empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women’s empowerment, Bangladesh 2014 Any method Any modern method Modern methods Any traditional method Not currently using Total Number of currently married women Empowerment indicator Female sterili- zation Male sterili- zation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 52.5 46.5 3.2 0.7 37.9 4.7 5.9 47.5 100.0 2,715 1-2 61.7 53.3 4.3 1.3 42.1 5.6 8.5 38.3 100.0 4,150 3 61.8 53.7 4.5 1.3 40.0 7.9 8.1 38.2 100.0 2,647 4 66.8 57.4 5.3 1.4 43.6 7.0 9.4 33.2 100.0 7,346 Number of reasons for which wife beating is justified3 0 62.7 54.0 4.2 1.3 41.2 7.4 8.7 37.3 100.0 12,129 1-2 62.3 54.5 5.8 1.2 43.0 4.5 7.8 37.7 100.0 3,202 3-4 60.7 53.0 5.4 0.9 43.5 3.1 7.7 39.3 100.0 1,226 5 62.9 56.1 5.2 2.2 46.4 2.3 6.8 37.1 100.0 301 Total 62.4 54.1 4.6 1.2 41.8 6.4 8.4 37.6 100.0 16,858 Note: If more than one method is used, only the most effective method is considered in this tabulation. 1 Pill, IUD, injectables, implants, and lactational amenorrhea method 2 See Table 13.4 for the list of decisions. 3 See Table 13.6 for the list of reasons. 13.8 IDEAL FAMILY SIZE AND UNMET NEED BY WOMEN’S EMPOWERMENT The inclusion of women in the development process is important in Bangladesh. However, this is not universally recognized in the country. The ability of women to make decisions effectively has important implications for their fertility preferences and for meeting their family-size goals. The general expectation is that more empowered women will desire smaller families and be better able to negotiate decisions about fertility and family planning. Hence, unmet for family planning, which reflects women’s unsatisfied need for contraception, should be lower among more empowered women. Table 13.9 shows how women’s ideal family size and their unmet need for family planning vary by the two indicators of women’s empowerment. The mean ideal family size shows no variation by the number of decisions in which women participate, but increases somewhat with the number of reasons women give that justify wife beating. The pattern remains the same as in the 2011 BDHS (NIPORT et al. 2013). Women who agree that wife beating is not justified for any reason desire 2.2 children compared with 2.4 children for women who agree that wife beating is justified for all five reasons. The 2014 BDHS shows that women’s participation in decision-making is associated with their level of unmet need for family planning. Women who participate in no household decisions have a slightly higher level of unmet need for family planning (15 percent) compared with women who participate in one or more decisions (11-12 percent). The total unmet need for family planning is similar, at 11-12 percent, among women who do not justify wife beating for any reason, 1-2 reasons, or 3-4 reasons. The percentage is higher for women who agree with five reasons justifying wife beating (14 percent). 198 • Women’s Empowerment and Health Seeking Behavior Table 13.9 Women’s empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for ever-married women age 15-49 and the percentage of currently married women age 15-49 with an unmet need for family planning, by indicators of women’s empowerment, Bangladesh 2014 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of currently married women For spacing For limiting Total Number of decisions in which women participate3 0 2.2 2,663 9.8 5.3 15.1 2,715 1-2 2.2 4,080 5.8 5.3 11.1 4,150 3 2.2 2,613 4.5 6.1 10.6 2,647 4 2.2 7,242 3.7 8.1 11.8 7,346 Number of reasons for which wife beating is justified4 0 2.2 12,616 5.3 6.7 12.0 12,129 1-2 2.2 3,323 5.2 6.8 12.0 3,202 3-4 2.3 1,296 5.2 5.7 11.0 1,226 5 2.4 320 7.8 6.2 13.9 301 Total 2.2 17,556 5.3 6.6 12.0 16,858 1 Mean excludes respondents who gave non-numeric responses. 2 See Table 7.14 for the definition of unmet need for family planning. 3 Restricted to currently married women. See Table 13.4 for the list of decisions. 4 See Table 13.6 for the list of reasons. 13.9 REPRODUCTIVE HEALTH CARE BY WOMEN’S EMPOWERMENT Table 13.10 examines whether empowered women are more likely to access antenatal, delivery, and postnatal care services from medically trained health personnel. In societies where health care is widespread, women’s empowerment may not affect their access to reproductive health services. In other societies, however, increased empowerment of women is likely to increase their ability to seek out and use health services from qualified health providers in meeting their own reproductive health goals, including safe motherhood. The table includes only women who had a birth in the three years preceding the survey and examines their access to antenatal care, delivery care, and postnatal care from trained health personnel for their most recent birth. Both indicators of women’s empowerment are related to women’s access to reproductive health care for their most recent birth. For example, the proportion of women receiving antenatal care from a medically trained provider increases from 61 percent among women who participate in no decisions to 65 percent among women who participate in all four types of decisions. The corresponding proportion of women receiving delivery assistance from a medically trained provider increases from 40 percent among women who participate in no decisions to 44 percent among women who participate in all four decisions. Similarly, the proportion of women receiving postnatal care within two days of delivery from a medically trained provider increases from 34 percent among women who participate in no decisions to 37 percent among women who participate in all four types of decisions. Women’s attitude toward wife beating is also related to their use of reproductive health services. Women who accept all five reasons for wife beating are much less likely than women who agree with no reason for wife beating to receive any of the three types of maternal care from a medically trained provider. Forty-two percent of women who agree with all five reasons justifying wife beating received antenatal care from a medically trained provider compared with 68 percent of women who do not agree with any of the reasons. Sixteen percent of women who agree with all five reasons received delivery care from a medically trained provider compared with 47 percent of women who do not agree with any of the reasons. Fifteen percent of women who agree with all five reasons received postnatal care from a medically trained provider within the first two days after delivery compared with 40 percent of women who do not agree with any of the reasons justifying wife-beating. Women’s Empowerment and Health Seeking Behavior • 199 Table 13.10 Reproductive health care by women’s empowerment Percentage of women age 15-49 with a live birth in the three years preceding the survey who received antenatal care, delivery assistance, and postnatal care from a medically trained provider for the most recent birth, by indicators of women’s empowerment, Bangladesh 2014 Empowerment indicator Percentage receiving antenatal care from a medically trained provider Percentage receiving delivery care from a medically trained provider Received postnatal care from a medically trained provider within the first two days of delivery1 Number of women with a child born in the last three years Number of decisions in which women participate2 0 60.7 39.8 33.5 855 1-2 64.2 43.0 37.3 1,159 3 65.1 44.0 38.6 575 4 65.4 44.4 36.9 1,981 Number of reasons for which wife beating is justified3 0 67.6 47.3 39.9 3,348 1-2 56.6 32.8 28.2 876 3-4 50.4 32.5 27.6 327 5 41.5 15.5 15.2 76 Total 63.9 43.0 36.4 4,627 Note: If more than one source of antenatal care was mentioned, only the provider with the highest qualifications is considered in this tabulation. For antenatal and postnatal care, medically trained providers include: qualified doctor, nurse/midwife/paramedic, FWV, CSBA, and SACMO. For delivery assistance, medically trained providers include= qualified doctor, nurse/midwife/paramedic, FWV, and CSBA. 1 Includes both women who gave birth in a health facility or those who did not give birth in a health facility 2 Restricted to currently married women. See Table 13.4 for the list of decisions. 3 See Table 13.6 for the list of reasons. 13.10 INFANT AND CHILD MORTALITY AND WOMEN’S EMPOWERMENT The ability of women to access information, make decisions, and act effectively in their own interests or in the interests of those who depend on them is an essential aspect of empowerment. It follows that if women, who are the primary caretakers of children, are empowered, they will be better able to take actions that enhance the health and survival of their children. In fact, mother’s empowerment fits into the Mosley-Chen framework on child survival as an intervening individual-level variable that affects child survival through proximate determinants (Mosley and Chen 1984). Table 13.11 shows infant mortality, child mortality, and under five-mortality rates by women’s participation in decision-making and women’s attitude about wife-beating. There is no clear pattern in the relationship between participation in decision-making and childhood mortality rates. Children of women who participate in 1-2 decisions have a higher mortality rate than children of women who do not participate in any decisions or who participate in 3-4 decisions. Childhood mortality increases sharply with women’s agreement with reasons for wife beating from none to 1-2. For example, under-five mortality for children of women who do not agree with any reason for wife beating is 42 deaths per 1,000 live births, but increases to 63 deaths per 1,000 live births for children of women who agree with 1-2 reasons justifying wife beating. The three childhood mortality rates are lowest for children of women who agree with 3-4 reasons for wife beating and highest for children of women who agree with all five reasons for wife beating. 200 • Women’s Empowerment and Health Seeking Behavior Table 13.11 Early childhood mortality rates by women’s empowerment Infant, child, and under-five mortality rates for the five-year period preceding the survey, by indicators of women’s status, Bangladesh 2014 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate1 0 37 8 45 1-2 45 12 56 3 31 9 40 4 37 6 42 Number of reasons for which wife beating is justified2 0 35 7 42 1-2 52 11 63 3-4 27 9 36 5 69 18 85 1 Restricted to currently married women. See Table 13.4 for the list of decisions. 2 See Table 13.6 for the list of reasons. Community Characteristics • 201 COMMUNITY CHARACTERISTICS 14 n the 2014 BDHS, the Community Questionnaire was administered in each of the selected clusters during the household listing operation. The community survey collected data on characteristics of the selected sample clusters, such as distance to upazila headquarters, school, and post office, as well as on the accessibility of health and family planning services that are located within or near the cluster. Another objective for conducting the community survey was to generate a list of health facilities in the sample clusters and a list of health and family planning fieldworkers who cover the cluster, including the identification of their affiliation (government or non-government). These lists were later provided to the main survey interviewing teams to help identify the specific sources of services used by the respondents. The Community Questionnaire was administered to a group of four to six key informants who were knowledgeable about the socioeconomic conditions and the availability of health and family planning services or facilities in the cluster. The key informants included community leaders, teachers, government officials, social workers, religious leaders, traditional healers, and health care providers, etc. Distance to facilities was measured in kilometers (km) from the center of each sample cluster. All interviewed women in the sample area were assumed to have the same distance from the facility. I Key Findings • Eighty percent of women live in a village/mohalla where there is a primary school, and the remaining 20 percent have access to a primary school within a distance of 1-4 km. Coeducational high schools are much more widespread than either a boys’ or a girls’ high school. • Eighty-seven percent of ever-married women age 15-49 live in villages/mohallas that have a Grameen Bank. Women in rural areas are more likely than women in urban areas to have access to a Grameen Bank (89 percent versus 83 percent). • Eighty-seven percent of sample clusters have a health facility within 1 km. This percentage is almost same in rural and in urban areas (87 and 88 percent, respectively). • Satellite clinics are also widely available; 76 percent of clusters have a satellite clinic available within 1 km; 78 percent in rural areas and 69 percent in urban areas. • Thirty-five percent of the clusters have a government health facility within 1 km; 40 percent in rural areas and 24 percent in urban areas. NGO and private facilities are more likely to be found in urban clusters. • Family planning and health providers are available in 94 percent of sample clusters. In both rural and urban areas, these workers are predominantly affiliated with the government. • More than 4 in 10 clusters have an allopathic/MBBS doctor; 74 percent in urban areas and 30 percent in rural areas. Close to 6 in 10 clusters have a homeopathic doctor and 4 in 10 clusters have a Unani or Ayurvedic doctor. • Thirty-six percent of the people in the rural clusters go to their upazila headquarters by car, bus, or tempo, which is the most common means of transport in all divisions except Chittagong, Rangpur, and Sylhet. • Seventy-two percent of the people in the rural clusters go to their district headquarters by car, bus, or tempo. 202 • Community Characteristics Table 14.1 presents the percent distribution of ever-married women age 15-49 by distance to various general services. Overall, 25 percent of ever-married women live less than 1 km from a post office and 67 percent live 1-4 km from the nearest post office, with a median distance of 2.1 km. Cinema halls are less widespread; 8 percent of women have access to a cinema hall within 1 km and 27 percent live 1-4 km from the nearest cinema hall, with a median distance of 7.9 km. Access to weekly markets was not asked in urban sample clusters because they are not the norm. In rural areas 35 percent of women have access to a weekly market less than 1 km away, and 57 percent have access within 1-4 km. The median distance to a weekly market in rural areas is 2.0 km. Access to a post office is similar in urban and rural areas. However, urban women are much more likely than rural women to live close to a cinema hall. Table 14.1 Distance to the nearest service location Percent distribution of ever-married women age 15-49 by distance to the nearest service location, according to distance, Bangladesh 2014 Distance Urban Rural Total Post office Cinema hall Weekly market Post office Cinema hall Weekly market Post office Cinema hall <1 km 35.2 15.2 34.7 21.1 4.8 34.7 25.1 7.7 1-4 km 60.7 58.9 56.9 69.9 14.9 56.9 67.3 27.3 5-9 km 4.1 14.6 6.2 8.0 24.2 6.2 6.9 21.5 ≥10 km 0.0 11.3 1.3 1.1 55.6 1.3 0.8 43.0 Don’t know 0.0 0.0 0.9 0.0 0.5 0.9 0.0 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 5,047 5,047 12,816 12,816 12,816 12,816 17,863 17,863 Median distance 1.5 2.7 2.0 2.3 10.8 2.0 2.1 7.9 Table 14.2 shows the percent distribution of ever-married women age 15-49 by distance to the nearest education facility, according to the type of facility. Religious schools are widespread in Bangladesh; 58 percent of women live in a village that has a madrasha and 39 percent of women have a madrasha within 1-4 km. Eighty percent of women live in a village/mohalla where there is a primary school and the remaining 20 percent have access to a primary school within 1-4 km. Coeducational high schools are much more widespread than either a boys’ or a girls’ high school. Overall, 40 percent of women live in a village/mohalla where there is a coeducational high school compared with only 17 percent with a boys’ high school and 20 percent with a girls’ high school. All of the specified educational facilities are more available in urban than in rural areas. Table 14.2 Distance to the nearest education facility Percent distribution of ever-married women age 15-49 by distance to the nearest education facility, according to distance, Bangladesh 2014 Distance Urban Rural Total Madra- sha1 Primary school Boys’ high school Girls’ high school Co-edu- cational high school Madra- sha1 Primary school Boys’ high school Girls’ high school Co-edu- cational high school Madra- sha1 Primary school Boys’ high school Girls’ high school Co-edu- cational high school Within village/ mohalla 75.3 86.5 28.5 35.8 56.2 50.7 78.0 12.6 13.9 34.1 57.7 80.4 17.1 20.1 40.3 1-4 km 23.8 13.4 53.4 56.4 41.6 45.5 22.0 23.2 42.1 62.0 39.4 19.6 31.7 46.1 56.2 5-9 km 0.9 0.1 7.3 4.8 1.2 2.9 0.0 14.1 16.9 3.6 2.3 0.0 12.9 13.5 3.0 ≥10 km 0.0 0.0 10.4 3.0 0.3 0.9 0.0 48.1 26.3 0.3 0.6 0.0 37.4 19.7 0.3 Don’t know 0.0 0.0 0.4 0.0 0.7 0.0 0.0 1.0 0.8 0.0 0.0 0.0 0.9 0.6 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 5,047 5,047 5,047 5,047 5,047 12,816 12,816 12,816 12,816 12,816 17,863 17,863 17,863 17,863 17,863 Median distance a a 2.0 1.5 a a a 9.3 4.3 1.9 a a 5.3 3.2 1.5 Note: Totals may not add to 100.0 due to missing values. 1 Religious school a = Unknown; median distance cannot be calculated because more than 50 percent of the cases are in the categories “within village” and “within mohalla.” Community Characteristics • 203 Informants to the Community Questionnaire were asked whether specific income-generating organizations such as the Grameen Bank, Bangladesh Rural Advancement Committee (BRAC), PROSHIKA, and the Association of Social Advancement (ASA) are available in the village/mohalla, because the availability of these organizations may influence women’s reproductive behavior. Table 14.3 shows that 87 percent of ever-married women age 15-49 live in a village/mohalla that has a Grameen Bank. Women in rural areas are more likely than women in urban areas to have access to a Grameen Bank (89 percent versus 83 percent). However, the other income-generating organizations are more accessible to urban women than rural women. For example, 80 percent of women live in a village/mohalla with a BRAC (81 percent in urban and 79 percent in rural areas). As another example, ASA is available in the village/mohalla to 74 percent of women (78 percent in urban areas and 73 percent in rural areas). Table 14.3 Availability of income-generating organizations Percentage of ever-married women age 15-49 who have access to specific income generating organizations, by residence, Bangladesh 2014 Income-generating organization Residence Total Urban Rural Mothers’ club or ladies’ association 28.5 19.4 21.9 Grameen Bank membership 83.3 88.9 87.3 Voluntary organization 37.7 27.5 30.4 BRAC income-generating activities 80.9 79.4 79.8 PROSHIKA 32.9 21.0 24.4 ASA 78.2 72.9 74.4 Cottage industries of BSIC 15.5 10.8 12.1 Cooperative society 65.0 53.9 57.1 Other NGO income-generating activities 41.5 39.9 40.4 Number of women 5,047 12,815 17,862 BRAC = Bangladesh Rural Advancement Committee PROSHIKA = name of an NGO ASA = Association of Social Advancement BSIC = Bangladesh Small Industries Corporation Table 14.4 shows the availability of health facilities within a specified distance from the sample cluster according to the type of health facility and by urban-rural residence. As Table 14.4 shows, 87 percent of clusters have a health facility within 1 km. This percentage is almost same in rural and urban areas (87 and 88 percent, respectively). Satellite clinics are also widely available; 76 percent of clusters have a satellite clinic available within 1 km. Satellite clinics are more common in rural areas (78 percent) than in urban areas (69 percent). Overall, 35 percent of the 2014 BDHS sample clusters have a government health facility within 1 km (40 percent in rural areas and 24 percent in urban areas). A private facility is available within 1 km for 13 percent of clusters (38 percent in urban areas and 3 percent in rural areas). An NGO facility is less common. Overall, it is available within 1 km to 9 percent of cluster residents, but much more available in urban than in rural areas (26 percent versus 2 percent). In conclusion, the data indicate that government facilities are more likely to be available within 1 km in a rural cluster, while NGOs and private facilities are more likely to be found in an urban cluster. 204 • Community Characteristics Table 14.4 Availability of health facility Percentage of sample clusters by availability of health facility according to type of facility and residence, Bangladesh 2014 Type of facility Distance in kilometers (km) Any facility Government facility1 NGO facility Private facility Rural dispensaries Satellite Clinics URBAN <1 km 88.2 24.0 25.6 37.5 0.6 69.0 1 to <2 km 9.5 30.5 20.8 23.2 0.6 6.5 2 to <5 km 2.4 32.9 24.4 22.6 0.6 3.0 5 km or more 0.0 12.6 13.1 16.7 0.0 0.0 No facility 0.0 0.0 16.1 0.0 98.2 21.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of clusters 169 169 169 169 169 169 RURAL <1 km 86.5 39.8 2.3 3.2 0.0 78.0 1 to <2 km 6.3 21.8 4.4 4.6 0.2 4.2 2 to <5 km 7.2 32.6 16.2 17.8 0.2 8.1 5 km or more 0.0 5.8 37.6 73.1 0.2 1.2 No facility 0.0 0.0 39.4 1.2 99.3 8.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of clusters 431 431 431 431 431 431 TOTAL <1 km 87.0 35.4 8.8 12.8 0.2 75.5 1 to <2 km 7.2 24.2 9.0 9.8 0.3 4.8 2 to <5 km 5.8 32.7 18.5 19.2 0.3 6.7 5 km or more 0.0 7.7 30.7 57.3 0.2 0.8 No facility 0.0 0.0 32.9 0.8 99.0 12.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of clusters 600 600 600 600 600 600 1 Government facility includes government hospital, upazila health complex, family welfare center, maternal and child welfare center, and community clinic. Informants to the Community Questionnaire were asked to list the names of health and family planning workers who work in the village/mohalla. Table 14.5 shows that family planning and health providers are available in almost all sample clusters (94 percent). In both rural and urban areas, health and family planning workers are predominantly affiliated with the government. Government health and family planning workers are more available in rural areas than in urban areas (96 percent and 61 percent, respectively). Informants to the Community Questionnaire were also asked about the medical practitioners that provide health services in the village/mohalla. More than four in ten clusters have an allopathic/MBBS doctor1. MBBS doctors are more common in urban areas than in rural areas (74 percent versus 30 percent). Close to six in ten clusters have a homeopathic doctor and four in ten clusters have a Unani or Ayurvedic doctor. Both of these alternative practitioners are more common in urban than in rural areas. 1 Informal allopathic providers (IAPs) comprised of village doctors and drug sellers. MBBS is Bachelor of Medicine, Bachelor of Surgery. Community Characteristics • 205 Table 14.5 Availability of health and family planning workers Percentage of sample clusters by availability of health and family planning field workers, by type and residence, Bangladesh 2014 Urban Rural Total Health and family planning field worker Government 61.3 95.6 86.0 NGO 44.6 31.0 34.8 Private 3.0 0.7 1.3 Others 5.4 2.5 3.3 Any worker 86.3 97.0 94.0 Medical practitioners Allopathic/MBBS 74.4 30.1 42.5 Homeopath 76.8 50.2 57.7 Unani/Ayurvedic 48.8 35.2 39.0 Number of clusters 169 431 600 Informants to the Community Questionnaire were asked to list the names of “depot holders,” who work in the village/mohalla, as well as pharmacies or shops and skilled birth attendants (SBA) that provide services to individuals in the village/mohalla. Table 14.6 shows that seven in ten women live in a village covered by SBA; 52 percent in urban areas and 76 percent in rural areas. Sixty-five percent of women live in a village where there are pharmacies or shops that sell family planning methods. Urban women are much more likely than rural women to have a pharmacy or shop in their village (89 percent versus 56 percent). Depot holders are available in the cluster to 12 percent of women (10 percent in urban areas and 13 percent in rural areas). Table 14.6 Availability of family planning and other health services Percentage of ever-married women age 15-49 by availability of family planning and other health services in the cluster, by type and residence, Bangladesh 2014 Service providers Urban Rural Total Depot holder who sells family planning methods 9.7 13.4 12.3 Pharmacy/shop that sells family planning contraceptives 88.6 56.2 65.3 Skilled birth attendant (SBA) 51.6 76.3 69.3 Number of women 5,047 12,816 17,863 Table 14.7 shows the percent distribution of rural sample clusters by the most common means of transport used by the village residents to go to the upazila headquarters in each division. Overall, 36 percent of the people in the rural clusters go to their upazila headquarters by car, bus, or tempo, which is the most common means of transport in all divisions except Chittagong, Rangpur, and Sylhet. Car, bus, or tempo use is highest in Khulna (66 percent), followed by Barisal (58 percent) and Rajshahi (47 percent). In Dhaka, the most common means of transport is car, bus, or tempo (32 percent), followed by rickshaw or rickshaw van (23 percent), and baby taxi (18 percent). Baby taxi use is the most common means of travel to upazila headquarters in Chittagong (79 percent) and Sylhet (54 percent). In Rangpur, two types of transport prevail; rickshaw or rickshaw van (36 percent) and car, bus, or tempo (34 percent). Overall, motorcycle use is limited (4 percent), with the highest use in Barisal (13 percent). Table 14.7 Means of transport to upazila headquarters Percent distribution of rural sample clusters by the most common means of transport to upazila headquarters, according to division, Bangladesh 2014 Division Most common transport Total Number of clusters Car/bus/ tempo Motorcycle Motor launch Bicycle Boat Path Rickshaw/ rickshaw van Train Baby taxi Other Missing Barisal 57.6 13.0 1.7 1.7 3.8 0.0 7.4 0.0 7.3 7.6 0.0 100.0 28 Chittagong 14.9 1.8 0.9 0.0 2.6 0.0 1.2 0.0 78.5 0.0 0.0 100.0 73 Dhaka 32.0 4.1 4.4 0.0 4.5 2.9 22.5 0.0 17.8 8.3 3.6 100.0 132 Khulna 65.5 8.2 0.0 1.6 2.0 1.7 14.5 0.0 3.1 3.4 0.0 100.0 47 Rajshahi 46.8 1.3 0.0 3.2 2.0 4.0 9.6 1.7 30.1 1.3 0.0 100.0 59 Rangpur 33.8 0.0 0.0 13.1 0.0 0.0 35.8 0.0 14.0 1.9 1.4 100.0 62 Sylhet 27.2 6.8 0.0 0.0 1.6 3.0 7.3 0.0 54.2 0.0 0.0 100.0 32 Total 36.3 4.0 1.6 2.6 2.7 1.8 16.1 0.2 29.6 3.9 1.3 100.0 432 206 • Community Characteristics Table 14.8 shows that 72 percent of the people in the rural clusters go to their district headquarters by car, bus, or tempo. This mode of transport is the most common in all divisions. The use of car, bus, or tempo is highest in Khulna division (91 percent) and lowest in Chittagong (55 percent). In other divisions the proportion ranges between 62 percent in Sylhet and 78 percent in Rajshahi. Overall, 17 percent of sample cluster residents travel to the district headquarters by baby taxi, which is the second most common means of travel to the district headquarters in all the divisions, except Barisal division, where motorcycle is the second most common means of travel (6 percent). Table 14.8 Means of transport to district headquarters Percent distribution of rural sample clusters by the most common transport means to the district headquarters, according to division, Bangladesh 2014 Division Most common transport Total Number of clusters Car/bus/ tempo Motorcycle Motor launch Boat Path Rickshaw/ rickshaw van Train Baby taxi Other Missing Barisal 75.8 6.3 3.3 3.8 0.0 3.3 0.0 3.3 4.2 0.0 100.0 28 Chittagong 55.2 1.8 1.8 0.9 0.0 2.1 0.0 38.2 0.0 0.0 100.0 73 Dhaka 73.8 1.9 3.1 0.0 0.0 2.7 1.1 13.8 0.0 3.6 100.0 132 Khulna 90.5 1.4 0.0 0.0 0.0 2.0 0.0 4.5 1.7 0.0 100.0 47 Rajshahi 77.5 0.0 0.0 2.0 2.3 1.4 0.0 16.8 0.0 0.0 100.0 59 Rangpur 73.2 1.2 0.0 1.4 0.0 7.2 2.6 13.1 0.0 1.4 100.0 62 Sylhet 61.9 10.2 3.2 0.0 0.0 0.0 0.0 24.8 0.0 0.0 100.0 32 Total 72.1 2.4 1.7 0.9 0.3 2.8 0.7 17.4 0.5 1.3 100.0 432 References • 207 REFERENCES Aaby, P. (1988). Malnutrition and overcrowding/intensive exposure in severe measles infection: review of community studies. Review of Infectious Diseases, 10(2), 478-491. Acevedo-Garcia, D. 2000. Residential segregation and the epidemiology of infectious diseases. Social science & medicine, 51(8), 1143-1161. Ahmed, S. and M. Khatun. 2008.” Gender Relations in Postmodern Societies: Impact of Globalization on Women’s Position.” Journal of Knowledge Globalization Vol. 1: 109-125. Akand, L. and I. Shamim. 1995. Women and Violence: A Comparative Study of Rural and Urban Violence in Bangladesh. Women’s Issue 1:1-32. Alirol, E., Getaz, L., Stoll, B., Chappuis, F., and Loutan, L. 2011. Urbanisation and infectious diseases in a globalised world. The Lancet infectious diseases, 11(2), 131-141. Ameen, N. 2005. Wife Abuse in Bangladesh: An Unrecognized Offence. Dhaka, Bangladesh: The University Press Limited. Bangladesh Bureau of Statistics (BBS) and UNICEF. 2014. Progotir Pathey Multiple Indicator Cluster Survey (MICS) 2012-13: Key Findings. Dhaka, Bangladesh: BBS and UNICEF Bangladesh. Page 6. Bangladesh Bureau of Statistics (BBS). 2011. Statistics Division, Ministry of Planning. Population & Housing Census: Preliminary Results, 2011. Dhaka, Bangladesh: BBS. Bangladesh Bureau of Statistics (BBS). 2012. Bangladesh Census Results at a Glance. http://www.bbs.gov.bd/WebTestApplication/userfiles/Image/Census2011/Bangladesh_glance.pdf. Bangladesh Bureau of Statistics (BBS). 2013. Gender Statistics of Bangladesh 2012. Dhaka: Planning Division, Ministry of Planning. Bangladesh Bureau of Statistics (BBS). 2014. Bangladesh Population and Housing Census 2011, National Volume-3: Urban Area Report. Dhaka, Bangladesh: Bureau of Statistics. Statistics and Informatics Division. Ministry of Planning. Bangladesh Bureau of Statistics (BBS). 2015a. Gross Domestic Product of Bangladesh at Current Prices, 2010-11 to 2014-15. http://www.bbs.gov.bd/WebTestApplication/userfiles/Image/GDP/ GDP_2014_15(p).pdf Bangladesh Bureau of Statistics (BBS). 2015b. Report on Bangladesh Sample Vital Statistics 2014. Dhaka, Bangladesh: Bureau of Statistics. Statistics and Informatics Division. Ministry of Planning. Basu, A. M. 1989. “Is Discrimination in Food Really Necessary for Explaining Sex Differentials in Childhood Mortality?” Population Studies 43(2):193-210. Bdnews24.com. 2015. http://bdnews24.com/health/2014/12/01/hiv-cases-on-rise-in-bangladesh Begum, H. A.; J. Huq, N. Choudhury, S. Khan and R. K. Choudhury. 1990. Women and National Planning in Bangladesh. Dhaka: Women for Women. Bhasin, K. 1993. What is Patriarchy? New Delhi: Kali for Women. 208 • References Black, Robert E. et al. 2008. “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences.” The Lancet 371(9608): 243–60. Black, Robert E. et al. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet 382(9890): 427–51. Boerma, T. J. 1988. “Monitoring and Evaluation of Health Interventions: Age- and Cause-specific Mortality and Morbidity in Childhood.” In Research and Interventions: Issues concerning Infant and Child Mortality and Health. Proceedings of the East Africa Workshop, Manuscript Report 200e. Ottawa, Canada: International Development Research Center. Pages 195-218. Bradley, Sarah E. K., Trevor N. Croft, Joy D. Fishel, and Charles F. Westoff. 2012. Revising Unmet Need for Family Planning. DHS Analytical Studies No. 25. Calverton, Maryland, USA: ICF International. Christian P, West KP Jr, Khatry SK, et al. Maternal night blindnessincreases risk of mortality in the first 6 months of life among infants in Nepal. J Nutr 2001; 131: 1510–12. Das Gupta, M. 1987. “Selective Discrimination against Female Children in Rural Punjab, India.” Population and Development Review 13(1):77-101. Expanded Program on Immunization (EPI). 2013. Bangladesh EPI Coverage Evaluation Survey 2013. EPI. Dhaka, Bangladesh: Directorate General of Health Services. Expanded Programme on Immunization (EPI) and Directorate General of Health Services [Bangladesh]. 2004. Immunizing Children against Hepatitis B. Dhaka, Bangladesh: EPI. Family Planning 2020. http://www.familyplanning2020.org/entities/70 Government of Bangladesh (GOB). 1994. Country Report: Bangladesh. Presented at the International Conference on Population and Development, Cairo, Egypt, September 5-13, 1994. Government of Bangladesh (GOB). 2014. Birth & Death Registration Project. Dhaka, Bangladesh: Government of Bangladesh, Local Government Division. http://br.lgd.gov.bd/english.html Heisse, L., M. Ellsberg, and M. Gottemoeller. 1999. Ending Violence Against Women. Baltimore, MD: Johns Hopkins University School of Public Health, Center for Communications Programs. Huq, M. N., and J. Cleland. 1990. Bangladesh Fertility Survey 1989: Main Report. Dhaka, Bangladesh: National Institute of Population Research and Training (NIPORT). International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). 2008. Center for Health and Population Research. SUZY—Scaling Up Zinc Treatment for Young Children in Bangladesh. http://www.icddrb.org/activity/SUZY. Islam, M.S., C.G. M-Taylor, S. Banu, M.N. Islam. 2009. “Methods for Improving Routine Childhood Vaccination Coverage in Bangladesh”. Journal of Preventive and Social Medicine 28(1): 10-16. Jamil, K., A. Bhuiya, K. Streatfield, and N. Chakraborty. 1999. “The Immunization Programme in Bangladesh: Impressive Gains in Coverage, but Gaps Remain.” Health Policy and Planning 14(1):49-58. Khatun, M. 2009. “The Empowerment of Women: They are Coming Anyway.” The Bangladesh Journal of Political Economy 24: 663-680. Khatun, M. and G. T. Cornwell. 2009. Power Relations and Contraceptive Use: Gender Differentials in Bangladesh. Canadian Social Science Vol. 5:1-15. References • 209 Management Information System (MIS). 2015. Health Bulletin 2015. Dhaka: MIS, Directorate General of Health Services. Ministry of Education (MOE) [Bangladesh]. National Education Policy (NEP) 2010. Dhaka, Bangladesh: MOE. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2004. Health, Nutrition and Population Sector Program, July 2003-June 2006; Program Implementation Plan (PIP). Dhaka, Bangladesh: MOHFW. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2011a. Health, Population and Nutrition Sector Development Program (HPNSDP), (July 2011-June 2016). Volume I, Program Implementation Plan (PIP). Dhaka, Bangladesh: MOHFW, Government of the People’s Republic of Bangladesh. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2011b. Strategic Plan for Health, Population, and Nutrition Sector Development Program (HPNSDP) 2011-16. Planning Wing, MOHFW, Government of the People’s Republic of Bangladesh. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2012. Bangladesh Population Policy 2012. Dhaka, Bangladesh: MOHFW, Government of the People’s Republic of Bangladesh. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2012. National AIDS/STD Programme, Directorate General of Health Services. Country Progress Report. Dhaka, Bangladesh: MOHFW. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2014. Health, Population and Nutrition Sector Development Program (2011-2016). Revised Program Implementation Plan (PIP), Volume I. Dhaka, Bangladesh: Planning Wing, MOHFW. Ministry of Health and Population Control (MOHPC) [Bangladesh]. 1978. Bangladesh Fertility Survey, 1975-76: First Country Report. Dhaka, Bangladesh: Government of the People’s Republic of Bangladesh and the World Fertility Survey. Ministry of Law, Justice and Parliamentary Affairs [Bangladesh]. 2010. Birth and Death Registration Act, 004. Bangladesh. http://bdlaws.minlaw.gov.bd/bangla_all_sections.php?id=921 Ministry of Women and Children Affairs. 2010. Gender Equality in Bangladesh: Progress and Road Ahead. Dhaka: MoWCA. Ministry of Women and Children Affairs. 2011. National Women Development Policy. Dhaka: MoWCA. Mitra, S. N., A. A1-Sabir, A. R. Cross, and K. Jamil. 1997. Bangladesh Demographic and Health Survey, 1996-1997. Dhaka, Bangladesh, and Calverton, Maryland, USA: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc. Mitra, S. N., C. Lerman, and S. Islam. 1993. Bangladesh Contraceptive Survey 1991: Final report. Dhaka, Bangladesh: Mitra and Associates. Mitra, S. N., M. N. Ali, S. Islam, A. R. Cross, and T. Saha. 1994. Bangladesh Demographic and Health Survey, 1993-1994. Dhaka, Bangladesh, and Calverton, Maryland: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc. Mosley, W. Henry, and Lincoln C. Chen. 1984. “An Analytical Framework for the Study of Child Survival in Developing Countries.” Population and Development Review Supplement to Vol. 10:25-45. 210 • References National AIDS/STD Program (NASP) et al. 2014. Assessment of Impact of Harm Reduction Interventions among People Who Inject Drugs in Dhaka City. Dhaka: NASP, Save the Children, UNAIDS/Bangladesh, and icddr,b. National AIDS/STD Programme (NASP) [Bangladesh] and Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2008. 2008 UNGASS Country Progress Report for Bangladesh. Dhaka, Bangladesh: NASP and MOHFW. National AIDS/STD Programme (NASP) [Bangladesh], Directorate General Health Services (DGHS) [Bangladesh], and Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2012. National HIV Serological Surveillance, 2011, Bangladesh: 9th round Technical Report. Dhaka, Bangladesh: NASP, DGHS, and MOHFW. National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ORC Macro. 2001. Bangladesh Demographic and Health Survey 1999-2000. Dhaka, Bangladesh, and Calverton, Maryland: NIPORT, Mitra and Associates, and ORC Macro. National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ORC Macro. 2005. Bangladesh Demographic and Health Survey 2004. Dhaka, Bangladesh, and Calverton, Maryland: NIPORT, Mitra and Associates, and ORC Macro. 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: NIPORT, Mitra and Associates, and Macro International. National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. 2013. Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. National Institute of Population Research and Training (NIPORT), MEASURE Evaluation, and International Center for Diarrhoeal Disease Research, Bangladesh ICDDR,B. 2011. Bangladesh Maternal Mortality and Health Care Survey 2010: Preliminary Results. Dhaka, Bangladesh: NIPORT, MEASURE Evaluation, and ICDDR,B. National Institute of Population Research and Training, 2015. Bangladesh Demographic and Health Survey 2014: Key Indicators. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. Naved, R. T. and Amin, S. (ed.). 2013. From Evidence to Policy: Addressing Gender Based Violence against Women and Girls in Bangladesh. Dhaka, Bangladesh: ICDDR, B. Pan American Health Organization (PAHO), and World Health Organization (WHO). 2003. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, D.C., and Geneva, Switzerland: WHO. Program Management and Monitoring Unit (PMMU). 2014. Health, Population, and Nutrition Sector Development Program Mid-term Program Implementation Report, July 2011-June 2014. Dhaka, Bangladesh: PMMU, Ministry of Health and Family Welfare. Program Management and Monitoring Unit (PMMU). 2015. Health, Population and Nutrition Sector Development Program (HPNSDP) 2011-2016: Monitoring and Evaluation Strategy and Action Plan. Dhaka, Bangladesh: PMMU, Planning Wing, Ministry of Health and Family Welfare. Rahman, A., and S. Chowdhury. 2007. “Determinants of Chronic Malnutrition among Preschool Children in Bangladesh.” J Biosoc Sci 39(2):161-173 References • 211 Retherford, R. D., M. K. Choe, S. Thapa, and B. B. Gubhaju. 1989. “To What Extent Does Breastfeeding Explain Birth-Interval Effects of Early Childhood Mortality? Demography 26:439-40. Rutstein, S. 1999. Wealth versus Expenditure: Comparison between the DHS Wealth Index and Household Expenditures in Four Departments of Guatemala. Calverton, Maryland: ORC Macro. Rutstein, S. O. 1984. Infant and child mortality: levels, trends and demographic differentials. Revised edition. (WFS Comparative Studies No. 43; Cross National Summaries). International Statistical Institute: Voorburg, Netherlands. http://www.popline.org/node/414876#sthash.SakAc5Bu.dpuf Rutstein, S., K. Johnson, and D. Gwatkin. 2000. Poverty, Health Inequality, and Its Health and Demographic Effects. Presented at the annual meeting of the Population Association of America, Los Angeles, California. Sultana, Shahin, Subrata K. Bhadra, and Mohammed Ahsanul Alam. 2014. Utilization of Essential Service Delivery (UESD) Survey 2013. Dhaka: National Institute of Population Research and Training (NIPORT). Tielsch J. M., Rahmathullah L., Katz J., et al. Maternal night blindnessduring pregnancy is associated with low birthweight, morbidity, and poor growth in South India. J Nutr 2008; 138: 787–92. UNAIDS. 2014. http://www.unaids.org/en/regionscountries/countries/bangladesh United Nations Children’s Fund (UNICEF) and World Health Organization (WHO). Low Birthweight: Country, Regional and Global Estimates. New York, NY: UNICEF. United Nations Children’s Fund (UNICEF). 2012. Maternal and newborn health. Available at: http://www.unicef.org/health/index_maternalhealth.html United Nations Development Program (UNDP), 2013. Human Development Report 2013. New York, NY: UNDP. United Nations Development Program (UNDP). 2015. Human Development Report 2015. New York, NY: UNDP. United Nations Population Fund, 2014. Programme of Action adopted at the International Conference on Population and Development Cairo, 5-13 September 1994 (20th Anniversary Edition). New York, NY: United Nations Population Fund. United Nations Population Information Network, 1995. Guidelines on Women’s Empowerment. New York, NY: POPIN. United Nations, Department of Economic and Social Affairs, Population Division. 2015. World Population Prospects: The 2015 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP.241. Van Lieshout R. J., V. H. Taylor, and M. H. Boyle. Pre-pregnancy andpregnancy obesity and neurodevelopmental outcomes in off spring: a systematic review. Obes Rev 2011; 12: e548–59. Victora, Cesar G. et al. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371(9609): 340–57. World Bank. 2015. Income Classification of World Economies. http://data.worldbank.org/about/country- and-lending-groups#South_Asia World Economic Forum. 2014. The Global Gender Gap Report 2014. Geneva: Switzerland. 212 • References World Health Organization (WHO) and UNICEF. 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO and UNICEF. World Health Organization (WHO) Multicentre Growth Reference Study Group. 2006. WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: WHO. World Health Organization (WHO) Expert Consultation. 2004. “Appropriate Body-Mass Index for Asian Populations and Its Implications for Policy and Intervention Strategies.” The Lancet 363(9403):157-163. doi:10.1016/S0140-6736(03)15268-3 World Health Organization (WHO). 2005. Guiding Principles for Feeding Nonbreastfed Children 6 to 24 Months of Age. Geneva, Switzerland: WHO. World Health Organization (WHO). 2007. Standards for Maternal and Neonatal Care. Geneva, Switzerland: WHO. http://www.who.int/maternal_child_adolescent/documents/a91272/en/ World Health Organization (WHO). 2008. Indicators for Assessing Infant and Young Child Feeding Practices: Conclusions of a Consensus Meeting Held 6-8 November 2007 in Washington D.C., USA. Geneva, Switzerland: WHO. World Health Organization (WHO). 2012. Handbook for guideline development. Geneva: WHO. Appendix A • 213 SAMPLE DESIGN AND IMPLEMENTATION Appendix A A.1 INTRODUCTION he 2014 Bangladesh Demographic and Health Survey (2014 BDHS) is the seventh DHS survey conducted in Bangladesh, following those implemented in 1993-94, 1996-97, 1999-2000, 2003-04, 2007-08, and 2010-2011. As with the prior surveys, the main objective of the 2014 BDHS is to provide up-to-date information on fertility and childhood mortality levels; fertility preferences; awareness, approval, and use of family planning methods; maternal and child health; knowledge and attitudes toward HIV/AIDS and other sexually transmitted infections (STI); and community-level data on accessibility and availability of health and family planning services. All ever-married women age 15-49 who were usual members of the selected households and those who spent the night before the survey in the selected households are eligible to be interviewed in the survey. The survey was designed to produce representative results for the country as a whole, for the urban and the rural areas separately, and for each of the seven administrative divisions. A.2 SAMPLING FRAME The sampling frame used for the 2014 BDHS is the complete list of enumeration areas (EAs) covering the whole country prepared by the Bangladesh Bureau of Statistics for the 2011 population census of the People’s Republic of Bangladesh. An EA is a geographic area covering on average 113 households. The sampling frame contains information about the EA location, type of residence (urban or rural), and the estimated number of residential households. A sketch map that delineates the EA geographic boundaries is available for each EA. Administratively, Bangladesh is divided into seven divisions. Each division is further sub-divided into progressively smaller zilas, thanas, unions, wards, and villages. An EA is either a village, or a group of small villages, or a part of a large village. These divisions allow the country as a whole to be easily separated into small geographical area units with an urban-rural designation. The urban areas were further classified into two groups: city corporations and other than city corporations. Table A.1 gives the percentage distribution of households by division and by type of residence. The division size varies from 5.6 percent (Sylhet, the smallest) to 33.7 percent (Dhaka, the largest). In Bangladesh, 23.3 percent of the households are in urban areas; 8.2 percent are in city corporations, and 15.1 percent are in other than city corporations. Table A.1 Percent distribution of households by division and type of residence Division Type of residence Total Urban + Rural Percent Urban Rural City corporation Other than city corporation Total Barisal 3.9 12.3 16.2 83.8 100.0 5.8 Chittagong 9.9 15.2 25.1 74.9 100.0 17.5 Dhaka 14.6 18.4 33.0 67.0 100.0 33.7 Khulna 4.2 13.6 17.8 82.2 100.0 11.6 Rajshahi 2.2 15.0 17.2 82.8 100.0 13.9 Rangpur 1.7* 11.0 12.7 87.3 100.0 11.9 Sylhet 5.5 10.1 15.6 84.4 100.0 5.6 Bangladesh 8.2 15.1 23.3 76.7 100.0 100.0 Source: Sampling frame of the 2011 Population Census. * This is estimated percentage. The census frame does not identify the City Corporation areas in Rangpur, because Rangpur municipality was upgraded as city corporation in 28 June 2012 and area demarcation was done after releasing 2011 census report on July 16, 2012. T 214 • Appendix A A.3 SAMPLE DESIGN The 2014 BDHS sample was stratified and selected in two stages. Each division was stratified into urban and rural areas. Except for Rangpur, the urban areas of each division are further stratified into two strata: city corporations and other than city corporations, yielding a total of 20 sampling strata. Urban areas in Rangpur are considered in a separate stratum, since the City Corporation areas are not identifiable in the census frame. Samples of EAs were selected independently in each stratum in two stages. Implicit stratification and proportional allocation were achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection, according to administrative units in different levels, and by using a probability proportional to size selection at the first stage of sampling. In the first stage, 600 EAs were selected with probability proportional to the EA size and with independent selection in each sampling stratum with the sample allocation given in Table A.2. A household listing operation will be carried out in all the selected EAs, and the resulting lists of households will be served as sampling frame for the selection of households in the second stage. Some of the selected EAs may be of large size. In order to minimize the task of household listing, for the selected EAs which have more than 200 households, each large EA will be segmented. Only one segment will be selected for the survey with probability proportional to the segment size. Household listing will be conducted only in the selected segment (see detailed instructions for segmentation in the Manual for Household Listing). So a 2014 BDHS cluster is either an EA or a segment of an EA. In the second stage of selection, a fixed number of 30 households per cluster will be selected with an equal probability systematic selection from the newly created household listing. The survey interviewer must interview only the pre-selected households. No replacements and no changes of the pre-selected households will be allowed in the implementing stages in order to prevent bias. All ever-married women aged 15-49 who are usual members of the selected households or who spent the night before the survey in the selected households are eligible for the female survey. Table A.3 shows the allocation of households according to division and urban-rural areas, and Table A.4 shows the expected number of completed women interviews according to division and urban-rural areas. To ensure that the survey precision is comparable across divisions, the sample allocation figures a power allocation between divisions and between different types of residence within each division. Based on a fixed sample take of 30 households per cluster, the survey selected 600 EAs, 207 in urban areas and 393 in rural areas. The survey will be conducted in 18,000 residential households, 6,210 in urban areas and 11,790 in rural areas. The sample is expected to result in about 17,886 completed interviews with ever-married women age 15-49, 6,150 in urban areas and 11,736 in rural areas. Appendix A • 215 Table A.2 Sample allocation of clusters by division and type of residence Division Number of clusters allocated Urban + Rural Urban Rural City corporation Other than city corporation Total urban Barisal 7 15 22 50 72 Chittagong 16 17 33 59 92 Dhaka 23 26 49 60 109 Khulna 9 20 29 56 85 Rajshahi 5 23 28 59 87 Rangpur 4 20 24 61 85 Sylhet 10 12 22 48 70 Bangladesh 74 133 207 393 600 Table A.3 Sample allocation of households by division and type of residence Division Number of households allocated Urban + Rural Urban Rural City corporation Other than city corporation Total urban Barisal 210 450 660 1,500 2,160 Chittagong 480 510 990 1,770 2,760 Dhaka 690 780 1,470 1,800 3,270 Khulna 270 600 870 1,680 2,550 Rajshahi 150 690 840 1,770 2,610 Rangpur 720 720 1,830 2,550 Sylhet 300 360 660 1,440 2,100 Bangladesh 2,220 3,990 6,210 11,790 18,000 Table A.4 Sample allocation of completed women interviews by division and type of residence Division Number of interviews with ever-married women age 15-49 Urban + Rural Urban Rural City corporation Other than city corporation Total urban Barisal 210 447 657 1,494 2,151 Chittagong 477 506 983 1,764 2,747 Dhaka 684 774 1,458 1,793 3,251 Khulna 269 596 865 1,673 2,538 Rajshahi 150 684 834 1,764 2,598 Rangpur 716 716 1,823 2,539 Sylhet 298 357 655 1,435 2,090 Bangladesh 2,199 3,951 6,150 11,736 17,886 The sample allocations were derived using information obtained from the 2011 BDHS. Based on the 2011 data, the average number of ever-married women age 15-49 per household is 1.05 in urban areas and 1.03 in rural areas. The household response rate is 97.2 percent in urban areas and 98.2 percent in rural areas, and women individual response rate is 97 percent in urban areas and 98.4 percent in rural areas. Results of the household sample implementation by urban-rural residence and by division is shown in Tables A.5. Table A.5 shows that 17,989 household were selected for the 2014 BDHS. Of these, 96 percent were successfully interviewed; 2 percent were not interviewed because the households were vacant, and 1 percent because there was no competent respondent in the household during the survey fieldworkers’ visit, The household response rate is higher in rural than in urban area. The rate varies by division, ranging from 99 percent in Rangpur to 97 percent in Dhaka. 216 • Appendix A Of 18,245 women eligible for individual interview, 98 percent were successfully interviewed and 2 percent were not interviewed because they were not at home. Urban women were as likely as rural women to be interviewed in the survey. The response rates varies little by division. Table A.5 Sample implementation Percent distribution of households and eligible women by results of the household and individual interviews, and household, eligible women and overall women response rates, according to urban-rural residence and region (unweighted), Bangladesh 2014 Residence Division Total Result Urban Rural Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Selected households Completed (C) 95.5 96.5 95.5 96.2 94.1 97.2 96.7 97.2 96.8 96.2 Household present but no competent respondent at home (HP) 1.1 0.9 1.3 1.1 1.2 0.6 1.2 0.6 0.9 1.0 Postponed (P) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Refused (R) 0.7 0.1 0.1 0.3 1.1 0.0 0.1 0.0 0.2 0.3 Dwelling not found (DNF) 0.2 0.1 0.1 0.2 0.2 0.2 0.1 0.1 0.1 0.2 Household absent (HA) 1.5 1.6 2.4 1.2 2.0 1.4 1.3 1.3 1.4 1.6 Dwelling vacant/address not a dwelling (DV) 0.6 0.5 0.4 0.8 0.7 0.4 0.3 0.6 0.4 0.5 Dwelling destroyed (DD) 0.1 0.2 0.3 0.0 0.4 0.0 0.1 0.0 0.0 0.1 Other (O) 0.1 0.1 0.0 0.2 0.2 0.2 0.2 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of sampled households 6,210 11,779 2,160 2,760 3,270 2,550 2,610 2,540 2,099 17,989 Household response rate (HRR)1 97.8 98.8 98.5 98.4 97.3 99.2 98.6 99.2 98.7 98.5 Eligible women Completed (EWC) 97.5 98.1 98.2 97.7 96.8 98.8 97.9 99.2 97.0 97.9 Not at home (EWNH) 2.0 1.4 1.2 2.0 2.7 1.0 1.6 0.5 2.2 1.6 Postponed (EWP) 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Refused (EWR) 0.3 0.1 0.0 0.2 0.2 0.0 0.3 0.1 0.3 0.2 Partly completed (EWPC) 0.0 0.1 0.0 0.0 0.1 0.0 0.1 0.0 0.2 0.1 Incapacitated (EWI) 0.1 0.2 0.4 0.1 0.2 0.1 0.1 0.2 0.3 0.2 Other (EWO) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 6,324 11,921 2,181 2,932 3,195 2,612 2,567 2,552 2,206 18,245 Eligible women response rate (EWRR)2 97.5 98.1 98.2 97.7 96.8 98.8 97.9 99.2 97.0 97.9 Overall women response rate (ORR)3 95.4 97.0 96.7 96.1 94.2 98.0 96.4 98.4 95.7 96.4 1 Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as: 100 * C —————————— C + HP + P + R + DNF 2 The eligible women response rate (EWRR) is equivalent to the percentage of interviews completed (EWC) 3 The overall women response rate (OWRR) is calculated as: OWRR = HRR * EWRR/100 A.4 SAMPLING WEIGHT Due to the non-proportional allocation of sample to different divisions and to their urban and rural areas and the possible differences in response rates, sampling weight will be required for any analysis using the 2014 BDHS data to ensure the actual representative of the survey results at national level and as well as at domain level. Since the 2014 BDHS sample is a two-stage stratified cluster sample, sampling weight will be calculated based on sampling probabilities separately for each sampling stage and for each cluster. We use the following notations: P1hi: first-stage sampling probability of the ith cluster in stratum h P2hi: second -stage sampling probability within the ith cluster (households) Let ah be the number of EAs selected in stratum h, Mhi the number of households according to the sampling frame in the ith EA, and M hi the total number of households in the stratum. The probability of selecting the ith EA in the 2014 BDHS sample is calculated as follows: Appendix A • 217 M M a hi hih  Let hib be the proportion of households in the selected cluster compared to the total number of households in EA i in stratum h if the EA is segmented, otherwise 1=hib . Then the probability of selecting cluster i in the sample is: hi hi hih 1hi b M M a = P × Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster is calculated as follows: hi hi hi L gP =2 The overall selection probability of each household in cluster i of stratum h is therefore the production of the two stages selection probabilities: hihihi PPP 21 ×= The sampling weight for each household in cluster i of stratum h is the inverse of its overall selection probability: hihi PW /1= A spreadsheet containing all sampling parameters and selection probabilities will be prepared to facilitate the calculation of the design weight. Design weight will be adjusted for household non-response and as well as for individual non-response to get the sampling weights for households, for women and men surveys respectively. The differences of the household sampling weight and the individual sampling weights are introduced by individual non-response. The final sampling weights will be normalized in order to give the total number of un-weighted cases equal to the total number of weighted cases at national level, for both household weight and individual weight, respectively. The normalized weights are relative weights which are valid for estimating means, proportions and ratios, but not valid for estimating population totals and for pooled data. Appendix B • 219 ESTIMATES OF SAMPLING ERRORS Appendix B he estimates from a sample survey are affected by two types of errors: non-sampling errors and sampling errors. Non-sampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2014 Bangladesh DHS (BDHS) to minimize this type of error, non-sampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2014 BDHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. Sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2014 BDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. Sampling errors are computed in either ISSA or SAS, using programs developed by ICF International. These programs use the Taylor linearization method of variance estimation for survey estimates that are means, proportions or ratios. The Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y x , where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance: ( ) ( ) 2 2 2 2 1 1 1var 1 hmH h h hi h ih h f m zSE r = r z x m m = =   − = −   −     in which hi hi hiz = y rx− , and h h hz = y rx− T 220 • Appendix B where h represents the stratum which varies from 1 to H, hm is the total number of clusters selected in the hth stratum, hiy is the sum of the weighted values of variable y in the ith cluster in the hth stratum, hix is the sum of the weighted number of cases in the ith cluster in the hth stratum, and f is the overall sampling fraction, which is so small that it is ignored. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample and calculates standard errors for these estimates using simple formula. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2014 BDHS, there were 600 non-empty clusters. Hence, 600 replications were created. The variance of a rate r is calculated as follows: ( ) ( ) ( ) ( ) 22 1 1var 1 k i i SE r = r r r k k = = − −  in which ( ) ( )1i ir = kr k r− − where r is the estimate computed from the full sample of 600 clusters, ( )ir is the estimate computed from the reduced sample of 599 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the design effect (DEFT) for each estimate is also calculated. The design effect is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design. Relative standard errors and confidence limits for the estimates are also calculated. Sampling errors for the 2014 BDHS are calculated for selected variables considered to be of primary interest. The results are presented in this appendix for the country as a whole, for urban and rural areas, and for each of the seven divisions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 through B.11 present the value of the statistic (R), its standard error (SE), the number of un-weighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each selected variable. The DEFT is considered undefined when the standard error considering a simple random sample is zero (when the estimate is close to 0 or 1). The confidence interval (e.g., as calculated for the number of children ever born for women 40-49 years) can be interpreted as follows: the overall average from the national sample is 3.886 and its standard error is 0.048. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, that is 3.886 ± 2×0.048. There is a high probability (95 percent) that the true proportion of women 40-49 with children ever born is between 3.790 and 3.982. For the total sample, the value of the DEFT, averaged over all variables, is 1.776. This means that, due to multi-stage clustering of the sample, the average standard error is increased by a factor of 1.776 over that in an equivalent simple random sample. Appendix B • 221 Table B.1 List of selected variables for sampling errors, Bangladesh 2014 Variable Estimate Base population Urban residence Proportion All women 15-49 No education Proportion All women 15-49 Secondary education or higher Proportion All women 15-49 Never married (never in union) Proportion All women 15-49 Currently married (in union) Proportion All women 15-49 Married before age 20 Proportion All women 20-49 Had sexual intercourse before age 18 Proportion All women 20-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women age 40-49 Mean All women 40-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using a traditional method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using condoms Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Currently using rhythm Proportion Currently married women 15-49 Currently using withdrawal Proportion Currently married women 15-49 Used public sector source Proportion Current users of modern method Want no more children Proportion Currently married women 15-49 Want to delay next birth at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women 15-49 Births with skilled attendant at delivery Proportion Births occurring 1-59 months before survey Had diarrhea in the past 2 weeks Proportion Children under 5 Treated with ORS Proportion Children under 5 with diarrhea in past 2 weeks Sought medical treatment for diarrhea Proportion Children under 5 with diarrhea in past 2 weeks Vaccination card seen Proportion Children 12-23 months Received BCG vaccination Proportion Children 12-23 months Received DPT vaccination (3 doses) Proportion Children 12-23 months Received polio vaccination (3 doses) Proportion Children 12-23 months Received measles vaccination Proportion Children 12-23 months Received all vaccinations Proportion Children 12-23 months Height-for-age (-2SD) Proportion Children under 5 who are measured Weight-for-height (-2SD) Proportion Children under 5 who are measured Weight-for-age (-2SD) Proportion Children under 5 who are measured Body mass index (BMI) <18.5 Proportion All women 15-49 who were measured Total fertility rate (3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate¹ Rate Children exposed to the risk of mortality Post-neonatal mortality rate¹ Rate Children exposed to the risk of mortality Infant mortality rate¹ Rate Children exposed to the risk of mortality Child mortality rate¹ Rate Children exposed to the risk of mortality Under-5 mortality rate¹ Rate Children exposed to the risk of mortality 1 The mortality rates are calculated for 3years before the survey for the national and regional samples. 222 • Appendix B Table B.2 Sampling errors: Total sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.283 0.011 17,863 17,863 3.402 0.041 0.260 0.305 No education 0.249 0.010 17,863 17,863 2.952 0.038 0.230 0.269 Secondary or higher education 0.459 0.010 17,863 17,863 2.618 0.021 0.439 0.479 Never married (never in union) 0.154 0.004 21,140 21,127 1.365 0.024 0.147 0.162 Currently married (in union) 0.798 0.004 21,140 21,127 1.406 0.005 0.790 0.806 Married before age 20 0.853 0.004 16,630 16,642 1.762 0.005 0.845 0.862 Had first sexual intercourse before age 18 0.688 0.007 16,630 16,642 1.987 0.010 0.675 0.702 Currently pregnant 0.051 0.002 21,140 21,127 1.320 0.039 0.047 0.055 Children ever born 2.075 0.023 21,140 21,127 1.553 0.011 2.030 2.121 Children surviving 1.886 0.020 21,140 21,127 1.534 0.011 1.846 1.926 Children ever born to women age 40-49 3.886 0.048 3,998 3,874 1.629 0.012 3.789 3.982 Currently using any method 0.624 0.007 16,830 16,858 1.786 0.011 0.611 0.638 Currently using a modern method 0.541 0.006 16,830 16,858 1.666 0.012 0.528 0.553 Currently using a traditional method 0.084 0.004 16,830 16,858 1.772 0.045 0.076 0.091 Currently using pill 0.270 0.006 16,830 16,858 1.872 0.024 0.257 0.283 Currently using condoms 0.064 0.003 16,830 16,858 1.635 0.048 0.058 0.071 Currently using injectables 0.124 0.005 16,830 16,858 2.131 0.044 0.113 0.135 Currently using female sterilization 0.046 0.002 16,830 16,858 1.415 0.050 0.041 0.051 Currently using rhythm 0.062 0.003 16,830 16,858 1.787 0.053 0.056 0.069 Currently using withdrawal 0.019 0.002 16,830 16,858 1.525 0.084 0.016 0.022 Used public sector source 0.487 0.011 9,130 9,110 2.027 0.022 0.466 0.509 Want no more children 0.567 0.006 16,830 16,858 1.595 0.011 0.555 0.579 Want to delay birth at least 2 years 0.197 0.004 16,830 16,858 1.464 0.023 0.188 0.206 Ideal number of children 2.207 0.012 17,527 17,556 2.298 0.005 2.183 2.231 Births with skilled attendant at delivery 0.422 0.015 4,734 4,904 2.112 0.037 0.391 0.453 Had diarrhea in the last 2 weeks 0.057 0.005 7,567 7,760 1.987 0.093 0.046 0.067 Treated with ORS 0.770 0.036 371 440 1.738 0.047 0.698 0.842 Sought medical treatment for diarrhea 0.363 0.042 371 440 1.830 0.117 0.278 0.447 Vaccination card seen 0.739 0.019 1,557 1,633 1.744 0.026 0.701 0.777 Received BCG vaccination 0.979 0.004 1,557 1,633 1.090 0.004 0.971 0.987 Received DPT vaccination (3 doses) 0.913 0.012 1,557 1,633 1.650 0.013 0.890 0.936 Received polio vaccination (3 doses) 0.914 0.011 1,557 1,633 1.599 0.012 0.892 0.936 Received measles vaccination 0.861 0.012 1,557 1,633 1.433 0.014 0.837 0.886 Received all vaccinations 0.838 0.014 1,557 1,633 1.489 0.016 0.811 0.865 Height-for-age (-2SD) 0.361 0.009 7,167 7,318 1.536 0.025 0.343 0.379 Weight-for-height (-2SD) 0.143 0.006 7,167 7,318 1.377 0.040 0.132 0.155 Weight-for-age (-2SD) 0.326 0.009 7,167 7,318 1.643 0.029 0.308 0.345 Body mass index (BMI) <18.5 0.186 0.006 16,444 16,478 1.975 0.032 0.174 0.198 Total fertility rate (3 years) 2.282 0.051 59,143 59,166 1.539 0.022 2.181 2.384 Neonatal mortality rate (last 0-4 years) 28.218 2.310 7,965 8,174 1.212 0.082 23.597 32.838 Post-neonatal mortality rate (last 0-4 years) 9.908 1.364 7,973 8,204 1.248 0.138 7.180 12.635 Infant mortality rate (last 0-4 years) 38.125 2.473 7,968 8,177 1.122 0.065 33.179 43.071 Child mortality rate (last 0-4 years) 8.265 1.362 7,929 8,151 1.400 0.165 5.541 10.989 Under-5 mortality rate (last 0-4 years) 46.075 2.775 7,996 8,204 1.177 0.060 40.525 51.626 Appendix B • 223 Table B.3 Sampling errors: Urban sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 1.000 0.000 6,167 5,047 na na 1.000 1.000 No education 0.193 0.012 6,167 5,047 2.303 0.060 0.169 0.216 Secondary or higher education 0.555 0.017 6,167 5,047 2.726 0.031 0.520 0.589 Never married (never in union) 0.142 0.008 7,161 5,882 1.730 0.053 0.127 0.157 Currently married (in union) 0.801 0.008 7,161 5,882 1.721 0.010 0.784 0.817 Married before age 20 0.796 0.009 5,809 4,736 1.915 0.012 0.777 0.814 Had first sexual intercourse before age 18 0.606 0.014 5,809 4,736 2.210 0.023 0.579 0.634 Currently pregnant 0.046 0.003 7,161 5,882 1.388 0.074 0.039 0.053 Children ever born 1.847 0.030 7,161 5,882 1.387 0.016 1.787 1.908 Children surviving 1.699 0.027 7,161 5,882 1.388 0.016 1.645 1.753 Children ever born to women age 40-49 3.377 0.068 1,447 1,133 1.540 0.020 3.242 3.512 Currently using any method 0.659 0.011 5,739 4,709 1.792 0.017 0.636 0.681 Currently using a modern method 0.562 0.011 5,739 4,709 1.615 0.019 0.541 0.583 Currently using a traditional method 0.097 0.007 5,739 4,709 1.788 0.072 0.083 0.111 Currently using pill 0.267 0.011 5,739 4,709 1.822 0.040 0.246 0.288 Currently using condoms 0.117 0.007 5,739 4,709 1.696 0.062 0.102 0.131 Currently using injectables 0.098 0.008 5,739 4,709 1.952 0.078 0.082 0.113 Currently using female sterilization 0.047 0.004 5,739 4,709 1.370 0.082 0.039 0.054 Currently using rhythm 0.070 0.007 5,739 4,709 1.979 0.096 0.056 0.083 Currently using withdrawal 0.024 0.004 5,739 4,709 1.794 0.152 0.017 0.031 Used public sector source 0.339 0.020 3,237 2,646 2.449 0.060 0.298 0.380 Want no more children 0.545 0.011 5,739 4,709 1.640 0.020 0.523 0.566 Want to delay birth at least 2 years 0.200 0.007 5,739 4,709 1.388 0.037 0.186 0.215 Ideal number of children 2.117 0.015 6,078 4,986 1.899 0.007 2.087 2.147 Births with skilled attendant at delivery 0.605 0.022 1,508 1,267 1.739 0.037 0.561 0.650 Had diarrhea in the last 2 weeks 0.057 0.006 2,399 1,984 1.320 0.109 0.044 0.069 Treated with ORS 0.834 0.039 120 112 1.209 0.047 0.755 0.913 Sought medical treatment for diarrhea 0.534 0.059 120 112 1.374 0.110 0.417 0.652 Vaccination card seen 0.743 0.021 494 423 1.072 0.028 0.702 0.785 Received BCG vaccination 0.989 0.004 494 423 0.913 0.004 0.981 0.998 Received DPT vaccination (3 doses) 0.936 0.013 494 423 1.194 0.014 0.910 0.962 Received polio vaccination (3 doses) 0.930 0.015 494 423 1.307 0.016 0.901 0.960 Received measles vaccination 0.900 0.015 494 423 1.169 0.017 0.869 0.931 Received all vaccinations 0.876 0.017 494 423 1.205 0.020 0.841 0.911 Height-for-age (-2SD) 0.308 0.017 2,246 1,828 1.716 0.056 0.273 0.342 Weight-for-height (-2SD) 0.122 0.009 2,246 1,828 1.294 0.073 0.104 0.140 Weight-for-age (-2SD) 0.261 0.016 2,246 1,828 1.643 0.060 0.229 0.292 Body mass index (BMI) <18.5 0.122 0.010 5,710 4,685 2.396 0.085 0.101 0.143 Total fertility rate (3 years) 2.021 0.065 21,062 17,272 1.291 0.032 1.892 2.150 Neonatal mortality rate (last 0-4 years) 28.922 3.355 5,263 4,329 1.289 0.116 22.211 35.633 Post-neonatal mortality rate (last 0-4 years) 11.643 2.064 5,277 4,350 1.389 0.177 7.514 15.772 Infant mortality rate (last 0-4 years) 40.564 4.042 5,267 4,331 1.363 0.100 32.481 48.648 Child mortality rate (last 0-4 years) 6.103 1.767 5,364 4,386 1.701 0.289 2.569 9.637 Under-5 mortality rate (last 0-4 years) 46.420 4.047 5,275 4,339 1.307 0.087 38.327 54.513 224 • Appendix B Table B.4 Sampling errors: Rural sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.000 0.000 11,696 12,816 na na 0.000 0.000 No education 0.272 0.012 11,696 12,816 2.916 0.044 0.248 0.296 Secondary or higher education 0.421 0.011 11,696 12,816 2.420 0.026 0.399 0.443 Never married (never in union) 0.159 0.004 13,979 15,245 1.247 0.027 0.151 0.168 Currently married (in union) 0.797 0.005 13,979 15,245 1.288 0.006 0.788 0.806 Married before age 20 0.876 0.004 10,821 11,906 1.573 0.005 0.868 0.885 Had first sexual intercourse before age 18 0.721 0.007 10,821 11,906 1.821 0.010 0.706 0.736 Currently pregnant 0.052 0.002 13,979 15,245 1.269 0.045 0.048 0.057 Children ever born 2.163 0.029 13,979 15,245 1.530 0.013 2.105 2.221 Children surviving 1.958 0.025 13,979 15,245 1.482 0.013 1.908 2.008 Children ever born to women age 40-49 4.096 0.064 2,551 2,741 1.693 0.016 3.967 4.224 Currently using any method 0.611 0.008 11,091 12,149 1.765 0.013 0.595 0.628 Currently using a modern method 0.532 0.008 11,091 12,149 1.652 0.015 0.517 0.548 Currently using a traditional method 0.079 0.005 11,091 12,149 1.780 0.058 0.070 0.088 Currently using pill 0.271 0.008 11,091 12,149 1.872 0.029 0.255 0.287 Currently using condoms 0.044 0.004 11,091 12,149 1.806 0.080 0.037 0.051 Currently using injectables 0.135 0.007 11,091 12,149 2.061 0.050 0.121 0.148 Currently using female sterilization 0.046 0.003 11,091 12,149 1.413 0.061 0.040 0.051 Currently using rhythm 0.059 0.004 11,091 12,149 1.719 0.065 0.052 0.067 Currently using withdrawal 0.017 0.002 11,091 12,149 1.394 0.100 0.014 0.021 Used public sector source 0.548 0.014 5,893 6,464 2.113 0.025 0.521 0.576 Want no more children 0.575 0.007 11,091 12,149 1.550 0.013 0.561 0.590 Want to delay birth at least 2 years 0.196 0.006 11,091 12,149 1.476 0.028 0.185 0.207 Ideal number of children 2.243 0.016 11,449 12,570 2.370 0.007 2.211 2.275 Births with skilled attendant at delivery 0.358 0.017 3,226 3,637 2.020 0.049 0.323 0.393 Had diarrhea in the last 2 weeks 0.057 0.007 5,168 5,777 2.088 0.120 0.043 0.070 Treated with ORS 0.748 0.048 251 328 1.846 0.064 0.653 0.844 Sought medical treatment for diarrhea 0.304 0.057 251 328 2.114 0.188 0.189 0.418 Vaccination card seen 0.738 0.025 1,063 1,210 1.849 0.033 0.688 0.787 Received BCG vaccination 0.976 0.005 1,063 1,210 1.083 0.005 0.965 0.986 Received DPT vaccination (3 doses) 0.904 0.015 1,063 1,210 1.689 0.017 0.875 0.934 Received polio vaccination (3 doses) 0.908 0.014 1,063 1,210 1.626 0.016 0.880 0.937 Received measles vaccination 0.848 0.015 1,063 1,210 1.422 0.018 0.817 0.878 Received all vaccinations 0.825 0.017 1,063 1,210 1.493 0.021 0.791 0.859 Height-for-age (-2SD) 0.379 0.010 4,921 5,490 1.457 0.027 0.358 0.399 Weight-for-height (-2SD) 0.151 0.007 4,921 5,490 1.383 0.047 0.137 0.165 Weight-for-age (-2SD) 0.348 0.011 4,921 5,490 1.598 0.032 0.326 0.370 Body mass index (BMI) <18.5 0.211 0.007 10,734 11,793 1.739 0.032 0.197 0.225 Total fertility rate (3 years) 2.391 0.066 38,224 41,855 1.555 0.028 2.259 2.523 Neonatal mortality rate (last 0-4 years) 33.153 1.932 11,491 12,784 1.081 0.058 29.288 37.017 Post-neonatal mortality rate (last 0-4 years) 11.889 1.241 11,546 12,864 1.208 0.104 9.407 14.371 Infant mortality rate (last 0-4 years) 45.042 2.424 11,501 12,792 1.180 0.054 40.193 49.891 Child mortality rate (last 0-4 years) 11.990 1.399 11,853 13,162 1.417 0.117 9.192 14.789 Under-5 mortality rate (last 0-4 years) 56.492 2.675 11,526 12,818 1.193 0.047 51.142 61.843 Appendix B • 225 Table B.5 Sampling errors: Barisal sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.284 0.075 2,142 1,111 7.547 0.262 0.135 0.433 No education 0.151 0.023 2,142 1,111 2.989 0.153 0.105 0.198 Secondary or higher education 0.481 0.036 2,142 1,111 3.316 0.075 0.410 0.553 Never married (never in union) 0.175 0.014 2,606 1,346 1.656 0.081 0.146 0.203 Currently married (in union) 0.781 0.011 2,606 1,346 1.288 0.015 0.758 0.803 Married before age 20 0.875 0.010 1,954 1,018 1.533 0.011 0.856 0.894 Had first sexual intercourse before age 18 0.722 0.014 1,954 1,018 1.398 0.019 0.695 0.749 Currently pregnant 0.051 0.005 2,606 1,346 1.162 0.097 0.041 0.061 Children ever born 2.097 0.067 2,606 1,346 1.450 0.032 1.963 2.231 Children surviving 1.896 0.059 2,606 1,346 1.453 0.031 1.778 2.014 Children ever born to women age 40-49 4.214 0.189 511 262 2.170 0.045 3.836 4.592 Currently using any method 0.633 0.023 2,030 1,051 2.191 0.037 0.586 0.680 Currently using a modern method 0.546 0.015 2,030 1,051 1.394 0.028 0.515 0.576 Currently using a traditional method 0.087 0.019 2,030 1,051 3.099 0.223 0.048 0.126 Currently using pill 0.272 0.013 2,030 1,051 1.313 0.048 0.246 0.297 Currently using condoms 0.044 0.009 2,030 1,051 2.022 0.209 0.026 0.063 Currently using injectables 0.172 0.021 2,030 1,051 2.452 0.120 0.131 0.213 Currently using female sterilization 0.031 0.005 2,030 1,051 1.308 0.163 0.021 0.041 Currently using rhythm 0.068 0.018 2,030 1,051 3.155 0.259 0.033 0.104 Currently using withdrawal 0.017 0.003 2,030 1,051 1.082 0.181 0.011 0.024 Used public sector source 0.494 0.021 1,108 573 1.368 0.042 0.453 0.535 Want no more children 0.606 0.011 2,030 1,051 1.002 0.018 0.584 0.627 Want to delay birth at least 2 years 0.230 0.010 2,030 1,051 1.091 0.044 0.209 0.250 Ideal number of children 2.224 0.049 2,108 1,094 3.189 0.022 2.127 2.322 Births with skilled attendant at delivery 0.369 0.055 551 279 2.553 0.148 0.260 0.478 Had diarrhea in the last 2 weeks 0.065 0.014 882 444 1.567 0.207 0.038 0.092 Treated with ORS 0.858 0.058 50 29 1.241 0.068 0.742 0.975 Sought medical treatment for diarrhea 0.325 0.074 50 29 1.121 0.228 0.177 0.474 Vaccination card seen 0.787 0.032 180 92 1.052 0.041 0.723 0.852 Received BCG vaccination 0.978 0.010 180 92 0.929 0.010 0.958 0.999 Received DPT vaccination (3 doses) 0.916 0.023 180 92 1.096 0.025 0.870 0.962 Received polio vaccination (3 doses) 0.882 0.036 180 92 1.497 0.041 0.810 0.955 Received measles vaccination 0.875 0.027 180 92 1.079 0.031 0.822 0.929 Received all vaccinations 0.815 0.034 180 92 1.167 0.042 0.748 0.883 Height-for-age (-2SD) 0.399 0.023 837 424 1.295 0.057 0.353 0.444 Weight-for-height (-2SD) 0.177 0.016 837 424 1.178 0.089 0.146 0.209 Weight-for-age (-2SD) 0.369 0.021 837 424 1.184 0.056 0.327 0.410 Body mass index (BMI) <18.5 0.205 0.023 1,955 1,016 2.564 0.114 0.158 0.251 Total fertility rate (3 years) 2.167 0.135 6,984 3,610 1.474 0.062 1.898 2.437 Neonatal mortality rate (last 0-4 years) 33.139 5.127 1,941 994 1.154 0.155 22.885 43.393 Post-neonatal mortality rate (last 0-4 years) 8.645 2.341 1,944 998 1.041 0.271 3.963 13.327 Infant mortality rate (last 0-4 years) 41.784 4.981 1,941 994 1.021 0.119 31.822 51.747 Child mortality rate (last 0-4 years) 10.510 2.261 1,981 1,018 0.989 0.215 5.988 15.033 Under-5 mortality rate (last 0-4 years) 51.855 5.112 1,944 996 0.991 0.099 41.632 62.079 226 • Appendix B Table B.6 Sampling errors: Chittagong sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.312 0.027 2,865 3,301 3.094 0.086 0.258 0.365 No education 0.216 0.020 2,865 3,301 2.649 0.095 0.175 0.256 Secondary or higher education 0.523 0.023 2,865 3,301 2.474 0.044 0.477 0.569 Never married (never in union) 0.154 0.009 3,392 3,903 1.408 0.057 0.137 0.172 Currently married (in union) 0.800 0.010 3,392 3,903 1.539 0.013 0.779 0.821 Married before age 20 0.826 0.011 2,647 3,059 1.707 0.013 0.804 0.848 Had first sexual intercourse before age 18 0.621 0.019 2,647 3,059 2.078 0.031 0.583 0.659 Currently pregnant 0.056 0.005 3,392 3,903 1.247 0.086 0.047 0.066 Children ever born 2.252 0.049 3,392 3,903 1.265 0.022 2.153 2.351 Children surviving 2.048 0.045 3,392 3,903 1.295 0.022 1.958 2.138 Children ever born to women age 40-49 4.373 0.118 573 652 1.436 0.027 4.137 4.610 Currently using any method 0.550 0.016 2,707 3,121 1.624 0.028 0.519 0.581 Currently using a modern method 0.472 0.013 2,707 3,121 1.321 0.027 0.447 0.497 Currently using a traditional method 0.078 0.008 2,707 3,121 1.537 0.102 0.062 0.094 Currently using pill 0.241 0.013 2,707 3,121 1.585 0.054 0.215 0.267 Currently using condoms 0.048 0.005 2,707 3,121 1.233 0.105 0.038 0.059 Currently using injectables 0.120 0.012 2,707 3,121 1.911 0.100 0.096 0.144 Currently using female sterilization 0.036 0.005 2,707 3,121 1.372 0.136 0.027 0.046 Currently using rhythm 0.056 0.008 2,707 3,121 1.767 0.139 0.040 0.072 Currently using withdrawal 0.020 0.004 2,707 3,121 1.391 0.185 0.013 0.028 Used public sector source 0.412 0.018 1,272 1,473 1.333 0.045 0.375 0.449 Want no more children 0.559 0.015 2,707 3,121 1.549 0.026 0.529 0.588 Want to delay birth at least 2 years 0.206 0.009 2,707 3,121 1.188 0.045 0.188 0.225 Ideal number of children 2.386 0.033 2,777 3,211 2.177 0.014 2.319 2.452 Births with skilled attendant at delivery 0.440 0.033 915 1,074 1.955 0.075 0.374 0.507 Had diarrhea in the last 2 weeks 0.067 0.008 1,453 1,668 1.197 0.119 0.051 0.083 Treated with ORS 0.795 0.055 93 111 1.293 0.069 0.686 0.904 Sought medical treatment for diarrhea 0.405 0.058 93 111 1.176 0.144 0.288 0.522 Vaccination card seen 0.691 0.030 294 349 1.119 0.043 0.631 0.751 Received BCG vaccination 0.969 0.010 294 349 1.022 0.011 0.948 0.989 Received DPT vaccination (3 doses) 0.883 0.030 294 349 1.596 0.034 0.823 0.942 Received polio vaccination (3 doses) 0.889 0.030 294 349 1.637 0.033 0.829 0.948 Received measles vaccination 0.876 0.026 294 349 1.342 0.029 0.824 0.927 Received all vaccinations 0.833 0.034 294 349 1.588 0.041 0.765 0.902 Height-for-age (-2SD) 0.380 0.019 1,350 1,541 1.323 0.049 0.343 0.417 Weight-for-height (-2SD) 0.156 0.011 1,350 1,541 1.108 0.072 0.133 0.178 Weight-for-age (-2SD) 0.360 0.019 1,350 1,541 1.407 0.054 0.321 0.398 Body mass index (BMI) <18.5 0.157 0.010 2,604 3,007 1.361 0.062 0.137 0.176 Total fertility rate (3 years) 2.542 0.084 9,895 11,381 1.076 0.033 2.375 2.710 Neonatal mortality rate (last 0-4 years) 33.576 4.235 3,142 3,686 1.112 0.126 25.107 42.045 Post-neonatal mortality rate (last 0-4 years) 14.366 2.572 3,158 3,702 1.199 0.179 9.222 19.511 Infant mortality rate (last 0-4 years) 47.942 5.330 3,146 3,690 1.234 0.111 37.281 58.603 Child mortality rate (last 0-4 years) 14.469 2.882 3,202 3,758 1.402 0.199 8.706 20.232 Under-5 mortality rate (last 0-4 years) 61.717 5.732 3,154 3,700 1.227 0.093 50.254 73.181 Appendix B • 227 Table B.7 Sampling errors: Dhaka sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.366 0.028 3,093 6,223 3.196 0.076 0.310 0.421 No education 0.272 0.021 3,093 6,223 2.667 0.079 0.229 0.314 Secondary or higher education 0.447 0.020 3,093 6,223 2.281 0.046 0.406 0.488 Never married (never in union) 0.150 0.007 3,631 7,324 1.146 0.049 0.136 0.165 Currently married (in union) 0.800 0.008 3,631 7,324 1.200 0.010 0.783 0.816 Married before age 20 0.844 0.009 2,898 5,824 1.560 0.011 0.826 0.862 Had first sexual intercourse before age 18 0.668 0.014 2,898 5,824 1.732 0.022 0.639 0.697 Currently pregnant 0.048 0.004 3,631 7,324 1.033 0.075 0.041 0.056 Children ever born 1.999 0.049 3,631 7,324 1.476 0.025 1.900 2.098 Children surviving 1.831 0.044 3,631 7,324 1.464 0.024 1.743 1.919 Children ever born to women age 40-49 3.733 0.103 641 1,316 1.440 0.027 3.528 3.938 Currently using any method 0.630 0.015 2,916 5,857 1.642 0.023 0.600 0.659 Currently using a modern method 0.542 0.015 2,916 5,857 1.613 0.027 0.513 0.572 Currently using a traditional method 0.087 0.008 2,916 5,857 1.591 0.095 0.071 0.104 Currently using pill 0.275 0.015 2,916 5,857 1.822 0.055 0.244 0.305 Currently using condoms 0.085 0.007 2,916 5,857 1.323 0.080 0.072 0.099 Currently using injectables 0.108 0.012 2,916 5,857 2.085 0.111 0.084 0.131 Currently using female sterilization 0.040 0.004 2,916 5,857 1.104 0.101 0.032 0.048 Currently using rhythm 0.064 0.007 2,916 5,857 1.569 0.111 0.049 0.078 Currently using withdrawal 0.018 0.004 2,916 5,857 1.475 0.203 0.011 0.025 Used public sector source 0.433 0.024 1,596 3,177 1.905 0.055 0.385 0.480 Want no more children 0.551 0.013 2,916 5,857 1.399 0.023 0.526 0.577 Want to delay birth at least 2 years 0.201 0.010 2,916 5,857 1.292 0.048 0.182 0.220 Ideal number of children 2.164 0.021 3,045 6,129 1.854 0.010 2.121 2.207 Births with skilled attendant at delivery 0.437 0.032 839 1,740 1.847 0.074 0.372 0.501 Had diarrhea in the last 2 weeks 0.065 0.013 1,335 2,733 1.883 0.195 0.040 0.090 Treated with ORS 0.818 0.065 68 177 1.496 0.080 0.687 0.948 Sought medical treatment for diarrhea 0.372 0.091 68 177 1.745 0.244 0.190 0.554 Vaccination card seen 0.726 0.043 297 624 1.702 0.060 0.639 0.813 Received BCG vaccination 0.991 0.005 297 624 1.007 0.005 0.980 1.002 Received DPT vaccination (3 doses) 0.939 0.017 297 624 1.253 0.018 0.905 0.973 Received polio vaccination (3 doses) 0.939 0.017 297 624 1.253 0.018 0.905 0.973 Received measles vaccination 0.884 0.024 297 624 1.328 0.027 0.835 0.932 Received all vaccinations 0.874 0.024 297 624 1.277 0.028 0.825 0.922 Height-for-age (-2SD) 0.339 0.019 1,249 2,546 1.447 0.057 0.301 0.378 Weight-for-height (-2SD) 0.119 0.010 1,249 2,546 1.103 0.084 0.099 0.139 Weight-for-age (-2SD) 0.285 0.017 1,249 2,546 1.335 0.060 0.251 0.319 Body mass index (BMI) <18.5 0.182 0.014 2,873 5,778 1.946 0.077 0.154 0.210 Total fertility rate (3 years) 2.343 0.091 10,135 20,404 1.154 0.039 2.162 2.525 Neonatal mortality rate (last 0-4 years) 26.779 2.913 2,874 5,931 0.948 0.109 20.953 32.605 Post-neonatal mortality rate (last 0-4 years) 10.880 2.146 2,901 5,996 1.128 0.197 6.589 15.172 Infant mortality rate (last 0-4 years) 37.659 3.629 2,875 5,933 1.001 0.096 30.401 44.918 Child mortality rate (last 0-4 years) 10.236 2.608 2,925 6,040 1.383 0.255 5.020 15.451 Under-5 mortality rate (last 0-4 years) 47.510 4.209 2,881 5,944 1.069 0.089 39.091 55.928 228 • Appendix B Table B.8 Sampling errors: Khulna sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.243 0.013 2,581 1,838 1.577 0.055 0.217 0.270 No education 0.216 0.014 2,581 1,838 1.784 0.067 0.187 0.245 Secondary or higher education 0.495 0.018 2,581 1,838 1.869 0.037 0.458 0.532 Never married (never in union) 0.150 0.009 3,048 2,162 1.232 0.062 0.132 0.169 Currently married (in union) 0.800 0.011 3,048 2,162 1.405 0.014 0.777 0.822 Married before age 20 0.885 0.006 2,407 1,714 1.066 0.007 0.874 0.897 Had first sexual intercourse before age 18 0.758 0.010 2,407 1,714 1.260 0.014 0.737 0.779 Currently pregnant 0.038 0.003 3,048 2,162 0.996 0.090 0.031 0.045 Children ever born 1.896 0.041 3,048 2,162 1.180 0.021 1.815 1.977 Children surviving 1.736 0.034 3,048 2,162 1.119 0.020 1.667 1.804 Children ever born to women age 40-49 3.401 0.087 658 467 1.418 0.026 3.228 3.575 Currently using any method 0.671 0.011 2,416 1,729 1.146 0.016 0.649 0.693 Currently using a modern method 0.564 0.012 2,416 1,729 1.143 0.020 0.541 0.587 Currently using a traditional method 0.107 0.008 2,416 1,729 1.290 0.076 0.091 0.123 Currently using pill 0.262 0.013 2,416 1,729 1.416 0.048 0.237 0.287 Currently using condoms 0.069 0.007 2,416 1,729 1.371 0.103 0.055 0.083 Currently using injectables 0.138 0.012 2,416 1,729 1.674 0.085 0.115 0.162 Currently using female sterilization 0.062 0.007 2,416 1,729 1.457 0.116 0.047 0.076 Currently using rhythm 0.077 0.007 2,416 1,729 1.355 0.096 0.062 0.092 Currently using withdrawal 0.030 0.004 2,416 1,729 1.092 0.127 0.022 0.037 Used public sector source 0.548 0.022 1,373 975 1.607 0.039 0.504 0.591 Want no more children 0.594 0.015 2,416 1,729 1.474 0.025 0.565 0.624 Want to delay birth at least 2 years 0.163 0.010 2,416 1,729 1.390 0.064 0.142 0.184 Ideal number of children 2.052 0.024 2,552 1,816 1.966 0.011 2.005 2.100 Births with skilled attendant at delivery 0.582 0.032 552 387 1.489 0.055 0.518 0.646 Had diarrhea in the last 2 weeks 0.036 0.007 822 580 1.113 0.202 0.021 0.050 Treated with ORS 0.700 0.098 29 21 1.155 0.140 0.504 0.896 Sought medical treatment for diarrhea 0.349 0.101 29 21 1.144 0.290 0.147 0.551 Vaccination card seen 0.782 0.030 181 129 0.962 0.038 0.723 0.841 Received BCG vaccination 0.989 0.008 181 129 0.988 0.008 0.974 1.004 Received DPT vaccination (3 doses) 0.920 0.020 181 129 0.966 0.021 0.881 0.959 Received polio vaccination (3 doses) 0.926 0.019 181 129 0.987 0.021 0.887 0.964 Received measles vaccination 0.862 0.025 181 129 0.979 0.029 0.811 0.912 Received all vaccinations 0.855 0.026 181 129 0.991 0.030 0.803 0.907 Height-for-age (-2SD) 0.281 0.019 793 565 1.137 0.066 0.243 0.318 Weight-for-height (-2SD) 0.135 0.014 793 565 1.129 0.101 0.108 0.163 Weight-for-age (-2SD) 0.255 0.020 793 565 1.266 0.079 0.215 0.296 Body mass index (BMI) <18.5 0.137 0.009 2,439 1,734 1.232 0.063 0.120 0.154 Total fertility rate (3 years) 1.935 0.073 8,281 5,879 1.093 0.038 1.788 2.081 Neonatal mortality rate (last 0-4 years) 37.462 5.012 1,894 1,350 1.045 0.134 27.438 47.486 Post-neonatal mortality rate (last 0-4 years) 5.082 1.517 1,902 1,357 0.955 0.298 2.049 8.115 Infant mortality rate (last 0-4 years) 42.544 5.012 1,894 1,350 0.994 0.118 32.520 52.568 Child mortality rate (last 0-4 years) 8.233 1.882 1,979 1,423 0.946 0.229 4.469 11.997 Under-5 mortality rate (last 0-4 years) 50.427 5.112 1,901 1,355 0.962 0.101 40.203 60.651 Appendix B • 229 Table B.9 Sampling errors: Rajshahi sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.211 0.009 2,512 2,103 1.113 0.043 0.193 0.229 No education 0.255 0.018 2,512 2,103 2.013 0.069 0.220 0.290 Secondary or higher education 0.444 0.019 2,512 2,103 1.921 0.043 0.406 0.482 Never married (never in union) 0.154 0.010 2,960 2,487 1.315 0.065 0.135 0.174 Currently married (in union) 0.807 0.009 2,960 2,487 1.186 0.012 0.788 0.826 Married before age 20 0.889 0.007 2,349 1,966 1.256 0.007 0.876 0.902 Had first sexual intercourse before age 18 0.764 0.010 2,349 1,966 1.275 0.014 0.743 0.785 Currently pregnant 0.041 0.004 2,960 2,487 1.168 0.102 0.032 0.049 Children ever born 1.929 0.045 2,960 2,487 1.259 0.023 1.839 2.019 Children surviving 1.731 0.039 2,960 2,487 1.261 0.023 1.652 1.809 Children ever born to women age 40-49 3.558 0.111 575 465 1.564 0.031 3.337 3.780 Currently using any method 0.694 0.012 2,389 2,007 1.279 0.017 0.669 0.718 Currently using a modern method 0.607 0.012 2,389 2,007 1.248 0.021 0.582 0.632 Currently using a traditional method 0.087 0.007 2,389 2,007 1.149 0.076 0.073 0.100 Currently using pill 0.279 0.013 2,389 2,007 1.405 0.046 0.253 0.305 Currently using condoms 0.074 0.007 2,389 2,007 1.336 0.097 0.060 0.088 Currently using injectables 0.159 0.016 2,389 2,007 2.149 0.101 0.127 0.191 Currently using female sterilization 0.056 0.007 2,389 2,007 1.444 0.121 0.043 0.070 Currently using rhythm 0.066 0.006 2,389 2,007 1.192 0.091 0.054 0.078 Currently using withdrawal 0.020 0.003 2,389 2,007 1.077 0.156 0.014 0.026 Used public sector source 0.539 0.018 1,447 1,218 1.403 0.034 0.502 0.576 Want no more children 0.600 0.011 2,389 2,007 1.144 0.019 0.577 0.622 Want to delay birth at least 2 years 0.174 0.010 2,389 2,007 1.325 0.059 0.154 0.195 Ideal number of children 2.089 0.020 2,481 2,077 1.766 0.010 2.048 2.129 Births with skilled attendant at delivery 0.416 0.030 575 488 1.420 0.072 0.356 0.476 Had diarrhea in the last 2 weeks 0.043 0.010 923 797 1.500 0.238 0.022 0.063 Treated with ORS 0.723 0.064 37 34 0.891 0.088 0.596 0.850 Sought medical treatment for diarrhea 0.343 0.065 37 34 0.851 0.189 0.214 0.473 Vaccination card seen 0.775 0.034 192 163 1.121 0.043 0.708 0.842 Received BCG vaccination 0.983 0.012 192 163 1.272 0.012 0.959 1.007 Received DPT vaccination (3 doses) 0.930 0.024 192 163 1.310 0.026 0.881 0.978 Received polio vaccination (3 doses) 0.929 0.024 192 163 1.305 0.026 0.881 0.977 Received measles vaccination 0.860 0.032 192 163 1.299 0.038 0.795 0.925 Received all vaccinations 0.836 0.033 192 163 1.228 0.039 0.771 0.902 Height-for-age (-2SD) 0.311 0.017 905 780 1.074 0.054 0.277 0.344 Weight-for-height (-2SD) 0.173 0.012 905 780 0.986 0.070 0.149 0.197 Weight-for-age (-2SD) 0.321 0.020 905 780 1.280 0.063 0.280 0.361 Body mass index (BMI) <18.5 0.196 0.012 2,354 1,966 1.493 0.062 0.171 0.220 Total fertility rate (3 years) 2.111 0.088 8,002 6,698 1.198 0.042 1.935 2.286 Neonatal mortality rate (last 0-4 years) 33.242 3.715 2,000 1,729 0.956 0.112 25.812 40.672 Post-neonatal mortality rate (last 0-4 years) 9.391 2.545 1,997 1,726 1.134 0.271 4.300 14.481 Infant mortality rate (last 0-4 years) 42.633 4.627 2,002 1,730 1.001 0.109 33.379 51.887 Child mortality rate (last 0-4 years) 7.851 2.159 2,022 1,748 1.175 0.275 3.533 12.169 Under-5 mortality rate (last 0-4 years) 50.149 5.063 2,004 1,732 1.030 0.101 40.022 60.275 230 • Appendix B Table B.10 Sampling errors: Rangpur sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.151 0.014 2,531 2,056 2.029 0.096 0.122 0.180 No education 0.272 0.017 2,531 2,056 1.873 0.061 0.239 0.305 Secondary or higher education 0.441 0.018 2,531 2,056 1.872 0.042 0.404 0.478 Never married (never in union) 0.171 0.011 3,051 2,481 1.349 0.062 0.150 0.193 Currently married (in union) 0.784 0.010 3,051 2,481 1.226 0.013 0.764 0.804 Married before age 20 0.889 0.007 2,345 1,900 1.317 0.008 0.875 0.902 Had first sexual intercourse before age 18 0.789 0.009 2,345 1,900 1.118 0.011 0.771 0.806 Currently pregnant 0.043 0.007 3,051 2,481 1.887 0.158 0.029 0.057 Children ever born 1.971 0.037 3,051 2,481 0.990 0.019 1.898 2.045 Children surviving 1.791 0.033 3,051 2,481 1.002 0.018 1.726 1.857 Children ever born to women age 40-49 3.693 0.086 592 465 1.231 0.023 3.521 3.866 Currently using any method 0.698 0.013 2,397 1,946 1.394 0.019 0.672 0.724 Currently using a modern method 0.630 0.014 2,397 1,946 1.398 0.022 0.603 0.658 Currently using a traditional method 0.067 0.007 2,397 1,946 1.446 0.110 0.053 0.082 Currently using pill 0.332 0.014 2,397 1,946 1.461 0.042 0.304 0.360 Currently using condoms 0.039 0.006 2,397 1,946 1.452 0.148 0.027 0.050 Currently using injectables 0.142 0.014 2,397 1,946 1.976 0.099 0.114 0.170 Currently using female sterilization 0.052 0.008 2,397 1,946 1.695 0.148 0.036 0.067 Currently using rhythm 0.051 0.005 2,397 1,946 1.185 0.105 0.040 0.061 Currently using withdrawal 0.015 0.003 2,397 1,946 1.295 0.215 0.008 0.021 Used public sector source 0.583 0.022 1,516 1,226 1.771 0.039 0.538 0.628 Want no more children 0.574 0.018 2,397 1,946 1.750 0.031 0.539 0.609 Want to delay birth at least 2 years 0.198 0.011 2,397 1,946 1.390 0.057 0.175 0.221 Ideal number of children 2.125 0.018 2,512 2,041 1.578 0.009 2.089 2.162 Births with skilled attendant at delivery 0.382 0.026 565 461 1.251 0.068 0.330 0.434 Had diarrhea in the last 2 weeks 0.027 0.006 920 768 1.165 0.228 0.015 0.040 Treated with ORS 0.494 0.147 24 21 1.479 0.297 0.201 0.787 Sought medical treatment for diarrhea 0.234 0.094 24 21 1.121 0.402 0.046 0.422 Vaccination card seen 0.856 0.023 192 146 0.890 0.027 0.809 0.903 Received BCG vaccination 1.000 0.000 192 146 na na 1.000 1.000 Received DPT vaccination (3 doses) 0.979 0.011 192 146 0.992 0.011 0.958 1.001 Received polio vaccination (3 doses) 0.979 0.011 192 146 0.992 0.011 0.958 1.001 Received measles vaccination 0.903 0.021 192 146 0.945 0.023 0.861 0.945 Received all vaccinations 0.900 0.021 192 146 0.942 0.024 0.857 0.942 Height-for-age (-2SD) 0.360 0.021 899 762 1.270 0.057 0.319 0.401 Weight-for-height (-2SD) 0.177 0.022 899 762 1.765 0.124 0.133 0.221 Weight-for-age (-2SD) 0.368 0.039 899 762 2.323 0.105 0.291 0.445 Body mass index (BMI) <18.5 0.203 0.015 2,365 1,913 1.844 0.075 0.173 0.234 Total fertility rate (3 years) 1.860 0.092 8,144 6,616 1.094 0.050 1.676 2.045 Neonatal mortality rate (last 0-4 years) 28.296 4.782 2,084 1,704 1.128 0.169 18.733 37.859 Post-neonatal mortality rate (last 0-4 years) 12.076 2.785 2,089 1,712 1.098 0.231 6.506 17.646 Infant mortality rate (last 0-4 years) 40.372 6.089 2,087 1,706 1.249 0.151 28.195 52.550 Child mortality rate (last 0-4 years) 4.907 1.533 2,183 1,791 1.041 0.312 1.841 7.973 Under-5 mortality rate (last 0-4 years) 45.081 6.465 2,090 1,709 1.272 0.143 32.151 58.011 Appendix B • 231 Table B.11 Sampling errors: Sylhet sample, Bangladesh DHS 2014 Variable R SE N WN DEFT SE/R R-2SE R+2SE Urban residence 0.185 0.022 2,139 1,232 2.609 0.119 0.141 0.229 No education 0.318 0.023 2,139 1,232 2.233 0.071 0.273 0.363 Secondary or higher education 0.330 0.032 2,139 1,232 3.126 0.096 0.266 0.394 Never married (never in union) 0.135 0.008 2,452 1,424 1.268 0.063 0.118 0.152 Currently married (in union) 0.806 0.010 2,452 1,424 1.295 0.012 0.786 0.825 Married before age 20 0.789 0.014 2,031 1,162 1.694 0.017 0.762 0.817 Had first sexual intercourse before age 18 0.542 0.021 2,031 1,162 1.945 0.039 0.500 0.584 Currently pregnant 0.097 0.008 2,452 1,424 1.292 0.078 0.082 0.112 Children ever born 2.671 0.098 2,452 1,424 1.825 0.037 2.475 2.867 Children surviving 2.377 0.087 2,452 1,424 1.826 0.036 2.204 2.551 Children ever born to women age 40-49 4.956 0.140 448 248 1.246 0.028 4.675 5.236 Currently using any method 0.478 0.023 1,975 1,147 2.038 0.048 0.432 0.524 Currently using a modern method 0.409 0.022 1,975 1,147 1.992 0.054 0.365 0.453 Currently using a traditional method 0.069 0.006 1,975 1,147 1.022 0.084 0.058 0.081 Currently using pill 0.214 0.015 1,975 1,147 1.610 0.070 0.184 0.244 Currently using condoms 0.040 0.007 1,975 1,147 1.612 0.179 0.025 0.054 Currently using injectables 0.065 0.009 1,975 1,147 1.673 0.143 0.046 0.083 Currently using female sterilization 0.067 0.008 1,975 1,147 1.482 0.125 0.050 0.083 Currently using rhythm 0.057 0.005 1,975 1,147 1.006 0.092 0.046 0.067 Currently using withdrawal 0.013 0.003 1,975 1,147 1.124 0.224 0.007 0.018 Used public sector source 0.577 0.026 818 468 1.488 0.045 0.526 0.629 Want no more children 0.521 0.018 1,975 1,147 1.565 0.034 0.486 0.556 Want to delay birth at least 2 years 0.212 0.014 1,975 1,147 1.486 0.065 0.184 0.239 Ideal number of children 2.513 0.051 2,052 1,187 2.503 0.020 2.412 2.614 Births with skilled attendant at delivery 0.271 0.040 737 474 2.404 0.146 0.192 0.350 Had diarrhea in the last 2 weeks 0.061 0.011 1,232 771 1.674 0.186 0.038 0.084 Treated with ORS 0.667 0.063 70 47 1.158 0.094 0.541 0.793 Sought medical treatment for diarrhea 0.327 0.086 70 47 1.573 0.263 0.155 0.499 Vaccination card seen 0.677 0.037 221 129 1.181 0.055 0.603 0.751 Received BCG vaccination 0.913 0.023 221 129 1.203 0.025 0.867 0.958 Received DPT vaccination (3 doses) 0.760 0.060 221 129 2.103 0.079 0.639 0.881 Received polio vaccination (3 doses) 0.779 0.046 221 129 1.666 0.060 0.686 0.872 Received measles vaccination 0.656 0.047 221 129 1.485 0.072 0.561 0.751 Received all vaccinations 0.611 0.056 221 129 1.719 0.092 0.498 0.723 Height-for-age (-2SD) 0.496 0.020 1,134 700 1.395 0.041 0.456 0.537 Weight-for-height (-2SD) 0.121 0.013 1,134 700 1.329 0.105 0.096 0.147 Weight-for-age (-2SD) 0.398 0.028 1,134 700 1.905 0.070 0.342 0.454 Body mass index (BMI) <18.5 0.298 0.018 1,854 1,063 1.654 0.059 0.262 0.333 Total fertility rate (3 years) 2.935 0.334 7,829 4,546 3.017 0.114 2.266 3.604 Neonatal mortality rate (last 0-4 years) 45.010 4.551 2,819 1,718 1.093 0.101 35.907 54.113 Post-neonatal mortality rate (last 0-4 years) 19.011 2.827 2,832 1,724 1.052 0.149 13.358 24.664 Infant mortality rate (last 0-4 years) 64.021 4.816 2,823 1,720 0.980 0.075 54.389 73.654 Child mortality rate (last 0-4 years) 13.622 3.177 2,925 1,770 1.389 0.233 7.268 19.977 Under-5 mortality rate (last 0-4 years) 76.771 5.288 2,827 1,723 0.972 0.069 66.195 87.348 Appendix C • 233 DATA QUALITY TABLES Appendix C Table C.1 Household age distribution Single-year age distribution of the de facto household population by sex (weighted), Bangladesh 2014 Women Men Women Men Age Number Percent Number Percent Age Number Percent Number Percent 0 742 1.9 863 2.3 37 473 1.2 217 0.6 1 768 1.9 848 2.2 38 438 1.1 424 1.1 2 773 1.9 810 2.2 39 423 1.1 148 0.4 3 779 2.0 814 2.2 40 469 1.2 1,087 2.9 4 755 1.9 824 2.2 41 399 1.0 149 0.4 5 761 1.9 749 2.0 42 412 1.0 321 0.9 6 856 2.2 866 2.3 43 463 1.2 382 1.0 7 964 2.4 1,048 2.8 44 415 1.0 204 0.5 8 930 2.3 936 2.5 45 425 1.1 895 2.4 9 735 1.9 852 2.3 46 356 0.9 198 0.5 10 1,052 2.7 1,080 2.9 47 343 0.9 168 0.4 11 837 2.1 853 2.3 48 342 0.9 338 0.9 12 931 2.3 1,000 2.7 49 350 0.9 136 0.4 13 898 2.3 843 2.2 50 102 0.3 920 2.4 14 861 2.2 872 2.3 51 218 0.6 184 0.5 15 906 2.3 795 2.1 52 297 0.7 238 0.6 16 949 2.4 781 2.1 53 387 1.0 247 0.7 17 862 2.2 626 1.7 54 238 0.6 90 0.2 18 1,030 2.6 869 2.3 55 482 1.2 663 1.8 19 794 2.0 472 1.3 56 272 0.7 138 0.4 20 881 2.2 689 1.8 57 204 0.5 106 0.3 21 716 1.8 338 0.9 58 284 0.7 245 0.7 22 793 2.0 625 1.7 59 184 0.5 122 0.3 23 755 1.9 415 1.1 60 534 1.3 835 2.2 24 742 1.9 469 1.2 61 142 0.4 124 0.3 25 776 2.0 854 2.3 62 137 0.3 125 0.3 26 737 1.9 605 1.6 63 167 0.4 147 0.4 27 714 1.8 465 1.2 64 57 0.1 33 0.1 28 688 1.7 691 1.8 65 368 0.9 569 1.5 29 673 1.7 245 0.6 66 71 0.2 54 0.1 30 748 1.9 1,257 3.3 67 35 0.1 61 0.2 31 588 1.5 179 0.5 68 96 0.2 181 0.5 32 638 1.6 610 1.6 69 55 0.1 40 0.1 33 545 1.4 236 0.6 70+ 1,173 3.0 1,575 4.2 34 596 1.5 226 0.6 Don’t know/ missing 35 580 1.5 1,320 3.5 1 0.0 8 0.0 36 478 1.2 274 0.7 Total 39,641 100.0 37,672 100.0 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Table C.2 Age distribution of eligible and interviewed women De facto household population of women age 10-54, interviewed women age 15-49; and percent distribution and percentage of eligible women who were interviewed (weighted), by five-year age groups, Bangladesh 2014 Household population of women age 10-54 Ever-married women age 10-54 Interviewed women age 15-49 Percentage of eligible women interviewed Age group Number Percentage 10-14 4,578 0 - - - 15-19 4,541 2,054 2,020 11.4 44.5 20-24 3,888 3,283 3,211 18.1 82.6 25-29 3,588 3,440 3,365 18.9 93.8 30-34 3,115 3,084 3,033 17.1 97.4 35-39 2,390 2,375 2,304 13.0 96.4 40-44 2,158 2,141 2,082 11.7 96.5 45-49 1,815 1,812 1,752 9.9 96.5 50-54 1,242 1,228 - - - 15-49 21,495 18,189 17,768 100.0 82.7 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household questionnaire. na = Not applicable 234 • Appendix C Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Bangladesh 2014 Subject Percentage with information missing Number of cases Month only (Births in the 15 years preceding the survey) 0.35 26,229 Month and Year (Births in the 15 years preceding the survey) 0.01 26,229 Age at Death (Deceased children born in the 15 years preceding the survey) 0.00 1,564 Age/date at first union1 (Ever married women age 15-49) 0.02 17,863 Respondent’s education (All women age 15-49) 0.00 17,863 Diarrhea in last 2 weeks (Living children 0-59 months) 0.35 7,760 Height (Living children age 0-59 months from the Household Questionnaire) 5.49 7,928 Weight (Living children age 0-59 months from the Household Questionnaire) 3.29 7,928 Height or weight (Living children age 0-59 months from the Household Questionnaire) 5.52 7,928 Height (Women age 15-49 from the household questionnaire) 2.98 18,189 Weight (Women age 15-49 from the household questionnaire) 2.94 18,189 Height or weight (Women age 15-49 from the household questionnaire) 3.01 18,189 1 Both year and age missing Table C.4 Births by calendar years Number of births, percentage with complete birth date, sex ratio at birth, and calendar year ratio by calendar year, according to living (L), dead (D), and total (T) children (weighted), Bangladesh 2014 Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 Calendar year L D T L D T L D T L D T 0 1,548 93 1,641 100.0 100.0 100.0 102.1 83.5 101.0 - - - 1 1,566 64 1,630 100.0 100.0 100.0 110.1 118.2 110.4 - - - 2 1,431 72 1,502 100.0 100.0 100.0 104.4 147.4 106.1 89.0 76.6 88.3 3 1,651 123 1,774 99.8 100.0 99.8 95.0 109.4 96.0 101.2 141.9 103.3 4 1,831 102 1,933 99.3 99.5 99.3 106.2 83.4 104.9 106.5 84.1 105.0 5 1,789 119 1,909 99.9 98.9 99.9 108.1 106.0 108.0 107.4 104.9 107.2 6 1,500 126 1,626 99.9 98.5 99.8 108.4 77.5 105.6 80.3 100.4 81.6 7 1,947 131 2,078 99.2 97.7 99.1 103.4 137.0 105.2 122.0 105.8 120.8 8 1,692 122 1,814 99.7 95.9 99.4 105.9 113.1 106.4 91.7 96.9 92.0 9 1,744 121 1,865 99.9 95.1 99.6 114.7 121.0 115.1 104.2 97.2 103.7 0-4 8,028 453 8,481 99.8 99.9 99.8 103.4 103.1 103.4 - - - 5-9 8,673 619 9,292 99.7 97.2 99.6 107.9 109.1 108.0 - - - 10-14 7,507 773 8,279 99.3 95.8 99.0 98.2 111.2 99.3 - - - 15-19 5,677 782 6,459 99.0 96.9 98.8 96.9 131.6 100.5 - - - 20+ 5,732 1,213 6,944 99.1 97.1 98.7 110.9 131.8 114.3 - - - All 35,615 3,839 39,455 99.4 97.1 99.2 103.4 119.9 104.9 - - - na = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x Appendix C • 235 Table C.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at ages 0-6 days, for five-year periods of birth preceding the survey (weighted), Bangladesh 2014 Number of years preceding the survey Total 0-19 Age at death (days) 0-4 5-9 10-14 15-19 <1 78 87 81 107 354 1 29 66 43 65 203 2 11 27 21 23 82 3 20 39 45 52 157 4 30 6 7 13 55 5 10 12 20 26 69 6 5 6 12 10 33 7 2 16 18 12 48 8 5 10 5 9 28 9 1 4 5 5 14 10 6 3 7 2 18 11 3 2 5 3 12 12 1 6 2 4 12 13 0 3 5 6 15 14 2 2 5 2 11 15 5 3 5 8 22 16 3 0 1 4 8 17 0 2 1 2 5 18 1 4 4 5 14 19 0 1 2 4 7 20 0 0 4 4 8 21 4 5 6 11 26 22 1 4 7 3 15 23 3 0 2 1 6 24 0 1 0 1 2 25 2 0 2 3 7 26 0 1 2 1 5 27 0 2 2 2 6 28 1 1 4 1 7 29 1 4 2 3 9 Total 0-30 225 317 325 392 1,259 Percentage early neonatal1 81.4 76.9 70.6 75.6 75.7 1 0-6 days / 0-30 days 236 • Appendix C Table C.6 Reporting of age at death in months Distribution of reported deaths under two years of age by age at death in months and the percentage of infant deaths reported to occur at age under one month, for five-year periods of birth preceding the survey, Bangladesh 2014 Number of years preceding the survey Total 0-19 Age at death (months) 0-4 5-9 10-14 15-19 <1 225 317 325 392 1,259 1 19 31 46 60 156 2 18 14 17 13 63 3 10 19 27 33 89 4 6 5 16 10 37 5 7 10 12 20 49 6 6 4 15 17 41 7 5 11 8 6 29 8 1 4 17 16 37 9 1 6 9 6 23 10 1 5 7 1 15 11 2 4 3 3 12 12 4 19 15 19 57 13 1 1 8 4 14 14 0 5 1 3 9 15 3 5 4 3 15 16 4 0 2 3 10 17 0 3 1 5 8 18 4 16 9 19 48 19 3 0 0 1 3 20 0 0 0 0 0 21 0 1 1 0 1 22 0 0 1 1 2 23 1 2 2 0 5 24+ 0 0 1 0 1 1 Year 0 0 1 0 1 Total 0-11 300 430 503 577 1,811 Percentage neonatal1 75.0 73.7 64.5 68.0 69.5 a Includes deaths under one month reported in days 1 Under one month / under one year Appendix D • 237 PERSONS INVOLVED IN THE SURVEY Appendix D Members of the Technical Review Committee and the Technical Working Group Technical Review Committee (TRC) Ms. Rownaq Jahan, Director General, NIPORT Chairman Ms. Kulsum Begum, Joint Secretary (FW), Ministry of Health and Family Welfare Member Mr. Md. Ashadul Islam, Director General, HEU, Ministry of Health and Family Welfare Member Dr. Mohammad Khairul Hasan, Deputy Chief (Health), Ministry of Health and Family Welfare Member Mr. Younus Mian, Deputy Chief (Family Welfare), Ministry of Health and Family Welfare Member Mr. Karar Zunaid Ahsan, Sr. M&E Advisor, PMMU, MOHFW Member Mr. Prodip Kumar Mahottam, Deputy Chief, Population Planning Wing, Planning Commission Member Director (PHC), Directorate General of Health Services Member Director (MIS), Directorate General of Health Services Member Director, IPHN, Directorate General of Health Services Member Director (Planning and Research) and Line Director (PMR), DGHS Member Director (MCH Services) and Line Director (MCRAH), DGFP Member Director (MIS), Directorate General of Family Planning Member Director (Planning), Directorate General of Family Planning Member Director, Census Wing, Bangladesh Bureau of Statistics Member Prof. Dr. Mohammad Shahidullah, Pro-Vice Chancellor, BSMMU Member Director, ISRT, University of Dhaka Member Chairperson, Dept. of Population Sciences, University of Dhaka Member Prof. Nitai Chakraborty, Department of Statistics, University of Dhaka Member WHO Representative, Bangladesh Member Country Representative, UNFPA, Bangladesh Member Chief Health and Nutrition, UNICEF, Bangladesh Member Task Team Leader for HPNSDP, World Bank, Dhaka Member Sr. Health & Population Advisor, DFID-Bangladesh Member Head, Project Support Unit, CIDA, Bangladesh Member Representative, SIDA, Bangladesh Member Country Representative, GiZ, Bangladesh Member Representative, JICA, Bangladesh Member Mr. Jan Borg, Health Adviser, AUSAID, Bangladesh Member Dr. Kanta Jamil, Sr. M&E and Research Advisor, OPHNE, USAID, Bangladesh Member Chief of Party, NHSDP Member Dr. Ishtiaq Mannan, Director, Health, Nutrition and HIV/AIDS, Save the Children Member Mr. Toslim Uddin Khan, General Manager (Program), Social Marketing Company (SMC) Member Dr. Kaosar Afsana, Director, BRAC Health Program Member Dr. Peter Kim Streatfield, Emeritus Scientist, HSPSD, ICDDR,B Member Dr. Shams El Arifeen, Senior Director, Maternal and Child Health Division (MCHD), ICDDR,B Member Sri Poedjastoeti, ICF International, USA Member Dr. Ahmed Al-Sabir, Consultant, ICF International, USA Member Mr. S. N. Mitra, Executive Director, Mitra and Associates Member Ms. Shahin Sultana, Sr. Research Associate, NIPORT Member Mr. Subrata K. Bhadra, Sr. Research Associate, NIPORT Member Mr. Mohammed Ahsanul Alam, Evaluation Specialist, NIPORT Member Mr. Md. Rafiqul Islam Sarker, Director (Research), NIPORT Member-Secretary Technical Working Group (TWG) Mr. Md. Rafiqul Islam Sarker, Director (Research), NIPORT Chairman Dr. Peter Kim Streatfield, Emeritus Scientist, HSPSD, ICDDR,B Member Dr. Shams El Arifeen, Senior Director, Maternal and Child Health Division (MCHD), ICDDR,B Member Dr. Kanta Jamil, Sr. M&E and Research Advisor, OPHNE, USAID, Bangladesh Member Dr. Istiaq Mannan, Director, Health, Nutrition, and HIV/AIDS, Save the Children Member Dr. Karar Zunaid Ahsan, Sr. M&E Advisor, PMMU, MOHFW Member Prof. Nitai Chakraborty, Department of Statistics, University of Dhaka Member Dr. Yasmin Ahmed, Independent Consultant Member Ms. Sri Poedjastoeti, ICF International, USA Member Dr. Ahmed Al-Sabir, Consultant, ICF International, USA Member Mr. S. N. Mitra, Executive Director, Mitra and Associates Member Ms. Shahin Sultana, Sr. Research Associate, NIPORT Member Mr. Mohammed Ahsanul Alam, Evaluation Specialist, NIPORT Member Mr. Subrata K. Bhadra, Sr. Research Associate, NIPORT Member-Secretary 238 • Appendix D NIPORT Professionals Ms. Rownaq Jahan Mr. Mohammad Wahid Hossain, ndc Mr. Md. Rafiqul Islam Sarker Ms. Shahin Sultana Mr. Subrata K. Bhadra ICF International Staff Ms. Sri Poedjastoeti Mr. Mahmoud Elkasabi Mr. Albert Themme Mr. Fidele Mutima Dr. Ahmed Al-Sabir, Consultant Prof. Nitai Chakraborty, Consultant Ms. Nancy Johnson Mr. Christopher Gramer Mitra and Associates Staff Project Director Mr. S. N. Mitra Deputy Project Director Mr. Shahidul Islam Project Managers Mr. A. B. Siddique Mozumder Mr. Jahangir Hossain Sharif Mr. Nripendra Chandra Barman Mr. Monir Hossain Bhuiyan Ms. Situl Muna Appendix D • 239 FIELD STAFF Household Listing Listing Supervisors Mr. Shafiqul Islam (Tarek) Mr. Sherajul Islam Mr. Abu Sayed Noman Mr. Abul Kalam Azad Mr. Probir Dey Mr. Ziaul Hoque Mr. Yakub Biswas Mr. Nurunnabe Mr. Abdullah-Al-Mamun Mr. Monirul Islam Listers/Mappers Mr. Sohag Mr. Samsul Islam Mr. Jahangir Hossain Mr. Nayan Kumar Sarkar Mr. Tawhidur Rahman Mr. Manzur Hosan Mr. Mrinal Kanti Sen Mr. Rahul Barman Mr. Khairuzzaman Mr. Tawhidul Islam Mr. Abdun Nur Mr. Harun Or Rashid Mr. Habib Ullah Mr. Zakirul Islam Mr. Mafuzur Rahman Mr. Sree Manik Ch. Roy Mr. Sreebash Hira Mr. Abdur Rahman Mr. Khalilur Rahman Mr. Anirban Adhikari Mr. Tanviruzzaman Mr. Mahabur Rahman Mr. Syful Islam Mr. Razu Ahmmed Mr. Shariful Islam Mr. Nur Alam Jiku Mr. Shyan Kumar Sarker Mr. Abu Hasan Mr. Saiful Islam Mr. Nazmul Hossain Mr. Ariful Islam Mr. Nazrul Islam Bhuiyan Mr. Shazedul Islam Mr. Kajim Uddin Mr. Shamim Khan Mr. Saifur Rahman Mr. Maharaj Adhikari Mr. Rafiqul Islam Mr. Mirazul Islam Mr. Hirok Kumar Sarker Mr. Rafayet Ullah Mr. Ruhul Amin Mr. Mohammad Al Amin Mr. Jannatur Rahman Mr. Sree Babul Ch. Das Household and Woman’s Survey Quality Control Officers Mr. Sankar Ch. Banik Ms. Marjina Mr. Abdur Razzak Ms. Taslima Bente Ansari Mr. Shafi Ahmed Ali Siddiki Ms. Minara Akter Mr. Zahurul Islam Ms. Nazma Khanum Mr. Billal Hossain Male Supervisors Mr. Anwar Hossain(Sohel) Mr. Alomgir Hossain Mr. Motiur Rahman Mr. Mehedi Hasan Mr. Md. Bazer Ali Mr. Shankar Kumar Paul Mr. Motaleb Shek Mr. Abdus Samad Mr. Shakawat Hossain Mr. Mobarek Hosain Mr. Ashikur Rahman Mr. Harunoor Rashid Mr. Anowarul Islam Mr. Anwar Hossin Mr. Musaraf Hossain Mr. Mujibur Rahman Mr. Abdus Sattar Mr. Abu Hana Mostafa Jaman Mr. Mostafazur Rahuman Mr. Zakirul Islam 240 • Appendix D Female Field Editors Ms. Laboni Yeasmin Ms. Sharmina Akter Ms. Rinky Khanom Ms. Monira Khatun Ms. Rubina Afruj Ms. Asma Khatun Ms. Sabina Yeasmin Ms. Beauty Akter (Selina) Ms. Afroja Akther Ms. Tahira Ms. Rashida Akter Ms. Rowshon Nahar Ms. Amena Akter Bithty Ms. Foyzunnessa Ms. Sharifa Khatun Ms. Tania Sultana Ms. Husneara Khatun Ms. Salma Akter Ms. Rabia Khatun Ms. Khadja Akhter Shila Female Interviewers Ms. Aysha Siddika Ms. Jannatul Nayem Ms. Shati Rani Ms. Shirin Alom Ms. Airin Ara Ms. Israt Jahan (Tang) Ms. Fatima Khatun Ms. Zannatun Piashi Ms. Khadiza Akter Ms. Taslima Akter Ms. Jannatun Ferdaus Ms. Rupa Akter Ms. Nasima Khatun Ms. Parul Aktari Ms. Sabrina Ms. Tahasina Ferdousi Ms. Yeasmin Akter Ms. Shima Khatun Ms. Taslima Akthar (Lipi) Ms. Golapi Shahrin Ms. Thamina Akter Ms. Lipchi Ms. Shahanaj Akter Ms. Minara Khatun Ms. Khadija Begum Ms. Lovely Yesmin Ms. Amena Khatun Ms. Momena Akter Shathy Ms. Badunnesa Begum Ms. Amina Ms. Rehana Parvin Ms. Umme Kulsum Ms. Rekha Gharami Ms. Morsheda Begum Ms. Rohima Khatun Ms. Mousumi Rani Paul Ms. Nilufar Yasmin Ms. Sharmin Akter Ms. Babia Sultana Ms. Shafia Akter (Lucky) Ms. Asmaul Husna Ms. Baby Akhter Ms. Kulsum Akter Ms. Eshrat Zahan Ms. Ruma Khatun Ms. Kulsum Khutun Ms. Talisultana Ms. Sonia Khatun Ms. Shanaz Sultana Ms. Sumia Akter Ms. Meherunnesa Ms. Banhi Biswas Ms. Nihar Sultana Ms. Anupama Alam Ms. Rahima Khatun Ms. Laily Khatun Ms. Joyenti Martina Baroi Ms. Najma Begum Ms. Rojina Khatun Ms. Tompa Rani Das Ms. Mahmuda Ms. Lipy Akter Ms. Khuku Rani Mistry Ms. Selina Khatun Ms. Khan Masura Ms. Aliza Khantun Ms. Bimala Rani Mondol Ms. Laiju Khanam Ms. Tasmiyafrin Mony Ms. Momena Khatun Ms. Mahbuba Alam Ms. Niva Mistry Ms. Mazeda Akter Ms. Kalpona Khatun Ms. Khadiza Akter Ms. Sumaia Akhter Ms. Khaleda Begum Ms. Daly Khatun Ms. Lyzu Yesmin Srete Ms. Asma Khatun Ms. Rifit Sultana Mirza Ms. Suraia Begum Ms. Sanjida Begum Ms. Hajera Khatun Ms. Khadiza Talukder Ms. Minoti Rani Ms. Sali Akter Ms. Syma Akter Ms. Rozina Khatun Ms. Sajia Mamnun Ms. Shilpi Akter Ms. Mahmuda Ms. Mohmuda Khatun Moushumi Ms. Marum Begum Ms. Jakia Sultana Ms. Moni Akter Ms. Ashia Akter Ruma Ms. Beuty Rani Dey Ms. Mokta Rani Roy Ms. Mahmuda Parvin Ms. Asma Akter Ms. Marufa Yesmin Ms. Mazmuna Khatun Ms. Roksana Akter Appendix D • 241 Computer Programmer Mr. Shishir Paul Data Entry Operators Mr. Pranab Das Mr. Ripon Barman Mr. Sumsun Arefen Mr. Mithun Bepari Mr. Obidul Islam Mr. Ataur Rahman Juny Mr. Khandoker Ibba Jayed Office Editors Ms. Samsun Nahar Lucky Ms. Nibedita Mandal Ms. Zakia Ferdous Ms. Hasina Khatun Ms. Zesmin Ara Khatun Ms. Farjana Jahan Administrative Staff Mr. S. Fuad Pasha, Deputy Project Director-Admin. Mr. Joynal Abdin, Secretary Mr. Bimal Chandra Datta, Accounts Officer Mr. Najim Uddin, Registration Officer Appendix E • 888 QUESTIONNAIRES Appendix E 243 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2014 HOUSEHOLD QUESTIONNAIRE NIPORT, MOHFW Mitra and Associates IDENTIFICATION DIVISION DISTRICT UPAZILA UNION/WARD VILLAGE/MOHALLA/BLOCK CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RURAL=1, CITY CORPORATION=2, OTHER URBAN=3 . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME OF THE HOUSEHOLD HEAD INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. CODE RESULT* RESULT* NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: TOTAL PERSONS IN HOUSEHOLD 1 COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT TOTAL ELIGIBLE AT HOME AT TIME OF VISIT WOMEN (EVER 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME MARRIED WOMEN 4 POSTPONED 15-49 YR 5 REFUSED 6 DWELLING VACANT OR ADDRESS NOT A DWELLING TOTAL NUMBER OF 7 DWELLING DESTROYED CHILDREN (0-5 YR) 8 DWELLING NOT FOUND 9 OTHER LINE NO.OF RESP. (SPECIFY) TO HOUSEHOLD QUESTIONNAIRE SUPERVISOR FIELD EDITOR NAME NAME 1 4 OFFICE KEYED BY EDITOR June 11, 2014 1 2 3 2 0 245Appendix E • INTRODUCTION AND CONSENT GIVE CARD WITH CONTACT INFORMATION NAME OF INTERVIEWER: DATE: . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . . 2 ENDRESPONDENT AGREES TO BE INTERVIEWED Do you have any questions? May I begin the interview now? Hello. My name is _______________________________________. I am working with NIPORT, the Ministry of Health and Family Welfare, and Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all over Bangladesh. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact with Mr. S. N Mitra, Executive Director, Mitra and Associates, 2/17 Iqbal Road, Block A, Mohammadpur, Dhaka 1207, Bangladesh. Telephone number are: 8118065,9115503, 01711278663. 246 • Appendix E IF A G E 1 5 IF A G E 5 Y E A R S IF A G E 8 O R 0- 4 13 O R IN T E R V IE W O R O LD E R O R O LD E R O LD E R Y E A R S O LD E R LI N E U S U A L R E S ID E N TS A N D A G E E V E R A TT E N D E D C U R R E N T/ R E C E N T C U R R E N T B IR TH M O B IL E W O M EN C H IL D R EN W O M EN N O . V IS IT O R S S C H O O L S C H O O L A TT E N D A N C E W O R K R E G IS - P H O N E S TA TU S 1 IF 9 5 IF N O , P R O B E : O R M O R E , 1 = C U R R E N TL Y S E E C O D E S S E E C O D E S R E C O R D M A R R IE D B E LO W . B E LO W . '9 5' . 2 = D IV O R C E D / S E E C O D E S A FT E R L IS TI N G T H E S E P A R A TE D / B E LO W . N A M E S A N D R E C O R D IN G D E S E R TE D / W ID O W E D FO R E A C H P E R S O N , A S K 3 = N E V E R - 1 = H A S Q U E S TI O N S 2 A -2 C T O B E M A R R IE D C E R TI FI C A TE S U R E T H A T TH E L IS TI N G 2 = R E G IS TE R E D IS C O M P LE TE . S E E C O D E S 3 = N E IT H E R B E LO W . 8 = D O N 'T TH E N A S K A P P R O P R IA TE K N O W Q U E S TI O N S IN C O LU M N S 5- 22 F O R E A C H P E R S O N . M F Y N Y N IN Y E A R S Y N L E V E L C LA S S Y N L E V E L C LA S S Y N Y N 01 1 2 1 2 1 2 1 2 1 2 1 2 1 2 01 01 01 G O T O 1 3 G O T O 1 3 02 1 2 1 2 1 2 1 2 1 2 1 2 1 2 02 02 02 G O T O 1 3 G O T O 1 3 03 1 2 1 2 1 2 1 2 1 2 1 2 1 2 03 03 03 G O T O 1 3 G O T O 1 3 04 1 2 1 2 1 2 1 2 1 2 1 2 1 2 04 04 04 G O T O 1 3 G O T O 1 3 05 1 2 1 2 1 2 1 2 1 2 1 2 1 2 05 05 05 G O T O 1 3 G O T O 1 3 06 1 2 1 2 1 2 1 2 1 2 1 2 1 2 06 06 06 G O T O 1 3 G O T O 1 3 TH E R E LA TI O N S H IP A N D S E X Is (N A M E ) cu rre nt ly w or ki ng ? D oe s (N A M E ) ha ve a b irt h ce rti fic at e? D oe s (N A M E ) ha ve a m ob ile ph on e? C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 C IR C LE L IN E N U M B E R O F A LL C H IL D R E N A G E 0 -5 C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 H as (N A M E )'s bi rth e ve r b ee n re gi st er ed w ith th e ci vi l au th or ity ? IF C O LU M N 7 IS 0 TO 5 H ow o ld is (N A M E )? W ha t i s (N A M E )'s cu rre nt m ar ita l st at us ? H as (N A M E ) ev er at te nd ed sc ho ol ? W ha t i s th e hi gh es t l ev el o f sc ho ol (N A M E ) ha s at te nd ed ? D id (N A M E ) at te nd sc ho ol a t an y tim e du rin g th e 20 14 sc ho ol ye ar ? D ur in g th is /th at sc ho ol y ea r (2 01 4) , w ha t l ev el an d cl as s [is /w as ] (N A M E ) at te nd in g? W ha t i s th e hi gh es t c la ss (N A M E ) co m pl et ed a t t ha t le ve l? 14 15 16 17 18 P le as e gi ve m e th e na m es o f th e pe rs on s w ho u su al ly li ve in yo ur h ou se ho ld a nd g ue st s of th e ho us eh ol d w ho s ta ye d he re la st n ig ht , s ta rti ng w ith th e he ad of th e ho us eh ol d. W ha t i s th e re la tio ns hi p of (N A M E ) t o th e he ad o f t he ho us eh ol d? Is (N A M E ) m al e or fe m al e? D oe s (N A M E ) us ua lly liv e he re ? D id (N A M E ) st ay h er e la st ni gh t? 8 9 10 11 12 13 TO H E A D O F S TA TU S H O U S E H O LD TR A TI O N 2 3 4 5 6 7 R E LA TI O N S H IP S E X R E S ID E N C E M A R IT A L H O U S E H O LD S C H E D U LE IF A G E 5 -2 4 Y E A R S IF A G E IF A G E E LI G IB IL IT Y A N T H R O P O M E T R Y 247Appendix E • IF A G E 1 5 IF A G E 5 Y E A R S IF A G E 8 O R 0- 4 13 O R O R O LD E R O R O LD E R O LD E R Y E A R S O LD E R LI N E U S U A L R E S ID E N TS A N D A G E E V E R A TT E N D E D C U R R E N T/ R E C E N T C U R R E N T B IR TH M O B IL E W O M EN C H IL D R EN W O M EN N O . V IS IT O R S S C H O O L S C H O O L A TT E N D A N C E W O R K R E G IS - P H O N E S TA TU S 1 IF 9 5 IF N O , P R O B E : O R M O R E , 1 = C U R R E N TL Y S E E C O D E S S E E C O D E S R E C O R D M A R R IE D B E LO W . B E LO W . '9 5' . 2 = D IV O R C E D / S E E C O D E S A FT E R L IS TI N G T H E IF L E S S S E P A R A TE D / B E LO W . N A M E S A N D R E C O R D IN G TH A N 1 D E S E R TE D / YE A R W ID O W E D FO R E A C H P E R S O N , A S K TH E N W R IT E 3 = N E V E R - 1 = H A S Q U E S TI O N S 2 A -2 C T O B E "0 " M A R R IE D C E R TI FI C A TE S U R E T H A T TH E L IS TI N G 2 = R E G IS TE R E D IS C O M P LE TE . S E E C O D E S 3 = N E IT H E R B E LO W . 8 = D O N 'T TH E N A S K A P P R O P R IA TE K N O W Q U E S TI O N S IN C O LU M N S 5- 18 F O R E A C H P E R S O N . 07 1 2 1 2 1 2 1 2 1 2 1 2 1 2 07 07 07 G O T O 1 3 G O T O 1 3 08 1 2 1 2 1 2 1 2 1 2 1 2 1 2 08 08 08 G O T O 1 3 G O T O 1 3 09 1 2 1 2 1 2 1 2 1 2 1 2 1 2 09 09 09 G O T O 1 3 G O T O 1 3 10 1 2 1 2 1 2 1 2 1 2 1 2 1 2 10 10 10 G O T O 1 3 G O T O 1 3 C O D E S F O R Q . 3 : R E LA T IO N S H IP T O H E A D O F H O U S E H O LD 01 = H E A D 08 = B R O TH E R O R S IS TE R LE V E L 02 = W IF E O R H U S B A N D 09 = O TH E R R E LA TI V E 1 = P R IM A R Y 00 = L E S S T H A N 1 Y E A R C O M P LE TE D 03 = S O N O R D A U G H TE R 10 = A D O P TE D /F O S TE R / 2 = S E C O N D A R Y (U S E '0 0' F O R Q . 1 0 O N LY . 04 = S O N -IN -L A W O R S TE P C H IL D 3 = H IG H E R TH IS C O D E IS N O T A LL O W E D D A U G H TE R -IN -L A W 11 = N O T R E LA TE D 6 = P R E -P R IM A R Y FO R Q . 1 2) 05 = G R A N D C H IL D 98 = D O N 'T K N O W 8 = D O N 'T K N O W 98 = D O N 'T K N O W 06 = P A R E N T 07 = P A R E N T- IN -L A W TH E R E LA TI O N S H IP A N D S E X C O D E S F O R Q s. 1 0 A N D 1 2: E D U C A T IO N C LA S S H as (N A M E ) ev er at te nd ed sc ho ol ? Is (N A M E ) cu rre nt ly w or ki ng ? D oe s (N A M E ) ha ve a b irt h ce rti fic at e? D oe s (N A M E ) ha ve a m ob ile ph on e? C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 C IR C LE L IN E N U M B E R O F A LL C H IL D R E N A G E 0 -5 C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 H as (N A M E )'s bi rth e ve r b ee n re gi st er ed w ith th e ci vi l au th or ity ? W ha t i s th e hi gh es t c la ss (N A M E ) co m pl et ed a t t ha t le ve l? IF C O LU M N 7 IS 0 TO 5 W ha t i s th e hi gh es t l ev el o f sc ho ol (N A M E ) ha s at te nd ed ? D id (N A M E ) at te nd sc ho ol a t an y tim e du rin g th e 20 14 sc ho ol ye ar ? D ur in g th is /th at sc ho ol y ea r (2 01 4) , w ha t l ev el an d cl as s [is /w as ] (N A M E ) at te nd in g? 16 17 18 P le as e gi ve m e th e na m es o f th e pe rs on s w ho u su al ly li ve in yo ur h ou se ho ld a nd g ue st s of th e ho us eh ol d w ho s ta ye d he re la st n ig ht , s ta rti ng w ith th e he ad of th e ho us eh ol d. W ha t i s th e re la tio ns hi p of (N A M E ) t o th e he ad o f t he ho us eh ol d? Is (N A M E ) m al e or fe m al e? D oe s (N A M E ) us ua lly liv e he re ? D id (N A M E ) st ay h er e la st ni gh t? H ow o ld is (N A M E )? W ha t i s (N A M E )'s cu rre nt m ar ita l st at us ? 10 11 12 13 14 15 H O U S E H O LD TR A TI O N 2 3 4 5 6 7 8 9 R E LA TI O N S H IP S E X R E S ID E N C E M A R IT A L TO H E A D O F S TA TU S IF A G E 5 -2 4 Y E A R S IF A G E IF A G E E LI G IB IL IT Y IN T E R V IE W A N T H R O P O M E T R Y 248 • Appendix E IF A G E 1 5 IF A G E 5 Y E A R S IF A G E 8 O R O LD E R O R O LD E R O R O LD E R0 -4 Y E A R S 13 O R O LD E R LI N E U S U A L R E S ID E N TS A N D A G E E V E R A TT E N D E D C U R R E N T/ R E C E N T B IR TH M O B IL E W O M EN C H IL D R EN W O M EN N O . V IS IT O R S S C H O O L S C H O O L A TT E N D A N C E R E G IS - P H O N E 1 IF 9 5 IF N O , P R O B E : O R M O R E , 1 = C U R R E N TL Y S E E C O D E S S E E C O D E S R E C O R D M A R R IE D B E LO W . B E LO W . '9 5' . 2 = D IV O R C E D / S E E C O D E S A FT E R L IS TI N G T H E S E P A R A TE D / B E LO W . N A M E S A N D R E C O R D IN G D E S E R TE D / W ID O W E D FO R E A C H P E R S O N , A S K 3 = N E V E R - 1 = H A S Q U E S TI O N S 2 A -2 C T O B E M A R R IE D C E R TI FI C A TE S U R E T H A T TH E L IS TI N G 2 = R E G IS TE R E D IS C O M P LE TE . S E E C O D E S 3 = N E IT H E R B E LO W . 8 = D O N 'T TH E N A S K A P P R O P R IA TE K N O W Q U E S TI O N S IN C O LU M N S 5- 18 F O R E A C H P E R S O N . M F Y N Y N Y N L E V E L C LA S S Y N L E V E L C LA S S Y N 11 1 2 1 2 1 2 1 2 1 2 1 2 1 2 11 11 11 G O T O 1 3 G O T O 1 3 12 1 2 1 2 1 2 1 2 1 2 1 2 1 2 12 12 12 G O T O 1 3 G O T O 1 3 13 1 2 1 2 1 2 1 2 1 2 1 2 1 2 13 13 13 G O T O 1 3 G O T O 1 3 14 1 2 1 2 1 2 1 2 1 2 1 2 1 2 14 14 14 G O T O 1 3 G O T O 1 3 15 1 2 1 2 1 2 1 2 1 2 1 2 1 2 15 15 15 G O T O 1 3 G O T O 1 3 16 1 2 1 2 1 2 1 2 1 2 1 2 1 2 16 16 16 G O T O 1 3 G O T O 1 3 W ha t i s th e hi gh es t c la ss (N A M E ) co m pl et ed a t t ha t le ve l? IF C O LU M N 7 IS 0 TO 5 TH E R E LA TI O N S H IP A N D S E X IN Y E A R S Is (N A M E ) cu rre nt ly w or ki ng ? D oe s (N A M E ) ha ve a b irt h ce rti fic at e? D oe s (N A M E ) ha ve a m ob ile ph on e? C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 C IR C LE L IN E N U M B E R O F A LL C H IL D R E N A G E 0 -5 C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 H as (N A M E )'s bi rth e ve r b ee n re gi st er ed w ith th e ci vi l au th or ity ? H ow o ld is (N A M E )? W ha t i s (N A M E )'s cu rre nt m ar ita l st at us ? H as (N A M E ) ev er at te nd ed sc ho ol ? W ha t i s th e hi gh es t l ev el o f sc ho ol (N A M E ) ha s at te nd ed ? D id (N A M E ) at te nd sc ho ol a t an y tim e du rin g th e 20 14 sc ho ol ye ar ? D ur in g th is /th at sc ho ol y ea r (2 01 4) , w ha t l ev el an d cl as s [is /w as ] (N A M E ) at te nd in g? 14 15 16 17 18 P le as e gi ve m e th e na m es o f th e pe rs on s w ho u su al ly li ve in yo ur h ou se ho ld a nd g ue st s of th e ho us eh ol d w ho s ta ye d he re la st n ig ht , s ta rti ng w ith th e he ad of th e ho us eh ol d. W ha t i s th e re la tio ns hi p of (N A M E ) t o th e he ad o f t he ho us eh ol d? Is (N A M E ) m al e or fe m al e? D oe s (N A M E ) us ua lly liv e he re ? D id (N A M E ) st ay h er e la st ni gh t? 8 9 10 11 12 13 2 3 4 5 6 7 TO H E A D O F S TA TU S W O R K H O U S E H O LD S TA TU S TR A TI O N E LI G IB IL IT Y IN T E R V IE W A N T H R O P O M E T R Y R E LA TI O N S H IP S E X R E S ID E N C E M A R IT A L C U R R E N T IF A G E 5 -2 4 Y E A R S IF A G E IF A G E 249Appendix E • IF A G E 1 5 IF A G E 5 Y E A R S IF A G E 8 O R O LD E R O R O LD E R O R O LD E R0 -4 Y E A R S 13 O R O LD E R LI N E U S U A L R E S ID E N TS A N D A G E E V E R A TT E N D E D C U R R E N T/ R E C E N T B IR TH M O B IL E W O M EN C H IL D R EN W O M EN N O . V IS IT O R S S C H O O L S C H O O L A TT E N D A N C E R E G IS - P H O N E 1 IF 9 5 IF N O , P R O B E : O R M O R E , 1 = C U R R E N TL Y S E E C O D E S S E E C O D E S R E C O R D M A R R IE D B E LO W . B E LO W . '9 5' . 2 = D IV O R C E D / S E E C O D E S A FT E R L IS TI N G T H E S E P A R A TE D / B E LO W . N A M E S A N D R E C O R D IN G D E S E R TE D / W ID O W E D FO R E A C H P E R S O N , A S K 3 = N E V E R - 1 = H A S Q U E S TI O N S 2 A -2 C T O B E M A R R IE D C E R TI FI C A TE S U R E T H A T TH E L IS TI N G 2 = R E G IS TE R E D IS C O M P LE TE . S E E C O D E S 3 = N E IT H E R B E LO W . 8 = D O N 'T TH E N A S K A P P R O P R IA TE K N O W Q U E S TI O N S IN C O LU M N S 5- 18 F O R E A C H P E R S O N . 17 1 2 1 2 1 2 1 2 1 2 1 2 1 2 17 17 17 G O T O 1 3 G O T O 1 3 18 1 2 1 2 1 2 1 2 1 2 1 2 1 2 18 18 18 G O T O 1 3 G O T O 1 3 19 1 2 1 2 1 2 1 2 1 2 1 2 1 2 19 19 19 G O T O 1 3 G O T O 1 3 20 1 2 1 2 1 2 1 2 1 2 1 2 1 2 20 20 20 G O T O 1 3 G O T O 1 3 TI C K H E R E IF C O N TI N U A TI O N S H E E T U S E D C O D E S F O R Q . 3 : R E LA T IO N S H IP T O H E A D O F H O U S E H O LD 01 = H E A D 08 = B R O TH E R O R S IS TE R LE V E L 02 = W IF E O R H U S B A N D 09 = O TH E R R E LA TI V E 1 = P R IM A R Y 00 = L E S S T H A N 1 Y E A R C O M P LE TE D YE S N O 03 = S O N O R D A U G H TE R 10 = A D O P TE D /F O S TE R / 2 = S E C O N D A R Y (U S E '0 0' F O R Q . 1 0 O N LY . 04 = S O N -IN -L A W O R S TE P C H IL D 3 = H IG H E R TH IS C O D E IS N O T A LL O W E D D A U G H TE R -IN -L A W 11 = N O T R E LA TE D 6 = P R E -P R IM A R Y FO R Q . 1 2) YE S N O 05 = G R A N D C H IL D 98 = D O N 'T K N O W 8 = D O N 'T K N O W 98 = D O N 'T K N O W 06 = P A R E N T 07 = P A R E N T- IN -L A W YE S N O 2B ) A re th er e an y ot he r p eo pl e w ho m ay n ot b e m em be rs of y ou r f am ily , s uc h as d om es tic s er va nt s, lo dg er s, o r fri en ds w ho u su al ly li ve h er e? A D D T O TA B LE 2C ) A re th er e an y gu es ts o r t em po ra ry v is ito rs s ta yi ng he re , o r a ny on e el se w ho s ta ye d he re la st n ig ht , w ho h av e no t b ee n lis te d? A D D T O TA B LE W ha t i s th e hi gh es t c la ss (N A M E ) co m pl et ed a t t ha t le ve l? IF C O LU M N 7 IS 0 TO 5 TH E R E LA TI O N S H IP A N D S E X C O D E S F O R Q s. 1 0 A N D 1 2: E D U C A T IO N 2A ) J us t t o m ak e su re th at I ha ve a c om pl et e lis tin g: a re th er e an y ot he r p er so ns s uc h as s m al l c hi ld re n or in fa nt s th at w e ha ve n ot li st ed ? C LA S S A D D T O TA B LE Is (N A M E ) cu rre nt ly w or ki ng ? D oe s (N A M E ) ha ve a b irt h ce rti fic at e? D oe s (N A M E ) ha ve a m ob ile ph on e? C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 C IR C LE L IN E N U M B E R O F A LL C H IL D R E N A G E 0 -5 C IR C LE LI N E N U M B E R O F A LL E V E R - M A R R IE D W O M E N A G E 1 5- 49 IF C O LU M N 4 IS 2 A N D IF C O LU M N 7 IS 1 5- 49 , A N D IF C O LU M N 8 IS 1 O R 2 H as (N A M E )'s bi rth e ve r b ee n re gi st er ed w ith th e ci vi l au th or ity ? H ow o ld is (N A M E )? W ha t i s (N A M E )'s cu rre nt m ar ita l st at us ? H as (N A M E ) ev er at te nd ed sc ho ol ? W ha t i s th e hi gh es t l ev el o f sc ho ol (N A M E ) ha s at te nd ed ? D id (N A M E ) at te nd sc ho ol a t an y tim e du rin g th e 20 14 sc ho ol ye ar ? D ur in g th is /th at sc ho ol y ea r (2 01 4) , w ha t l ev el an d cl as s [is /w as ] (N A M E ) at te nd in g? 14 15 16 17 18 P le as e gi ve m e th e na m es o f th e pe rs on s w ho u su al ly li ve in yo ur h ou se ho ld a nd g ue st s of th e ho us eh ol d w ho s ta ye d he re la st n ig ht , s ta rti ng w ith th e he ad of th e ho us eh ol d. W ha t i s th e re la tio ns hi p of (N A M E ) t o th e he ad o f t he ho us eh ol d? Is (N A M E ) m al e or fe m al e? D oe s (N A M E ) us ua lly liv e he re ? D id (N A M E ) st ay h er e la st ni gh t? 8 9 10 11 12 13 2 3 4 5 6 7 TO H E A D O F S TA TU S W O R K H O U S E H O LD S TA TU S TR A TI O N IN T E R V IE W A N T H R O P O M E T R Y R E LA TI O N S H IP S E X R E S ID E N C E M A R IT A L C U R R E N T IF A G E 5 -2 4 Y E A R S IF A G E IF A G E E LI G IB IL IT Y 250 • Appendix E NO. QUESTIONS AND FILTERS SKIP 102 PIPED WATER PIPED INTO DWELLING . . . . . . . . . . . . 11 PIPED TO YARD/PLOT . . . . . . . . . . . . . . . 12 105 PUBLIC TAP/STANDPIPE . . . . . . . . . . . . 13 TUBE WELL OR BOREHOLE . . . . . . . . . . . . 21 DUG WELL PROTECTED WELL . . . . . . . . . . . . . . . . . 31 UNPROTECTED WELL . . . . . . . . . . . . . . . 32 WATER FROM SPRING PROTECTED SPRING . . . . . . . . . . . . . . . 41 UNPROTECTED SPRING . . . . . . . . . . . . 42 RAINWATER . . . . . . . . . . . . . . . . . . . . . . . . . . 51 105 TANKER TRUCK . . . . . . . . . . . . . . . . . . . . . 61 CART WITH SMALL TANK . . . . . . . . . . . . 71 SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/ IRRIGATION CHANNEL) . . . . . . . . . . . . 81 BOTTLED WATER . . . . . . . . . . . . . . . . . . . . . 91 OTHER 96 (SPECIFY) 103 IN OWN DWELLING . . . . . . . . . . . . . . . . . . . 1 IN OWN YARD/PLOT . . . . . . . . . . . . . . . . . 2 105 ELSEWHERE . . . . . . . . . . . . . . . . . . . . . . . . 3 104 MINUTES . . . . . . . . . . . . . . . . . DON'T KNOW . . . . . . . . . . . . . . . . . . . . . 998 104A YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 105 104B NO. OF HOUSEHOLDS IF LESS THAN 10 . . . . . . . . . . 10 OR MORE HOUSEHOLDS . . . . . . . . 95 DON'T KNOW . . . . . . . . . . . . . . . . . . . . . 98 105 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . 8 107 106 BOIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A ADD BLEACH/CHLORINE . . . . . . . . . . . . B STRAIN THROUGH A CLOTH . . . . . . . . . . C USE WATER FILTER (CERAMIC/ SAND/COMPOSITE/ETC.) . . . . . . . . . . . . D RECORD ALL MENTIONED. SOLAR DISINFECTION . . . . . . . . . . . . . . . . . E LET IT STAND AND SETTLE . . . . . . . . . . . . F OTHER X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . Z HOUSEHOLD CHARACTERISTICS Do you do anything to the water to make it safer to drink? How long does it take to go there, get water, and come CODING CATEGORIES Do you share this source with other households? 0 What do you usually do to make the water safer to drink? What is the main source of drinking water for members of your your household? Where is that water source located? How many households use this source of water? back? Anything else? 251Appendix E • NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 107 FLUSH OR POUR FLUSH TOILET FLUSH TO PIPED SEWER SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . 11 FLUSH TO SEPTIC TANK . . . . . . . . . . . . 12 FLUSH TO PIT LATRINE . . . . . . . . . . . . 13 FLUSH TO SOMEWHERE ELSE . . . . . . . . 14 FLUSH, DON'T KNOW WHERE . . . . . . . . 15 PIT LATRINE VENTILATED IMPROVED PIT LATRINE . . . . . . . . . . . . . . . . . . . . . 21 PIT LATRINE WITH SLAB . . . . . . . . . . . . 22 PIT LATRINE WITHOUT SLAB/ OPEN PIT . . . . . . . . . . . . . . . . . . . . . . . . 23 COMPOSTING TOILET . . . . . . . . . . . . . . . . . 31 BUCKET TOILET . . . . . . . . . . . . . . . . . . . . . 41 HANGING TOILET/HANGING LATRINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 NO FACILITY/BUSH/FIELD . . . . . . . . . . . . 61 110 OTHER 96 (SPECIFY) 108 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 110 109 NO. OF HOUSEHOLDS IF LESS THAN 10 . . . . . . . . . . 10 OR MORE HOUSEHOLDS . . . . . . . . 95 DON'T KNOW . . . . . . . . . . . . . . . . . . . . . 98 110 YES NO ELECTRICITY . . . . . . . . . . . . . . . 1 2 1 2 RADIO . . . . . . . . . . . . . . . . . . . . . 1 2 TELEVISION . . . . . . . . . . . . . . . 1 2 MOBILE TELEPHONE . . . . . . 1 2 NON-MOBILE TELEPHONE . . . . 1 2 REFRIGERATOR . . . . . . . . . . 1 2 An almirah/wardrobe? ALMIRAH/WARDROB . . . . . . . . . . 1 2 An electric fan? ELETRIC FAN . . . . . . . . . . 1 2 A DVD/VCD player? DVD/VCD PLAYER . . . . . . . . . . 1 2 A water pump? WATER PUMP . . . . . . . . . . 1 2 An IPS/generator? IPS/GENERATOR . . . . . . . . . . 1 2 An air conditioner? AIR CONDITIONER . . . . . . . . . . 1 2 A computer/laptop? COMPUTER/LAPTOP . . . . . . 1 2 111 ELECTRICITY . . . . . . . . . . . . . . . . . . . . . . . . . . 01 LPG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02 NATURAL GAS . . . . . . . . . . . . . . . . . . . . . . . . 03 BIOGAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 KEROSENE . . . . . . . . . . . . . . . . . . . . . . . . . . 05 COAL, LIGNITE . . . . . . . . . . . . . . . . . . . . . . . . 06 CHARCOAL . . . . . . . . . . . . . . . . . . . . . . . . . . 07 WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08 STRAW/SHRUBS/GRASS . . . . . . . . . . . . . . . 09 AGRICULTURAL CROP . . . . . . . . . . . . . . . . . 10 ANIMAL DUNG . . . . . . . . . . . . . . . . . . . . . . . . 11 NO FOOD COOKED IN HOUSEHOLD . . . . . . . . . . . . . . . . . . . . . 95 114 OTHER 96 (SPECIFY) A radio? 0 usually use? Do you share this toilet facility with other households? What kind of toilet facility do members of your household cooking? What type of fuel does your household mainly use for A refrigerator? A mobile telephone? A television? Solar Elecricity A non-mobile telephone? Does your household have: Electricity? How many households use this toilet facility? Solar Electricity 252 • Appendix E NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 112 IN THE HOUSE . . . . . . . . . . . . . . . . . . . . . . . . 1 IN A SEPARATE BUILDING . . . . . . . . . . . . 2 OUTDOORS . . . . . . . . . . . . . . . . . . . . . . . . . . 3 OTHER 6 (SPECIFY) 113 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 114 MAIN MATERIAL OF THE FLOOR. NATURAL FLOOR EARTH/SAND . . . . . . . . . . . . . . . . . . . . . 11 RECORD OBSERVATION. RUDIMENTARY FLOOR WOOD PLANKS . . . . . . . . . . . . . . . . . . . 21 PALM/BAMBOO . . . . . . . . . . . . . . . . . . . 22 FINISHED FLOOR PARQUET OR POLISHED WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . 31 CERAMIC TILES . . . . . . . . . . . . . . . . . . . 33 CEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . 34 CARPET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 OTHER 96 (SPECIFY) 115 MAIN MATERIAL OF THE ROOF. NATURAL ROOFING NO ROOF . . . . . . . . . . . . . . . . . . . . . . . . . . 11 RECORD OBSERVATION. THATCH/PALM LEAF . . . . . . . . . . . . . . . . . 12 RUDIMENTARY ROOFING PALM/BAMBOO . . . . . . . . . . . . . . . . . . . . . 22 WOOD PLANKS . . . . . . . . . . . . . . . . . . . . . 23 CARDBOARD . . . . . . . . . . . . . . . . . . . . . 24 FINISHED ROOFING TIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CERAMIC TILES . . . . . . . . . . . . . . . . . . . . . 34 CEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 ROOFING SHINGLES . . . . . . . . . . . . . . . . . 36 OTHER 96 (SPECIFY) 114 Do you have a separate room which is used as a kitchen? Is the cooking usually done in the house, in a separate building, or outdoors? 253Appendix E • NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 116 MAIN MATERIAL OF THE EXTERIOR WALLS. NATURAL WALLS NO WALLS . . . . . . . . . . . . . . . . . . . . . . . . . . 11 RECORD OBSERVATION. CANE/PALM/TRUNKS . . . . . . . . . . . . . . . 12 DIRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 RUDIMENTARY WALLS BAMBOO WITH MUD . . . . . . . . . . . . . . . . . 21 STONE WITH MUD . . . . . . . . . . . . . . . . . 22 PLYWOOD . . . . . . . . . . . . . . . . . . . . . . . . 24 CARDBOARD . . . . . . . . . . . . . . . . . . . . . 25 FINISHED WALLS TIN . . . . . . . . . . . . . . . . . . . . . . . . . . 31 CEMENT . . . . . . . . . . 32 STONE WITH LIME/CEMENT . . . . . . . . . . 33 BRICKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 WOOD PLANKS/SHINGLES . . . . . . . . . . 36 OTHER 96 (SPECIFY) 117 ROOMS . . . . . . . . . . . . . . . . . . . . . . . . 118 YES NO CAR/TRUCK/MICROBUS 1 2 An autobike/tempo/CNG? AUTOBIKE/TEMPO/CNG . . . . . . . . . . . 1 2 RICKSHAW/V 1 2 BICYCLE . . . . . . . . . . . . . . . . . . . 1 2 MOTORCYCLE/SCOOTER . . . . 1 2 121 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 122A 122 IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'. BUFFALOES MILK COWS/BULLS OTHER FARM ANIMALS A car/truck/microbus? Other farm animals? . . . . . . . . . . . . . . . . . A rickshaw/van? Does this household own any livestock, herds, other farm animals, or poultry? A bicycle? A motorcycle or motor scooter? Does any member of this household own: Buffaloes? GOAT/SHEEPGoats or sheep? Cows? How many rooms in this household are used for sleeping? How many of the following animals does this household own? CHICKENS/DUCKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chickens or ducks? 254 • Appendix E NO. QUESTIONS AND FILTERS SKIPCODING CATEGORIES 122A Does your household own any homestead? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 IF 'NO' PROBE: NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Does your household own homestead in any other places? 122B Does your household own any land (other than the YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 homestead land)? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 123 122C How much land does your household own (other than the ACRES DECIMALS homestead land)? AMOUNT AREA . SPECIFY UNIT 95 OR MORE ACRES IF 95 OR MORE CIRCLE '9995' DON'T KNOW 123 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 137 OBSERVED . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NOT OBSERVED, NOT IN DWELLING/YARD/PLOT . . . . . . 2 NOT OBSERVED, NO PERMISSION TO SEE . . . . . . . . . . . . 3 NOT OBSERVED, OTHER REASON . . . . . . 4 (SKIP TO 201) 138 OBSERVATION ONLY: WATER IS AVAILABLE . . . . . . . . . . . . . . . 1 OBSERVE PRESENCE OF WATER AT THE WATER IS NOT AVAILABLE . . . . . . . . . . . . 2 PLACE FOR HANDWASHING. 139 OBSERVATION ONLY: SOAP (BAR, LIQUID, PASTE) . . . . . . . . . . . . A . . . . B OBSERVE PRESENCE OF SOAP, DETERGENT, OR ASH, MUD, SAND . . . . . . . . . . . . . . . . . . . . . C OTHER CLEANSING AGENT. NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D 140 OBSERVATION ONLY: 1 OPEN SPACE, NOT SHARED 2 OBSERVE TYPE OF PLACE FOR HAND WASHING OPEN SPACE, SHARED 3. . . . . . . . . . . . COVERED SPACE (INSIDE DWELLING) 9998 . . . . . . . . . . . . . . . Does any member of this household have a bank account? DETERGENT (BAR, LIQUID, POWDER) 9995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Please show me where members of your household most often wash their hands. 255Appendix E • WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5 CLUSTER NUMBER HOUSEHOLD NUMBER MEASURER CODE 201 CHECK COLUMN 17 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). CHILD 1 CHILD 2 CHILD 3 202 LINE NUMBER FROM COLUMN 17 LINE LINE LINE NUMBER . . . . . . NUMBER . . . . . . NUMBER . . . . . . NAME FROM COLUMN 2 NAME NAME NAME 203 IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH DAY . . . . . . . . . . . DAY . . . . . . . . . . . DAY . . . . . . . . . . . FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT MONTH . . . . . . MONTH . . . . . . MONTH . . . . . . INTERVIEWED, ASK: YEAR YEAR YEAR 204 CHECK 203: YES . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . 1 CHILD BORN IN JANUARY NO . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . 2 2009 OR LATER? (GO TO 203 FOR NEXT (GO TO 203 FOR NEXT (GO TO 203 FOR NEXT CHILD OR, IF NO CHILD OR, IF NO CHILD OR, IF NO MORE CHILDREN, MORE CHILDREN, MORE CHILDREN, GO TO 214) GO TO 214) GO TO 214) 205 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 206 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 207 MEASURED LYING DOWN OR LYING DOWN . . . . . . . . 1 LYING DOWN . . . . . . . . 1 LYING DOWN . . . . . . . . 1 STANDING UP? STANDING UP . . . . . . . . 2 STANDING UP . . . . . . . . 2 STANDING UP . . . . . . . . 2 NOT MEASURED . . . . . . 3 NOT MEASURED . . . . . . 3 NOT MEASURED . . . . . . 3 213 GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214. What is (NAME)'s birth date? 256 • Appendix E WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5 CLUSTER NUMBER HOUSEHOLD NUMBER MEASURER CODE 201 CHECK COLUMN 17 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). CHILD 4 CHILD 5 CHILD 6 202 LINE NUMBER FROM COLUMN 17 LINE LINE LINE NUMBER . . . . . . NUMBER . . . . . . NUMBER . . . . . . NAME FROM COLUMN 2 NAME NAME NAME 203 IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH DAY . . . . . . . . . . . DAY . . . . . . . . . . . DAY . . . . . . . . . . . FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT MONTH . . . . . . MONTH . . . . . . MONTH . . . . . . INTERVIEWED, ASK: YEAR YEAR YEAR 204 CHECK 203: YES . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . . 1 CHILD BORN IN JANUARY NO . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . . 2 2009 OR LATER? (GO TO 203 FOR NEXT (GO TO 203 FOR NEXT (GO TO 203 FOR NEXT CHILD OR, IF NO CHILD OR, IF NO CHILD OR, IF NO MORE CHILDREN, MORE CHILDREN, MORE CHILDREN, GO TO 214) GO TO 214) GO TO 214) 205 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 206 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 NOT PRESENT . . . . 9994 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 REFUSED . . . . . . . . 9995 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . 9996 207 MEASURED LYING DOWN OR LYING DOWN . . . . . . . . 1 LYING DOWN . . . . . . . . 1 LYING DOWN . . . . . . . . 1 STANDING UP? STANDING UP . . . . . . . . 2 STANDING UP . . . . . . . . 2 STANDING UP . . . . . . . . 2 NOT MEASURED . . . . . . 3 NOT MEASURED . . . . . . 3 NOT MEASURED . . . . . . 3 213 GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214. What is (NAME)'s birth date? 257Appendix E • WEIGHT AND HEIGHT MEASUREMENT FOR EVER-MARRIED WOMEN AGE 15- 49 CLUSTER NUMBER HOUSEHOLD NUMBER MEASURER CODE 214 CHECK COLUMN 18 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGIBLE EVER-MARRIED WOMEN IN 215. IF THERE ARE MORE THAN THREE EVER MARRIED WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). WOMAN 1 WOMAN 2 WOMAN 3 215 LINE NUMBER LINE LINE LINE FROM COLUMN 18 NUMBER . . . . . . . . . . . . . NUMBER . . . . . . . . . . . . . NUMBER . . . . . . . . . . . . . NAME FROM COLUMN 2 NAME NAME NAME 216 WEIGHT IN KILOGRAMS KG. . KG. . KG. . NOT PRESENT . . . . . . . . . . . 99994 NOT PRESENT . . . . . . . . . . . 99994 NOT PRESENT . . . . . . . . . . . 99994 REFUSED . . . . . . . . . . . . . . . 99995 REFUSED . . . . . . . . . . . . . . . 99995 REFUSED . . . . . . . . . . . . . . . 99995 OTHER . . . . . . . . . . . . . . . . . . 99996 OTHER . . . . . . . . . . . . . . . . . . 99996 OTHER . . . . . . . . . . . . . . . . . . 99996 217 HEIGHT IN CENTIMETERS CM. . CM. . CM. . NOT PRESENT . . . . . . . . . . . . . 9994 NOT PRESENT . . . . . . . . . . . . . 9994 NOT PRESENT . . . . . . . . . . . . . 9994 REFUSED . . . . . . . . . . . . . . . . . . 9995 REFUSED . . . . . . . . . . . . . . . . . . 9995 REFUSED . . . . . . . . . . . . . . . . . . 9995 OTHER . . . . . . . . . . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . . . . . . . . . . 9996 OTHER . . . . . . . . . . . . . . . . . . . . 9996 223 GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE: IF NO MORE EVER-MARRIED WOMEN AGE 15-49, END MEASUREMENT. 258 • Appendix E BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2014 WOMAN'S QUESTIONNAIRE IDENTIFICATION CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME OF THE HOUSEHOLD HEAD NAME AND LINE NUMBER OF ELIGIBLE WOMAN INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. CODE RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: 1 COMPLETED 4 REFUSED 2 NOT AT HOME 5 PARTLY COMPLETED 7 OTHER 3 POSTPONED 6 INCAPACITATED (SPECIFY) SUPERVISOR FIELD EDITOR NAME NAME DATE DATE 1 2 3 2 OFFICE KEYED BY EDITOR 0 1 4 259Appendix E • SECTION 1. RESPONDENT'S BACKGROUND INTRODUCTION AND CONSENT INFORMED CONSENT or you can stop he interview at any time. NAME OF INTERVIEWER: DATE: RESPONDENT AGREES TO BE INTERVIEWED . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . 2 END NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 RECORD THE TIME. HOUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 In what month and year were you born? MONTH . . . . . . . . . . . . . . . . . . DON'T KNOW MONTH . . . . . . . . . . . . 98 YEAR . . . . . . . . . . . . DON'T KNOW YEAR . . . . . . . . . . . . 9998 103 AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT. 103A Are you now married, separated, deserted, divorced, CURRENTLY MARRIED 1 widowed, or have you never been married? SEPARATED 2 DESERTED 3 DIVORCED 4 WIDOWED 5 NEVER MARRIED 6 END 104 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 108 104A What type of school have you last attended? SCHOOL . . . . . . . . . . . . . . . . . . . . . . . 1 MADRASHA . . . . . . . . . . . . . . . . . . . . 2 105 PRIMARY . . . . . . . . . . . . . . . . . . . . . . . 1 SECONDARY . . . . . . . . . . . . . . . . . . . . 2 HIGHER . . . . . . . . . . . . . . . . . . . . . . . . . 3 106 CLASS IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'. What is the highest level of school you attended: primary, secondary, or higher? What is the highest class you completed at that level? . . . . . . . . . . . . . . . . . . . . Do you have any questions? May I begin the interview now? How old were you at your last birthday? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Have you ever attended school/madrasha? your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question MINUTES Hello. My name is _______________________________________. I am working with NIPORT, the Ministry of Health and Family Welfare, and Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all Bangladesh. The information we collect will help the government to plan health services. Your household was selected for the The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions In case you need more information about the survey, you may contact with Mr. S. N Mitra, Executive Director, Mitra and Associates, 2/17 Iqbal Road, Block A, Mohammadpur, Dhaka 1207, Bangladesh. Telephone number are: 8118065,9115503, 01711278663. 260 • Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 107 CHECK 105: PRIMARY SECONDARY OR HIGHER 110 108 CANNOT READ AT ALL . . . . . . . . . . . . 1 ABLE TO READ ONLY PARTS OF SHOW CARD TO RESPONDENT. SENTENCE . . . . . . . . . . . . . . . . . . . . 2 ABLE TO READ WHOLE SENTENCE 3 IF RESPONDENT CANNOT READ WHOLE SENTENCE, NO CARD WITH REQUIRED LANGUAGE 4 (SPECIFY LANGUAGE) BLIND/VISUALLY IMPAIRED . . . . . . . 5 109 CHECK 108: CODE '2', '3' CODE '1' OR '5' OR '4' CIRCLED 111 CIRCLED 110 AT LEAST ONCE A WEEK . . . . . . . . . . 1 LESS THAN ONCE A WEEK . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . 3 111 AT LEAST ONCE A WEEK . . . . . . . . . . 1 LESS THAN ONCE A WEEK . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . 3 112 AT LEAST ONCE A WEEK . . . . . . . . . . 1 LESS THAN ONCE A WEEK . . . . . . . . 2 NOT AT ALL . . . . . . . . . . . . . . . . . . . . 3 113 ISLAM . . . . . . . . . . . . . . . . . . . . 1 HINDUISM . . . . . . . . . . . . . . . . . . . . 2 BUDDHISM . . . . . . . . . . . . . . . . . . . . 3 CHRISTIANITY 4 OTHER 6 (SPECIFY) 114 YES NO GRAMEEN BANK . . . . . . . . 1 2 BRAC 1 2 BRDB 1 2 ASHA 1 2 PROSHIKA 1 2 MOTHER'S CLUB . . . . . . . . 1 2 OTHER 1 2 (SPECIFY) Any other organization (such as micro credit)? Do you listen to the radio at least once a week, less than once a week or not at all? Do you watch television at least once a week, less than once a week or not at all? What is your religion? BRDB? ASHA? PROSHIKA? Mother's Club? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you read a newspaper or magazine at least once a week, less than once a week or not at all? . . . . . . . . . . . . . . . . . . Do you belong to any of the following organizations: Grameen Bank? BRAC? . . . . . . . . . . . . . . . . Now I would like you to read this sentence to me. PROBE: Can you read any part of the sentence to me? 261Appendix E • SECTION 2. REPRODUCTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 201 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 206 202 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 204 203 SONS AT HOME . . . . . . . . . . . DAUGHTERS AT HOME . . . . . IF NONE, RECORD '00'. 204 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 206 205 SONS ELSEWHERE . . . . . . . DAUGHTERS ELSEWHERE IF NONE, RECORD '00'. 206 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 IF NO, PROBE: NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 208 207 BOYS DEAD . . . . . . . . . . . . . GIRLS DEAD . . . . . . . . . . . . . IF NONE, RECORD '00'. 208 SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'. TOTAL BIRTHS . . . . . . . . . . . 209 CHECK 208: PROBE AND YES NO CORRECT 201-208 AS NECESSARY. 210 CHECK 208: ONE OR MORE NO BIRTHS BIRTHS 226 Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct? Now I would like to ask about all the births you have had during your life. Have you ever given birth? Do you have any sons or daughters to whom you have given birth who are now living with you? How many sons live with you? And how many daughters live with you? Do you have any sons or daughters to whom you have given birth who are alive but do not live with you? How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? Have you ever given birth to a boy or girl who was born alive but later died? Any baby who cried or showed signs of life but did not survive? How many boys have died? And how many girls have died? 262 • Appendix E 211 Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW). IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD: RECORD HOUSE- HOLD LINE NUMBER OF IF '1 YR', PROBE: PROBE: CHILD How many months old RECORD RECORD (RECORD '00' was (NAME)? NAME. AGE IN IF CHILD NOT RECORD DAYS IF COM- LISTED IN LESS THAN 1 BIRTH PLETED HOUSE- MONTH; MONTHS IF HISTORY YEARS. HOLD). LESS THAN TWO NUMBER YEARS; OR YEARS. 01 MONTH HOUSEHOLD DAYS . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER YEAR MONTHS 2 GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 YEARS . . 3 220 (NEXT BIRTH) 02 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 03 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 04 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 05 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 06 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 07 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH YEARS AGE IN YEARS AGE IN YEARS AGE IN Is (NAME) still alive? YEARS 218 AGE IN YEARS AGE IN YEARS AGE IN YEARS AGE IN 219 220 221 How old was (NAME) at his/her last birthday? 217 Is (NAME) living with you? How old was (NAME) when he/she died? Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth? When is his/her birthday? 212 213 214 215 216 What name was given to your (first/next) baby? Is (NAME) a boy or a girl? Were any of these births twins? In what month and year was (NAME) born? W-5 263Appendix E • IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD: RECORD HOUSE- HOLD LINE NUMBER OF IF '1 YR', PROBE: PROBE: CHILD How many months old RECORD RECORD (RECORD '00' was (NAME)? NAME. AGE IN IF CHILD NOT RECORD DAYS IF COM- LISTED IN LESS THAN 1 BIRTH PLETED HOUSE- MONTH; MONTHS IF HISTORY YEARS. HOLD). LESS THAN TWO NUMBER YEARS; OR YEARS. 08 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 09 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 10 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 11 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 12 MONTH HOUSEHOLD DAYS . . . 1 YES . . . . 1 BOY 1 SING 1 YES . . 1 YES . . . 1 LINE NUMBER ADD YEAR MONTHS 2 BIRTH GIRL 2 MULT 2 NO . . . 2 NO . . . . 2 NO . . . . . 2 YEARS . . 3 NEXT 220 (GO TO 221) BIRTH 222 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 223 COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK: NUMBERS NUMBERS ARE ARE SAME DIFFERENT (PROBE AND RECONCILE) 224 CHECK 215: NUMBER OF BIRTHS . . . . . . . . . . . . . . . . ENTER THE NUMBER OF BIRTHS IN 2009 OR LATER. NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 226 YEARS Have you had any live births since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE. AGE IN YEARS AGE IN YEARS AGE IN YEARS YEARS 218 219 220 AGE IN AGE IN 221 How old was (NAME) at his/her last birthday? 217 Is (NAME) living with you? How old was (NAME) when he/she died? Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth? When is his/her birthday? 212 213 214 215 216 What name was given to your next baby? Is (NAME) a boy or a girl? Were any of these births twins? In what month and year was (NAME) born? Is (NAME) still alive? W-6264 • Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 225 FOR EACH BIRTH SINCE JANUARY 2009, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.) 226 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 UNSURE . . . . . . . . . . . . . . . . . . . . . . . . . 8 229A 227 How many months pregnant are you? MONTHS . . . . . . . . . . . . . . . . . . RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS. 228 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 229A NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 229 LATER . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO MORE . . . . . . . . . . . . . . . . . . . . . . . 2 229A YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 230 229B Have you ever used MR? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 230 229C In the last three years did you use MR? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 230 229D Where did you use it the last time? PUBLIC SECTOR . . . . . . . . . . . . . . 11 DISTRICT HOSPITAL . . . . . . . . . . . . 12 MCWC . . . . . . . . . . . . . . . . . . . . . . . 13 UPAZILLA HEALTH COMPLEX . . . 14 15 17 OTHER PUBLIC SECTOR 16 (SPECIFY) NGO SECTOR NGO STATIC CLINIC . . . . . . . . . . . . 21 OTHER NGO SECTOR 26 (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . 31 QUALIFIED DOCTOR’S CHAMBER . 32 NON-QUALIFIED DOCTOR’S CHAMBER . . . . . . . . . . 33 OTHER PRIVATE MEDICAL SECTOR 36 (SPECIFY) OTHER 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 C Are you pregnant now? C When you got pregnant, did you want to get pregnant at that time? Did you want to have a baby later on or did you not want any (more) children? HOSP./MEDICAL COLLEGE/SPE. MED. COL FAMILY WELFARE VISITOR (FWV) Have you ever heard of menstrual regulation (MR)? UH & FWC . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 230 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 238 231 MONTH . . . . . . . . . . . . . . . . . . YEAR . . . . . . . . . . . . 232 CHECK 231: LAST PREGNANCY LAST PREGNANCY ENDED IN ENDED BEFORE 238 JAN. 2009 OR LATER 233 MONTHS . . . . . . . . . . . . . . . . . . RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS. 234 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 236 235 ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2009 ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS. 236 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 238 237 MONTH . . . . . . . . . . . . . . . . . . YEAR . . . . . . . . . . . . 238 DAYS AGO . . . . . . . . . . . . 1 WEEKS AGO . . . . . . . . . . 2 MONTHS AGO . . . . . . . . . . 3 (DATE, IF GIVEN) YEARS AGO . . . . . . . . . . 4 IN MENOPAUSE/ HAS HAD HYSTERECTOMY . . . 994 BEFORE LAST BIRTH . . . . . . . . . . . . 995 NEVER MENSTRUATED . . . . . . . . . . 996 239 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 8 301A 240 JUST BEFORE HER PERIOD BEGINS . 1 DURING HER PERIOD 2 RIGHT AFTER HER PERIOD HAS ENDED . . . . . . . . . . . . . . . . . . 3 4 OTHER 6 (SPECIFY) 8 Have you ever had a pregnancy that miscarried, ended using menstrual regulation, was aborted, or ended in a stillbirth? When did the last such pregnancy end? How many months pregnant were you when the last such pregnancy ended? C From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant? Did you have any miscarriages, abortions or stillbirths that ended before 2009? When did the last such pregnancy that terminated before 2009 end? HALFWAY BETWEEN TWO PERIOD DON'T KNOW DON'T KNOW . . . . . . . . . . . . . . . . . Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods? Since January 2009, have you had any other pregnancies that did not result in a live birth? C When did your last menstrual period start? JAN. 2009 266 • Appendix E SECTION 3. CONTRACEPTION NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. 301A YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 301D 301B Have you ever used EC? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 301D 301C Did you use EC in last 12 months? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 301D Have you heard about LACTATIONAL AMENORRHEA METHOD YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (LAM)? Up to 6 months after child birth, a woman can use a NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 302 method that requires she breastfeeds frequently, day and night, and that her menstrual period has not returned. 301E Have you ever used LAM? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 302 CHECK 103A: CURRENTLY SEPARATED/DESERTED MARRIED DIVORCED/WIDOWED 311 302A CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 311 303 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 311 304 FEMALE STERILIZATION . . . . . . . . . . A MALE STERILIZATION . . . . . . . . . . . . B 307 CIRCLE ALL MENTIONED. IUD . . . . . . . . . . . . . . . . . . . . . . . . . . C INJECTABLES . . . . . . . . . . . . . . . . . . D 308A IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP IMPLANTS . . . . . . . . . . . . . . . . . . E INSTRUCTION FOR HIGHEST METHOD IN LIST. PILL . . . . . . . . . . . . . . . . . . . . . . F CONDOM . . . . . . . . . . . . . . . . . . . . . . G 306 H . . . I 308A WITHDRAWAL . . . . . . . . . . . . . . . . . . J OTHER X SPECIFY 305 PACKAGE/CHART SEEN . . . . . . . . . . 1 RECORD NAME OF BRAND IF PACKAGE SEEN. IF PACKAGE NOT SEEN SHOW THE BRAND CHART. BRAND NAME (SPECIFY) 306A Please tell me among these which brand of pills are you using? SHOW AND WRITE THE BRAND NAME OF THE PILLS. DON'T KNOW . . . . . . . . . . . . 8 Have you heard about EMERGENCY CONTRACEPTION PILLS (ECP) As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within three days to prevent pregnancy. Are you currently doing something or using any method to delay or avoid getting pregnant? Which method are you using? LACTATIONAL AMEN. METHOD SAFE PERIOD/PERIODIC ABST. May I see the brand name of the pills you are using? 267Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 306 PACKAGE/CHART SEEN . . . . . . . . . . 1 RECORD NAME OF BRAND IF PACKAGE SEEN. IF PACKAGE NOT SEEN SHOW THE BRAND CHART. BRAND NAME (SPECIFY) Please tell me among these which brand of condom are you using? DON'T KNOW . . . . . . . . . . . . 8 SHOW AND WRITE THE BRAND NAME OF CONDOMS. 306A Who obtained the (pills/condoms) the last time you got them? RESPONDENT 1 HUSBAND 2 SON/DAUGHTER 3 308A OTHER RELATIVE 4 OTHER 6 (SPECIFY) 307 PUBLIC SECTOR 11 PROBE TO IDENTIFY THE TYPE OF SOURCE. DISTRICT HOSPITAL . . . . . . . . . . . . 12 MCWC . . . . . . . . . . . . . . . . . . . . . . 13 UPAZILLA HEALTH COMPLEX . . . 14 15 OTHER PUBLIC SECTOR 16 (SPECIFY) IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE. NGO SECTOR NGO STATIC CLINIC . . . . . . . . . . . . 21 OTHER NGO (NAME OF PLACE) SECTOR 26 (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . 31 32 OTHER PRIVATE MEDICAL SECTOR 36 (SPECIFY) OTHER 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . 98 308 308A MONTH . . . . . . . . . . . . . . . . . . YEAR . . . . . . . . . . . . QUALIFIED DOCTOR’S CHAMBER In what month and year was the sterilization performed? Since what month and year have you been using (CURRENT METHOD) without stopping? UH & FWC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL May I see the brand name of the condom you are using? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In what facility did the sterilization take place? . . . . . . . . PROBE: For how long have you been using (CURRENT METHOD) now without stopping? 268 • Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 309 CHECK 308/308A, 215 AND 231: ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YES NO YEAR OF START OF USE OF CONTRACEPTION IN 308/308A GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION). 310 CHECK 308/308A: YEAR IS 2009 OR LATER YEAR IS 2008 OR EARLIER ENTER CODE FOR METHOD USED IN MONTH ENTER CODE FOR METHOD USED IN MONTH OF OF INTERVIEW IN THE CALENDAR INTERVIEW IN THE CALENDAR AND AND IN EACH MONTH BACK TO THE DATE EACH MONTH BACK TO JANUARY 2009. STARTED USING. THEN SKIP TO 311 USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2009. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS. IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH. ILLUSTRATIVE QUESTIONS: * * * IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1. ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT. ILLUSTRATIVE QUESTIONS: * 312 CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH NO METHOD USED ANY METHOD USED 314 313 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 324 Have you ever used anything or tried in any way to delay or avoid getting pregnant? I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years. C When was the last time you used a method? Which method was that? When did you start using that method? How long after the birth of (NAME)? C C 314 How long did you use the method then? Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason? IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER ‘0’ IN EACH SUCH MONTH IN COLUMN 1. 269Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 314 CHECK 304: NO CODE CIRCLED . . . . . . . . . . . . . . 00 324 FEMALE STERILIZATION . . . . . . . . . . 01 MALE STERILIZATION . . . . . . . . . . . . 02 325A CIRCLE METHOD CODE: IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 INJECTABLES . . . . . . . . . . . . . . . . . . . . 04 IF MORE THAN ONE METHOD CODE CIRCLED IN 304, IMPLANTS . . . . . . . . . . . . . . . . . . 05 CIRCLE CODE FOR HIGHEST METHOD IN LIST. PILL . . . . . . . . . . . . . . . . . . . . . . 06 CONDOM . . . . . . . . . . . . . . . . . . . . . . 07 11 SAFE PERIOD . . . . . . . . . . . . . . . . 12 WITHDRAWAL . . . . . . . . . . . . . . . . . . 13 324 OTHER MODERN METHOD . . . . . . . . 96 323 PUBLIC SECTOR 11 PROBE TO IDENTIFY THE TYPE OF SOURCE. DISTRICT HOSPITAL . . . . . . . . . . . . 12 MCWC . . . . . . . . . . . . . . . . . . . . . . 13 IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE UPAZILLA HEALTH COMPLEX . . . 14 SECTOR, WRITE THE NAME OF THE PLACE. 15 SAT. CLINIC/EPI OUTREACH . . . . . 17 COMMUNITY CLINIC . . . . . . . . . . . . 18 GOVT. FIELD WORKER (FWA) 19 OTHER PUBLIC (NAME OF PLACE) SECTOR 16 (SPECIFY) NGO SECTOR NGO STATIC CLINIC . . . . . . . . . . . . 21 NGO SATELLITE CLINIC . . . . . . . . . . 22 NGO DEPO HOLDER . . . . . . . . . . . . 23 NGO FIELD WORKER . . . . . . . . . . . . 24 325A OTHER NGO SECTOR 26 (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . 31 QUALIFIED DOCTOR’S CHAMBER . 32 NON-QUALIFIED DOCTOR’S CHAMBER. . . . . . . . . . 33 . . . . . . . . . . 34 OTHER PRIVATE MEDICAL SECTOR 36 (SPECIFY) OTHER SOURCE SHOP 41 FRIENDS/RELATIVES . . . . . . . . . . . . 42 OTHER 96 (SPECIFY) HOSP./MEDICAL COLLEGE/SPE. MED. COL LACTATIONAL AMEN. METHOD Where did you obtain (CURRENT METHOD) the last time? . . . . . . . . UH & FWC . . . . . . . . . . . . . . . . . . . . PHARMACY/DRUG STOR . . . . . . . . . . . . . . . . . . . . . . 270 • Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 324 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 325A 325 PUBLIC SECTOR . . . . . . . . A DISTRICT HOSPITAL . . . . . . . . . . . . B MCWC . . . . . . . . . . . . . . . . . . . . . . C PROBE TO IDENTIFY EACH TYPE OF SOURCE. UPAZILLA HEALTH COMPLEX . . . D E IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SAT. CLINIC/EPI OUTREACH . . . . . F SECTOR, WRITE THE NAME OF THE PLACE. COMMUNITY CLINIC . . . . . . . . . . . . G GOVT. FIELD WORKER (FWA) . . . H OTHER PUBLIC SECTOR I (SPECIFY) (NAME OF PLACE(S)) NGO SECTOR NGO STATIC CLINIC . . . . . . . . . . . . J NGO SATELLITE CLINIC . . . . . . . . . . K NGO DEPO HOLDER . . . . . . . . . . . . L NGO FIELD WORKER . . . . . . . . . . . . M OTHER NGO SECTOR N (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC . . . . . O QUALIFIED DOCTOR’S CHAMBER . P NON-QUALIFIED DOCTOR’S CHAMBER. . . . . . . . . . Q . . . . . . . . . . R OTHER PRIVATE MEDICAL SECTOR S (SPECIFY) OTHER SOURCE SHOP . . . . . . . . . . . . . . . . . . V FRIENDS/RELATIVES . . . . . . . . . . . . W OTHER X (SPECIFY) 325A In some places, there is a clinic set up for a day or part of a day YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 in someone's house or in a school. During the past three months, NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 was there any such clinic in this village or mohalla? DON'T KNOW 8 325D 325B Did you visit such temporary health clinic in the past three YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 months? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 325D HOSP./MEDICAL COLLEGE/SPE. MED. COL PHARMACY/DRUG STOR . . . . . . . . . . . . . . . . . . . . Do you know of a place where you can obtain a method of family planning? Where is that? Any other place? UH & FWC . . . . . . . . . . . . . . . . . . . . 271Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 325C What services did you receive? FAMILY PLANNING METHODS A IMMUNIZATIONS B CHILD GROWTH MONITORING C TETANUS INJECTION D ANTENATAL CARE E VITAMIN A FOR CHILDREN F OTHER _________________________ X (SPECIFY) DON'T KNOW Z 325D Are you aware of any community clinic in your area? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 326 325E Did you visit the community clinic in the past three months? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 326 325F What services did you receive? FAMILY PLANNING METHO A IMMUNIZATIONS B CHILD GROWTH MONITOR C TETANUS INJECTION D ANTENATAL CARE E VITAMIN A FOR CHILDRE F MEDICINE G OTHER _________________________ X (SPECIFY) DON'T KNOW Z 326 TALKED . . . . . . . . . . . . . . . . . . . . . . . . 1 GAVE FAMILY PLANNING METHOD . 2 TALKED AND GAVE METHOD . . . . . 3 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 401 326A Who visited you to talk about family planning or to give you family GOVT. FP WORKER . . . . . . . . . . . . . . A planning methods? GOVT. HEALTH WORKER . . . . . . . . . . B NGO WORKER . . . . . . . . . . . . . . . . . . C Name OTHER _______________________ X Anyone else? (SPECIFY) Name 326B During the last six months, how many times did a health worker or workers visit you to talk about family planning or to give you NUMBER OF TIMES family planning methods? DON'T KNOW . . . . . . . . . . . . . . . . . . 326C When was the last time you were visited by a fieldworker who talked to you about family planning? MONTHS AGO IF MORE THAN ONE WORKER VISITED: When did the last worker visit you? DON'T KNOW . . . . . . . . . . . . . . . . . . IF LESS THAN ONE MONTH AGO WRITE '0' In the last 6 months, were you visited by a fieldworker who talked to you about family planning or gave you a family planning method? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 . . . . . . . . . . . . . . . . . 8 272 • Appendix E SECTION 4. PREGNANCY AND POSTNATAL CARE 401 CHECK 215: ONE OR MORE NO BIRTHS BIRTHS IN 2011 IN 2011 OR LATER OR LATER 402 CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2011 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). 403 BIRTH HISTORY NUMBER LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH FROM 212 IN BIRTH HISTORY BIRTH BIRTH BIRTH HISTORY HISTORY HISTORY NUMBER NUMBER NUMBER 404 FROM 212 AND 216 NAME _______________________ NAME ____________________ NAME ____________________ LIVING DEAD LIVING DEAD LIVING DEAD 405 YES . . . . . . . . . . . . . . . . . . . 1 YES. . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 (SKIP TO 408) (SKIP TO 430) (SKIP TO 430) NO . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 406 LATER . . . . . . . . . . . . . . . . . 1 LATER. . . . . . . . . . . . . . 1 LATER . . . . . . . . . . . . 1 NO MORE . . . . . . . . . . . . 2 NO MORE . . . . . . . . . . 2 NO MORE . . . . . . . . . . 2 (SKIP TO 408) (SKIP TO 430) (SKIP TO 430) 407 MONTHS . 1 MONTHS MONTHS YEARS 2 YEARS YEARS DON'T KNOW . . . . 998 DON'T KNOW . . . . . 998 DON'T KNOW . . . . 998 408 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 (SKIP TO 415) 409 HEALTH PERSONNEL QUAL. DOCTOR . . . . . A NURSE/MIDWIFE/ PARAMEDIC . . . . . B PROBE TO IDENTIFY EACH TYPE FAMILY WELFARE OF PERSON AND RECORD ALL VISITOR . . . . . . . . . . C MENTIONED. COMMUNITY SKILLED BIRTH ATTENDANT . . . . . D MA/SACMO . . . . . . . . . . E IF `D' MENTIONED WRITE THE COMMUNITY HEALTH NAME OF THE CSBA. CARE PROVIDER F HEALTH ASST. . . . . . G NAME FAMILY WELFARE ASSISTANT . . . . . . . H NAME NGO WORKER . . . . . . . I OTHER PERSON TRAINED TBA . . . . . . . J UNTRAINED TBA . . . . . K UNQUALIFIED DOCTOR . . . . . . . . . . L OTHER X (SPECIFY) Anyone else? Whom did you see? 501 Now I would like to ask some questions about your children born in the last three years. (We will talk about each separately.) When you got pregnant with (NAME), did you want to get pregnant at that time? Did you want to have a baby later on, or did you not want any (more) children? Did you see anyone for antenatal care for this pregnancy? . . 2 . . 2 How much longer did you want to wait? . .1 . .1. . . . . . 273Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 410 HOME HOME . . . . . . . . . . . . . . A PUBLIC SECTOR . . . . . B PROBE TO IDENTIFY EACH TYPE DIST. HOSP. . . . . . . . C OF SOURCE. MCWC . . . . . . . . . . . . . . D UPAZILLA HEALTH IF UNABLE TO DETERMINE COMPLEX . . . . . . . E IF PUBLIC OR PRIVATE UH & FAMILY WELFARE SECTOR, WRITE THE NAME CENTRE . . . . . . . . . . F OF THE PLACE. SAT. CLINIC/EPI OUTREACH . . . . . G COMM. CLINIC . . . . . . . H (NAME OF PLACE(S)) OTHER PUBLIC SECTOR I (SPECIFY) NGO SECTOR NGO STATIC CLINIC . . . . . . . . . . . . J NGO SAT CLINIC . K OTHER L (SPECIFY) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . . . . . M QUAL.DOCTOR . . . . . . . N TRAD. DOCTOR . . . . . O PHARMACY . . . . . . . . . . P OTHER X (SPECIFY) 412 NUMBER OF TIMES DON'T KNOW . . . . . . . . . . 98 413 YES NO WEIGHT 1 2 BP 1 2 URINE 1 2 BLOOD 1 2 ULTRASON 1 2 DANGER SIGNS 1 2 414 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . 8 415 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 416 HEALTH ASST. A FAMILY WELFARE ASSISTANT B NGO WORKER C TRAINED TBA D UNTRAINED TBA E OTHER X (SPECIFY) . . . . . . . . . . Did you counsel about danger signs? Who visited? As part of your antenatal care during this pregnancy, were any of the following done at least once? Was your weight measured? visited you at your home to counsel Where did you receive antenatal care for this pregnancy? Anywhere else? How many times did you receive antenatal care during this pregnancy? During (any of) your antenatal care visit(s), were you told about signs of pregnancy complications? on healthy pregnancy or checkup? Was your blood pressure measured? . . . . . . . . . . . . . . . . . Did you have a blood test? Did you have an ultrasonography? When you got pregnant with (NAME), did any fieldworker/ community worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . Did you have a urine test? . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL (SKIP TO 430) . . . . . . . . . . . . . . . . . . . . 274 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 417 NO WEIGHT 1 2 BP 1 2 URINE 1 2 BLOOD 1 2 DANGER SIGNS 1 2 418 NUMBER OF TIMES DON'T KNOW . . . . . . . . . . 98 430 VERY LARGE . . . . . . . . . . 1 VERY LARGE . . . . . . . . 1 VERY LARGE . . . . . . . 1 LARGER THAN LARGER THAN LARGER THAN AVERAGE . . . . . . . . . . 2 AVERAGE . . . . . . . . 2 AVERAGE . . . . . . . 2 AVERAGE . . . . . . . . . . . . 3 AVERAGE . . . . . . . . . . 3 AVERAGE . . . . . . . . . . 3 SMALLER THAN SMALLER THAN SMALLER THAN AVERAGE . . . . . . . . . . 4 AVERAGE . . . . . . . . 4 AVERAGE . . . . . . . 4 VERY SMALL . . . . . . . . . . 5 VERY SMALL . . . . . . . . 5 VERY SMALL . . . . . . . 5 DON'T KNOW . . . . . . . . . . 8 DON'T KNOW . . . . . . . . 8 DON'T KNOW . . . . . . . 8 433 HEALTH PERSONNEL HEALTH PERSONNEL HEALTH PERSONNEL QUAL. DOCTOR . . . . . A QUAL. DOCTOR . . A QUAL. DOCTOR . . A NURSE/MIDWIFE/ NURSE/MIDWIFE/ NURSE/MIDWIFE/ PARAMEDIC . . . . . B PARAMEDIC . . B PARAMEDIC . . B FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE PROBE FOR THE TYPE(S) OF VISITOR . . . . . . . . . . C VISITOR . . . . . . . . C VISITOR . . . . . . . C PERSON(S) AND RECORD ALL COMMUNITY COMMUNITY COMMUNITY SKILLED BIRTH SKILLED BIRTH SKILLED BIRTH ATTENDANT . . . . . D ATTENDANT . D ATTENDANT . . D MENTIONED. MA/SACMO . . . . . . . . . . E MA/SACMO . . . . . . . . E MA/SACMO . . . . . . . E COMMUNITY HEALTH COMMUNITY HEALTH COMMUNITY HEALTH F F F HEALTH ASST. . . . . . G HEALTH ASST. . G HEALTH ASST. . . G IF RESPONDENT SAYS NO ONE FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE ASSISTED, PROBE TO ASSISTANT . . . . . . . H ASSISTANT . . . . . H ASSISTANT . . . . . G DETERMINE WHETHER ANY ADULTS WERE PRESENT AT NGO WORKER . . . . . . . I NGO WORKER . . . . . I NGO WORKER . . . . . I THE DELIVERY. OTHER PERSON OTHER PERSON OTHER PERSON IF `D' MENTIONED WRITE THE TRAINED TBA . . . . . . . J TRAINED TBA . . . . . J TRAINED TBA . . . . . J NAME OF THE CSBA. UNTRAINED TBA . . . . . K UNTRAINED TBA . . K UNTRAINED TBA . . K UNQUALIFIED UNQUALIFIED UNQUALIFIED NAME DOCTOR . . . . . . . . . . L DOCTOR . . . . . . . . L DOCTOR . . . . . . . L RELATIVES . . . . . . . . . . M RELATIVES . . . . . . . . M RELATIVES . . . . . . . M NAME NEIGHBORS/ NEIGHBORS/ NEIGHBORS/ FRIENDS . . . . . . . . . . N FRIENDS . . . . . . . . N FRIENDS . . . . . . . N OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) NO ONE ASSISTED . . . . . Y NO ONE ASSISTED . . Y NO ONE ASSISTED . . Y 434 HOME HOME HOME HOME . . . . . . . 11 HOME . . . . . 11 HOME . . . . . 11 PROBE TO IDENTIFY THE TYPE (SKIP TO 435i) (SKIP TO 448) (SKIP TO 448) OF SOURCE. PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR IF UNABLE TO DETERMINE . . . . . 21 21 21 IF PUBLIC OR PRIVATE DIST. HOSP. . . . . . . . 22 DIST. HOSP. . . . . . 22 DIST. HOSP. . . . . . 22 SECTOR, WRITE THE MCWC . . . . . . . . . . . . . . 23 MCWC . . . . . . . . . . . . 23 MCWC . . . . . . . . . . . . 23 UPAZILLA HEALTH UPAZILLA HEALTH UPAZILLA HEALTH COMPLEX . . . . . . . 24 COMPLEX . . . . . 24 COMPLEX . . . . . 24 UH & FAMILY WELFARE UH & FAMILY WELFARE UH & FAMILY WELFARE (NAME OF PLACE) CENTRE . . . . . . . . . . 25 CENTRE . . . . . . . . 25 CENTRE . . . . . . . 25 COM. CLINIC . . . . . . . 27 COM. CLINIC . . . . . 27 COM. CLINIC . . . . . 27 OTHER PUBLIC OOTHER PUBLIC OTHER PUBLIC SECTOR 26 SECTOR 26 SECTOR 26 (SPECIFY) (SPECIFY) (SPECIFY) NGO SECTOR NGO SECTOR NGO SECTOR NGO STATIC NGO STATIC NGO STATIC CLINIC . . . . . . . . . . . . 31 CLINIC . . . . . . . . . . 31 CLINIC . . . . . . . . . . 31 DELIVERY HUT . . . . . . . 36 DELIVERY HUT. . . . . 36 36 PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ CLINIC . . . . . . . . . . . . 41 CLINIC . . . . . . . . . . 41 CLINIC . . . . . . . . . . 41 OTHER 96 OTHER 96 OTHER 96 (SPECIFY) (SPECIFY) (SPECIFY) (SKIP TO 435i) (SKIP TO 448) (SKIP TO 448) Did s/he measure your weight? CARE PROVIDER YES When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small? CARE PROVIDER Did s/he do a blood test? Did s/he counsel about danger signs? CARE PROVIDER Who assisted with the delivery of (NAME)? Anyone else? HOSP./MEDICAL COLLEGE/SPE. MED. COL HOSP./MEDICAL COLLEGE/SPE. MED. COL DELIVERY HUT Where did you give birth to (NAME)? How many home visits did you receive during the last pregnancy? NAME OF THE PLACE. . . . . . . . . . . . . Did s/he measure your blood pressure? Did s/he do a urine test? HOSP./MEDICAL COLLEGE/SPE. MED. COL What did they do: . . . . . . . . . . . . . . . . . . 275Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 434A HOURS 1 DAYS 2 IF LESS THAN ONE DAY, RECORD HOURS. WEEKS 3 IF LESS THAN ONE WEEK, RECORD DAYS. DON'T KNOW . . . . 998 435 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 435A SUNDAY . . . . . . . . . . 01 MONDAY . . . . . . . . . . 02 TUESDAY . . . . . . . . . . 03 . . . . . . . . . . 04 THURSDAY . . . . . . . . . . 05 FRIDAY . . . . . . . . . . 06 SATURDAY . . . . . . . . . . 07 435B 06:01 AM TO 09:00 AM 01 09:01 AM TO 12:00 NOON 02 12:01 PM TO 02:00 PM 03 02:01 PM TO 04:00 PM 04 04:01 PM TO 06:00 PM 05 06:01 PM TO 09:00 PM 06 09:01 PM TO 12:00 AM 07 12:01 AM TO 03:00 AM 08 03:01 AM TO 06:00 AM 09 435C THE DAY OF DELIVERY 1 THE DAY BEFORE DELIVERY 2 2 - 7 DAYS BEFORE DELIVERY 3 8 - 30 DAYS BEFORE DELIVERY 4 30+ DAYS BEFORE DELIVERY 5 435D RESPONDENT 1 (SKIP TO 435F) FAMILY MEMBER . . . . . 2 DOCTOR 3 435E YES 1 NO 2 435F CONVENIENCE . . . . . . . A DO NOT WANT TO GO THROUGH LABOR PAIN B MAL PRESENTATION C PREMATURE BABY . . . . . D CORD PROLAPSED . . . . . E MULTIPLE BIRTHS . . . . . F FAILURE TO PROGRESS IN LABOR G PRE-ECLAMPSIA H DIABETES I PREVIOUS C/S J LESS PRESSURE ON BABY'S BRAIN K OTHER COMPLICATIONS . . . . . L OTHER X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Were you or your family told the reasons for having the operation? Who proposed first to have the section, you, a family member or WEDNESDAY (SKIP TO 435i) . . . . . . . . . . . . . . . . . . . . . . . . . . . . (SKIP TO 435G) . . . . . . . . . . . . . . . . . . . . What were the reasons for making the decision to have the operation? Any other reason? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DURING DELIVERY CIRCLE ALL MENTIONED. How many days before the birth delivered by caesarean section? . . . . . . . . . . At what time of day was the caesarean section or operation done? a doctor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . birth delivered by caesarean delivery was the decision to have caesarean section made? . . . What day of the week was the birth How long after (NAME) was delivered did you stay there? Was (NAME) delivered by caesarean section, that is, did they cut your belly open to take the baby out? . . . . . . 276 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 435G CHECK 212: CHILD NOT CHILD FIRST FIRST BIRTH BIRTH 435i 435H Did you have caesarean section YES . . . . . . . . . . . . . . . . . . . 1 before this birth? NO . . . . . . . . . . . . . . . . . . . 2 435i YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 435ii TO ASK WHAT TO DO A TO CONTACT B Any other reason? TRANSPORT C CIRCLE ALL MENTIONED. D OF DELIVERY E X (SPECIFY) 435iii Who did you call? HEALTH PERSONNEL/ QUAL. DOCTOR A Any other person? NURSE/MIDWIFE/ PARAMEDIC B FAMILY WELFARE CIRCLE ALL MENTIONED. VISITOR . . . . . . . . . . C COMMUNITY SKILLED BIRTH ATTENDANT D MA/SACMO . . . . . . . . . . E COMMUNITY HEALTH CARE PROVIDER F HEALTH ASST. . G FAMILY WELFARE ASSISTANT . . . . . . . H . . . . . . . I OTHER PERSON TRAINED TBA . . . . . . . J UNTRAINED TBA . . . . . K UNQUALIFIED DOCTOR . . . . . . . . . . L RELATIVES . . . . . . . . . . M FRIENDS . . . . . . . . . . N OTHER X (SPECIFY) 435iv Taka IF MORE THAN 999995, WRITE DON'T KNOW NOTHING 435v FAMILY FUND A BORROWED B MORTGAGE C GIFT FROM FAMILY D CIRCLE ALL MENTIONED. FRIEND E VOUCHER F G OTHER X (SPECIFY) . . . . . . . . . . . . NEIGHBORS/ 000000 . . . . . . . . . . TO ARRANGE FOR MONEY TO ARRANGE What was the reason the mobile phone was used? Any other source? (SKIP TO 435AA) Where did you get the money for (NAME'S) delivery? (SKIP TO 435iv) SERVICE PROVIDER TO ARRANGE Did you or any of your family member ever used a mobile phone to get health services or advice for you or (NAME) during pregnancy or delivery? 999995 . . . . . . . . . . . . . . OTHER . . . . . . . GIFT FROM NEIGHBOR/ How much did you pay in total for your last delivery? SOLD ASSETS/ . . . . . . . . . . . . . . . . . . . . NGO WORKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999998. . . . . . . . . . . . . INSURANCE 277Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 435AA CHECK 434: YES NO (CODE 11 (ANY CODE DELIVERED AT HOME? CIRCLED) 21 TO 96 CIRCLED) (SKIP TO 435AE) 435AB Now I would like to ask you some YES . . . . . . . . . . . . . . . . . . . 1 specific questions about what was done with (NAME) during and NO . . . . . . . . . . . . . . . . . . . 2 immediately following delivery. Was a Clean Delivery Kit used DON'T KNOW . . . . . . . . . . 8 during the delivery of (NAME)? SHOW THE DELIVERY KIT. 435AC What was used to cut the cord? BLADE FROM DELIVERY KIT . . . . . . . 1 BLADE FROM . . . . . 2 BAMBOO STRIPS . . . . . . . 3 4 OTHER 6 (SPECIFY) CORD WAS NOT CUT 7 (SKIP TO 435AE) DON'T KNOW . . . . . . . . . . 8 435AD Was the (INSTRUMENT IN 435AC) YES . . . . . . . . . . . . . . . . . . . 1 boiled before the cord was cut? NO . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . 8 435AE Was anything applied to the cord YES . . . . . . . . . . . . . . . . . . . 1 immediately after cutting and NO . . . . . . . . . . . . . . . . . . . 2 tying it? (SKIP TO 435AG) DON'T KNOW . . . . . . . . . . 8 435AF What was applied to the cord after ANTIBIOTICS it was cut and tied? (POWDER/OINTMT.) . . . . . A ANTISEPTIC (DETOL/SAVLON HEXISOL) . . . . . . . . . . . . B Anything else? SPIRIT/ALCOHOL . . . . . . . C MUSTARD OIL WITH GARLIC . . . . . . . . . . . . D . . . . . . . E TUMERIC JUICE/ POWDER . . . . . . . . . . . . F . . . . . . . G SHIDUR . . . . . . . . . . . . . . H BORIC POWDER . . . . . . . I GENTIAN VIOLET (BLUE INK) . . . . . . . . . . J TALCUM POWDER . . . . . K L OTHER X (SPECIFY) DON'T KNOW . . . . . . . . . . Z 435AG How long after delivery was (NAME) bathed for the first time? HOURS 1 DAYS 2 IF LESS THAN ONE DAY, RECORD IN HOURS WEEKS 3 IF LESS THAN ONE WEEK, . RECORD IN DAYS NOT BATHED . . . . . . . . . . DON'T KNOW . . . . . . . . . . 435AH How long after birth was 1 (NAME) dried ? 2 3 NOT DRIED . . . . . . . . . . 4 8 . . . . . . . . . 5-9 MINUTES . . . . . . . . . . CHLORHEXIDINE . . . . . . . . . . . . . . . . . . . 10+ MINUTES . . . . . . . . . . DON'T KNOW 995 998 SCISSORS GINGER JUICE CHEWED RICE OTHER SOURCE <5 MINUTES . . . . . . . . . . 278 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 435AI After the birth, was (NAME) put YES . . . . . . . . . . . . . . . . . . . 1 directly on the bare skin of your chest? NO . . . . . . . . . . . . . . . . . . . 2 Show the woman a picture of skin- DON'T KNOW . . . . . . . . . . 8 to-skin position. 435AJ CHECK 434: YES NO (CODE 11 (ANY CODE DELIVERED AT HOME? CIRCLED) 21 TO 96 CIRCLED) (SKIP TO 438) 436 I would like to talk to you about checks on your health after delivery, for example, someone asking you YES . . . . . . . . . . . . . . . . . . . 1 questions about your health or (SKIP TO 439) examining you. Did anyone check on your health while you were still in the NO . . . . . . . . . . . . . . . . . . . 2 facility? 437 Did anyone check on your health after YES . . . . . . . . . . . . . . . . . . . 1 you left the facility? (SKIP TO 439) NO . . . . . . . . . . . . . . . . . . . 2 (SKIP TO 442) 438 I would like to talk to you about checks YES . . . . . . . . . . . . . . . . . . . 1 on your health after delivery, for example, someone asking you questions about your health or NO . . . . . . . . . . . . . . . . . . . 2 examining you. Did anyone check on (SKIP TO 442) your health after you gave birth do (NAME)? 439 Who checked on your health at that HEALTH PERSONNEL time? QUAL. DOCTOR . . . . . 11 NURSE/MIDWIFE/ PROBE FOR MOST QUALIFIED PARAMEDIC . . . . . 12 PERSON. FAMILY WELFARE VISITOR . . . . . . . . . . 13 IF `14' IS CIRCLED, WRITE THE COMMUNITY NAME OF THE CSBA. SKILLED BIRTH ATTENDANT . . . . . 14 NAME MA/SACMO . . . . . . . . . . 15 COMMUNITY HEALTH CARE PROVIDER 16 HEALTH ASST. . 17 FAMILY WELFARE ASSISTANT . . . . . . . 18 NGO WORKER . . . . . . . 21 OTHER PERSON TRAINED TBA . . . . . . . 31 UNTRAINED TBA . . . . . 32 UNQUALIFIED DOCTOR . . . . . . . . . . 33 OTHER 96 (SPECIFY) 279Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 439A Where did this first check take HOME place? HOME 11 PUBLIC SECTOR . . . . . 21 DIST. HOSP. . . . . . . . 22 MCWC . . . . . . . . . . . . . . 23 UPAZILLA HEALTH COMPLEX . . . . . . . 24 UH & FAMILY WELFARE CENTRE . . . . . . . . . . 25 SAT. CLINIC/EPI OUTREACH . . . . . . . 27 COMM. CLINIC . . . . . . . 28 OTHER 26 (SPECIFY) NGO SECTOR NGO STATIC CLINIC . . . . . . . . . . . . 31 NGO SAT CLINIC . 32 OTHER 36 (SPECIFY) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . . . . . 41 QUALIFIED DOC. CHAMBER . . . . . . . 42 UNQUALIFIED DOC. CHAMBER . . . . . . . 43 PHARMACY 44 OTHER 96 (SPECIFY) 440 HOURS 1 DAYS 2 IF LESS THAN ONE DAY, RECORD HOURS. WEEKS 3 IF LESS THAN ONE WEEK, RECORD DAYS. DON'T KNOW 998 440A During the first two days after delivery, did any health care provider either do the following for you at home or at a health facility: YES NO Breast examination? BREAST EXAM. 1 2 Check vaginal discharge? VAG. DISCHARGE 1 2 Check temperature? TEMPERATURE 1 2 COUNSEL ON Counsel on danger signs? DANGER SIGNS 1 2 442 In the two months after (NAME) was YES . . . . . . . . . . . . . . . . . . . 1 born, did any health care provider or a traditional birth attendant check on NO . . . . . . . . . . . . . . . . . . . 2 his/her health? (SKIP TO 445B) DON'T KNOW . . . . . . . . . . 8 How long after delivery did the first check take place? HOSP./MEDICAL COLLEGE/SPE. MED. COL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 443 HRS AFTER BIRTH 1 DAYS AFTER BIRTH 2 IF LESS THAN ONE DAY, WKS AFTER RECORD HOURS. BIRTH 3 IF LESS THAN ONE WEEK, RECORD DAYS. DON'T KNOW . . . . 998 444 HEALTH PERSONNEL QUAL. DOCTOR . . . . . 11 NURSE/MIDWIFE/ PROBE FOR MOST QUALIFIED PARAMEDIC . . . . . . . 12 PERSON. FAMILY WELFARE VISITOR . . . . . . . . . . 13 COMMUNITY SKILLED BIRTH ATTENDANT . . . . . . . 14 MA/SACMO . . . . . . . . . . 15 COMMUNITY HEALTH CARE PROVIDER 16 HEALTH ASST. . . . . . . . 17 IF `14' MENTIONED WRITE THE FAMILY WELFARE NAME OF THE CSBA. ASSISTANT . . . . . . . 18 NGO WORKER . . . . . . . 21 OTHER PERSON NAME TRAINED TBA . . . . . . . 31 UNTRAINED TBA . . . . . 32 UNQUALIFIED DOCTOR . . . . . . . . . . 33 OTHER 96 (SPECIFY) 445 HOME YOUR HOME . . . . . . . 11 PUBLIC SECTOR . . . . . 21 PROBE TO IDENTIFY THE TYPE DIST. HOSP. . . . . . . . 22 OF SOURCE AND CIRCLE THE MCWC . . . . . . . . . . . . . . 23 APPROPRIATE CODE. UPAZILLA HEALTH COMPLEX . . . . . . . 24 UH & FAMILY WELFARE CENTRE . . . . . . . . . . 25 SAT. CLINIC/EPI OUTREACH . . . . . 27 IF UNABLE TO DETERMINE COMM. CLINIC . . . . . . . 28 IF PUBLIC OR PRIVATE OTHER 26 SECTOR, WRITE THE (SPECIFY) NAME OF THE PLACE. NGO SECTOR NGO STATIC (NAME OF PLACE) CLINIC . . . . . . . . . . . . 31 NGO SAT CLINIC 32 OTHER 36 (SPECIFY) PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . . . . . 41 QUALIFIED DOC. CHAMBER . . . . . . . 42 UNQUALIFIED DOC. CHAMBER . . . . . . . 43 PHARMACY . . . . . . . . . . 44 OTHER 96 (SPECIFY) Where did this first check of (NAME) take place? . . . . . . Who checked on (NAME)'s health at that time? . . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL How many hours, days or weeks after the birth of (NAME) did the first check take place? . . . . . . . . . . . . 281Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 445A During the first two days after delivery, did any health care provider do the following for (NAME) either at home or at a facility: YES NO Examine the cord? EXAMINE CORD . 1 2 Counsel on danger signs? COUNSEL ON DANGER SIGNS . 1 2 Assess temperature? TEMPERATURE … 1 2 Counsel you on breastfeeding COUNSEL BF 1 2 OBSERVE BF 1 2 Assess weight? WEIGHT 1 2 445B YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 445C Did you seek advice or treatment for YES . . . . . . . . . . . . . . . . . . . 1 the illness from any source? NO . . . . . . . . . . . . . . . . . . . 2 445D HOME A PUBLIC SECTOR . . . . . B Any other place? DISTRICT HOSP. C MCWC D E UH & FWC F EPI OUTREACH SITE G COMMUNITY CLINIC H FAMILY WELFARE ASSIST. . . . . . . . . . . I OTHER J (SPECIFY) NGO SECTOR NGO STATIC CLINIC L NGO SATELLITE CLINIC . . . . . . . . . . . . M NGO DEPO HOLDER . . . . . . . . . . N NGO FIELD WORKER . . . . . . . . . . O OTHER (SPECIFY) P PRIVATE MED. SECTOR PVT. HOSPITAL/ CLINIC . . . . . . . . . . . . Q QUALIFIED DOCTOR . . . . . . . . R UNQUALIFIED DOCTOR . . . . . . . S PHARMACY/ DRUG STORE . . . . . T OTHER PVT. U (SPECIFY) OTHER X (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UHC . . . . . . . . . . . . . . . . . SATELITE CLINIC/ . . . . . . . . . . . . . . . . . . . . . . . . Observe breastfeeding? Where did you seek advice or treatment? (SKIP TO 446) During the first month of (NAME)'s birth, did s(he) experience any illness? (SKIP TO 446) . . . . . . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL . . . . . . . . . . . . . 282 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 445E Who provided the care? HEALTH PROFESSIONAL/ WORKER QUALIFIED DOCTOR A NURSE/MIDWIFE/ PARAMEDIC B FAMILY WELFARE VISITOR C CSBA D MA/SACMO E COMMUNITY HEALTH CARE PROVIDER F HEALTH ASSISTANT G FAMILY WELFARE ASSISTANT . . . . . . . H NGO WORKER I OTHER PROVIDER TRAINED TBA J UNTRAINED TBA . . . . . K UNQUALIFIED DOCTOR . . . . . . . . . . L RELATIVES M FRIENDS N OTHER X (SPECIFY) 446 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 SHOW COMMON TYPES OF DON'T KNOW . . . . . . . . . . 8 AMPULES/CAPSULES/SYRUPS. 447 YES . . . . . . . . . . . . . . . . . . . 1 (SKIP TO 449) NO . . . . . . . . . . . . . . . . . . . 2 (SKIP TO 450) 448 YES. . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 (SKIP TO 452) (SKIP TO 452) 449 MONTHS MONTHS. . . MONTHS . . . DON'T KNOW . . . . . . . . . . 98 DON'T KNOW . . . . . . . . 98 DON'T KNOW . . . . . . . 98 450 CHECK 226: NOT PREGNANT PREG- OR IS RESPONDENT PREGNANT? NANT UNSURE (SKIP TO 452) 451 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 (SKIP TO 453) 452 MONTHS MONTHS. . . MONTHS . . . DON'T KNOW . . . . . . . . . . 98 DON'T KNOW . . . . . . . . 98 DON'T KNOW . . . . . . . 98 453 YES . . . . . . . . . . . . . . . . . . . 1 YES. . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 (SKIP TO 455) NO . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 454 CHECK 404: LIVING DEAD IS CHILD LIVING? (SKIP TO 460) (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501) . . . . . . In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)? Has your menstrual period returned since the birth of (NAME)? Did your period return between the birth of (NAME) and your next pregnancy? NEIGHBORS/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For how many months after the birth of (NAME) did you not have a period? Have you had sexual intercourse since the birth of (NAME)? For how many months after the birth of (NAME) did you not have sexual intercourse? Did you ever breastfeed (NAME)? . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME _______________________ NAME ____________________ NAME ____________________ 455 IMMEDIATELY . . . . 000 IF LESS THAN 1 HOUR, RECORD ‘00' HOURS. IF LESS THAN 24 HOURS, HOURS 1 RECORD HOURS. OTHERWISE, RECORD DAYS. DAYS 2 456 YES . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 (SKIP TO 458) 457 MILK (OTHER THAN BREAST MILK ) A PLAIN WATER . . . . . . . B SUGAR OR GLU- RECORD ALL LIQUIDS COSE WATER . . . . . . . C MENTIONED. GRIPE WATER . . . . . . . D SUGAR-SALT-WATER SOLUTION . . . . . . . . . . E FRUIT JUICE . . . . . . . . . . F INFANT FORMULA G TEA/INFUSIONS . . . . . . . H COFFEE . . . . . . . . . . . . . . I HONEY . . . . . . . . . . . . . . J OTHER X (SPECIFY) 458 CHECK 404: LIVING DEAD LIVING DEAD LIVING DEAD IS CHILD LIVING? (GO BACK TO (GO BACK TO (GO BACK TO 405 IN NEXT 405 IN NEXT 405 IN NEXT-TO-LAST COLUMN; OR, COLUMN; OR, COLUMN OF NEW IF NO MORE IF NO MORE QUESTIONNAIRE; BIRTHS, GO BIRTHS, GO OR, IF NO MORE TO 501) TO 501) BIRTHS, GO TO 501) 459 YES . . . . . . . . . . . . . . . . . . . 1 (SKIP TO 460) NO . . . . . . . . . . . . . . . . . . . 2 459A For how many months did you breastfeed (NAME)? MONTHS DON'T KNOW 98 460 YES . . . . . . . . . . . . . . . . . . . 1 YES. . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . 8 DON'T KNOW . . . . . . . . 8 DON'T KNOW . . . . . . . 8 461 GO BACK TO 405 IN GO BACK TO 405 IN GO BACK TO 405 IN NEXT COLUMN; OR, IF NEXT COLUMN; OR, IF NEXT-TO-LAST NO MORE BIRTHS, GO NO MORE BIRTHS, GO COLUMN OF NEW TO 501. TO 501. QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 501. How long after birth did you first put (NAME) to the breast? Did (NAME) drink anything from a bottle with a nipple yesterday or last night? . . . . . . . . . . . . . . . . Are you still breastfeeding (NAME)? In the first three days after delivery, was (NAME) given anything to drink other than breast milk? Anything else? What was (NAME) given to drink? 284 • Appendix E SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION 501 ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). 502 LAST BIRTH NEXT-TO-LAST BIRTH BIRTH HISTORY BIRTH NUMBER FROM 212 BIRTH HISTORY BIRTH HISTORY BIRTH HISTORY IN BIRTH HISTORY NUMBER . . . . . . NUMBER . . . . . . NUMBER . . . . . 503 FROM 212 NAME NAME NAME AND 216 LIVING DEAD LIVING DEAD LIVING DEAD (GO TO 503 (GO TO 503 (GO TO 503 IN NEXT- IN NEXT COLUMN IN NEXT COLUMN TO-LAST COLUMN OF OR, IF NO MORE OR, IF NO MORE NEW QUESTIONNAIRE, BIRTHS, GO TO 557) BIRTHS, GO TO 557) OR IF NO MORE BIRTHS, GO TO 557) 504 1 YES, SEEN 1 YES, SEEN 1 (SKIP TO 506) (SKIP TO 506) (SKIP TO 506) 2 2 2 IF YES: (SKIP TO 509) (SKIP TO 509) (SKIP TO 509) 3 N 3 3 505 YES. . . . . . . . . . . . . . . 1 YES. . . . . . . . . . . . . . . 1 YES. . . . . . . . . . . . . . 1 (SKIP TO 509) (SKIP TO 509) (SKIP TO 509) NO . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 506 (1) COPY DATES FROM THE CARD. (2) WRITE ‘44' IN ‘DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED. 506A DAY MONTH YEAR DAY MONTH YEAR DAY MONTH YEAR DATE OF BIRTH BIRTH DAY MONTH YEAR DAY MONTH YEAR DAY MONTH YEAR 507 CHECK 506A: BCG TO VIT. A BCG TO VIT. A BCG TO VIT. A AT 15 MONTHS AT 15 MONTHS ALL RECORDED ALL RECORDED ALL RECORDED (GO TO 510I) (GO TO 510I) (GO TO 510I) Do you have a card where (NAME)'s vaccinations are written down? YES, SEEN . . . . . . . . . . . . . . . . . . . . . YES, NOT SEEN . . . . YES, NOT SEEN . . . . YES, NOT SEEN May I see it please? NO CARD . . . . . . . . . NO CARD . . . . . . . . Did you ever have a vaccination card for (NAME)? SECOND-FROM-LAST BCG BCG BCG POLIO 0 (POLIO GIVEN AT BIRTH) P0 P0 PENTA 1 PT1 PT1 PENTA 2 PT2 PT2 PENTA 3 PT3 PT3 POLIO 1 P1 P1 POLIO 2 P2 P2 POLIO 3 P3 P3 POLIO 4 P4 P4 MR AT 9 MONTHS MR9 MR9 MEASLES AT 9 MONTHS M9 M9 SECOND-FROM-LAST LAST BIRTH NEXT-TO-LAST BIRTH MEASLES MEASLES . . . NO CARD . . . . . . . . MEASLES MEASLES AT 15 MONTHS M15 M15 AT 15 MONTHS 285Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 508 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 (PROBE FOR (PROBE FOR (PROBE FOR VACCINATIONS AND VACCINATIONS AND VACCINATIONS AND WRITE ‘66' IN THE WRITE ‘66' IN THE WRITE ‘66' IN THE CORRESPONDING CORRESPONDING CORRESPONDING DAY COLUMN IN 506A) DAY COLUMN IN 506A) DAY COLUMN IN 506A) RECORD 'YES' ONLY IF THE (SKIP TO 510I) (SKIP TO 510I) (SKIP TO 510I) RESPONDENT MENTIONS AT LEAST ONE OF THE NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 VACCINATIONS IN 506 THAT (SKIP TO 510I) (SKIP TO 510I) (SKIP TO 510I) ARE NOT RECORDED AS DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 HAVING BEEN GIVEN. 509 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 510I) (SKIP TO 510I) (SKIP TO 510I) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 510 510A YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 510B YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 510E) (SKIP TO 510E) (SKIP TO 510E) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 510C FIRST 2 WEEKS . . . 1 FIRST 2 WEEKS . . . 1 FIRST 2 WEEKS . . . 1 LATER. . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 LATER . . . . . . . . . . . . 2 510D NUMBER NUMBER NUMBER OF TIMES . . . . . OF TIMES . . . . . OF TIMES . . . . . 510E YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 510G) (SKIP TO 510G) (SKIP TO 510G) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 510F NUMBER NUMBER NUMBER OF TIMES . . . . . OF TIMES . . . . . OF TIMES . . . . . 510G YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 510H YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 510I Did (NAME) receive any polio YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 vaccine from the National NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 Immunization Days (NID)? (SKIP TO 511) (SKIP TO 511) (SKIP TO 511) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 Has (NAME) had any vaccinations that are not recorded on this card, including vaccinations given in a national immunization day campaign? Please tell me if (NAME) had any of the following vaccinations: Polio vaccine, that is, drops in the mouth? Was the first polio vaccine given in the first two weeks after birth or later? How many times was the polio vaccine given? Did (NAME) ever have any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign? A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar? A measles injection or a measles and rubella (MR) injection - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles and or rubella? How many times was the Pentavalent vaccination given? A Pentavalent vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops? A measles injection, that is, a shot in the arm at the age of 15 months or older - to prevent him/her from getting measles? 286 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 510J At which national immunization CAMPAIGN 1 CAMPAIGN 1 CAMPAIGN 1 day campaigns did (NAME) (POLIO/JAN 2011. A (POLIO/JAN 2011 . A (POLIO/JAN 2011. A receive vaccinations? CAMPAIGN 2 CAMPAIGN 2 CAMPAIGN 2 (POLIO/FEB 2011. B (POLIO/FEB 2011 . B (POLIO/FEB 2011. B RECORD ALL CAMPAIGNS CAMPAIGN 3 CAMPAIGN 3 CAMPAIGN 3 MENTIONED. (POLIO/JAN 2012. C (POLIO/JAN 2012 . C (POLIO/JAN 2012. C CAMPAIGN 4 CAMPAIGN 4 CAMPAIGN 4 (POLIO/FEB 2012. D (POLIO/FEB 2012 . D (POLIO/FEB 2012. D CAMPAIGN 5 CAMPAIGN 5 CAMPAIGN 5 (POLIO/DEC 201 . E (POLIO/DEC 2013. E (POLIO/DEC 2013. E CAMPAIGN 6 CAMPAIGN 6 CAMPAIGN 6 (MR/JAN 2014 F (MR/JAN 2014) F (MR/JAN 2014) F CAMPAIGN 7 CAMPAIGN 7 CAMPAIGN 7 (MR/FEB 2014 G (MR/FEB 2014) G (MR/FEB 2014) G 511 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS. DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 512 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 SHOW COMMON TYPES OF DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 PILLS/SPRINKLES/SYRUPS. 513 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 514 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 525) (SKIP TO 525) (SKIP TO 525) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 515 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 516 MUCH LESS 1 MUCH LESS 1 MUCH LESS 1 . 2 . 2 . 2 . 3 . 3 . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 5 5 5 about the same amount, or more DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 than usual to drink? 517 MUCH LESS 1 MUCH LESS 1 MUCH LESS 1 . 2 . 2 . 2 . 3 . 3 . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 STOPPED FOOD 5 STOPPED FOOD 5 STOPPED FOOD 5 6 6 6 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 518 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 522) (SKIP TO 522) (SKIP TO 522) NOTHING TO DRINK NOTHING TO DRINK NEVER GAVE FOOD . . . . . . . . . . . . . . . . . . NOTHING TO DRINK SOMEWHAT LESS ABOUT THE SAME ABOUT THE SAME ABOUT THE SAME Did you seek advice or treatment for the diarrhea from any source? IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less? . . . NEVER GAVE FOOD . . . NEVER GAVE FOOD Was there any blood in the stools? Was (NAME) given any drug for intestinal worms in the last six months? Within the last six months, was (NAME) given a vitamin A dose like In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)? Has (NAME) had diarrhea in the last 2 weeks? (PLEASE USE THE LOCAL NAME) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). . . . . . . . . . . . . . . . . . . . . . SOMEWHAT LESS SOMEWHAT LESS SOMEWHAT LESS ABOUT THE SAME ABOUT THE SAME ABOUT THE SAME Was he/she given less than usual t IF LESS, PROBE: Was he/she given much less than usual to drink or . . . . . . . . . . . . . . . . . . . . . When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat? SOMEWHAT LESS SOMEWHAT LESS . . . 287Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 519 PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR A A A DISTRICT HOSP. B DISTRICT HOSP. B DISTRICT HOSP. B MCWC C MCWC C MCWC C D D D UH & FWC E UH & FWC E UH & FWC E PROBE TO IDENTIFY EACH TYPE OF SOURCE. EPI OUTREACH EPI OUTREACH EPI OUTREACH SITE F SITE F SITE F IF UNABLE TO DETERMINE COMMUNITY COMMUNITY COMMUNITY IF PUBLIC OR PRIVATE CLINIC G CLINIC G CLINIC G SECTOR, WRITE THE NAME FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE OF THE PLACE. ASSISTANT H ASSISTANT H ASSISTANT H OTHER OTHER OTHER I I I (SPECIFY) (SPECIFY) (SPECIFY) NGO SECTOR NGO SECTOR NGO SECTOR NGO STATIC NGO STATIC NGO STATIC CLINIC J CLINIC J CLINIC J NGO SATELLITE NGO SATELLITE NGO SATELLITE CLINIC K CLINIC K CLINIC K NGO FIELD NGO FIELD NGO FIELD WORKER L WORKER L WORKER L OTHER OTHER OTHER M M M (SPECIFY) (SPECIFY) (SPECIFY) PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR (NAME OF PLACE(S)) PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ CLINIC . . . . . . . N CLINIC . . . . . . . N CLINIC . . . . . . . N QUALIFIED QUALIFIED QUALIFIED DOCTOR . . . O DOCTOR . . . O DOCTOR . . . O UNQUALIFIED UNQUALIFIED UNQUALIFIED DOCTOR P DOCTOR P DOCTOR P PHARMACY Q PHARMACY Q PHARMACY Q OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE SECTOR R SECTOR R SECTOR R (SPECIFY) (SPECIFY) (SPECIFY) OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 522 at any time since he/she started having YES NO DK YES NO DK YES NO DK the diarrhea: ORS PKT 1 2 8 ORS PKT 1 2 8 ORS PKT 1 2 8 LABAN GUR1 2 8 LABAN GUR 1 2 8 LABAN GUR 1 2 8 ZINC SYRU 1 2 8 ZINC SYRUP 1 2 8 ZINC SYRUP 1 2 8 ZINC TABLE1 2 8 ZINC TABLET1 2 8 ZINC TABLET1 2 8 . . . . . . . . . . . . . . . . . . . . . . . . . . Zinc tablets? Zinc syrup? Was he/she given any of the follow A fluid made from a special saline packet called ORSaline PACKET? c) d) Where did you seek advice or or treatment? b) a) . . . . . . . . . . . . . . . . . . . . . . . . . A homemade sugar-salt-water solution (laban gur)? Anywhere else? . . . . . . . . . . . . . . . . . SATELITE CLINIC/ . . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL UHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UHC . . . . . . . . . . . . . . . . . . . . . SATELITE CLINIC/ UHC . . . . . . . . . . . . . . SATELITE CLINIC/ . . . . . . . . . . . . . . . . . . . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL HOSP./MEDICAL COLLEGE/SPE. MED. COL 288 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 525 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 527 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 530) (SKIP TO 530) (SKIP TO 530) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 528 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 531) (SKIP TO 531) (SKIP TO 531) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 529 CHEST ONLY . . . 1 CHEST ONLY . . . 1 CHEST ONLY . . . 1 NOSE ONLY . . . . . 2 NOSE ONLY . . . . . 2 NOSE ONLY . . . . . 2 BOTH . . . . . . . . . . . . 3 BOTH . . . . . . . . . . . . 3 BOTH . . . . . . . . . . . . 3 OTHER 6 OTHER 6 OTHER 6 (SPECIFY) (SPECIFY) (SPECIFY) DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 (SKIP TO 531) (SKIP TO 531) (SKIP TO 531) 530 CHECK 525: YES NO OR DK YES NO OR DK YES NO OR DK HAD FEVER? (GO BACK TO (GO BACK TO (GO TO 503 503 IN NEXT 503 IN NEXT IN NEXT-TO-LAST COLUMN; OR, COLUMN; OR, COLUMN OF NEW IF NO MORE IF NO MORE QUESTIONNAIRE; OR, BIRTHS, GO BIRTHS, GO IF NO MORE BIRTHS, TO 557) TO 557) GO TO 557) 531 MUCH LESS 1 MUCH LESS 1 MUCH LESS 1 . 2 . 2 . 2 . 3 . 3 . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 5 5 5 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 532 MUCH LESS 1 MUCH LESS 1 MUCH LESS 1 . 2 . 2 . 2 . 3 . 3 . 3 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 MORE . . . . . . . . . . . . 4 STOPPED FOOD 5 STOPPED FOOD 5 STOPPED FOOD 5 6 6 6 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 533 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 537) (SKIP TO 537) (SKIP TO 537) NEVER GAVE FOOD . . . . . . . SOMEWHAT LESS ABOUT THE SAME SOMEWHAT LESS ABOUT THE SAME . . . NEVER GAVE FOOD Did you seek advice or treatment for the illness from any source? Has (NAME) had an illness with a cough at any time in the last 2 weeks? Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose? IF LESS, PROBE: Was he/she given much less than usual to eat or When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing? Has (NAME) been ill with a fever When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat? Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). at any time in the last 2 weeks? . . . . . . . . . . . . . . . . . . . . . Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS, PROBE: Was he/she given much less than usual to drink or . . . . . . . . . . . . . . . . . SOMEWHAT LESS ABOUT THE SAME NOTHING TO DRINK SOMEWHAT LESS . . . NEVER GAVE FOOD NOTHING TO DRINK NOTHING TO DRINK ABOUT THE SAME ABOUT THE SAME SOMEWHAT LESS SOMEWHAT LESS ABOUT THE SAME 289Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 536 SEQUENCE OF CARE SEQUENCE OF CARE SEQUENCE OF CARE FILL UP THE BOXES ACCORDING TO THE SEQUENCE OF CARE RECEIVED. HOME A HOME A HOME A PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR B B B DISTRICT HOSP. . C DISTRICT HOSP. . C DISTRICT HOSP. . C MCWC D MCWC D MCWC D E E E UH & FWC F UH & FWC F UH & FWC F EPI OUTREACH EPI OUTREACH EPI OUTREACH SITE G SITE G SITE G COMMUNITY COMMUNITY COMMUNITY CLINIC H CLINIC H CLINIC H FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE ASSIST. . . . . . I ASSIST. . . . . . I ASSIST. . . . . . I OTHER OTHER OTHER J J J (SPECIFY) (SPECIFY) (SPECIFY) NGO SECTOR NGO SECTOR NGO SECTOR NGO STATIC NGO STATIC NGO STATIC CLINIC K CLINIC K CLINIC K NGO SATELLITE NGO SATELLITE NGO SATELLITE CLINIC . . . . . . . L CLINIC . . . . . . . L CLINIC . . . . . . . L NGO DEPO NGO DEPO NGO DEPO HOLDER . . . . . M HOLDER . . . . . M HOLDER . . . . . M NGO FIELD NGO FIELD NGO FIELD WORKER . . . . . N WORKER . . . . . N WORKER . . . . . N OTHER OTHER OTHER (SPECIFY) O (SPECIFY) O (SPECIFY) O PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ CLINIC . . . . . . . Q CLINIC . . . . . . . Q CLINIC . . . . . . . Q QUALIFIED QUALIFIED QUALIFIED DOCTOR R DOCTOR R DOCTOR R UNQUALIFIED UNQUALIFIED UNQUALIFIED DOCTOR S DOCTOR S DOCTOR S PHARMACY/ PHARMACY/ PHARMACY/ DRUG STORE . T DRUG STORE . T DRUG STORE . T OTHER PVT. U OTHER PVT. U OTHER PVT. U (SPECIFY) (SPECIFY) (SPECIFY) OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 537 YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (GO BACK TO 503 (GO BACK TO 503 (GO TO 503 IN IN NEXT COLUMN; IN NEXT COLUMN; NEXT-TO-LAST OR, IF NO MORE OR, IF NO MORE COLUMN OF NEW BIRTHS, GO TO 557) BIRTHS, GO TO 557) QUESTIONNAIRE; DON'T KNOW . . . . . 8 DON'T KNOW . . . . . 8 OR, IF NO MORE BIRTHS, GO TO 557) DON'T KNOW . . . . . 8 At any time during the illness, did (NAME) take any drugs for the illness? 3 4 1 . . . . . . . 2 . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 UHC . . . . . . . SATELITE CLINIC/ 1 2 . . . . . . . . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Where did you first seek advice or treatment? . . . . . . . UHC . . . . . . . SATELITE CLINIC/ . . . . . . . . . . . . . . . . . . . . . . . . . . UHC . . . . . . . SATELITE CLINIC/ . . . . . . . . . . . 43 HOSP./MEDICAL COLLEGE/SPE. MED. COL HOSP./MEDICAL COLLEGE/SPE. MED. COL HOSP./MEDICAL COLLEGE/SPE. MED. COL 290 • Appendix E LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 538 ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS ANTIMALARIAL DRUGS SP/FANSIDAR . . . A SP/FANSIDAR . . . A SP/FANSIDAR . . . A CHLOROQUIN B CHLOROQUINE B CHLOROQUINE B PRIMAQUINE C PRIMAQUINE C PRIMAQUINE C QUININE . . . . . . . D QUININE . . . . . . . D QUININE . . . . . . . D COMBINATION COMBINATION COMBINATION WITH WITH WITH RECORD ALL MENTIONED. ARTEMISININ E ARTEMISININ E ARTEMISININ E OTHER ANTI- OTHER ANTI- OTHER ANTI- MALARIAL MALARIAL MALARIAL F F F (SPECIFY) (SPECIFY) (SPECIFY) ANTIBIOTIC DRUGS ANTIBIOTIC DRUGS ANTIBIOTIC DRUGS BETA LACTUM G BETA LACTUM G BETA LACTUM G MACROLIDES H MACROLIDES H MACROLIDES H QUINOLONE I QUINOLONE I QUINOLONE I CEPHALOS- CEPHALOS- CEPHALOS- PORIN J PORIN J PORIN J COTRIMOXA- COTRIMOXA- COTRIMOXA- ZOLE K ZOLE K ZOLE K GENTAMYCIN L GENTAMYCIN L GENTAMYCIN L METRONI- METRONI- METRONI- DAZOLE M DAZOLE M DAZOLE M OTHER DRUGS OTHER DRUGS OTHER DRUGS X X X DON'T KNOW . . . . . Z DON'T KNOW . . . . . Z DON'T KNOW . . . . . Z 539 Did anybody prescribe the drug? YES. . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . 2 (SKIP TO 552) (SKIP TO 552) (SKIP TO 552) 540 Who prescribed the drug? HEALTH PROFESSIONAL/ HEALTH PROFESSIONAL/ HEALTH PROFESSIONAL/ WORKER WORKER WORKER QUALIFIED QUALIFIED QUALIFIED DOCTOR A DOCTOR A DOCTOR A NURSE/MIDWIFE/ NURSE/MIDWIFE/ NURSE/MIDWIFE/ PARAMEDIC B PARAMEDIC B PARAMEDIC B FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE VISITOR C VISITOR C VISITOR C CSBA D CSBA D CSBA D MA/SACMO E MA/SACMO E MA/SACMO E COMMUNITY COMMUNITY COMMUNITY HEALTH CARE HEALTH CARE HEALTH CARE PROVIDER F PROVIDER F PROVIDER F HEALTH HEALTH HEALTH ASSISTANT G ASSISTANT G ASSISTANT G FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE ASSISTANT . . . H ASSISTANT . . . H ASSISTANT . . . H NGO WORKER I NGO WORKER I NGO WORKER I OTHER PROVIDER OTHER PROVIDER OTHER PROVIDER TRAINED TBA J TRAINED TBA J TRAINED TBA J UNTRAINED TBA . K UNTRAINED TBA . K UNTRAINED TBA . K UNQUALIFIED UNQUALIFIED UNQUALIFIED DOCTOR . . . . . L DOCTOR . . . . . L DOCTOR . . . . . L DRUG SELLER . M DRUG SELLER . M DRUG SELLER . M OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What drugs did (NAME) take? Any other drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . (SPECIFY) . . . 291Appendix E • LAST BIRTH NEXT-TO-LAST BIRTH SECOND-FROM-LAST BIRTH NO. QUESTIONS AND FILTERS NAME ________________ NAME _________________ NAME _________________ 541 Where did you get the drug? PUBLIC SECTOR PUBLIC SECTOR PUBLIC SECTOR A A A DISTRICT HOSPT. B DISTRICT HOSPT. B DISTRICT HOSPT. B MCWC C MCWC C MCWC C D D D UH & FWC E UH & FWC E UH & FWC E EPI OUTREACH EPI OUTREACH EPI OUTREACH SITE F SITE F SITE F COMMUNITY COMMUNITY COMMUNITY CLINIC G CLINIC G CLINIC G FAMILY WELFARE FAMILY WELFARE FAMILY WELFARE ASST. (FWA) H ASST. (FWA) H ASST. (FWA) H OTHER OTHER OTHER I I I (SPECIFY) (SPECIFY) (SPECIFY) NGO SECTOR NGO SECTOR NGO SECTOR NGO STATIC NGO STATIC NGO STATIC CLINIC J CLINIC J CLINIC J NGO SATELLITE NGO SATELLITE NGO SATELLITE CLINIC K CLINIC K CLINIC K NGO DEPO NGO DEPO NGO DEPO HOLDER . . . . . L HOLDER . . . . . L HOLDER . . . . . L NGO FIELD NGO FIELD NGO FIELD WORKER . . . . . M WORKER . . . . . M WORKER . . . . . M OTHER OTHER OTHER N N N (SPECIFY) (SPECIFY) (SPECIFY) PRIVATE MED. SECTOR PRIVATE MED. SECTOR PRIVATE MED. SECTOR PVT. HOSPITAL/ PVT. HOSPITAL/ PVT. HOSPITAL/ CLINIC . . . . . . . O CLINIC . . . . . . . O CLINIC . . . . . . . O QUALIFIED QUALIFIED QUALIFIED DOCTOR . . . P DOCTOR . . . P DOCTOR . . . P UNQUALIFIED UNQUALIFIED UNQUALIFIED DOCTOR Q DOCTOR Q DOCTOR Q PHARMACY PHARMACY/ PHARMACY/ DRUG STORE . R DRUG STORE . R DRUG STORE . R OTHER PRIVATE OTHER PRIVATE OTHER PRIVATE S S S OTHER SOURCE OTHER SOURCE OTHER SOURCE SHOP . . . . . . . . . V SHOP . . . . . . . . . . V SHOP . . . . . . . . . . V FRIEND/RELATIVE W FRIEND/RELATIVE W FRIEND/RELATIVE W OTHER X OTHER X OTHER X (SPECIFY) (SPECIFY) (SPECIFY) 552 GO BACK TO 503 IN GO BACK TO 503 IN GO TO 503 IN NEXT COLUMN; OR, IF NEXT COLUMN; OR, IF NEXT-TO-LAST NO MORE BIRTHS, GO NO MORE BIRTHS, GO COLUMN OF NEW TO 557. TO 557. QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 557. . . . . . . . . . . . . . . . . . . . . . . . . . . . . UHC . . . . . . . . . . . . . . . . . UHC . . . . . . . . . . . . . . . . . . . . . . . . . . SATELITE CLINIC/ . . . . . . . . . . . . . . . . . . . . . . . . . . UHC . . . . . . . . . . . . . . . . . . . (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . SATELITE CLINIC/SATELITE CLINIC/ (SPECIFY) (SPECIFY) . . . . . . . . . . . . . . . . . . . . . HOSP./MEDICAL COLLEGE/SPE. MED. COL HOSP./MEDICAL COLLEGE/SPE. MED. COL . HOSP./MEDICAL COLLEGE/SPE. MED. COL 292 • Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 557 CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2012 OR LATER LIVING WITH THE RESPONDENT ONE OR MORE NONE 601 RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 558 (NAME) 558 YES NO DK a) a) 1 2 8 b) b) 1 2 8 c) c) 1 2 8 d) d) 1 2 8 NUMBER OF TIMES IF 7 OR MORE TIMES, RECORD '7'. DRANK MILK e) e) 1 2 8 NUMBER OF TIMES IF 7 OR MORE TIMES, RECORD '7'. DRANK FORMULA f) f) 1 2 8 g) g) 1 2 8 NUMBER OF TIMES IF 7 OR MORE TIMES, RECORD '7'. ATE YOGURT h) h) 1 2 8 i) i) 1 2 8 j) j) 1 2 8 k) k) 1 2 8 l) l) 1 2 8 m) m) 1 2 8 n) n) 1 2 8 o) o) 1 2 8 p) p) 1 2 8 q) q) 1 2 8 r) r) 1 2 8 s) s) 1 2 8 t) t) 1 2 8 u) u) 1 2 8 Any other fruits like banana, grapes, apple, guava or other vegetables like cabbage, patal, kopi? White potatoes, white yams, manioc, cassava, or any other foods made from roots? Ripe mangoes, papayas, ripe kathal, bangi or other Vitamin A rich fruits? Liver, kidney, heart or other organ meats? Any meat, such as beef, pork, lamb, goat, chicken, or duck? Eggs? Any other solid, semi-solid, or soft food (bengali sweets)? Now I would like to ask you about liquids or foods that (NAME FROM 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods. Did (NAME FROM 557) (drink/eat): Pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside? Infant formula like Lactogen? IF YES: How many times did (NAME) drink milk? Bread, rice, noodles, porridge, or other foods made from grains? Yogurt? Any commercially fortified baby food like Cerelac? Any other liquids? Any foods made from beans, peas, lentils, or nuts? Cheese or other food made from milk like paneer? Fish, shrimps or crab ? Any dark green, leafy vegetables like spinach, poi sag, methi, kolmi, kochu, Plain water? Juice or juice drinks? Clear broth? IF YES: How many times did (NAME) drink infant formula? Milk such as tinned, powdered, or fresh animal milk? IF YES: How many times did (NAME) eat yogurt? 293Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 559 CHECK 558 (CATEGORIES "g" THROUGH "u"): NOT A SINGLE AT LEAST ONE "YES" "YES" 561 560 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 601 561 NUMBER OF TIMES . . . . . . . . . . . . . . . . . . . . . . . . IF 7 OR MORE TIMES, RECORD ‘7'. DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night? Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night? IF ‘YES’ PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat? 294 • Appendix E SECTION 6. MARRIAGE NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 601 CHECK 103A: CURRENTLY SEPARATED/DESERTED MARRIED DIVORCED/WIDOWED 609 604 LIVING WITH HER . . . . . . . . . . . . . . . . 1 605 STAYING ELSEWHERE . . . . . . . . . . . . 2 604A How often did he come home in the past 12 months? NUMBER OF TIMES. . . . . . . . . DID NOT COME IN THE LAST 12 MONTHS . . . . . . . . . . . 605 RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NAME _____________________________ NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. LINE NO. . . . . . . . . . . . . . . . . . . 609 ONLY ONCE . . . . . . . . . . . . . . . . . . . . 1 MORE THAN ONCE . . . . . . . . . . . . . . . . 2 610 CHECK 609: MARRIED MARRIED MONTH . . . . . . . . . . . . . . . . . . ONLY ONCE MORE THAN ONCE DON'T KNOW MONTH . . . . . . . . . . . . . . 98 YEAR . . . . . . . . . . . . 611A DON'T KNOW YEAR . . . . . . . . . . . . 9998 611 AGE . . . . . . . . . . . . . . . . . . . . 611A Do you think you got married at an age that was right for you, EARLIER 1 or would you have preferred to marry earlier or later? RIGHT TIME 2 611C LATER 3 611B At what age would you have preferred to get married? AGE IN YEARS 611C Were you studying or attending school just before you got married? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 611E 611D Did you continue your studies after marriage? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 IF YES: For how long? YES, FOR 1-2 YEARS 3 YES, FOR 3-4 YEARS 4 YES, FOR 5+ YEARS 5 611E Were you working outside home just before you got married? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 612 YES, LESS THAN A YEAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How old were you when you first started living with him? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is your husband living with you now or is he staying elsewhere? In what month and year did you start living with your (husband/partner)? Now I would like to ask about your first (husband/partner). In what month and year did you start living with him? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Have you been married only once or more than once? 295Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 611F Did you continue working after marriage? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 IF YES: For how long? YES, FOR 1-2 YEARS 3 YES, FOR 3-4 YEARS 4 YES, FOR 5+ YEARS 5 612 CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. 613 NEVER HAD SEXUAL INTERCOURSE . . . . . . . . . . . . . . . .00 701 AGE IN YEARS . . . . . . . . . . . . FIRST TIME WHEN STARTED LIVING WITH (FIRST) 95 614 615 DAYS AGO . . . . . . . . . . . . 1 IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS. WEEKS AGO . . . . . . . . . 2 IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS. MONTHS AGO . . . . . . . 3 YEARS AGO . . . . . . . . . 4 701 616 How many times during the last month did you have sexual intercourse? IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'. NUMBER OF TIMES . . . . . . HUSBAND/PARTNER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues. YES, LESS THAN A YEAR . . . . . . . . . When was the last time you had sexual intercourse? Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question. How old were you when you had sexual intercourse for the very first time? 296 • Appendix E SECTION 7. FERTILITY PREFERENCES NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 701 CHECK 103A: CURRENTLY SEPARATED/DESERTED MARRIED DIVORCED/WIDOWED 712 701A CHECK 304: NEITHER HE OR SHE STERILIZED 710 STERILIZED 702 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 704 703 HAVE ANOTHER CHILD . . . . . . . . . . . . 1 705 NO MORE . . . . . . . . . . . . . . . . . . . . . . . 2 UNDECIDED/DON'T KNOW . . . . . . . . . . 8 711 704 HAVE (A/ANOTHER) CHILD . . . . . . . . . . 1 NO MORE/NONE . . . . . . . . . . . . . . . . . . 2 707 SAYS SHE CAN'T GET PREGNANT 3 712 UNDECIDED/DON'T KNOW . . . . . . . . . . 8 710 705 CHECK 226: MONTHS . . . . . . . . . . . . . . 1 NOT PREGNANT PREGNANT OR UNSURE YEARS . . . . . . . . . . . . . . 2 SOON/NOW . . . . . . . . . . . . . . . . . . 993 710 SAYS SHE CAN'T GET PREGNANT 994 712 OTHER _______________________ 996 (SPECIFY) 710 DON'T KNOW . . . . . . . . . . . . . . . . . . 998 706 CHECK 226: NOT PREGNANT PREGNANT OR UNSURE 711 707 CHECK 303: USING A CONTRACEPTIVE METHOD? NOT CURRENTLY CURRENTLY USING 712 USING 708 CHECK 705: NOT 24 OR MORE MONTHS 00-23 MONTHS ASKED OR 02 OR MORE YEARS OR 00-01 YEAR 711 Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children? Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children? How long would you like to wait from now before the birth of (a/another) child? After the birth of the child you are expecting now, how long would you like to wait before the birth of another child? 297Appendix E • NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 709 CHECK 703 AND 704: WANTS TO HAVE WANTS NO MORE/ FERTILITY-RELATED REASONS A/ANOTHER CHILD NONE NOT HAVING SEX . . . . . . . . . . . . . . B INFREQUENT SEX . . . . . . . . . . . . . . C MENOPAUSAL/HYSTERECTOMY D CAN'T GET PREGNANT . . . . . . . . . . E NOT MENSTRUATED SINCE LAST BIRTH . . . . . . . . . . . . . . . . F BREASTFEEDING . . . . . . . . . . . . . . G UP TO GOD/FATALISTIC . . . . . . . . . . H OPPOSITION TO USE RESPONDENT OPPOSED . . . . . . . . I HUSBAND/PARTNER OPPOSED . . . J OTHERS OPPOSED . . . . . . . . . . . . K RELIGIOUS PROHIBITION . . . . . . . . L RECORD ALL REASONS MENTIONED. LACK OF KNOWLEDGE KNOWS NO METHOD . . . . . . . . . . . . M KNOWS NO SOURCE . . . . . . . . . . . . N METHOD-RELATED REASONS SIDE EFFECTS/HEALTH CONCERNS . . . . . . . . . . . . . . . . . . O LACK OF ACCESS/TOO FAR . . . . . P COSTS TOO MUCH . . . . . . . . . . . . Q PREFERRED METHOD NOT AVAILABLE . . . . . . . . . . . . . . R NO METHOD AVAILABLE . . . . . . . . S INCONVENIENT TO USE . . . . . . . . T INTERFERES WITH BODY'S NORMAL PROCESSES . . . . . . . . U OTHER _______________________ X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . . . Z 710 CHECK 303: USING A CONTRACEPTIVE METHOD? NOT ASKED NOT CURRENTLY USING CURRENTLY USING 712 711 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 711B 711A Which contraceptive method would you prefer to use? FEMALE STERILIZATION . . . . . . . . . . 01 MALE STERILIZATION . . . . . . . . . . . . 02 IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 INJECTABLES . . . . . . . . . . . . . . . . . . . . 04 IMPLANTS . . . . . . . . . . . . . . . . . . . . 05 PILL . . . . . . . . . . . . . . . . . . . . . . . 06 712 CONDOM . . . . . . . . . . . . . . . . . . . . . . . 07 11 SAFE PERIOD . . . . . . . . . . . . . . . . . . 12 WITHDRAWAL . . . . . . . . . . . . . . . . . . 13 OTHER _______________________ 96 (SPECIFY) UNSURE . . . . . . . . . . . . . . . . . . . . . . . . . 98 Can you tell me why you are not using a method to prevent pregnancy? You have said that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy? You have said that you do not want (a/another) child soon. LACTATIONAL AMEN. METHOD Any other reason? Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the future? Any other reason? 298 • Appendix E NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 711B What is the main reason that you think you will not use a FERTILITY-RELATED REASONS contraceptive method at any time in the future? NO SEX 21 INFREQUENT SEX 22 MENOPAUSAL/HYSTERECTOMY 23 SUBFECUND/INFECUND . . . . . 24 WANTS AS MANY CHILDREN AS POSSIBLE . . . . . . . . . . . . . . . . 26 OPPOSITION TO USE RESPONDENT OPPOSED . . . . . 31 HUSBAND/PARTNER OPPOSED 32 OTHERS OPPOSED . . . . . . . . . . 33 RELIGIOUS PROHIBITION . . . . . 34 LACK OF KNOWLEDGE KNOWS NO METHOD . . . . . . . . . . 41 KNOWS NO SOURCE . . . . . . . . . . 42 METHOD-RELATED REASONS HEALTH CONCERNS . . . . . . . . . . 51 FEAR OF SIDE EFFECTS . . . . . 52 LACK OF ACCESS/TOO FAR . . . 53 COSTS TOO MUCH . . . . . . . . . . 54 INCONVENIENT TO USE . . . . . . . . 55 INTERFERES WITH BODY'S NORMAL PROCESSES . . . . . 56 OTHER _______________________ 96 (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . 98 712 CHECK 216: HAS LIVING CHILDREN NO LIVING CHILDREN NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 714 NUMBER . . . . . . . . . . . . . . . . . . OTHER _______________________ 96 714 (SPECIFY) PROBE FOR A NUMERIC RESPONSE. 713 BOYS GIRLS EITHER NUMBER OTHER _______________________ 96 (SPECIFY) 714 YES NO RADIO . . . . . . . . . . . . . . . . . . . . . . . 1 2 TELEVISION . . . . . . . . . . . . . . . . 1 2 NEWSPAPER OR MAGAZINE . . . 1 2 Read about family planning in a poster, billboard or leaflet? POSTER/BILLBOARD . . . . . . . . . . 1 2 Heard about family planning from a community event? COMMUNITY EVENT . 1 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If you could choose exactly the number of children to have in your whole life, how many would that be? If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be? Heard about family planning on the radio? How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it’s a boy or a girl? In the last month have you: Seen anything about family planning on the television? Read about family planni