Bangladesh DHS Final Report (2011)

Publication date: 2013

Bangladesh Demographic and Health Survey 2011 B angladesh 2011 D em ographic and H ealth Survey BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2011 National Institute of Population Research and Training Dhaka, Bangladesh Mitra and Associates Dhaka, Bangladesh MEASURE DHS ICF International Calverton, Maryland, U.S.A. January 2013 Cover motif: A tapestry by Rashid Chowdhury, 1984 Courtesy: H. E. Mr. Md. Abdul Hannan, Ambassador & Permanent Representative, Permanent Mission of Bangladesh to the UN Office and other International Organizations in Geneva and Vienna. This report summarizes the findings of 2011 Bangladesh Demographic and Health Surveys (BDHS) conducted under the authority of the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare and implemented by Mitra and Associates of Dhaka. ICF International provided financial and technical assistance for the survey through USAID/Bangladesh. The BDHS is part of the worldwide Demographic and Health Surveys program, which is designed to collect data on fertility, family planning, and maternal and child health. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID, the Government of Bangladesh, or donor organizations. Additional information about the 2011 BDHS may be obtained from: NIPORT Azimpur Dhaka, Bangladesh Telephone: 862-5251 Fax: 861-3362 http://www.niport.gov.bd Mitra and Associates 2/17 Iqbal Road, Block A Mohammadpur, Dhaka, Bangladesh Telephone: 911-5053 Fax: 912-6806 Additional information about the MEASURE DHS project may be obtained from: ICF International 11785 Beltsville Drive Suite 300 Calverton, MD 20705 USA Telephone: 301-572-0200 Fax: 301-572-0999 Email: reports@macrointernational.com Internet: http://www.measuredhs.com Suggested citation: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. 2013. Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, 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 MDG INDICATORS . xxiii MAP OF BANGLADESH . xxvi CHAPTER 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 2011 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 . 6 1.4.4 Training and Fieldwork . 8 1.4.5 Data Processing . 8 1.4.6 Coverage of the Sample . 8 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 11 2.1 Household Characteristics . 12 2.1.1 Water and Sanitation . 12 2.1.2 Housing Characteristics . 14 2.1.3 Household Possessions . 16 2.2 Socioeconomic Status Index . 17 2.3 Household Population by Age and Sex . 18 2.4 Household Composition . 20 2.5 Birth Registration . 21 2.6 School Attendance . 22 2.7 Education of Household Population . 23 2.7.1 Educational Attainment of the Household Population . 23 2.7.2 School Attendance Ratios . 25 2.8 Employment . 27 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS . 29 3.1 Characteristics of Survey Respondents . 29 3.2 Educational Attainment . 31 3.3 Literacy . 34 3.4 Access to Mass Media . 36 3.5 Employment . 39 3.6 Occupation . 41 3.7 Earnings, Employers, and Continuity of Employment . 44 3.8 Sufficiency of Earning . 45 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY . 47 4.1 Introduction . 47 4.2 Current Marital Status . 47 4.3 Polygyny . 49 4.4 Age at First Marriage . 50 4.5 Age at First Sexual Intercourse . 53 4.6 Recent Sexual Activity . 55 4.7 Spousal Separation . 56 iv • Contents CHAPTER 5 FERTILITY . 59 5.1 Current Fertility . 60 5.2 Fertility Differentials . 61 5.3 Fertility Trends . 63 5.4 Children Ever Born and Living . 65 5.5 Birth Intervals . 66 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 67 5.7 Menopause . 70 5.8 Age at First Birth . 70 5.9 Teenage Pregnancy and Motherhood . 71 CHAPTER 6 FERTILITY PREFERENCES . 73 6.1 Desire for More Children . 73 6.2 Desire to Limit Childbearing . 75 6.3 Ideal Family Size . 77 6.4 Fertility Planning . 78 6.5 Wanted Fertility Rates . 80 6.6 Spousal Agreement in Desired Number of Children . 81 CHAPTER 7 FERTILITY REGULATION . 83 7.1 Current Use of Contraception . 83 7.2 Differentials in Current Use of Family Planning . 84 7.3 Trends in Current Use of Family Planning . 86 7.4 Timing of Sterilization . 88 7.5 Knowledge and Use of Menstrual Regulation . 89 7.6 Sources of Family Planning Methods . 90 7.7 Use of Social Marketing Brands . 92 7.8 Contraceptive Discontinuation . 94 7.9 Need for Family Planning Services . 97 7.10 Future Use of Contraception . 100 7.11 Reasons for Not Intending to Use Contraception . 101 7.12 Exposure to Family Planning Messages . 102 7.13 Fieldworker Visits . 104 7.14 Satellite Clinics . 106 7.15 Community Clinics . 108 CHAPTER 8 INFANT AND CHILD MORTALITY . 111 8.1 Assessment of Data Quality . 112 8.2 Levels and Trends in Infant and Child Mortality . 113 8.3 Socioeconomic Differentials in Infant and Child Mortality . 115 8.4 Demographic Differentials in Infant and Child Mortality . 116 8.5 Perinatal Mortality . 118 8.6 High-risk Fertility Behavior . 119 CHAPTER 9 MATERNAL AND NEWBORN HEALTH . 121 9.1 Antenatal Care . 122 9.1.1 Antenatal Care Coverage . 122 9.1.2 Place of Antenatal Care . 124 9.1.3 Number of Antenatal Visits . 125 9.1.4 Tetanus Toxoid Injections . 126 9.2 Delivery Care . 128 9.2.1 Place of Delivery . 128 9.2.2 Caesarean Section . 128 9.2.3 Assistance during Delivery . 130 9.3 Postnatal Care for Mothers and Children . 132 9.3.1 Postnatal Checkup for Mother . 132 9.3.2 Postnatal Checkup for the Newborn . 135 9.4 Newborn Care . 137 9.4.1 Care of the Umbilical Cord . 138 9.4.2 Drying, Wrapping, and Bathing the Newborn . 140 9.4.3 Essential Newborn Care. 143 Contents • v CHAPTER 10 CHILD HEALTH . 145 10.1 Child’s Size at Birth . 145 10.2 Vaccination of Children . 146 10.2.1 Vaccination Coverage . 147 10.2.2 Differentials in Vaccination Coverage . 148 10.2.3 Trends in Vaccination Coverage . 149 10.3 Childhood Illness and Treatment . 150 10.3.1 Childhood Diarrhea . 150 10.3.2 Treatment of Diarrhea . 152 10.3.3 Feeding Practices during Diarrhea . 154 10.3.4 Acute Respiratory Infections (ARI) . 155 10.4 Fever . 157 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS . 161 11.1 Nutritional Status of Children . 162 11.1.1 Measurement of Nutritional Status among Young Children . 162 11.1.2 Data Collection . 163 11.1.3 Levels of Child Malnutrition . 165 11.1.4 Trends in Children’s Nutritional Status . 166 11.2 Breastfeeding and Complementary Feeding . 167 11.2.1 Initiation of Breastfeeding . 167 11.3 Breastfeeding Status by Age . 169 11.4 Duration of Breastfeeding . 172 11.5 Types of Complementary Foods . 173 11.6 Infant and Young Child Feeding Practices . 175 11.7 Prevalence of Anemia In Children . 178 11.8 Micronutrient Intake Among Children . 180 11.9 Household Iodized Salt Consumption . 182 11.10 Adult Nutritional Status . 183 11.10.1 Nutritional Status of Women . 183 11.10.2 Nutritional Status of Men . 186 11.11 Prevalence of Anemia in Women . 188 11.12 Micronutrient Intake Among Mothers . 190 11.13 Household Food Security . 191 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 197 12.1 Knowledge of HIV/AIDS and Transmission and Prevention Methods. 198 12.1.1 Knowledge of AIDS . 198 12.1.2 Knowledge of HIV Prevention Methods . 199 12.1.3 Comprehensive Knowledge about AIDS . 201 12.2 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 204 12.3 Knowledge of Means of Transmission of HIV . 205 12.4 Attitudes toward Negotiating Safe Sexual Relations with Husbands . 206 12.5 Self-reported Prevalence of Sexually Transmitted Infections (STIs) and STI Symptoms . 208 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 211 13.1 Employment and Form of Earnings . 212 13.2 Women’s Control over their Own Earnings . 212 13.3 Freedom of Movement . 214 13.4 Women’s Empowerment . 215 13.5 Attitudes toward Wife Beating . 218 13.6 Indicators of Women’s Empowerment . 219 13.7 Current Use of Contraception by Women’s Empowerment . 220 13.8 Ideal Family Size and Unmet Need by Women’s Empowerment . 221 13.9 Reproductive Health Care by Women’s Empowerment . 222 13.10 Infant and Child Mortality and Women’s Empowerment . 223 CHAPTER 14 CAUSES OF DEATH IN CHILDREN UNDER AGE 5 . 225 14.1 Data Collection . 225 14.2 Assignment of Cause of Death . 226 vi • Contents 14.3 Causes of Death among Children under Age 5 . 227 14.4 Differentials in Cause of Under-5 Deaths . 228 14.5 Comparison of Cause-specific Mortality Rates between 2004 and 2011 . 231 14.6 Conclusion . 232 CHAPTER 15 OTHER ADULT HEALTH ISSUES. 233 15.1 Coverage rates for Blood Pressure and Blood Glucose Measurement . 234 15.2 Hypertension . 235 15.2.1 History of Hypertension. 236 15.2.2 Prevalence and Treatment of Hypertension . 237 15.3 Diabetes . 241 15.3.1 History of Diabetes . 242 15.3.2 Prevalence and Treatment of Diabetes . 243 CHAPTER 16 COMMUNITY CHARACTERISTICS . 247 REFERENCES . 251 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION . 259 A.1 Introduction . 259 A.2 Sampling Frame . 259 A.3 Sample Design . 260 A.4 Sampling Weight . 261 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 263 APPENDIX C DATA QUALITY TABLES . 275 APPENDIX D WHOLE BLOOD GLUCOSE VALUES . 281 APPENDIX E PERSONS INVOLVED IN THE SURVEY . 283 APPENDIX F QUESTIONNAIRES . 289 APPENDIX G SUMMARY INDICATORS . 429 Tables and Figures • vii TABLES AND FIGURES CHAPTER 1 INTRODUCTION . 1 Table 1.1 Basic demographic indicators . 2 Table 1.2 Eligibility for anthropometric measurements and biomarker testing, 2011 Bangladesh DHS . 6 Table 1.3 Results of the household and individual interviews . 9 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 11 Table 2.1 Household drinking water . 12 Table 2.2 Household sanitation facilities . 13 Table 2.3 Hand washing . 14 Table 2.4 Household characteristics . 15 Table 2.5 Household possessions . 16 Table 2.6 Wealth quintiles . 18 Table 2.7 Household population by age, sex, and residence . 18 Table 2.8 Trends in population by age . 20 Table 2.9 Household composition . 21 Table 2.10 Birth registration of children under age five . 22 Table 2.11 School attendance . 23 Table 2.12.1 Educational attainment of the male household population . 24 Table 2.12.2 Educational attainment of the female household population. 25 Table 2.13 School attendance ratios . 26 Table 2.14 Employment status . 27 Figure 2.1 Population pyramid . 19 Figure 2.2 Distribution of the de facto household population by single year of age and sex . 20 Figure 2.3 Age-specific attendance rates of the de facto population age 5-24 . 27 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS . 29 Table 3.1 Background characteristics of respondents . 30 Table 3.2.1 Educational attainment: Women . 32 Table 3.2.2 Educational attainment: Men . 33 Table 3.3.1 Literacy: Women. 35 Table 3.3.2 Literacy: Men . 36 Table 3.4.1 Exposure to mass media: Women . 37 Table 3.4.2 Exposure to mass media: Men . 38 Table 3.5.1 Employment status: Women . 40 Table 3.5.2 Employment status: Men . 41 Table 3.6.1 Occupation: Women . 42 Table 3.6.2 Occupation: Men . 43 Table 3.7 Type of employment: Women . 44 Table 3.8 Continuity of employment: Men . 45 Table 3.9 Sufficiency of earnings: Men . 46 Figure 3.1 Trends in age differential between spouses, 1999-2011 BDHS . 31 Figure 3.2 Trends in education of couples, 1999-2011 BDHS . 34 Figure 3.3 Percentage of ever-married women and men age 15 49 exposed to various media at least once a week . 39 viii • Tables and Figures CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY . 47 Table 4.1 Current marital status . 48 Table 4.2 Trends in proportion never married . 49 Table 4.3 Number of men’s wives . 50 Table 4.4 Age at first marriage . 51 Table 4.5 Median age at first marriage by background characteristics . 53 Table 4.6 Age at first sexual intercourse . 54 Table 4.7 Median age at first sexual intercourse by background characteristics . 55 Table 4.8 Recent sexual activity . 56 Table 4.9 Husband’s visits . 57 Figure 4.1 Trends in proportion of women age 20-24 who were first married by age 18 . 52 CHAPTER 5 FERTILITY . 59 Table 5.1 Current fertility . 60 Table 5.2 Fertility by background characteristics . 62 Table 5.3.1 Trends in age-specific fertility rates . 63 Table 5.3.2 Trends in current fertility rates . 64 Table 5.4 Children ever born and living . 65 Table 5.5 Birth intervals . 67 Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility . 68 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 69 Table 5.8 Menopause . 70 Table 5.9 Age at first birth . 70 Table 5.10 Median age at first birth . 71 Table 5.11 Teenage pregnancy and motherhood . 72 Figure 5.1 Age-specific fertility rates by urban-rural residence . 61 Figure 5.2 Trends in total fertility rates, 1975-2011 . 64 Figure 5.3 Total fertility rates by division, 2007 and 2011 . 65 CHAPTER 6 FERTILITY PREFERENCES . 73 Table 6.1 Fertility preferences by number of living children . 75 Table 6.2 Desire to limit childbearing . 76 Table 6.3 Ideal number of children by number of living children . 77 Table 6.4 Mean ideal number of children . 78 Table 6.5 Fertility planning status . 79 Table 6.6 Wanted fertility rates . 80 Table 6.7 Comparison of desired number of children . 81 Figure 6.1 Fertility preferences among currently married women age 15-49 . 74 Figure 6.2 Trends in currently married women with two children who want no more children, 1993-2011 . 75 Figure 6.3 Trends in gap between wanted and unwanted fertility rates, 1993-2011 . 80 CHAPTER 7 FERTILITY REGULATION . 83 Table 7.1 Current use of contraception by age . 84 Table 7.2 Current use of contraception by background characteristics . 85 Table 7.3 Trends in current use of contraceptive methods . 86 Table 7.4 Timing of sterilization . 89 Table 7.5 Menstrual regulation . 89 Tables and Figures • ix Table 7.6 Use of menstrual regulation . 90 Table 7.7 Source of modern contraception methods . 90 Table 7.8 Knowledge of specific sources of family planning services . 92 Table 7.9 Use of pill brands . 93 Table 7.10 Use of condom brands . 94 Table 7.11 12-month contraceptive discontinuation rates . 95 Table 7.12 Reasons for discontinuation . 96 Table 7.13 Need and demand for family planning among currently married women . 99 Table 7.14 Future use of contraception . 100 Table 7.15 Preferred method of contraception for future use . 101 Table 7.16 Reason for not intending to use contraception in the future . 102 Table 7.17.1 Exposure to family planning messages: Women . 103 Table 7.17.2 Exposure to family planning messages: Men . 104 Table 7.18 Contact with family planning providers: type of service . 105 Table 7.19 Contact with family planning providers: type of fieldworker . 106 Table 7.20 Satellite clinics . 107 Table 7.21 Community clinics . 109 Figure 7.1 Contraceptive use by background characteristics . 85 Figure 7.2 Trends in contraceptive use among currently married women age 10-49, 1975-2011 . 87 Figure 7.3 Trends in contraceptive method mix among currently married women, age 10-49, from1991-2011 . 88 Figure 7.4 Distribution of current users of modern methods by source of supply . 91 Figure 7.5 Twelve-month contraceptive discontinuation rates for any reason . 96 Figure 7.6 Trends in unmet need for family planning among currently married women age 15-49, 2007 and 2011 BDHS . 100 CHAPTER 8 INFANT AND CHILD MORTALITY . 111 Table 8.1 Early childhood mortality rates . 113 Table 8.2 Trends in early childhood mortality . 114 Table 8.3 Early childhood mortality rates by socioeconomic characteristics . 115 Table 8.4 Early childhood mortality rates by demographic characteristics . 116 Table 8.5 Perinatal mortality . 118 Table 8.6 High-risk fertility behavior . 119 Figure 8.1 Trends in childhood mortality, 1989-2011 . 114 Figure 8.2 Under-5 mortality rates by socioeconomic characteristics . 116 Figure 8.3 Under-5 mortality rates by demographic characteristics . 117 CHAPTER 9 MATERNAL AND NEWBORN HEALTH . 121 Table 9.1 Antenatal care . 123 Table 9.2 Place of antenatal care . 125 Table 9.3 Number of antenatal care visits . 126 Table 9.4 Tetanus toxoid injections . 127 Table 9.5 Place of delivery . 129 Table 9.6 Assistance during delivery . 131 Table 9.7 Postnatal care for mothers and children . 133 Table 9.8 Timing of first postnatal checkup for the mother . 134 Table 9.9 Type of provider of first postnatal checkup for the mother . 135 Table 9.10 Timing of first postnatal checkup for the children . 136 Table 9.11 Type of provider of first postnatal checkup for the newborn . 137 Table 9.12 Type of instrument used to cut the umbilical cord . 138 Table 9.13 Application of material after the umbilical cord was cut . 140 x • Tables and Figures Table 9.14 Newborn care practices: Timing of drying and wrapping . 141 Table 9.15 Newborn care practices: Timing of first bath . 142 Table 9.16 Essential newborn care . 143 Figure 9.1 Trend in utilization of antenatal care from a medically-trained provider by division, 2007-2011 . 124 Figure 9.2 Trend in antenatal care visits, 2004-2011 . 126 Figure 9.3 Place of delivery by wealth quintile . 130 Figure 9.4 Trend in skilled attendance at deliveries . 132 Figure 9.5 Trend in utilization of postnatal care for women and children from a medically trained provider within two days of delivery, 2004-2011 . 133 Figure 9.6 Trend in use of appropriate cord care, 2007-2011 . 139 Figure 9.7 Trend in essential newborn care . 144 CHAPTER 10 CHILD HEALTH . 145 Table 10.1 Child’s size at birth . 146 Table 10.2 Vaccinations by source of information . 148 Table 10.3 Vaccinations by background characteristics . 149 Table 10.4 Prevalence of diarrhea . 151 Table 10.5 Diarrhea treatment. 152 Table 10.6 Diarrhea treatment with ORT and zinc . 153 Table 10.7 Source of ORS packets . 154 Table 10.8 Feeding practices during diarrhea . 155 Table 10.9 Prevalence and treatment of symptoms of ARI . 156 Table 10.10 Prevalence and treatment of fever . 158 Table 10.11 First source of treatment of fever . 159 Figure 10.1 Trends in vaccination coverage among children age 12-23 months . 150 Figure 10.2 Source of antibiotics . 157 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS . 161 Table 11.1 Nutritional status of children . 163 Table 11.2 Initial breastfeeding . 169 Table 11.3 Breastfeeding status by age . 170 Table 11.4 Median duration of breastfeeding . 173 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 174 Table 11.6 Infant and young child feeding (IYCF) practices . 177 Table 11.7 Prevalence of anemia in children . 179 Table 11.8 Micronutrient intake among children . 181 Table 11.9 Presence of iodized salt in household . 183 Table 11.10.1 Nutritional status of ever-married women . 184 Table 11.10.2 Nutritional status of ever-married men age 15-34 . 187 Table 11.10.3 Nutritional status of men age 35 and older . 188 Table 11.11 Prevalence of anemia in women . 189 Table 11.12 Micronutrient intake among mothers . 191 Table 11.13 Availability of meals every day . 192 Table 11.14 Frequency of skipping meals . 193 Table 11.15 Frequency of having less food in a meal . 193 Table 11.16 Frequency of having rice replacement . 194 Table 11.17 Frequency of having to ask food . 195 Table 11.18 Food security by background characteristics . 196 Tables and Figures • xi Figure 11.1 Nutritional status of children by age . 165 Figure 11.2 Trends in nutritional status of children under age 5, 2004, 2007, and 2011 . 167 Figure 11.3 Infant feeding practices by age . 171 Figure 11.4 IYCF indicators on breastfeeding status . 172 Figure 11.5 Trends in complementary feeding for breastfeeding children 6-9 months . 175 Figure 11.6 Percentage fed according to minimum standard of acceptable feeding practices . 178 Figure 11.7 Trends in nutritional status of ever-married women . 186 CHAPTER 12 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 197 Table 12.1 Knowledge of AIDS . 199 Table 12.2 Knowledge of HIV prevention methods . 200 Table 12.3.1 Comprehensive knowledge about AIDS: Women . 202 Table 12.3.2 Comprehensive knowledge about AIDS: Men . 203 Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV: Women . 205 Table 12.5 Knowledge of transmission of HIV through unclean needles and unsafe blood transfusions 206 Table 12.6 Attitudes toward negotiating safer sexual relations with husband . 207 Table 12.7 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 209 Figure 12.1 Comprehensive knowledge about AIDS among ever-married women and men 15-49 . 204 Figure 12.2 Women and men seeking treatment for STIs . 210 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 211 Table 13.1 Employment and cash earnings of currently married women . 212 Table 13.2 Control over women’s cash earnings . 213 Table 13.3 Freedom of movement . 215 Table 13.4 Participation in decision making . 216 Table 13.5 Women’s participation in decision making by background characteristics . 217 Table 13.6 Women’s attitude toward wife beating . 219 Table 13.7 Indicators of women’s empowerment . 220 Table 13.8 Current use of contraception by women’s empowerment . 221 Table 13.9 Women’s empowerment and ideal number of children and unmet need for family planning 222 Table 13.10 Reproductive health care by women’s empowerment. 223 Table 13.11 Early childhood mortality rates by women’s empowerment . 224 Figure 13.1 Number of decisions in which currently married women participate. 218 CHAPTER 14 CAUSES OF DEATH IN CHILDREN UNDER AGE 5 . 225 Table 14.1 Causes of death among children under five by age group . 228 Table 14.2 Causes of death among children under 5 by sex of child and residence . 229 Table 14.3 Causes of death among children under 5 by mother’s education . 230 Table 14.4 Causes of death among children under 5 by division . 231 Figure 14.1 Specific causes of death among children under age 5, 2004 BDHS and 2011 BDHS . 232 CHAPTER 15 OTHER ADULT HEALTH ISSUES. 233 Table 15.1 Coverage of testing for blood pressure and fasting blood glucose measurement among women and men age 35 and older . 235 Table 15.2 History of hypertension and actions taken to lower blood pressure . 237 Table 15.3.1 Blood pressure levels and treatment status by background characteristics: Women . 238 Table 15.3.2 Blood pressure levels and treatment status by background characteristics: Men . 239 Table 15.4 History of diabetes . 243 Table 15.5.1 Fasting plasma glucose values and treatment status: Women . 244 Table 15.5.2 Fasting plasma glucose values and treatment status by background characteristics: Men . 245 xii • Tables and Figures Figure 15.1 Prevalence of hypertension and pre-hypertension among women and men age 35 and older . 240 Figure 15.2 Awareness of hypertension and treatment status among hypertensive women and men age 35 and over . 241 Figure 15.3 Prevalence of diabetes and pre-diabetes among women and men age 35 and older . 246 Figure 15.4 Awareness of diabetes and treatment status among diabetic women and men age 35 and over . 246 CHAPTER 16 COMMUNITY CHARACTERISTICS . 247 Table 16.1 Distance to the nearest general services . 247 Table 16.2 Distance to the nearest education facility . 248 Table 16.3 Availability of income-generating organizations . 249 Table 16.4 Availability of family planning and health services . 249 Table 16.5 Means of transport to upazila headquarters . 250 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION . 259 Table A.1 Percent distribution of households by division and type of residence . 260 Table A.2 Sample allocation of clusters by division and type of residence . 260 Table A.3 Sample allocation of households by division and type of residence . 261 Table A.4 Sample allocation of completed women interviews by division and type of residence . 261 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 263 Table B.1 List of selected variables for sampling errors, Bangladesh 2011 . 263 Table B.2 Sampling errors: Total sample, BDHS 2011 . 264 Table B.3 Sampling errors: Urban sample, BDHS 2011 . 265 Table B.4 Sampling errors: Rural sample, BDHS 2011 . 266 Table B.5 Sampling errors: Barisal sample, BDHS 2011 . 267 Table B.6 Sampling errors: Chittagong sample, BDHS 2011 . 268 Table B.7 Sampling errors: Dhaka sample, BDHS 2011 . 269 Table B.8 Sampling errors: Khulna sample, BDHS 2011 . 270 Table B.9 Sampling errors: Rajshahi sample, BDHS 2011 . 271 Table B.10 Sampling errors: Rangpur sample, BDHS 2011 . 272 Table B.11 Sampling errors: Sylhet sample, BDHS 2011 . 273 APPENDIX C DATA QUALITY TABLES . 275 Table C.1 Household age distribution . 275 Table C.2.1 Age distribution of eligible and interviewed women . 276 Table C.2.2 Age distribution of eligible and interviewed men . 276 Table C.3 Completeness of reporting . 277 Table C.4 Births by calendar years . 277 Table C.5 Reporting of age at death in days . 278 Table C.6 Reporting of age at death in months . 279 APPENDIX D WHOLE BLOOD GLUCOSE VALUES . 281 Table D.15.5.1 Fasting whole blood glucose values and treatment status by background characteristics: Women . 281 Table D.15.5.2 Fasting whole blood glucose values and treatment status by background characteristics: Men . 282 Foreword • xiii FOREWORD The 2011 Bangladesh Demographic and Health Survey (BDHS) is the sixth national demographic and health survey designed to provide information on basic national indicators of social progress, including fertility, childhood mortality and causes of death, fertility preferences and fertility regulation, maternal and child health, nutritional status of mothers and children, awareness and attitudes towards HIV/AIDS, and prevalence of noncommunicable diseases. In addition to presenting the main findings 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 the previous BDHS surveys. Results illustrate that the Total Fertility Rate continues to decline—three of seven divisions are at replacement level. Contrarily, the Contraceptive Prevalence Rate (CPR) continues to increase, and in the last four years Sylhet division demonstrates the highest increase in CPR, followed by Chittagong. BDHS data show continued decline in childhood mortality, and Bangladesh is on-track to achieve the MDG 4 target by 2015. There is also evidence that Bangladesh is moving ahead in achieving MDG 5. Since the 2007 BDHS, deliveries attended by skilled providers and deliveries in health facilities have increased by more than 50 percent, and the equity gap between rich and poor has narrowed. However, improvement of the nutritional status of children is a great challenge for us—more than one in three children is still underweight. Similarly, challenges remain from the high prevalence of two major non-communicable diseases: hypertension and diabetes. One in three adult women and one in five adult men are hypertensive, while one in nine adult men and women suffer from diabetes. The findings of this report and its policy and programmatic implications are very important for monitoring and evaluation of the Health, Population and Nutrition Sector Development Program (HPNSDP). The need, however, for further detailed analysis of BDHS data remains. I hope that such analysis will be carried out by academicians, researchers, and program personnel to provide more in-depth knowledge for the future direction and effective implementation of the HPNSDP in the coming years. The successful completion of the 2011 BDHS was made possible by the contributions of a number of organizations and individuals. I would like to thank NIPORT, Mitra and Associates, and ICF International for their efforts in conducting the 2011 BDHS. I deeply appreciate the United States Agency for International Development (USAID), Bangladesh, for providing the financial assistance that has helped ensure the ultimate success of this important national survey. Md. Humayun Kabir Preface • xv PREFACE The 2011 Bangladesh Demographic and Health Survey (BDHS) is the sixth 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 and Associates. The financial support for the survey was provided by the United States Agency for International Development (USAID), Bangladesh. The 2011 BDHS is a nationwide sample survey of men and women of reproductive age that provides information on childhood mortality levels; fertility preferences; use of family planning methods; and maternal, child, and newborn health. Included are breastfeeding practices; nutrition levels, including the presence of anemia and iodine deficiency; knowledge and attitudes toward HIV/AIDS and other sexually transmitted infections; and community-level data on accessibility and availability of health and family planning services. The special feature of this survey is its provision of biomarker indices of adult male and female populations, which are instrumental in determining the increasing risk of noncommunicable diseases. Members of the Technical Review Committee (TRC), consisting of experts from government, nongovernment, and international organizations as well as researchers and professionals working in the health, nutrition, and population sectors, contributed their expert opinion in various phases of the survey implementation. A Technical Working Group (TWG) was also formed with the representatives from NIPORT; ICDDR,B; USAID, Bangladesh; ICF International; and Mitra and Associates for designing the survey questionnaires and implementing the survey. I would like to put on record my sincere appreciation to TRC and TWG members for their efforts in different stages of the survey. The preliminary results of the 2011 BDHS, with its key indicators, were released through a dissemination seminar in April 2012. This final report brings more comprehensive analysis of the survey results. Along with the key results, detailed findings and possible interpretations are presented. I hope this information will give a hand to the policymakers and program managers as they monitor and design programs and strategies for improving health and family planning services in the country. It is worth mentioning that this report is an outcome of contributions from professionals at NIPORT, NIPSOM, Mitra and Associates, Dhaka University, Jahangirnagar University, ICDDR,B, MEASURE Evaluation, Population Council, SMC, Save the Children, and Eminence. I would like to acknowledge with great appreciation the contributions of the individual authors for their contributions to 2011 BDHS final report. I am deeply indebted and grateful to all the professionals of the Research Unit of NIPORT for the successful completion of the survey. I also extend my thanks to ICF International and Mitra and Associates for completing the task in time. USAID, Bangladesh, deserves special thanks for providing technical and financial support for the survey. Shelina Afroza, PhD Contributors to the Report • xvii CONTRIBUTORS TO THE REPORT Mr. Shahidul Islam, Mitra and Associates Mr. Md. Moshiur Rahman, Population Council Mr. Md. Rabiul Haque, Dhaka University Dr. Mohd. Muzibur Rahman, Jahangeer Nagar University Ms. Shahin Sultana, National Institute of Population Research and Training Mr. Subrata K. Bhadra, National Institute of Population Research and Training Mr. Toslim Uddin Khan, Social Marketing Company Mr. Shamal Chandra Karmaker, Dhaka University Ms. Shumona Sharmin Salam, International Center for Diarrheal Disease Research, Bangladesh Dr. Muhibbul Abrar, MaMoni, Save the Children Dr. Santhia Ireen, International Center for Diarrheal Disease Research, Bangladesh Dr. Muttaquina Hossain, International Center for Diarrheal Disease Research, Bangladesh Ms. Rashida-E-Ijdi, Research Fellow, Measure Evaluation Mr. Md. Hamidul Huque, International Center for Diarrheal Disease Research, Bangladesh Ms. Shusmita Hossain Khan, Eminence Dr. Md. Shamim Hayder Talukder, Eminence Dr. Md. Shafiqul Islam, National Institute of Preventative and Social Medicine Ms. Sri Poedjastoeti, ICF International Ms. Adrienne Cox, ICF International Dr. Ahmed Al-Sabir, ICF International Prof. Nitai Chakraborty, Dhaka University Dr. Kanta Jamil, United States Agency for International Development, Bangladesh Dr. Peter Kim Streatfield, International Center for Diarrheal Disease Research, Bangladesh Dr. Shams El Arifeen, International Center for Diarrheal Disease Research, Bangladesh Dr. Tahmeed Ahmed, International Center for Diarrheal Disease Research, Bangladesh Dr. Ishtiaq Mannan, Chief of Party, MCHIP Special acknowledgement Dr. Kanta Jamil, Senior Monitoring, Evaluation and Research Advisor, Office of Population, Health, Nutrition, and Education, USAID, Bangladesh, for technical assistance at all steps of survey implementation, analysis, and report generation. 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 BP Blood pressure BRAC Bangladesh Rural Advancement Committee CBR Crude birth rate CDC The Centers for Disease Control and Prevention CPS Contraceptive Prevalence Survey CSBA Community-skilled birth attendant DBP Diastolic blood pressure 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 FPG Fasting plasma glucose 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 xx • Abbreviations HNPSP Health, Nutrition and Population Sector Program HPI Human Poverty Index 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 SBP Systolic blood pressure SD Standard deviation SHS Secondhand smoke SMC Social Marketing Company STI Sexually-transmitted infection SWAp Sector-Wide Approach Abbreviations • xxi TBA Traditional birth attendant TC-NAC Technical Committee of the National AIDS Council TFR Total fertility rate TT Tetanus toxoid TWFR Total wanted fertility rate 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 2011 Value Goal Female Male Total 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under five years of age 38.5 34.3 36.4 2. Achieve universal primary education 2.1 Net enrollment ratio in primary education1 76.6 73.0 74.8 2.3 Literacy rate of 15-24 year olds 81.9 67.8 74.9 3. Promote gender equality and empower women 3.1a Ratio of girls to boys in primary education na na 1.1 3.1b Ratio of girls to boys in secondary education na na 1.1 3.1c Ratio of girls to boys in tertiary education na na 0.6 4. Reduce child mortality 4.1 Under-five mortality rate (per 1000 live births)2 50 57 53 4.2 Infant mortality rate (per 1000 live births)2 37 48 43 4.3 Proportion of 1 year-old children immunized against measles 86.8 88.3 87.5 5. Improve maternal health 5.1 Proportion of births attended by skilled health personnel3 na na 31.7 5.2 Contraceptive prevalence rate4 61.2 na na 5.3 Adolescent birth rate5 118.3 na na 5.4a Antenatal care coverage: at least 1 visit by skilled health professional3 54.6 na na 5.4b Antenatal care coverage: at least 4 visits by any provider3 25.5 na na 5.5 Unmet need for family planning 13.5 na na 6. Combat HIV/AIDS, malaria and other diseases 6.1 Percentage of population 15-24 years with comprehensive knowledge of HIV/AIDS6 11.9 14.4 13.1 na = Not applicable 1 Net attendance ratio measured in BDHS approximates MDG indicator 2.1 2 Expressed in terms of deaths per 1,000 live births 3 Rate refers to live births in the three years preceding the survey 4 Percentage of currently married women age 15-49 using any method of contraception 5 Equivalent to the age-specific fertility rate for women age 15-19, expressed in terms of births per 1,000 women age 15-19 6 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. xxiv • Millennium Development Goal Indicators Millennium Development Goal Indicators by residence Bangladesh 2011 Goal Urban Rural Total 7. Ensure environmental sustainability 7.1 Percentage of population using an improved drinking water source1 99.4 98.2 98.5 7.2 Percentage of population with access to improved sanitation2 43.3 34.4 36.6 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. xxvi • Map of Bangladesh INDIA INDIA BURMA NEPAL Dhaka Khulna Chittagong Rajshahi Rangpur Sylhet Barisal BANGLADESH 0 100 20050 Kilometers ¯ Bay of Bengal Introduction • 1 INTRODUCTION 1 1.1 GEOGRAPHY AND ECONOMY Bangladesh is located in the northeastern part of South Asia and covers an area of 147,570 square kilometers. It is almost entirely surrounded by India, except for a short southeastern frontier with Myanmar and a southern coastline on the Bay of Bengal. It lies between latitudes 20° 34′ and 26° 38′ north and longitudes 88° 01′ and 92° 41′ east. The entire country has a tropical climate. The Moguls ruled the country from the 13th century until the 18th century, when the British took over and administered the subcontinent until 1947. During British rule, Bangladesh was 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 the world map as a sovereign state on March 26, 1971, after fighting a nine-month war of liberation. Most of Bangladesh is low, flat land that consists of alluvial soil. The most significant feature of the land is the extensive network of large and small rivers that are of primary importance to the socioeconomic life of the nation. Chief among these, lying like a fan on the face of the land, are the Ganges-Padma, Brahmaputra-Jamuna, and Megna rivers. The climate of Bangladesh is dominated by seasonal monsoons. The country experiences a hot summer season with high humidity from March to June; a somewhat cooler, but still hot and humid, monsoon season from July through early October; and a cool, dry winter from November through the end of February. The fertile delta is subject to frequent natural calamities, such as floods, cyclones, tidal bores, and drought. For administrative purposes, the country consists of 7 divisions, 64 districts, and 545 upazilas/thanas (BBS, 2012a). 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, 2007). 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 to the gross domestic product (GDP). The GDP exhibited a robust growth rate of 6.7 percent in fiscal year (FY) 2010-2011 compared with 6.1 percent recorded in FY 2009-2010. The overall growth was led by the manufacturing and construction sub-sectors, which recorded impressive expansions of 10 and 6 percent, respectively, in FY 2010-2011. 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 20 percent to the total GDP in FY 2010-2011. The largest contributor in the agricultural sector is crops and horticulture (11 percent) followed by the fishery sector (4 percent). The average per capita income in Bangladesh has increased from US$599 during FY 2007-2008 to US$848 during FY 2011-2012 (BBS, 2008; MOF, 2012). Bangladesh is still struggling to emerge from poverty. Bangladesh ranks 146th among nations on the Human Development Index (HDI) as presented in the 2011 Human Development Report (UNDP, 2011). The HPI is a multidimensional measure of poverty for developing countries; it takes into account social exclusion, lack of economic opportunities, and deprivations in survival, livelihood, and knowledge. The country’s HDI value of 0.500 is above the average of 0.456 for countries in the low human development group and below the average of 0.548 for countries in South Asia. Countries in South Asia that are close to Bangladesh in its 2011 HDI rank and population size are Pakistan and Nepal, which rank 145th and 157th on the HDI, respectively. 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 from the 2001 and 2011 Population and Housing Census (PHC). According to the results of the 2011 PHC, the population of the country stood at about 149.8 million1, with a population density of 1,015 persons per square kilometer (BBS, 2012b). During the past century, the population of Bangladesh has increased exponentially. Between 2001 and 2011, about 19.8 million people were added to the population, which represents a 15 percent increase and a 1.37 percent annual growth rate. Between the 2001 and 2011 censuses, life expectancy in Bangladesh increased by about two years for males and by more than three years for females. Female life expectancy is slightly higher than male life expectancy (69 years versus 67 years). The country is now experiencing a demographic transition. The continuous decline of the natural growth rate is expected to lead to a smaller population increase in the coming decades. In comparison with other countries in the region, this population growth rate places Bangladesh 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, 2011a). The 2010 projections by the United Nations estimated that the population of Bangladesh in 2050 would be about 194 million (medium variant) and 226 million (high variant (UN, 2010). Table 1.1 Basic demographic indicators Demographic indicators from selected sources, Bangladesh, 2001 and 2011 Indicators Census 2001 Census 2011 Population (millions) 130.03 149.8 Intercensal growth rate (percent) 1.54 1.374 Density (population/km2) 881 1015 Percent urban 23.5 27.0 Life expectancy(year)* 2002 2010 Male 64.5 66.6 Female 65.4 68.8 Source: Bangladesh Bureau of Statistics (2012b) * Source: BBS, 2011b According to the National Population Policy, Bangladesh aims to achieve replacement level fertility by 2015 (MOHFW, 2009). Additionally, the Health Population Nutrition Sector Development Program (HPNSDP) plans to reduce the Total Fertility Rate (TFR) to 2.0 children per woman by 2016 (MOHFW, 2011). 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 the 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 1 According to BBS projection, the population on July 17, 2012 was 152.5 million. Introduction • 3 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 that have come into power have identified population control as the 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. 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 (MOHFW, 2004b). The current HPNSDP was initiated by the Ministry of Health and Family Welfare (MOHFW) for a period of 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 is working toward achieving Millennium Development Goals (MDGs). Of the eight MDGs, three are related 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) are closely related to human resource development. The HPNSDP Program Implementation Plan (PIP) document sets out the sector- specific strategies to achieve its goal (MOHFW, 2011). 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). 4 • Introduction • Expand noncommunicable disease control efforts at all levels by streamlining referral systems and strengthening hospital accreditation and management systems. • Strengthen support systems by increasing the health workforce at Upazila and at community clinic levels, including capacity building and enhanced focus on coordinated implementation of operational plan, management information system, and monitoring and evaluation functions. • Strengthen drug management and improve quality drug provision and procurement with information communication technology and additional staff to reduce the time between procurement and distribution. • Increase coverage and quality of services by strengthening coordination with other intra- and intersectoral and private sector service providers. • Pursue priority institutional and policy reforms, such as decentralization and local level planning, incentives for service providers in hard-to-reach areas, public-private partnerships, and a single annual work plan. 1.4 ORGANIZATION OF THE 2011 BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 1.4.1 Survey Objectives and Implementing Organizations The 2011 Bangladesh Demographic and Health Survey (BDHS) is the sixth DHS undertaken in Bangladesh, following those implemented in 1993-94, 1996-97, 1999-2000, 2004, and 2007. The main objectives of the 2011 BDHS are to: • Provide information to meet the monitoring and evaluation needs of health and family planning programs, and • Provide program managers and policy makers involved in these programs with the information they need to plan and implement future interventions. The specific objectives of the 2011 BDHS were as follows: • To provide up-to-date data on demographic rates, particularly fertility and infant mortality rates, at the national and subnational level; • To analyze the direct and indirect factors that determine the level of and trends in fertility and mortality; • To measure the level of contraceptive use of currently married women; • To provide data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS; • To assess the nutritional status of children (under age 5), women, and men by means of anthropometric measurements (weight and height), and to assess infant and child feeding practices; • To provide data on maternal and child health, including antenatal care, assistance at delivery, breastfeeding, immunizations, and prevalence and treatment of diarrhea and other diseases among children under age 5; Introduction • 5 • To measure biomarkers, such as hemoglobin level for women and children, and blood pressure, and blood glucose for women and men 35 years and older; • To measure key education indicators, including school attendance ratios and primary school grade repetition and dropout rates; • To provide information on the causes of death among children under age 5; • To provide community-level data on accessibility and availability of health and family planning services; • To measure food security. The 2011 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 Calverton, Maryland, USA, provided technical assistance to the project as part of its international Demographic and Health Surveys program (MEASURE DHS). Financial support was provided by the U.S. Agency for International Development (USAID). 1.4.2 Sample Design The sample for the 2011 BDHS is nationally representative and covers the entire population residing in noninstitutional dwelling units in the country. The survey used as a sampling frame the list of enumeration areas (EAs) prepared for the 2011 Population and Housing Census, provided by the Bangladesh Bureau of Statistics (BBS). The primary sampling unit (PSU) for the survey is an EA that was created to have an average of about 120 households. Bangladesh has seven administrative divisions: Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet. Each division is subdivided into zilas, and each zila into upazilas. Each urban area in an upazila is divided into wards, and into mohallas within a ward. A rural area in the upazila is divided into union parishads (UP) and mouzas within a UP. These divisions allow the country as a whole to be easily 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 clusters in urban areas and 393 in rural areas. A complete household listing operation was then carried out in all 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). In addition, in a subsample of one-third of the households, all ever- married men age 15-54 were selected and interviewed for the male survey. In this subsample, a group of eligible members were selected to participate in testing of the biomarker component, including blood pressure measurements, anemia, blood glucose testing, and height and weight measurements. Table 1.2 shows which household members were eligible for which biomarker testing. 6 • Introduction Table 1.2 Eligibility for anthropometric measurements and biomarker testing, 2011 Bangladesh DHS Groups eligible for biomarker collection Weight measurement Height measurement Anemia testing Blood pressure measurement Blood glucose testing Children 0–6 months All households All households Children 6–59 months All households All households 1/3 households Ever-married women 12-34 years All households All households 1/3 households Ever-married women 35-49 years All households All households 1/3 households 1/3 households 1/3 households Ever-married women 50+ years 1/3 households 1/3 households 1/3 households 1/3 households Never-married women 35+ years 1/3 households 1/3 households 1/3 households 1/3 households Ever-married men 15-34 years 1/3 households 1/3 households All men 35+ years 1/3 households 1/3 households 1/3 households 1/3 households 1.4.3 Questionnaires The 2011 BDHS used five types of questionnaires: a Household Questionnaire, a Woman’s Questionnaire, a Man’s Questionnaire, a Community Questionnaire, and two Verbal Autopsy Questionnaires to collect data on causes of death among children under age 5. The contents of the household and individual 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 Centre for Diarrheal Diseases and Control, Bangladesh (ICDDR,B), USAID/Bangladesh, and MEASURE DHS (see Appendix E for a list of the TWG members). Draft questionnaires were then circulated to other interested groups and were reviewed by the 2011 BDHS Technical Review Committee (see Appendix E). The questionnaires were developed in English and then translated and printed into 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, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. In addition, information was collected about the dwelling unit, such as the source of water, type of toilet facilities, materials used to construct the floors and walls, and ownership of various consumer goods. The Household Questionnaire was also used to record for eligible individuals: • Height and weight measurements • Anemia test results • Measurements of blood pressure and blood glucose The Woman’s Questionnaire was used to collect information from ever-married women age 12- 49. Women were asked questions on the following topics: • Background characteristics (e.g., age, education, religion, and 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 childhood illnesses • Marriage • Fertility preferences • Husband’s background and respondent’s work • Awareness of AIDS and other sexually transmitted infections • Food security Introduction • 7 The Man’s Questionnaire was used to collect information from ever-married men age 15-54. Men were asked questions on the following topics: • Background characteristics (including respondent’s work) • Marriage • Fertility preferences • Participation in reproductive health care • Awareness of AIDS and other sexually transmitted infections The Community Questionnaire was administered in each selected cluster during the household listing operation. Data were collected by administering the Community Questionnaire to a group of four to six community leaders who were knowledgeable about socioeconomic conditions and the availability of health and family planning services/facilities, in or near the sample area (cluster). Community leaders included such persons as government officials, social workers, teachers, religious leaders, traditional healers, and health care providers. The Community Questionnaire collected information 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 of each cluster were also recorded. The information obtained in these questionnaires was also used to verify information gathered in the Woman’s and Man’s Questionnaires on the types of facilities accessed and health services personnel seen. The Verbal Autopsy Questionnaires were developed based on the work done by an expert group led by the WHO, consisting of researchers, data users, and other stakeholders under the sponsorship of the Health Metrics Network (HMN). The verbal autopsy tools are intended to serve the various needs of the users of mortality information. Two questionnaires were used to collect information related to the causes of death among young children; the first questionnaire collected data on neonatal deaths (deaths at 0-28 days), and the second questionnaire collected data on deaths between four weeks and five years. These questionnaires were administered to mothers who reported the death of a child under age 5 in the five-year period prior to the 2011 BDHS survey or care taker who were knowledgeable about the symptoms and treatment preceding the death. The questionnaires contained both structured (pre-coded) questions and nonstructured (open-ended) questions. The following topics were covered in the Verbal Autopsy Questionnaires: • Identification including detailed address of respondent • Informed consent • Detailed age description of deceased child • Respondent’s account of illness/events leading to death • Maternal history, including questions on prenatal care, labor and delivery, and obstetrical complications • Information about accidental deaths • Detailed signs and symptoms preceding death • Mother’s health and contextual factors • Information on treatment module and information on direct, underlying contributing causes of death from the death certificate, if available. 8 • Introduction 1.4.4 Training and Fieldwork Forty-seven people were trained to carry out the listing of households, to delineate Enumeration Areas (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 seven days from May 11-21, 2011. A household listing operation was carried out in all selected EAs from May 22 to October 5, 2011 in four phases, each about three weeks in length. Initially, 19 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 15 in the second and third phases and to 6 in the final phase. In addition, six supervisors were deployed to check and verify the work of the listing teams. The Household, Woman’s and Man’s Questionnaires were pre-tested in March 2011. Four supervisors, 10 interviewers, and 4 biomarker staff were trained for the pretest. The questionnaires were pre-tested on 100 households, 100 women, and 70 men in one urban and one rural cluster in Comilla District and one urban and one rural cluster in Dhaka. Based on observations in the field and suggestions made by the pretest teams, revisions were made to the wording and translations of the questionnaires. Training for the main survey was conducted for four weeks from June 6 to July 5, 2011. A total of 173 fieldworkers were recruited based on their educational level, prior experience with surveys, maturity, and willingness to spend up to six months on the project. Training included (1) lectures on how to conduct an interview and complete the questionnaires, (2) mock interviews by participants, and (3) field practice. Fieldwork for the 2011 BDHS was carried out by 16 interviewing teams, each consisting of one supervisor, one field editor, five female interviewers, two male interviewers, and one logistics staff member. Data collection was implemented in five phases, starting on July 8, 2011 and ending on December 27, 2011. In addition, from January 2-19, 2012 there were re-visits to collect blood samples from respondents interviewed during Ramadan who had agreed to participate in blood testing, but declined to be tested during Ramadan. Data quality was ensured through four quality control teams, each comprised of one male and one female staff person. In addition, NIPORT monitored fieldwork by using extra quality control teams. Data quality was also monitored through field check tables generated concurrently with data processing. This was an advantage because the quality control teams were able to advise field teams of problems detected during data entry. In particular, tables were generated to check various data quality parameters. Fieldwork was also monitored through visits by representatives from USAID, ICF International, and NIPORT. 1.4.5 Data Processing The completed 2011 BDHS questionnaires were periodically returned to Dhaka for data processing at Mitra and Associates offices. The data processing began shortly after the start of fieldwork. Data processing consisted of office editing, coding of open-ended questions, data entry, and editing of inconsistencies found by the computer program. The data were processed by 16 data entry operators and two data entry supervisors. Data processing commenced on July 23, 2011 and ended on January 15, 2012. Data processing was carried out using the Census and Survey Processing System (CSPro), a joint software product of the U.S. Census Bureau, ICF International, and Serpro S.A. 1.4.6 Coverage of the Sample Table 1.3 shows the results of the household and individual women’s and men’s interviews. From a total of 17,964 selected households, 17,511 were found to be occupied. Interviews were successfully completed in 17,141 households, or 98 percent of all the occupied households. A total of 18,222 ever- married women age 12-49 were identified in these households, and 17,842 were interviewed, yielding a response rate of 98 percent. In one-third of the households, ever-married men over age 15 were eligible for Introduction • 9 interview. Of the 4,343 eligible men, 3,997, or 92 percent, were successfully interviewed. The 2011 response rates were similar to those in the 2007 BDHS. The principal reason for nonresponse among women and men was their absence from home despite repeated visits to the household. The response rates do not vary notably by urban-rural residence. Table 1.3 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Bangladesh 2011 Result Residence Total Urban Rural Household interviews Households selected 6,210 11,754 17,964 Households occupied 6,035 11,476 17,511 Households interviewed 5,868 11,273 17,141 Household response rate1 97.2 98.2 97.9 Interviews with ever-married women age 12-49 Number of eligible women 6,390 11,832 18,222 Number of eligible women interviewed 6,196 11,646 17,842 Eligible women response rate2 97.0 98.4 97.9 Interviews with ever-married men age 15-54 Number of eligible men 1,586 2,757 4,343 Number of eligible men interviewed 1,437 2,560 3,997 Eligible men response rate2 90.6 92.9 92.0 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 11 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 his chapter provides an overview of socioeconomic characteristics of the population, which includes conditions of the households, sources of drinking water, sanitation facilities, hand washing, 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 2011 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. T Key Findings • Access to an improved source of drinking water is almost universal (99 percent) in Bangladesh. • One in ten households uses an appropriate water treatment method. • The proportion of households with no toilet facilities declined from 8 percent in 2007 to 5 percent in 2011. One-third of the households have an improved toilet facility that is not shared with other households. • Six in ten households have electricity. This is a marked improvement from 2007, when only 47 percent of households had access to electricity. There is a wide urban-rural gap (90 and 49 percent, respectively). • Eighty-six percent of households use solid fuel for cooking. • Forty-five percent of households are exposed daily to secondhand smoke. • Possession of mobile phones has increased sharply from 32 percent in 2007 to 78 percent in 2011 (89 percent in urban areas and 75 percent in rural areas). • Thirty-five percent of the population is under age 15. • Eleven percent of households are headed by a woman. • Thirty-one percent of children under age 5 are registered, and 22 percent have a birth certificate. • One in four women and 29 percent of men are not educated. School attendance for all age groups between 6-24 years in 2011 has increased from that in 2007. • Sixty-four percent of men and 11 percent of women are currently working. 12 • Housing Characteristics and Household Population 2.1 HOUSEHOLD CHARACTERISTICS Access to basic utilities, sources of drinking water and water treatment practices, access to sanitation facilities, housing structure and crowdedness of dwelling spaces, and type of fuel used for cooking are physical characteristics of a household that are used to assess the general wellbeing and socioeconomic status of its members. This section provides information from the 2011 BDHS on drinking water, sanitation facilities, housing characteristics, and possession of basic amenities. 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 and diarrheal diseases remain the leading causes of child deaths in Bangladesh (NIPORT et al., 2005). Table 2.1 presents information on household drinking water by urban-rural residence. Access to an improved source of drinking water is universal in Bangladesh (99 percent). The most common source of drinking water in urban areas is a tube well or borehole (55 percent), followed by water piped into the 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 2011 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 99.4 98.2 98.5 99.4 98.2 98.5 Piped into dwelling 21.0 0.5 5.7 21.3 0.6 5.6 Piped to yard/plot 16.2 0.7 4.5 15.0 0.6 4.1 Public tap/standpipe 7.0 0.5 2.1 6.9 0.5 2.0 Tube well or borehole 54.6 95.8 85.5 55.7 95.8 86.0 Protected well 0.1 0.2 0.2 0.1 0.2 0.2 Protected spring 0.0 0.0 0.0 0.0 0.1 0.0 Rain water 0.3 0.5 0.4 0.3 0.4 0.4 Bottled water 0.3 0.0 0.1 0.2 0.0 0.1 Non-improved source 0.6 1.8 1.5 0.6 1.8 1.5 Unprotected well 0.0 0.3 0.2 0.0 0.3 0.2 Tanker truck/cart with drum 0.1 0.0 0.0 0.1 0.0 0.1 Surface water 0.4 1.4 1.2 0.4 1.4 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 99.4 98.2 98.5 99.4 98.2 98.5 Time to obtain drinking water (round trip) Water on premises 82.5 67.6 71.4 82.5 68.1 71.6 Less than 30 minutes 15.6 27.9 24.8 15.5 27.3 24.4 30 minutes or longer 1.8 4.4 3.7 1.9 4.6 4.0 Don’t know/missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 23.4 0.6 6.3 23.3 0.6 6.1 Bleach/chlorine added 0.4 0.3 0.3 0.4 0.3 0.3 Strained through cloth 1.0 0.3 0.5 1.1 0.3 0.5 Ceramic, sand or other filter 10.8 2.3 4.4 11.2 2.5 4.6 Other 0.4 0.6 0.6 0.4 0.6 0.5 No treatment 68.7 96.2 89.3 68.8 96.0 89.4 Percentage using an appropriate treatment method2 30.9 3.2 10.2 30.8 3.5 10.1 Number 4,305 12,836 17,141 19,158 59,752 78,909 1 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Housing Characteristics and Household Population • 13 dwelling (21 percent), water piped to the yard or plot (16 percent), and a public tap or standpipe (7 percent). In contrast, a tube well or borehole is practically the only source of drinking water in rural areas (96 percent). For 71 percent of households the source of drinking water is within the premises. One in four households spend 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. Nationally, 10 percent of households use an appropriate water treatment method. Rural households are much less likely than urban households to treat their water appropriately (3 percent and 31 percent, respectively). Overall, boiling water prior to drinking is the most common treatment method (6 percent). However less than 1 percent of rural households boil water, while almost one in four urban 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. Table 2.2 shows that 34 percent of households have an improved (not shared) toilet facility and 19 percent 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 half of the households use a non-improved toilet facility (47 percent); 31 percent of households use pit latrines without slabs, and 7 percent use a hanging toilet. Five percent of households have no toilet facility, an improvement since the 2007 BDHS, when 8 percent of households had no toilet facility (NIPORT, Mitra and Associates and Macro International, 2009). Rural households are more likely than urban households to have no toilet facility (6 percent versus 1 percent). Although the majority of households (60 percent) do not share their toilet, rural households are more likely than urban households to use a toilet facility that is not shared (62 versus 55 percent, respectively). Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Bangladesh 2011 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 39.6 31.7 33.7 43.3 34.4 36.6 Flush/pour flush to piped sewer system 6.5 0.1 1.7 6.8 0.1 1.8 Flush/pour flush to septic tank 12.7 3.1 5.6 13.5 3.7 6.1 Flush/pour flush to pit latrine 0.9 0.5 0.6 0.9 0.6 0.7 Ventilated improved pit (VIP) latrine 8.6 7.8 8.0 9.6 8.6 8.8 Pit latrine with slab 10.8 20.0 17.7 12.4 21.4 19.3 Composting toilet 0.0 0.0 0.0 0.0 0.0 0.0 Shared facility1 25.6 16.7 18.9 22.3 14.9 16.7 Flush/pour flush to piped sewer system 4.5 0.1 1.2 4.0 0.0 1.0 Flush/pour flush to septic tank 6.5 0.9 2.3 5.4 0.9 2.0 Flush/pour flush to pit latrine 0.8 0.3 0.4 0.7 0.3 0.4 Ventilated improved pit (VIP) latrine 6.0 3.8 4.4 5.2 3.5 3.9 Pit latrine with slab 7.7 11.6 10.6 7.1 10.2 9.4 Composting toilet 0.0 0.0 0.0 0.0 0.0 0.0 Non-improved facility 34.8 51.6 47.4 34.3 50.7 46.7 Flush/pour flush not to sewer/septic tank/pit latrine 18.1 0.1 4.6 17.4 0.1 4.3 Pit latrine without slab/open pit 13.8 37.1 31.3 14.1 36.6 31.2 Hanging toilet/hanging latrine 2.0 8.6 6.9 1.9 8.8 7.1 No facility/bush/field 0.9 5.8 4.6 0.8 5.2 4.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Shared sanitation facility Not shared 54.5 62.2 60.3 59.7 66.2 64.6 Shared with 1-4 households 25.6 33.9 31.8 23.0 30.2 28.5 5-9 households 11.7 3.3 5.4 10.0 2.9 4.6 10+ households 7.9 0.6 2.4 7.1 0.6 2.2 Don’t know/missing 0.2 0.1 0.1 0.3 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,305 12,836 17,141 19,158 59,752 78,909 1 Shared facility of an otherwise improved type 14 • Housing Characteristics and Household Population 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 quintile. In the 2011 BDHS, interviewers were instructed to observe the place where household members usually wash their hands. They looked for regularity of water supply and observed whether the household had cleansing agents near the place of hand washing. In 86 percent of households, the interviewers observed designated places for hand washing; urban households, households in Rangpur, and households in the highest wealth quintile were more likely to have this facility observed than other households. One in four households has soap and water in the place where household members wash their hands, 6 percent have water and other cleansing agents (ash, mud, sand, etc.), and the majority (67 percent) have water only. Overall, 2 percent of households do not have water, soap, or any cleansing agent. Forty-six percent of urban households have soap and water compared with 17 percent of rural households. Availability of hand washing facilities varies across divisions, ranging from 28 percent of households in Dhaka to 14 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 (4 percent) and highest (67 percent) among those in the highest wealth quintile. Table 2.3 Hand washing 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 2011 Background characteristics 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 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 92.8 4,305 46.3 3.5 48.7 0.1 0.1 1.2 0.1 100.0 3,997 Rural 83.7 12,836 17.0 6.9 73.1 0.0 0.1 2.9 0.1 100.0 10,738 Division Barisal 74.9 1,014 13.6 5.1 77.5 0.0 0.2 3.4 0.2 100.0 760 Chittagong 82.8 2,939 24.3 3.2 68.3 0.0 0.0 4.0 0.1 100.0 2,433 Dhaka 87.5 5,599 28.2 5.6 64.5 0.1 0.0 1.5 0.0 100.0 4,900 Khulna 84.7 2,024 20.3 5.5 72.9 0.0 0.2 0.9 0.2 100.0 1,714 Rajshahi 85.5 2,572 24.2 6.1 65.4 0.0 0.0 4.2 0.1 100.0 2,200 Rangpur 95.8 2,079 26.6 12.0 60.6 0.0 0.0 0.7 0.2 100.0 1,991 Sylhet 80.7 914 25.1 2.9 65.7 0.0 0.2 5.7 0.4 100.0 737 Wealth quintile Lowest 76.2 3,756 3.8 6.8 84.9 0.0 0.2 4.2 0.1 100.0 2,861 Second 81.5 3,481 8.5 7.9 79.3 0.0 0.0 4.2 0.1 100.0 2,835 Middle 85.3 3,325 12.7 6.9 77.7 0.0 0.0 2.5 0.2 100.0 2,835 Fourth 90.8 3,283 27.5 6.5 64.6 0.0 0.0 1.3 0.2 100.0 2,980 Highest 97.8 3,296 66.5 2.2 30.7 0.1 0.1 0.3 0.1 100.0 3,224 Total 86.0 17,141 24.9 6.0 66.5 0.0 0.1 2.4 0.1 100.0 14,736 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 2.1.2 Housing Characteristics Housing characteristics and household assets can be used to measure the socioeconomic status of household members. Cooking practices and cooking fuels also have an impact on health and the environment. Table 2.4 presents information on the availability of electricity, type of flooring material, number of rooms for sleeping, type of fuel used for cooking, and place where cooking is done. The table shows that 60 percent of households in Bangladesh have access to electricity. This is a marked Housing Characteristics and Household Population • 15 improvement from 2007, when only 47 percent of households had access to electricity. The increase in access to electricity is seen in rural and urban areas. In rural areas access to electricity increased from 37 percent in 2007 to 49 percent in 2011, and in urban areas access increased from 82 percent in 2007 to 90 percent in 2011 (NIPORT, Mitra and Associates and Macro International, 2009). However, access to electricity varies widely between urban (90 percent) and rural areas (49 percent). Earth and sand are the most common flooring materials used in Bangladesh (74 percent). These materials are predominantly used in rural areas (88 percent), while in urban areas the most common flooring material is cement (62 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 acute respiratory infections and skin diseases, which particularly affect children and the elderly. The proportion of households using one room for sleeping has decreased from 40 percent in 2007 to 35 percent in 2011. There are small differences in the number of rooms used for sleeping by urban-rural residence. Indoor pollution has important implications for the health of household members. The type of fuel used for cooking, the place where cooking is done, and the type of stove used are all related to indoor air quality and the degree to which household members are exposed to the risk of respiratory infections and other diseases. In Bangladesh, the risk of indoor pollution from cooking fuel is limited because only 12 percent of households cook in the house; 64 percent of households cook in a separate building, and 23 percent cook outdoors. Urban households are much more likely than rural households to cook in the house (23 and 9 percent, respectively). Half of households in urban areas (51 percent) use solid fuel for cooking while virtually all rural households (99 percent) use solid fuel, including wood, agricultural crops, animal dung, straw, shrubs, grass, and charcoal. The proportion of urban households that rely on wood for fuel has decreased from 44 percent in 2007 to 35 percent in 2011. On the other hand, the use Table 2.4 Household characteristics Percent distribution of households by housing characteristics and percentage using solid fuel for cooking; and percent distribution by frequency of smoking in the home, according to residence, Bangladesh 2011 Housing characteristic Residence Total Urban Rural Electricity Yes 90.2 49.3 59.6 No 9.8 50.7 40.4 Total 100.0 100.0 100.0 Flooring material Earth, sand 32.1 88.3 74.1 Wood/planks 0.2 0.1 0.2 Palm/bamboo 0.0 0.0 0.0 Parquet or polished wood 0.0 0.0 0.0 Ceramic tiles 5.3 0.2 1.5 Cement 62.1 11.3 24.1 Carpet 0.2 0.0 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 38.5 34.4 35.4 Two 34.7 37.5 36.8 Three or more 26.7 27.9 27.6 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Place for cooking In the house 22.8 8.8 12.3 In a separate building 63.0 64.7 64.3 Outdoors 13.9 26.4 23.3 Other 0.2 0.1 0.1 Total 100.0 100.0 100.0 Cooking fuel Electricity 0.5 0.0 0.1 LPG/natural gas/biogas 48.4 1.3 13.1 Kerosene 0.6 0.0 0.2 Coal/lignite 0.0 0.0 0.0 Charcoal 0.3 0.1 0.2 Wood 35.0 47.7 44.6 Straw/shrubs/grass 1.8 1.0 1.2 Agricultural crop 9.5 39.1 31.7 Animal dung 3.8 10.4 8.7 Other 0.1 0.3 0.2 Total 99.9 100.0 100.0 Percentage using solid fuel for cooking1 50.4 98.4 86.3 Frequency of smoking in the home Daily 40.2 46.8 45.1 Weekly 3.2 2.5 2.7 Monthly 0.9 1.2 1.1 Less than monthly 3.1 2.6 2.7 Never 52.5 46.7 48.2 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Number 4,305 12,836 17,141 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 16 • Housing Characteristics and Household Population of wood for fuel has increased in rural areas, from 44 percent in 2007 to 48 percent in 2011. As expected, use of liquid petroleum gas (LPG), natural gas, and biogas is 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 2011 BDHS shows that Bangladesh is slowly making some progress toward this goal; the proportion of the population that uses solid fuels in Bangladesh has declined from 91 percent in 2007 to 86 percent in 2011. Information on smoking was collected in the 2011 BDHS to assess the percentage of household members who are exposed to secondhand smoke (SHS), which is a risk factor for those who do not smoke. Pregnant women who are exposed to SHS have a higher risk of giving birth to a low birth weight baby (Windham et al., 1999). Also, children who are exposed to SHS are at a higher risk of respiratory and ear infections and poor lung development (U.S. Department of Health and Human Services, 2006). Table 2.4 provides information on the frequency of smoking in the home, which is used as a proxy for level of SHS exposure. Overall, 45 percent of households are exposed daily to SHS; rural households are more likely than urban households to be exposed to SHS (47 percent and 40 percent, respectively). 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 2.5 shows the percentages of urban and rural households that possess various durable commodities, means of transportation, and agricultural land and farm animals. Table 2.5 shows that televisions and mobile telephones are common information and communication devices possessed by most households. Possession of mobile phones has increased sharply, from 32 percent in 2007 to 78 percent in 2011 (NIPORT, Mitra and Associates and Macro International, 2009). About nine in 10 households in urban areas and more than seven in 10 households in rural areas possess mobile phones. Four out of ten households have a television. Urban households are more likely to possess a television (70 percent) than rural households (30 percent). Possession of a radio has decreased from 24 percent to 8 percent in the last four years, while ownership of a television has increased from 30 percent to 40 percent. A refrigerator is available in 14 percent of households, with urban households six times as likely (36 percent) as rural households (6 percent) to own one. More than 7 out of 10 households possess a table and a chair. More than half of all households possess an electric fan, with a higher percentage in urban areas than rural areas (86 percent and 41 percent, respectively). Twelve percent of households own a DVD/VCD player: 24 percent in urban areas and 8 percent in rural areas. Table 2.5 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Bangladesh 2011 Possession Residence Total Urban Rural Household effects Radio 6.9 8.7 8.2 Television 70.2 29.8 39.9 Mobile telephone 89.2 74.8 78.4 Non-mobile telephone 7.6 0.3 2.1 Refrigerator 35.6 6.2 13.5 Cupboard 54.3 28.7 35.2 Table 74.6 72.1 72.7 Chair 75.7 74.5 74.8 Electric fan 85.9 41.2 52.4 DVD/VCD player 23.8 8.1 12.1 Water pump 10.8 4.2 5.8 Means of transport Bicycle 16.6 28.4 25.4 Autobike 0.6 0.4 0.4 Motorcycle/scooter 7.1 4.9 5.4 Rickshaw/van 4.5 6.7 6.1 Ownership of agricultural land Homestead 90.4 95.8 94.4 Other land 38.6 49.4 46.6 Neither 8.7 3.9 5.1 Ownership of farm animals Bulls/Buffaloes 0.1 0.5 0.4 Cows 12.0 45.7 37.2 Goats/sheep 7.8 28.9 23.6 Chicken/ducks 24.7 70.3 58.9 Number 4,305 12,836 17,141 Housing Characteristics and Household Population • 17 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 little difference between rural and urban households. Ownership of a motorcycle is slightly higher in urban areas (7 percent) than in rural areas (5 percent). Ninety-four percent of households own a homestead, while 47 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 has declined slightly since 2004, from 52 to 47 percent, especially in rural areas, while ownership of a homestead has remained unchanged. Chicken or ducks, the most commonly owned type of livestock, are owned by 59 percent of households. Almost four out of ten households own cows, and one-quarter of households own goats or sheep. As expected, rural households are more likely than urban households to own each 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 2.6 presents the wealth quintiles by urban-rural residence and administrative division. More than half of the population (55 percent) residing in urban areas is in the highest wealth quintile, compared with 9 percent in rural areas. Among the administrative divisions, people living in Dhaka are more likely to fall in the highest wealth quintile than people living in other divisions. In contrast, Rangpur and Sylhet divisions have the highest proportion of the population in the lowest wealth quintile (30 and 24 percent, respectively). 18 • Housing Characteristics and Household Population Table 2.6 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini Coefficient, according to residence and region, Bangladesh 2011 Residence/ region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 5.8 5.9 9.2 24.0 55.1 100.0 19,158 24.4 Rural 24.5 24.5 23.5 18.7 8.8 100.0 59,752 30.3 Division Barisal 20.7 28.4 24.7 17.7 8.5 100.0 4,603 30.7 Chittagong 15.3 19.6 21.0 24.5 19.7 100.0 15,386 33.1 Dhaka 19.1 16.2 17.1 18.3 29.3 100.0 25,126 40.6 Khulna 16.4 18.6 22.7 22.6 19.8 100.0 8,742 31.5 Rajshahi 21.3 21.9 23.2 21.1 12.5 100.0 11,001 30.4 Rangpur 30.0 27.4 18.2 15.4 8.9 100.0 8,916 29.1 Sylhet 24.0 17.4 19.0 18.1 21.5 100.0 5,135 34.3 Total 20.0 20.0 20.0 20.0 20.0 100.0 78,909 32.7 Table 2.6 also includes information on the Gini coefficient, which indicates the level of concentration of wealth (0 being an equal distribution and 1 being a totally unequal distribution). This ratio is expressed as a proportion between 0 and 1. Wealth inequality, as measured by the Gini coefficient, is higher in rural than in urban areas (30 percent vs. 24 percent. Inequality in wealth is highest in Dhaka (41 percent). 2.3 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.7 shows the distribution of the de facto household population by age, sex, and residence. The 2011 BDHS enumerated a total of 77,514 persons (37,381 males and 40,133 females). The sex ratio is 93 males per 100 females. This is similar to the sex ratio of 95 males per 100 females obtained in the 2007 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’ 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. Table 2.7 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 2011 Age Urban Rural Total Total Male Female Total Male Female Total Male Female <5 10.4 9.4 9.9 12.2 11.0 11.6 11.7 10.6 11.2 5-9 11.3 10.1 10.7 13.4 12.0 12.7 12.9 11.6 12.2 10-14 11.4 10.8 11.1 12.7 11.7 12.2 12.4 11.5 11.9 15-19 8.8 11.9 10.4 8.8 10.6 9.8 8.8 10.9 9.9 20-24 8.5 11.7 10.1 7.0 9.9 8.5 7.3 10.3 8.9 25-29 8.8 9.8 9.3 6.5 8.6 7.6 7.1 8.9 8.0 30-34 7.6 7.5 7.5 6.1 6.5 6.3 6.4 6.8 6.6 35-39 6.8 6.3 6.6 5.6 5.5 5.5 5.9 5.7 5.8 40-44 6.0 5.9 6.0 5.1 5.4 5.2 5.3 5.5 5.4 45-49 5.4 5.1 5.3 4.9 4.5 4.7 5.0 4.7 4.8 50-54 4.3 2.8 3.5 4.6 3.4 4.0 4.5 3.3 3.9 55-59 3.7 2.8 3.3 3.0 3.1 3.0 3.2 3.0 3.1 60-64 2.3 2.1 2.2 3.1 2.6 2.8 2.9 2.5 2.7 65-69 1.8 1.0 1.4 2.3 1.6 2.0 2.2 1.5 1.8 70-74 1.4 1.1 1.3 2.0 1.5 1.7 1.9 1.4 1.6 75-79 0.5 0.5 0.5 1.0 0.6 0.8 0.9 0.6 0.7 80+ 0.8 1.0 0.9 1.7 1.5 1.6 1.5 1.3 1.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 9,318 9,749 19,067 28,063 30,384 58,447 37,381 40,133 77,514 Housing Characteristics and Household Population • 19 More than one-third of the de facto household population (37 percent) is under age 15, and 11 percent is under age 5. People age 65 and older account for just 6 percent of the total population. The proportion of the population under age 15 is somewhat lower in urban than rural areas, as is the proportion of the population older than age 65. The age-sex structure of the population is shown by the population pyramid in Figure 2.1. The pyramid is wider at the base than the top and narrows slightly at the youngest age group. This pattern is typical of a historically high-fertility regime that has recently started to stabilize or decline. Figure 2.2 shows the distribution of the male and female household populations by single years of age. The figure shows noticeable heaping at ages ending with 0 and 5, and heaping is more prominent among males than females. Ages ending with 1 and 9 are underreported. Figure 2.1 Population pyramid 8 6 4 2 0 2 4 6 8 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Percent Age Male Female BDHS 2011 20 • Housing Characteristics and Household Population Figure 2.2 Distribution of the de facto household population by single year of age and sex 0 1 2 3 4 5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70+ Percent Single year of age Male Female BDHS 2011 Table 2.8 presents changes in the broad age structure of the population since 1989. The proportion of the population under age 15 has declined from 43 percent in 1989 to 35 percent in 2011. In contrast, the proportion of the population age 15-59 has increased over time, as has the proportion age 60 and over. Table 2.8 Trends in population by age Percent distribution of the de facto population by age group, selected sources, Bangladesh 1989-2011 Age group 1989 BFS 1989 CPS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS <15 43.2 43.2 42.7 42.6 41.0 39.2 38.2 36.3 35.3 15-59 50.9 50.9 51.2 51.2 53.1 54.4 55.1 56.6 56.5 60+ 5.9 5.9 6.0 6.2 5.9 6.4 6.6 7.1 8.2 Total 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 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 2.9 presents information on household composition. The majority (89 percent) of households are headed by men. Only 11 percent of households are headed by women. The proportion of female-headed households has dropped from 13 percent in 2007 to 11 percent in 2011, with the drop more marked in rural than urban areas. More than half of the households in Bangladesh are composed of two to four members. The average household size is 4.6 persons, as compared with 4.7 in 2007; household sizes are larger in rural (4.7) than in urban (4.4) areas. Housing Characteristics and Household Population • 21 Table 2.9 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 2011 Characteristic Residence Total Urban Rural Household headship Male 88.8 89.0 89.0 Female 11.2 11.0 11.0 Total 100.0 100.0 100.0 Number of usual members 1 1.3 1.9 1.7 2 9.5 8.6 8.8 3 20.2 17.7 18.3 4 27.7 24.8 25.5 5 19.5 20.2 20.0 6 11.1 12.7 12.3 7 5.0 6.4 6.0 8 2.7 3.3 3.1 9+ 3.1 4.5 4.1 Total 100.0 100.0 100.0 Mean size of households 4.4 4.7 4.6 Number of households 4,305 12,836 17,141 Note: Table is based on de jure household members, i.e., usual residents. 2.5 BIRTH REGISTRATION UNICEF supported the government’s program for birth registration in Bangladesh from 2001- 2006 in 28 districts and 4 city corporations. According to the amended Birth and Death Registration Act of 2004, which came into force in 2006, children born in Bangladesh must be registered and have a birth certificate. The government of Bangladesh set the target of universal registration for the end of 2008. This deadline was extended for children under age 18 to the end of June 2010. After this date a fee for registration was instituted. However, the registration of babies under age 2 remains free of charge. Birth certificates were made mandatory for 16 services, including school enrollment, passports, voter registration, and marriage registration. The local governmental and nongovernmental organizations (NGOs) are participating in birth registration for populations where they work. In 2009 a computerized birth registration system was introduced in Bangladesh on a pilot basis. Upon completion of the pilot, the system will be expanded to the entire country (UNICEF, nd). In the 2011 BDHS, information on birth registration was solicited for children under age 5. Table 2.10 presents the percentage of the de jure population under age 5 whose births are registered with the civil authorities, according to background characteristics. More than three in ten children (31 percent) have their births registered, and 22 percent of children under age 5 have a birth certificate. Although the vital registration system of the government requires that a newborn be registered within the shortest possible time, Table 2.10 indicates that children under age 2 are much less likely to be registered than children age 2-4 (13 and 41 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. 22 • Housing Characteristics and Household Population Table 2.10 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, according to background characteristics, Bangladesh 2011 Background characteristic Children whose births are registered Number of children Percentage who had a birth certificate Percentage who did not have birth certificate Percentage registered Age <2 9.4 3.9 13.3 3,187 2-4 30.3 10.6 40.9 5,300 Sex Male 22.2 8.3 30.5 4,304 Female 22.7 7.8 30.5 4,183 Residence Urban 26.5 8.6 35.0 1,880 Rural 21.3 8.0 29.2 6,606 Division Barisal 24.4 9.2 33.6 476 Chittagong 24.5 6.7 31.2 1,956 Dhaka 19.2 7.6 26.9 2,646 Khulna 25.7 6.2 31.9 761 Rajshahi 17.5 8.5 26.0 1,077 Rangpur 22.8 10.2 33.1 924 Sylhet 31.7 11.7 43.5 646 Wealth quintile Lowest 17.2 6.3 23.5 2,066 Second 19.4 8.5 27.9 1,719 Middle 23.0 8.1 31.1 1,594 Fourth 24.8 7.3 32.1 1,613 Highest 30.0 11.0 41.0 1,494 Total 22.4 8.1 30.5 8,487 Table 2.10 shows that birth registration is higher in urban (35 percent) than in rural (29 percent) areas. There is no difference regarding the extent of birth registration among male and female children. Among the administrative divisions, 44 percent of children from Sylhet, and around one-third of children from Barisal, Chittagong, Khulna, and Rangpur divisions are registered. Only one-quarter of the children from Dhaka and Rajshahi are registered. Children from the highest wealth quintile are more likely to have their births registered (41 percent) than children from the lowest wealth quintile (24 percent). 2.6 SCHOOL ATTENDANCE In the 2011 BDHS, information was collected about school attendance of household members age 6 to 24. Table 2.11 shows that the proportion of the population that attends school declines with age. Whereas 88 percent of children age 6-10 are in school, the percentage decreases to 79 percent for children age 11-15, and to 34 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, which had a special focus on female education. 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 from that in the 2007 BDHS. For example, the proportion of children age 6-15 who are attending school has increased from 80 percent in 2007 (NIPORT, Mitra and Associates and Macro International, 2009) to 84 percent in 2011. Housing Characteristics and Household Population • 23 Table 2.11 School attendance Percentage of the de facto household population age 6-24 attending school, by age, sex, and residence, Bangladesh 2011 Background characteristic Male Female Total Urban Rural Total Urban Rural Total Urban Rural Total 6-15 81.7 82.3 82.2 82.9 85.8 85.2 82.3 84.1 83.7 6-10 86.3 86.9 86.7 87.7 88.8 88.6 87.0 87.9 87.7 11-15 76.7 76.9 76.8 77.8 82.3 81.2 77.2 79.6 79.0 16-20 44.6 40.1 41.3 35.1 27.0 29.2 38.9 32.6 34.3 21-24 24.5 17.5 19.6 14.5 6.9 9.0 18.5 10.9 13.1 2.7 EDUCATION OF HOUSEHOLD POPULATION Studies have shown that education is one of the major socioeconomic factors that influences 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 methods, 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. The country is responsible for providing 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 an opening up of non-grade-level schools, which offer pre-primary education. Government also is implementing nonformal 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. Tables 2.12.1 and 2.12.2 show the distribution of the male and female household populations age 6 and older by the highest level of education completed and the median number of years of education completed, according to background characteristics. The majority of Bangladeshis who are age 6 and older have attended school. Only one in four men and about one in three women have never attended school. There is no gender difference in primary education. However, men are more likely to have completed secondary school or have attained a higher education compared with women (15 percent versus 10 percent). There has been an increase in the proportions of men and women who have completed secondary or higher education since 2007. For men, the proportion has increased from 12 percent to 15 percent, and for women it has increased from 7 percent to 10 percent in 2011. 24 • Housing Characteristics and Household Population Table 2.12.1 Educational attainment of the male household population Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Bangladesh 2011 Background characteristic No education Primary incomplete Completed primary1 Secondary incomplete Completed secondary or higher2 Don’t know/ missing Total Number Median years completed Age 6-9 28.5 71.4 0.0 0.1 0.0 0.0 100.0 4,002 0.0 10-14 5.8 60.9 3.6 29.5 0.2 0.0 100.0 4,624 3.0 15-19 7.4 17.7 11.5 43.3 20.2 0.0 100.0 3,302 6.4 20-24 12.6 16.8 13.5 29.9 27.2 0.0 100.0 2,738 6.1 25-29 17.1 15.8 14.5 29.5 23.0 0.0 100.0 2,651 5.2 30-34 24.3 17.8 11.6 23.2 23.1 0.0 100.0 2,410 4.6 35-39 31.1 16.9 10.2 19.5 22.3 0.0 100.0 2,197 4.2 40-44 33.6 15.1 9.3 18.5 23.5 0.0 100.0 1,983 4.1 45-49 37.1 17.9 8.4 17.5 19.0 0.0 100.0 1,881 3.1 50-54 42.0 16.7 10.2 16.0 15.1 0.0 100.0 1,689 1.9 55-59 38.4 12.1 8.1 16.9 24.6 0.0 100.0 1,194 3.9 60-64 44.9 15.0 13.4 11.1 15.6 0.0 100.0 1,085 1.4 65+ 50.4 15.1 10.5 14.1 10.0 0.0 100.0 2,419 0.0 Residence Urban 16.9 24.3 8.4 24.2 26.3 0.0 100.0 8,170 4.8 Rural 27.4 31.4 8.9 21.0 11.3 0.0 100.0 24,008 2.7 Division Barisal 17.9 34.1 9.1 24.2 14.7 0.0 100.0 1,821 3.7 Chittagong 22.2 33.0 8.7 22.7 13.5 0.0 100.0 5,809 3.3 Dhaka 26.6 27.5 8.5 20.4 17.1 0.0 100.0 10,374 3.3 Khulna 22.0 28.2 8.0 25.1 16.7 0.0 100.0 3,707 4.0 Rajshahi 26.5 27.9 8.3 21.6 15.8 0.0 100.0 4,623 3.3 Rangpur 27.6 29.0 9.3 21.4 12.7 0.0 100.0 3,764 3.1 Sylhet 24.4 34.5 11.3 19.9 9.9 0.0 100.0 2,080 2.7 Wealth quintile Lowest 45.0 37.1 7.6 9.3 1.0 0.0 100.0 6,143 0.0 Second 31.0 35.3 10.0 18.6 5.1 0.0 100.0 6,426 1.7 Middle 23.1 31.0 10.2 24.5 11.2 0.0 100.0 6,501 3.5 Fourth 16.9 26.0 9.4 28.6 19.0 0.0 100.0 6,386 4.6 Highest 9.2 19.4 6.7 27.2 37.5 0.0 100.0 6,721 7.6 Total 24.7 29.6 8.8 21.8 15.1 0.0 100.0 32,177 3.4 Note: Total includes one man with missing information on age. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 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 (37 percent) among those age 45-49 than among boys age 10-14 (6 percent). Similarly, 54 percent of women age 45-49 have no education compared with only 4 percent of girls age 10-14. Overall, levels of educational attainment are higher in urban than in rural areas (Tables 2.12.1 and 2.12.2). The proportions of men and women with no education are lower in urban areas (17 percent of men and 22 percent of women) than in rural areas (27 percent of men and 32 percent of women), while the proportions who have completed secondary or higher schooling are greater in urban areas (26 percent of men and 19 percent of women) than in rural areas (11 percent of men and 7 percent of women). On average, men and women living in urban areas have completed almost two more years of school than those living in rural areas. There are also regional variations in educational attainment. Barisal division has the highest proportion of men and women with some education (82 percent of men and 79 percent of women) and Rangpur has the lowest (72 percent of men and 67 percent of women). Housing Characteristics and Household Population • 25 Table 2.12.2 Educational attainment of the female household population Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Bangladesh 2011 Background characteristic No education Primary incomplete Completed primary1 Secondary incomplete Completed secondary or higher2 Don’t know/ missing Total Number Median years completed Age 6-9 24.1 75.8 0.0 0.1 0.0 0.0 100.0 3,923 0.0 10-14 4.1 55.6 4.4 35.8 0.1 0.0 100.0 4,597 3.5 15-19 5.8 12.5 9.6 52.8 19.3 0.0 100.0 4,383 6.9 20-24 9.8 14.4 12.5 44.9 18.3 0.0 100.0 4,135 6.5 25-29 18.7 18.8 11.8 33.5 17.2 0.0 100.0 3,564 4.9 30-34 30.9 20.8 10.6 21.8 15.8 0.0 100.0 2,717 3.8 35-39 41.3 18.7 10.0 17.8 12.3 0.0 100.0 2,297 1.9 40-44 49.0 18.7 10.4 13.4 8.5 0.0 100.0 2,206 0.0 45-49 54.4 18.9 10.0 10.9 5.8 0.0 100.0 1,878 0.0 50-54 62.2 16.7 9.3 8.1 3.7 0.0 100.0 1,305 0.0 55-59 67.9 12.2 8.9 7.6 3.3 0.0 100.0 1,208 0.0 60-64 73.9 13.7 6.7 4.4 1.2 0.0 100.0 1,001 0.0 65+ 81.3 9.7 5.2 3.1 0.6 0.0 100.0 1,925 0.0 Residence Urban 22.0 24.0 8.0 27.3 18.7 0.0 100.0 8,676 4.4 Rural 31.7 29.2 8.3 24.4 6.5 0.0 100.0 26,465 2.3 Division Barisal 20.6 32.2 11.3 26.6 9.4 0.0 100.0 2,087 3.7 Chittagong 27.1 28.1 8.0 27.9 8.8 0.0 100.0 6,819 3.2 Dhaka 30.3 27.1 8.1 23.3 11.2 0.0 100.0 11,248 2.8 Khulna 26.7 27.6 6.7 29.3 9.6 0.0 100.0 4,022 3.4 Rajshahi 31.4 27.2 8.6 24.0 8.8 0.0 100.0 4,872 2.6 Rangpur 33.5 28.1 6.9 23.2 8.3 0.0 100.0 3,847 2.0 Sylhet 31.6 28.9 10.9 22.1 6.5 0.0 100.0 2,246 2.3 Wealth quintile Lowest 46.8 34.7 6.5 11.5 0.4 0.0 100.0 6,573 0.0 Second 34.7 32.1 8.7 21.9 2.7 0.0 100.0 6,915 1.6 Middle 28.2 27.9 9.6 28.7 5.7 0.0 100.0 7,153 3.2 Fourth 22.9 25.7 9.3 31.2 10.9 0.0 100.0 7,226 4.1 Highest 15.8 19.9 7.0 30.8 26.6 0.0 100.0 7,275 6.1 Total 29.3 27.9 8.2 25.1 9.5 0.0 100.0 35,141 2.9 Note: Total includes three women with missing information on age. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Wealth exerts a positive influence on educational attainment. Women from the highest wealth quintile are more likely to be educated than other women. Men and women in the lowest wealth quintiles are less likely to have attended school. Among men, 45 percent of those in the lowest quintile have never attended school compared with 9 percent in the highest quintile. Differences by wealth are equally large among women; 47 percent of women from the lowest quintile have no schooling compared with 16 percent from the highest wealth quintile. A comparison of the 2007 and 2011 BDHS surveys shows a marked rise in completed median years of schooling. Over this four-year period, the completed median years of schooling among men have increased from 2.9 to 3.4 years. Similarly, the completed median years of schooling have increased from 2.1 to 2.9 among women. 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 2.13 provides 26 • Housing Characteristics and Household Population data on net attendance ratios and gross attendance ratios by sex and level of schooling. The NAR at the primary level is 75 percent (73 percent for males and 77 percent for females). The NAR at the secondary level is 38 percent (36 percent for males and 40 percent for females). Table 2.13 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 2011 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 72.1 73.6 72.8 1.02 108.6 106.1 107.4 0.98 Rural 73.3 77.4 75.4 1.06 114.3 116.7 115.5 1.02 Division Barisal 78.3 84.9 81.6 1.08 118.7 127.6 123.1 1.07 Chittagong 71.8 73.4 72.6 1.02 113.2 114.4 113.8 1.01 Dhaka 69.7 74.5 72.1 1.07 107.1 108.7 107.9 1.01 Khulna 78.8 83.3 81.0 1.06 117.8 118.4 118.1 1.00 Rajshahi 72.1 74.2 73.1 1.03 115.9 118.9 117.4 1.03 Rangpur 74.8 80.0 77.3 1.07 113.2 113.5 113.3 1.00 Sylhet 78.0 78.4 78.2 1.01 122.9 117.9 120.4 0.96 Wealth quintile Lowest 65.7 69.8 67.7 1.06 102.7 109.8 106.1 1.07 Second 74.5 78.0 76.2 1.05 124.0 124.4 124.2 1.00 Middle 73.3 82.0 77.7 1.12 119.9 119.6 119.7 1.00 Fourth 78.8 77.8 78.3 0.99 110.9 113.3 112.1 1.02 Highest 76.3 77.1 76.7 1.01 110.5 104.5 107.4 0.95 Total 73.0 76.6 74.8 1.05 113.1 114.4 113.7 1.01 SECONDARY SCHOOL Residence Urban 39.0 40.8 40.0 1.05 43.3 43.9 43.6 1.01 Rural 35.3 39.3 37.4 1.11 40.1 42.8 41.5 1.07 Division Barisal 42.8 43.0 42.9 1.00 46.8 46.5 46.6 0.99 Chittagong 34.5 39.5 37.1 1.15 39.2 44.3 41.9 1.13 Dhaka 35.0 36.9 36.0 1.05 39.1 39.6 39.4 1.01 Khulna 40.7 46.5 43.7 1.14 45.6 49.4 47.5 1.09 Rajshahi 36.2 38.6 37.4 1.07 42.3 41.7 42.0 0.99 Rangpur 37.9 43.8 40.9 1.16 41.9 46.5 44.2 1.11 Sylhet 31.4 35.6 33.5 1.14 36.5 39.5 38.0 1.08 Wealth quintile Lowest 15.8 22.4 19.0 1.42 18.0 24.0 20.9 1.33 Second 30.4 35.2 32.9 1.16 35.2 39.0 37.1 1.11 Middle 37.8 44.8 41.5 1.19 43.8 49.0 46.5 1.12 Fourth 47.1 45.9 46.4 0.98 53.0 50.0 51.4 0.94 Highest 51.9 49.1 50.5 0.95 56.0 52.1 54.0 0.93 Total 36.2 39.7 38.0 1.10 40.8 43.1 42.0 1.05 1 The NAR for primary school is the percentage of the primary-school age (age 6-10) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (age 11-17) 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. 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, and Sylhet has one of the highest NARs and GARs 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. However, at the secondary level, children in the highest wealth quintile have the highest NAR and GAR and children in the lowest wealth quintile have the lowest NAR and GAR (Table 2.13). Housing Characteristics and Household Population • 27 Table 2.13 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 attend school. The indexes for NAR and GAR at the primary level are slightly higher than 1.00 (1.05 versus 1.01), indicating that the gender gap is very narrow. Figure 2.3 shows that, for ages 5-14, girls have a higher level of school attendance than boys. The pattern reverses at age 15 and older. Attendance is highest at age 10 for boys and at age 11 for girls. Figure 2.3 Age-specific attendance rates of the de facto population age 5-24 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 (years) Male Female BDHS 2011 2.8 EMPLOYMENT The 2011 BDHS collected information regarding the working status of each person age 8 and older at the time of the survey. Table 2.14 shows that men are much more likely than women to be employed (64 percent and 11 percent, respectively). The proportion of people who are employed has decreased since 2007. For men, the proportion has decreased from 68 percent to 64 percent and for women, from 23 percent to 11 percent. The urban population is much more likely to be employed than the rural population. For men, the proportion is 67 percent urban versus 63 percent rural, and for women, the proportion is 18 percent urban and 8 percent rural, respectively. Table 2.14 Employment status Percentage of male and female de facto household population age eight and over who are working at the time of the survey, by age, sex, and residence, Bangladesh 2011 Age Male Female Urban Rural Total Urban Rural Total 8-9 1.4 1.0 1.1 2.2 0.5 0.8 10-14 10.4 8.9 9.3 9.6 1.6 3.4 15-19 44.4 42.8 43.2 15.9 5.0 7.9 20-24 69.5 75.4 73.7 20.8 11.6 14.1 25-29 91.2 92.9 92.4 29.2 12.9 17.2 30-34 97.3 96.5 96.8 27.2 12.9 16.8 35-39 98.0 98.4 98.3 25.3 14.0 17.0 40-44 97.3 97.7 97.6 20.4 13.0 14.9 45-49 97.7 97.6 97.6 22.2 12.6 15.2 50-54 94.8 96.4 96.0 14.1 10.9 11.6 55-59 89.6 88.8 89.0 11.1 6.1 7.2 60-64 70.2 81.5 79.3 5.2 5.1 5.1 65+ 43.8 49.7 48.6 2.6 2.2 2.3 Total 66.9 63.2 64.1 18.0 8.2 10.6 Number 7,721 22,409 30,130 8,245 24,885 33,130 Characteristics of Survey Respondents • 29 CHARACTERISTICS OF RESPONDENTS 3 his chapter presents the demographic and socioeconomic profile of the Bangladesh respondents in 2011. The profile 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 2011 BDHS includes results from completed interviews with 17,749 ever-married women age 15-491 and 3,997 ever-married men age 15-54. 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS Basic background characteristics of the 17,749 ever-married women and 3,997 ever-married men, age 15-49, are presented in Table 3.1. Half of the women (50 percent) and 26 percent of the men are under age 30. The majority of women (94 percent) and nearly all men (99 percent) are currently married. The majority of respondents (74 percent of women and 72 percent of men) reside in the rural areas. The respondents are not evenly distributed across geographic divisions. Almost one-third of respondents live in Dhaka. The distribution of sampled women by division is similar to that in the 2007 BDHS, except in Rajshahi division, which was divided into two administrative divisions, Rajshahi and Rangpur, between the two BDHS surveys; 15 percent of women resided in Rajshahi and 12 percent in Rangpur in the current survey. Twenty-eight percent of women and 26 percent of men age 15-49 have no education, while 12 percent of women and 18 percent of men have completed secondary- or higher-level education. The vast majority of the respondents (90 percent) are Muslims. Most of the remaining women and men are Hindus. Very few of the respondents are Buddhists or Christians. Because the male respondents in the 2011 BDHS come from the same households as the female respondents, it is possible to match married men to their spouses. Figure 3.1 shows the age differentials 1 The survey interviewed ever-married women age 12-49. However, less than 1 percent of ever-married women were age 12-14. These women have been removed from the data set, and the weights have been recalculated for the 15-49 age group. T Key Findings: • Twenty-eight percent of ever-married women and 26 percent of ever- married men age 15-49 have no education. The percentage of women and men with no education has decreased since 2007. However, the percentage of women and men with secondary or higher education has remained stable over the same period. • Forty-nine percent of women and 22 percent of men are not regularly exposed to any media source. • Fifteen percent of women were employed in the 12 months preceding the survey, with the highest percentages employed in factory or blue collar (25 percent) and semi-skilled services (22 percent). • The majority of working men consider their earnings moderately sufficient (62 percent) or sufficient (10 percent) to provide for their family’s basic needs. 30 • Characteristics of Survey Respondents between spouses for matched couples in the current and the three previous BDHS surveys. Not surprisingly, the husband is older than the wife for almost all couples. Since 2004, the percentage of couples for which the husband is less than 5 years older than the wife has increased, while the percentage of couples for which the husband is 15 years or more older than the wife has declined. Table 3.1 Background characteristics of respondents Percent distribution of ever-married women and men age 15-49 by selected background characteristics, Bangladesh 2011 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 11.1 1,970 1,911 0.6 21 18 20-24 19.8 3,514 3,456 7.3 249 222 25-29 19.1 3,394 3,387 18.3 621 629 30-34 15.0 2,654 2,690 18.4 625 618 35-39 12.7 2,246 2,300 19.5 660 673 40-44 12.1 2,152 2,157 18.5 629 636 45-49 10.3 1,820 1,848 17.3 586 586 Marital status Currently married 93.7 16,635 16,616 99.1 3,360 3,355 Divorced/separated/ widowed 6.3 1,114 1,133 0.9 31 27 Residence Urban 26.0 4,619 6,179 28.0 949 1,224 Rural 74.0 13,130 11,570 72.0 2,442 2,158 Division Barisal 5.6 1,002 2,050 5.1 174 341 Chittagong 18.2 3,222 2,864 15.3 519 478 Dhaka 32.3 5,736 3,062 32.3 1,095 586 Khulna 12.0 2,139 2,640 12.7 430 530 Rajshahi 14.9 2,646 2,590 16.4 556 529 Rangpur 11.5 2,039 2,457 13.0 442 534 Sylhet 5.4 967 2,086 5.2 175 384 Educational attainment No education 27.7 4,912 4,629 26.2 890 823 Primary incomplete 18.4 3,264 3,199 24.3 823 830 Primary complete1 11.6 2,062 2,097 9.0 305 306 Secondary incomplete 30.3 5,383 5,458 22.4 758 753 Secondary complete or higher2 12.0 2,127 2,366 18.1 615 670 Religion Islam 90.0 15,980 15,758 89.6 3,038 2,971 Hinduism 9.5 1,689 1,907 9.9 337 394 Buddhism 0.2 44 36 0.2 6 5 Christianity 0.2 37 48 0.3 10 12 Wealth quintile Lowest 18.3 3,250 3,077 19.3 654 602 Second 19.6 3,487 3,315 19.6 666 636 Middle 20.1 3,567 3,403 19.1 647 644 Fourth 20.6 3,664 3,762 21.4 726 714 Highest 21.3 3,781 4,192 20.6 699 786 Total 15-49 100.0 17,749 17,749 100.0 3,392 3,382 50-54 na na na na 605 615 Total 15-54 na na na na 3,997 3,997 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. na = Not applicable Characteristics of Survey Respondents • 31 Figure 3.1 Trends in age differential between spouses, 1999-2011 BDHS 2 14 41 31 12 1 14 40 30 14 1 17 40 30 12 1 19 40 30 10 Wife older 0-4 years 5-9 years 10-14 years 15+ years Age difference 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Percent 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. Tables 3.2.1 and 3.2.2 present differentials in the educational attainment of women and men by selected background characteristics. Table 3.2.1 shows that 28 percent of ever-married women age 15-49 have never been to school, 18 percent have completed some primary education, 12 percent have completed all primary education, 30 percent have completed some secondary education, and 12 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 pronounced at the secondary and higher levels. For example, urban women are almost three times more likely than rural women to have completed secondary or higher education (23 percent and 8 percent, respectively). Between 10 and 14 percent of women in all geographic divisions have completed secondary or higher-level education except in Sylhet, where only 7 percent of women have completed secondary or higher-level education. Sylhet also has the highest proportion of women with no education (35 percent). Women in the highest wealth quintile are most likely to complete secondary or higher-level education; 35 percent of women in the highest wealth quintile achieved this level. In Bangladesh, women age 15-49 have completed a median of 4.3 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 eight years compared with no years of schooling for women in the lowest quintile. 32 • Characteristics of Survey Respondents Table 3.2.1 Educational attainment: Women Percent distribution of ever-married women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Bangladesh 2011 Background characteristic Highest level of schooling Total Median years completed Number of women No education Primary incomplete Completed primary1 Secondary incomplete Secondary complete or higher2 Age 15-19 8.1 14.9 12.3 54.9 9.9 100.0 6.1 1,970 20-24 10.2 16.0 13.6 47.6 12.6 100.0 6.0 3,514 25-29 18.5 19.4 12.3 34.1 15.7 100.0 4.9 3,394 30-34 30.7 21.2 10.9 21.9 15.2 100.0 3.7 2,654 35-39 40.8 19.0 10.3 17.7 12.2 100.0 2.0 2,246 40-44 48.7 19.0 10.5 13.5 8.3 100.0 0.0 2,152 45-49 54.3 19.4 9.8 11.1 5.4 100.0 0.0 1,820 Residence Urban 19.5 15.9 9.7 32.0 23.0 100.0 5.6 4,619 Rural 30.6 19.3 12.3 29.7 8.1 100.0 4.0 13,130 Division Barisal 16.3 21.7 16.0 33.8 12.3 100.0 4.6 1,002 Chittagong 24.8 16.4 11.1 35.0 12.7 100.0 4.7 3,222 Dhaka 28.1 18.7 11.5 27.8 14.0 100.0 4.2 5,736 Khulna 23.5 19.7 9.8 35.9 11.2 100.0 4.6 2,139 Rajshahi 30.4 18.8 11.8 29.0 10.0 100.0 4.1 2,646 Rangpur 34.1 18.1 10.0 27.1 10.7 100.0 3.6 2,039 Sylhet 34.8 16.9 16.6 24.4 7.3 100.0 3.7 967 Wealth quintile Lowest 51.3 25.1 10.0 13.2 0.3 100.0 0.0 3,250 Second 36.3 22.5 13.9 24.8 2.4 100.0 2.8 3,487 Middle 25.7 19.5 13.5 35.0 6.2 100.0 4.3 3,567 Fourth 17.9 16.8 12.8 38.9 13.7 100.0 5.2 3,664 Highest 10.8 9.3 7.9 37.4 34.6 100.0 8.0 3,781 Total 27.7 18.4 11.6 30.3 12.0 100.0 4.3 17,749 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Differentials in educational attainment across groups of ever-married men are similar to those of women. Younger men, those in urban areas, and those in the higher wealth quintiles are more likely to be educated than other men. The percentage of men with no education is lower than that of women (26 and 28 percent, respectively), and the percentage of men who have secondary or higher education is higher than that of women (18 and 12 percent, respectively) (Table 3.2.2). There have been improvements in educational attainment in Bangladesh over the past four years. The percentage of ever-married women and men with no education has declined. For women, the percentage has declined from 34 percent in 2007 to 28 percent in 2011, and for men it has declined from 31 percent in 2007 to 26 percent in 2011. However, the proportion of women and men who have completed secondary school or higher remained unchanged between 2007 and 2011. Another indicator of progress in education is the median length of schooling. For women, it increased from 3.2 years in 2007 to 4.3 years in 2011, and for men it increased from 2.7 years to 3.9 years. Characteristics of Survey Respondents • 33 Table 3.2.2 Educational attainment: Men Percent distribution of ever-married men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Bangladesh 2011 Background characteristic Highest level of schooling Total Median years completed Number of men No education Primary incomplete Completed primary1 Secondary incomplete Secondary complete or higher2 Age 15-19 * * * * * * * 21 20-24 16.6 32.0 10.5 30.4 10.6 100.0 4.1 249 25-29 17.3 24.3 13.8 31.2 13.3 100.0 4.6 621 30-34 26.0 24.4 9.3 20.9 19.5 100.0 3.9 625 35-39 26.9 25.0 6.7 20.0 21.4 100.0 3.7 660 40-44 31.0 20.5 6.7 18.6 23.2 100.0 3.7 629 45-49 34.8 23.8 7.3 18.0 16.0 100.0 2.3 586 Residence Urban 15.8 21.1 8.7 23.4 31.0 100.0 6.6 949 Rural 30.3 25.5 9.1 21.9 13.1 100.0 3.1 2,442 Division Barisal 14.9 34.9 11.9 21.0 17.4 100.0 4.0 174 Chittagong 25.6 28.2 9.2 19.8 17.2 100.0 3.5 519 Dhaka 26.0 21.7 8.4 22.6 21.3 100.0 4.3 1,095 Khulna 21.5 25.1 9.0 26.1 18.3 100.0 4.4 430 Rajshahi 29.7 22.5 9.6 22.5 15.7 100.0 3.6 556 Rangpur 29.7 23.2 8.4 21.4 17.4 100.0 3.4 442 Sylhet 33.1 24.4 8.7 22.7 11.2 100.0 3.1 175 Wealth quintile Lowest 53.6 29.9 7.0 8.7 0.9 100.0 0.0 654 Second 35.1 30.5 10.0 19.8 4.5 100.0 1.8 666 Middle 24.9 28.1 11.7 24.0 11.2 100.0 3.6 647 Fourth 14.7 22.3 10.2 29.5 23.4 100.0 6.0 726 Highest 5.5 11.5 6.2 28.7 48.2 100.0 8.9 699 Total 15-49 26.2 24.3 9.0 22.4 18.1 100.0 3.9 3,392 50-54 36.3 25.7 7.3 15.6 15.1 100.0 1.7 605 Total 15-54 27.8 24.5 8.7 21.3 17.7 100.0 3.7 3,997 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Figure 3.2 shows the educational differences between spouses in matched couples. The proportion of couples who have some education continues to increase, growing from 44 percent in 1999-2000 to 60 percent in 2011, and the percentage in which neither spouse is educated continues to decline, dropping from 25 to 14 percent. For more than one-fourth of couples, only one partner is educated. The probability that the husband is the only educated partner has decreased, while the probability that the wife is the only educated partner remained unchanged between 2007 and 2011. 34 • Characteristics of Survey Respondents Figure 3.2 Trends in education of couples, 1999-2011 BDHS 44 21 10 25 49 20 11 20 55 14 15 16 60 11 15 14 Husband and wife: both educated Husband educated, wife not Wife educated, husband not Husband and wife: neither educated 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Percent 3.3 LITERACY Literacy is widely acknowledged as benefiting both the individual and society. Particularly among women, literacy is associated with many 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 2011 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. Tables 3.3.1 and 3.3.2 present the findings. Tables 3.3.1 and 3.3.2 indicate that 63 percent each of ever-married women and men age 15-49 are literate. The level of literacy decreases as age increases; 84 percent of women age 15-19 are literate compared with 36 percent of women age 45-49. Literacy varies by urban-rural residence; 72 percent of urban women are literate compared with 60 percent of rural women (Table 3.3.1). Characteristics of Survey Respondents • 35 Divisional differences in literacy are notable. The proportion of women who are literate ranges from 56 percent in Rangpur to 73 percent in Barisal. There is also a marked difference in literacy level by household wealth, ranging from 36 percent among women in the lowest wealth quintile to 85 percent among women in the highest wealth quintile. Table 3.3.1 Literacy: Women Percent distribution of ever-married women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Bangladesh 2011 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all Age 15-19 64.8 8.7 10.2 16.2 100.0 83.6 1,970 20-24 60.2 11.4 9.5 18.9 100.0 81.0 3,514 25-29 49.9 10.9 11.2 28.0 100.0 72.0 3,394 30-34 37.1 10.2 12.2 40.4 100.0 59.6 2,654 35-39 29.9 10.2 9.1 50.8 100.0 49.2 2,246 40-44 21.8 9.7 10.0 58.3 100.0 41.5 2,152 45-49 16.5 9.4 10.2 63.7 100.0 36.1 1,820 Residence Urban 55.0 8.8 8.4 27.6 100.0 72.3 4,619 Rural 37.8 10.8 11.1 40.3 100.0 59.7 13,130 Division Barisal 46.1 15.2 11.3 27.3 100.0 72.5 1,002 Chittagong 47.7 9.9 9.7 32.6 100.0 67.3 3,222 Dhaka 41.8 10.0 10.7 37.5 100.0 62.4 5,736 Khulna 47.1 9.3 10.6 32.9 100.0 66.9 2,139 Rajshahi 39.0 10.8 9.6 40.5 100.0 59.4 2,646 Rangpur 37.8 7.4 10.7 44.1 100.0 55.8 2,039 Sylhet 31.7 14.5 11.1 42.6 100.0 57.3 967 Wealth quintile Lowest 13.6 10.5 11.6 64.3 100.0 35.7 3,250 Second 27.3 11.3 13.0 48.3 100.0 51.6 3,487 Middle 41.3 11.2 11.5 36.0 100.0 63.9 3,567 Fourth 52.5 11.3 10.3 25.8 100.0 74.1 3,664 Highest 72.0 7.1 5.9 14.8 100.0 85.1 3,781 Total 42.3 10.2 10.4 37.0 100.0 62.9 17,749 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 36 • Characteristics of Survey Respondents Differentials in literacy rate by the selected background characteristics among men are similar to those among women (Table 3.3.2). Table 3.3.2 Literacy: Men Percent distribution of ever-married men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Bangladesh 2011 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all Missing Age 15-19 * * * * * * * 21 20-24 41.0 11.5 16.4 31.1 0.0 100.0 68.9 249 25-29 44.5 11.5 14.7 28.9 0.4 100.0 70.7 621 30-34 40.3 7.5 15.7 36.4 0.0 100.0 63.6 625 35-39 41.5 8.1 12.9 37.2 0.3 100.0 62.5 660 40-44 41.8 8.3 11.0 38.6 0.0 100.0 61.2 629 45-49 34.1 7.6 10.5 47.8 0.0 100.0 52.2 586 Residence Urban 54.4 9.5 10.8 24.8 0.5 100.0 74.7 949 Rural 35.1 8.5 14.3 42.0 0.0 100.0 57.9 2,442 Division Barisal 38.4 11.8 19.9 29.6 0.0 100.0 70.1 174 Chittagong 37.1 11.4 13.1 38.4 0.0 100.0 61.6 519 Dhaka 43.9 8.7 10.6 36.5 0.4 100.0 63.1 1,095 Khulna 44.4 8.6 15.7 31.2 0.0 100.0 68.6 430 Rajshahi 38.1 6.5 15.4 39.7 0.2 100.0 60.1 556 Rangpur 38.8 6.3 12.6 42.2 0.1 100.0 57.7 442 Sylhet 33.9 12.5 14.4 39.2 0.0 100.0 60.8 175 Wealth quintile Lowest 9.5 8.4 12.3 69.6 0.0 100.0 30.3 654 Second 24.3 10.2 15.4 49.8 0.2 100.0 49.9 666 Middle 35.2 10.0 18.7 36.1 0.0 100.0 63.9 647 Fourth 52.8 9.5 14.0 23.3 0.3 100.0 76.4 726 Highest 76.9 5.7 6.8 10.3 0.3 100.0 89.4 699 Total 15-49 40.5 8.8 13.3 37.2 0.2 100.0 62.6 3,392 50-54 30.7 8.2 10.7 50.3 0.2 100.0 49.5 605 Total 15-54 39.0 8.7 12.9 39.2 0.2 100.0 60.6 3,997 Note: Total includes a small number of men who had no card with the required language, are blind or visually impaired, or with missing information. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Includes men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 3.4 ACCESS TO MASS MEDIA Access to information through the media is essential to increase people’s knowledge and awareness of what takes place around them. The 2011 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 3.4.1 shows that 48 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 5 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 (49 percent) of women have no exposure to any of the mass media on a weekly basis. The proportion of women listening to the radio every week has decreased markedly over the years, dropping from 33 percent in 2004, to 19 percent in 2007, and to 5 percent in 2011. Television reached the most women throughout the period (46 percent in 2004, to 47 percent in 2007, and 48 percent in 2011). Characteristics of Survey Respondents • 37 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 read a newspaper once a week is 15 percent compared with 3 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. Table 3.4.1 Exposure to mass media: Women Percentage of ever-married women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Bangladesh 2011 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 4.1 53.6 6.8 0.9 43.0 1,970 20-24 6.1 52.9 5.1 0.6 44.2 3,514 25-29 6.4 51.6 4.8 0.7 45.4 3,394 30-34 6.7 48.8 4.4 0.5 48.9 2,654 35-39 8.6 43.8 5.1 0.5 52.6 2,246 40-44 6.7 43.0 3.3 0.2 54.9 2,152 45-49 4.6 39.5 3.6 0.2 58.0 1,820 Residence Urban 15.4 77.9 3.4 1.1 20.9 4,619 Rural 3.1 38.0 5.2 0.4 58.6 13,130 Division Barisal 3.9 32.8 7.9 0.3 61.1 1,002 Chittagong 5.9 48.8 5.1 0.7 49.0 3,222 Dhaka 9.3 58.1 3.8 0.8 40.3 5,736 Khulna 5.0 48.7 5.3 0.3 47.4 2,139 Rajshahi 4.0 46.7 5.4 0.3 49.3 2,646 Rangpur 4.3 33.5 4.3 0.5 63.1 2,039 Sylhet 4.9 41.1 4.0 0.5 57.1 967 Educational attainment No education 0.0 27.8 2.7 0.0 70.5 4,912 Primary incomplete 0.5 39.5 3.8 0.1 57.9 3,264 Primary complete1 1.5 46.1 4.9 0.2 50.8 2,062 Secondary incomplete 5.7 61.0 6.0 0.5 36.0 5,383 Secondary complete or higher2 35.6 79.9 7.4 2.9 15.0 2,127 Wealth quintile Lowest 0.5 12.9 2.9 0.1 85.1 3,250 Second 1.2 21.0 5.0 0.3 74.9 3,487 Middle 2.4 42.9 6.1 0.4 52.8 3,567 Fourth 4.4 69.8 5.3 0.5 27.7 3,664 Highest 21.4 88.6 4.2 1.5 10.2 3,781 Total 6.3 48.4 4.7 0.5 48.8 17,749 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Men are more likely to be exposed to each type of mass media than women. For instance, 29 percent of men age 15-49 read a newspaper at least once a week compared with 6 percent of women (Table 3.4.2). Three percent of men are exposed to all three media sources each week compared with less than 1 percent of women. Similar to the trend observed with women, the proportion of men who regularly listen to the radio has decreased over the last seven years from 52 percent in 2004 to 38 percent in 2007 and to 10 percent in 2011. This may account for the decrease in the proportion of men exposed to all three types of media: dropping from 10 percent in 2007 to 3 percent in 2011. 38 • Characteristics of Survey Respondents Table 3.4.2 Exposure to mass media: Men Percentage of ever-married men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Bangladesh 2011 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 men Age 15-19 * * * * * 21 20-24 25.1 75.9 12.1 2.9 21.2 249 25-29 30.1 78.4 10.9 3.2 16.8 621 30-34 31.2 73.3 9.7 3.7 23.3 625 35-39 28.4 75.4 9.0 2.5 22.2 660 40-44 32.4 71.2 9.3 3.1 24.0 629 45-49 26.9 72.8 10.1 2.0 23.9 586 Residence Urban 48.5 86.7 6.3 3.6 10.8 949 Rural 22.0 69.7 11.5 2.6 26.1 2,442 Division Barisal 25.7 69.4 14.8 2.8 24.0 174 Chittagong 25.3 70.8 9.8 2.2 25.2 519 Dhaka 34.9 78.2 9.2 3.6 19.1 1,095 Khulna 30.6 73.1 10.4 2.8 23.5 430 Rajshahi 25.5 73.4 12.1 3.0 21.6 556 Rangpur 26.9 77.2 6.9 1.6 19.7 442 Sylhet 26.2 66.2 11.2 3.5 28.9 175 Educational attainment No education 0.2 58.7 7.7 0.0 39.1 890 Primary incomplete 8.7 72.5 11.7 1.2 25.1 823 Primary complete1 23.1 78.1 9.3 2.2 18.4 305 Secondary incomplete 45.9 82.1 11.8 5.8 12.7 758 Secondary complete or higher2 82.1 88.7 9.3 6.0 5.3 615 Wealth quintile Lowest 4.1 54.3 8.3 0.3 42.6 654 Second 12.0 64.0 11.5 2.1 31.3 666 Middle 22.8 75.2 13.4 2.1 20.1 647 Fourth 37.9 84.0 10.2 4.8 12.2 726 Highest 66.9 92.6 7.0 4.8 4.9 699 Total 15-49 29.4 74.4 10.0 2.9 21.8 3,392 50-54 24.0 59.8 8.4 3.4 35.6 605 Total 15-54 28.6 72.2 9.8 3.0 23.9 3,997 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Characteristics of Survey Respondents • 39 Figure 3.3 confirms that men are much more likely to be exposed to each type of mass media than women. For both men and women, exposure to television is more common than exposure to other media types. Figure 3.3 Percentage of ever-married women and men age 15 49 exposed to various media at least once a week 22 3 10 74 29 49 1 5 48 6 No media All three media Radio Television Newspaper Women Men Percent BDHS 2011 3.5 EMPLOYMENT The 2011 BDHS asked respondents a number of questions regarding their employment status, including whether they had worked in the 12 months before the survey. The results for women and men are presented in Tables 3.5.1 and 3.5.2. At the time of the survey, 13 percent of ever-married women age 15-49 were currently employed. Two percent were not working although they had been employed in the 12 months prior to the survey, while the remaining 85 percent said that they had not been employed in the previous 12 months (Table 3.5.1). The proportion currently employed is lowest among women age 15-19 (6 percent) and peaks at 16 percent in the 30-34 age group. Women who are divorced, separated, or widowed are much more likely to be employed than currently married women. Women who have 0-2 children are around twice as likely as those with five or more children to be employed. Urban women are more likely than rural women to be employed (21 percent compared with 10 percent). Small variations are found across geographic divisions. The proportion of women who are employed ranges from 16 percent in Dhaka to 9 percent in Barisal. The proportion of women who are currently employed decreases with education, except for women with secondary or higher education. For example, 16 percent of women with no education are employed compared with 10 percent of women who attended but have not the completed secondary level. Women in the lowest and highest wealth quintiles are most likely to be currently employed (15 percent and 16 percent, respectively). 40 • Characteristics of Survey Respondents Table 3.5.1 Employment status: Women Percent distribution of ever-married women age 15-49 by employment status, according to background characteristics, Bangladesh 2011 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 6.2 2.0 91.8 100.0 1,970 20-24 12.1 1.6 86.3 100.0 3,514 25-29 14.8 2.0 83.2 100.0 3,394 30-34 15.6 1.9 82.6 100.0 2,654 35-39 14.4 2.3 83.4 100.0 2,246 40-44 13.6 1.8 84.6 100.0 2,152 45-49 14.2 1.2 84.6 100.0 1,820 Marital status Currently married 11.6 1.7 86.7 100.0 16,635 Divorced/separated/ widowed 36.6 3.7 59.7 100.0 1,114 Number of living children 0 14.7 3.0 82.2 100.0 1,867 1-2 15.0 1.7 83.2 100.0 8,889 3-4 11.0 1.7 87.3 100.0 5,359 5+ 8.2 1.3 90.5 100.0 1,635 Residence Urban 21.2 1.5 77.2 100.0 4,619 Rural 10.3 1.9 87.8 100.0 13,130 Division Barisal 9.3 2.5 88.2 100.0 1,002 Chittagong 10.9 1.4 87.7 100.0 3,222 Dhaka 15.7 1.8 82.5 100.0 5,736 Khulna 12.8 1.8 85.5 100.0 2,139 Rajshahi 13.3 2.3 84.4 100.0 2,646 Rangpur 12.8 2.1 85.1 100.0 2,039 Sylhet 10.5 1.0 88.6 100.0 967 Educational attainment No education 15.5 2.3 82.2 100.0 4,912 Primary incomplete 12.7 2.4 84.9 100.0 3,264 Primary complete2 10.4 1.6 88.0 100.0 2,062 Secondary incomplete 9.6 1.2 89.2 100.0 5,383 Secondary complete or higher3 20.2 1.6 78.3 100.0 2,127 Wealth quintile Lowest 14.9 3.3 81.9 100.0 3,250 Second 11.0 1.8 87.3 100.0 3,487 Middle 10.5 1.6 87.8 100.0 3,567 Fourth 13.8 1.6 84.6 100.0 3,664 Highest 15.6 1.0 83.4 100.0 3,781 Total 13.2 1.8 85.0 100.0 17,749 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. Characteristics of Survey Respondents • 41 Practically all men were employed in the 12 months preceding the survey (Table 3.5.2). There are small variations in the employment status of men by background characteristics. Table 3.5.2 Employment status: Men Percent distribution of ever-married men age 15-49 by employment status, according to background characteristics, Bangladesh 2011 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 * * * * 21 20-24 98.3 0.8 0.9 100.0 249 25-29 98.6 1.2 0.2 100.0 621 30-34 99.0 0.8 0.3 100.0 625 35-39 98.4 0.8 0.8 100.0 660 40-44 99.5 0.3 0.2 100.0 629 45-49 98.5 0.6 0.8 100.0 586 Marital status Married or living together 98.8 0.7 0.5 100.0 3,360 Divorced/separated/ widowed (92.0) (8.0) (0.0) (100.0) 31 Residence Urban 98.5 0.8 0.7 100.0 949 Rural 98.8 0.8 0.5 100.0 2,442 Division Barisal 98.8 1.2 0.0 100.0 174 Chittagong 97.9 0.9 1.2 100.0 519 Dhaka 98.5 0.8 0.7 100.0 1,095 Khulna 99.4 0.2 0.5 100.0 430 Rajshahi 98.9 0.9 0.2 100.0 556 Rangpur 99.4 0.6 0.0 100.0 442 Sylhet 98.3 1.1 0.6 100.0 175 Educational attainment No education 98.7 0.8 0.5 100.0 890 Primary incomplete 99.4 0.1 0.5 100.0 823 Primary complete1 97.6 1.4 1.0 100.0 305 Secondary incomplete 98.9 0.7 0.4 100.0 758 Secondary complete or higher2 98.0 1.3 0.7 100.0 615 Wealth quintile Lowest 98.7 1.0 0.4 100.0 654 Second 99.4 0.3 0.3 100.0 666 Middle 98.6 0.8 0.5 100.0 647 Fourth 98.7 0.9 0.4 100.0 726 Highest 98.1 0.9 1.0 100.0 699 Total 15-49 98.7 0.8 0.5 100.0 3,392 50-54 96.3 1.3 2.4 100.0 605 Total 15-54 98.3 0.9 0.8 100.0 3,997 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 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. 3.6 OCCUPATION Respondents who had worked in the 12 months preceding the survey were asked about their occupation. The results are presented in Tables 3.6.1 and 3.6.2, which show the distributions of employed women and men by occupation, according to background characteristics. 42 • Characteristics of Survey Respondents One in four working women are engaged in factory or blue collar services, 22 percent work as semi-skilled labor, and 13 percent each perform professional or technical services and home-based manufacturing work (Table 3.6.1). The relationship between women’s occupation and age is mixed; younger women are more likely than older women to be engaged in factory work, blue collar services, 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. Table 3.6.1 Occupation: Women Percent distribution of ever-married women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Bangladesh 2011 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 6.6 3.7 32.5 27.7 0.4 0.9 0.0 19.6 6.6 0.0 2.0 100.0 162 20-24 9.9 3.6 29.8 29.1 1.1 2.9 0.8 15.1 6.3 0.5 0.9 100.0 480 25-29 14.5 4.5 22.1 27.3 0.9 6.7 0.6 12.9 9.8 0.4 0.3 100.0 570 30-34 16.9 4.9 23.0 20.6 0.9 7.5 0.7 12.6 10.8 1.1 1.0 100.0 462 35-39 14.1 7.2 22.9 17.9 1.2 7.9 0.2 11.3 14.2 2.7 0.3 100.0 374 40-44 11.4 5.3 24.9 17.0 1.7 8.0 1.2 10.8 18.8 0.8 0.0 100.0 331 45-49 10.0 8.9 24.7 12.4 1.2 11.0 0.0 6.7 22.7 1.9 0.5 100.0 280 Marital status Married or living together 14.5 5.1 23.9 24.6 1.1 6.1 0.6 13.5 9.4 0.8 0.6 100.0 2,210 Divorced/separated/ widowed 3.6 6.4 30.8 11.0 1.1 8.9 0.6 7.7 26.4 2.6 0.9 100.0 449 Number of living children 0 16.4 3.9 31.1 25.5 0.6 1.9 0.0 8.8 7.6 1.6 2.6 100.0 331 1-2 16.6 5.2 23.4 25.0 1.0 5.3 0.5 12.2 9.5 1.1 0.4 100.0 1,489 3-4 5.0 5.6 25.1 18.1 1.4 10.1 0.9 14.1 18.9 0.5 0.3 100.0 683 5+ 0.5 8.4 27.2 8.7 1.5 13.3 1.6 16.9 19.5 2.4 0.0 100.0 156 Residence Urban 15.1 4.9 35.1 21.6 0.4 0.4 0.0 6.2 15.1 0.4 0.7 100.0 1,051 Rural 11.1 5.6 18.4 22.8 1.5 10.6 1.0 16.6 10.4 1.5 0.6 100.0 1,608 Division Barisal 9.1 9.9 17.8 28.2 1.2 9.1 0.0 12.8 10.0 1.8 0.3 100.0 118 Chittagong 13.7 4.1 24.7 18.8 1.3 4.6 0.6 21.5 10.2 0.2 0.3 100.0 396 Dhaka 14.8 5.4 31.6 21.7 0.0 1.8 1.0 7.3 13.9 1.4 1.0 100.0 1,005 Khulna 10.2 4.7 26.6 23.7 1.7 3.6 0.6 16.4 11.5 1.0 0.0 100.0 311 Rajshahi 10.8 6.1 16.0 30.1 2.5 5.6 0.3 16.2 10.8 1.4 0.3 100.0 414 Rangpur 10.2 4.1 18.7 17.0 1.5 26.6 0.0 10.1 11.0 0.3 0.7 100.0 304 Sylhet 13.9 5.9 21.2 16.2 1.8 11.6 0.0 9.2 17.4 2.0 0.9 100.0 111 Educational attainment No education 0.1 7.5 30.5 8.0 1.9 12.1 0.6 11.4 25.9 1.4 0.5 100.0 874 Primary incomplete 1.0 5.1 32.9 18.2 1.8 9.4 0.9 17.9 11.6 0.3 0.9 100.0 492 Primary complete1 1.0 4.4 38.4 27.9 0.9 4.3 1.3 13.1 7.3 0.2 1.3 100.0 247 Secondary incomplete 6.1 4.7 21.2 42.1 0.2 2.1 0.3 17.1 4.1 1.7 0.4 100.0 584 Secondary complete or higher2 63.5 2.7 3.8 25.8 0.0 0.0 0.2 2.8 0.0 0.9 0.4 100.0 462 Wealth quintile Lowest 1.1 4.2 27.3 9.7 2.6 15.9 0.2 15.0 22.4 1.6 0.0 100.0 589 Second 4.8 4.3 23.2 19.2 1.8 10.8 1.0 21.8 11.1 1.1 1.1 100.0 444 Middle 9.2 6.8 18.4 31.5 0.7 5.9 0.4 17.3 8.2 0.9 0.6 100.0 434 Fourth 15.0 7.7 31.6 25.2 0.4 0.6 0.7 8.0 9.1 0.9 0.9 100.0 565 Highest 29.5 4.0 22.8 27.5 0.0 0.7 0.7 4.3 9.2 0.8 0.6 100.0 626 Total 12.7 5.3 25.0 22.3 1.1 6.6 0.6 12.5 12.2 1.1 0.6 100.0 2,659 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 agricultural and home-based manufacturing work. In contrast, women in urban areas are more likely to be engaged in professional or technical services, factory work or blue collar services, and as domestic servants. Characteristics of Survey Respondents • 43 Two in three women (64 percent) with secondary or higher levels of education are employed in professional or technical jobs, and one in four works 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 lowest wealth quintile work in factory or blue collar services (27 percent) and as domestic servants (22 percent). Thirty-four percent of employed men age 15-49 are engaged in farming and agricultural activities, and 25 percent are engaged in business services (Table 3.6.2). Younger men are more likely than older men to be engaged in factory work or blue collar services and semi-skilled labor services, while older men are more likely than younger men to work in professional or technical jobs and work in agriculture. Table 3.6.2 Occupation: Men Percent distribution of ever-married men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Bangladesh 2011 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 men Age 15-19 * * * * * * * * * * * * 19 20-24 3.1 17.9 18.6 23.8 7.9 27.9 0.0 0.0 0.0 0.0 0.8 100.0 247 25-29 3.2 20.3 13.7 19.5 9.2 32.0 0.0 0.0 0.1 0.8 1.3 100.0 620 30-34 5.4 28.0 12.8 15.0 8.3 27.9 0.4 0.2 0.0 0.7 1.2 100.0 623 35-39 7.4 27.9 8.7 16.2 7.6 30.9 0.0 0.0 0.0 0.1 1.2 100.0 655 40-44 6.4 27.7 7.1 12.9 5.7 37.8 0.2 0.3 0.0 1.5 0.3 100.0 628 45-49 5.9 22.1 8.3 13.7 5.5 42.6 0.0 0.3 0.0 1.0 0.6 100.0 581 Marital status Married or living together 5.5 24.7 10.7 16.1 7.3 33.7 0.1 0.1 0.0 0.8 0.9 100.0 3,342 Divorced/separated/ widowed (0.0) (13.1) (18.6) (3.6) (7.1) (49.7) (0.0) (0.0) (0.0) (0.0) (8.0) (100.0) 31 Residence Urban 9.8 32.4 17.5 23.8 7.0 7.5 0.0 0.1 0.0 1.0 1.0 100.0 943 Rural 3.8 21.6 8.1 13.0 7.5 44.1 0.2 0.1 0.0 0.7 0.9 100.0 2,431 Division Barisal 7.2 24.3 8.9 12.6 9.4 35.2 0.0 0.5 0.0 0.7 1.2 100.0 174 Chittagong 3.9 24.7 13.5 18.5 9.8 26.8 0.0 0.4 0.0 0.9 1.4 100.0 513 Dhaka 6.3 27.0 15.1 19.7 5.9 23.9 0.0 0.0 0.0 1.1 1.0 100.0 1,087 Khulna 4.9 27.7 6.6 15.5 4.5 40.7 0.0 0.0 0.0 0.0 0.2 100.0 428 Rajshahi 5.0 21.7 5.0 12.8 7.6 45.1 0.7 0.2 0.0 0.8 1.1 100.0 555 Rangpur 6.0 19.9 8.1 10.9 9.4 44.9 0.0 0.0 0.0 0.2 0.6 100.0 442 Sylhet 4.6 24.1 12.9 13.6 7.9 33.8 0.0 0.0 0.3 1.5 1.2 100.0 174 Educational attainment No education 0.2 13.4 12.8 10.9 13.4 48.0 0.0 0.3 0.1 0.2 0.8 100.0 886 Primary incomplete 0.2 21.0 12.2 14.7 10.4 41.1 0.0 0.1 0.0 0.3 0.1 100.0 819 Primary complete1 0.0 27.8 12.7 20.9 6.0 30.8 0.0 0.0 0.0 0.3 1.4 100.0 302 Secondary incomplete 1.3 33.6 11.5 20.3 3.1 27.6 0.2 0.2 0.0 1.6 0.7 100.0 755 Secondary complete or higher2 28.1 33.1 4.0 17.7 0.3 12.8 0.4 0.0 0.0 1.3 2.2 100.0 611 Wealth quintile Lowest 0.1 8.9 11.0 9.9 15.5 52.7 0.0 0.3 0.0 0.8 1.0 100.0 651 Second 1.0 15.6 10.5 11.8 11.8 48.7 0.0 0.0 0.1 0.3 0.3 100.0 664 Middle 3.8 23.2 8.6 15.6 4.9 40.9 0.2 0.2 0.0 1.3 1.2 100.0 643 Fourth 7.4 30.1 13.7 20.5 3.8 22.8 0.2 0.2 0.0 0.5 0.9 100.0 723 Highest 14.4 43.8 9.7 21.6 1.3 6.8 0.2 0.0 0.0 0.9 1.3 100.0 692 Total 15-49 5.5 24.6 10.8 16.0 7.3 33.8 0.1 0.1 0.0 0.8 0.9 100.0 3,374 50-54 5.2 21.3 8.0 8.7 4.1 50.1 0.0 0.1 0.0 0.9 1.6 100.0 591 Total 15-54 5.4 24.1 10.3 14.9 6.8 36.3 0.1 0.1 0.0 0.8 1.0 100.0 3,965 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. As in the case of women, men from the wealthiest households are most likely to be engaged in professional or technical jobs, business, and semi-skilled labor services, while men from the poorest households are most likely to work as farmers or unskilled labor. 44 • Characteristics of Survey Respondents 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 and continuity of employment. This table also presents data on whether respondents work in the agricultural or nonagricultural sector. Overall, nine in ten women who were employed work for cash only and 6 percent receive cash and in-kind payment. There are only small variations between women who work in agriculture and those who do not work in agriculture. Table 3.7 Type of employment: Women 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 (agricultural or non-agricultural) employment, Bangladesh 2011 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 88.9 90.5 90.1 Cash and in-kind 7.7 5.5 5.9 In-kind only 2.1 2.1 2.1 Not paid 1.2 1.2 1.2 Missing 0.0 0.7 0.7 Total 100.0 100.0 100.0 Type of employer Employed by family member 17.1 13.8 14.4 Employed by nonfamily member 68.0 73.2 72.2 Self-employed 14.9 12.2 12.7 Missing 0.0 0.7 0.7 Total 100.0 100.0 100.0 Continuity of employment All year 51.6 79.3 73.7 Seasonal 25.5 7.5 11.0 Occasional 22.9 12.5 14.6 Missing 0.0 0.7 0.7 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 523 2,120 2,659 Note: Total includes women with information missing on type of employment who are not shown separately. The proportion of women in agricultural work who receive cash payment has increased from 75 percent in 2007 to 90 percent in 2011. At the same time, the proportion of women who were paid entirely in kind has also declined from 4 percent in 2007 to 2 percent in 2011. Seven in ten women (72 percent) are employed by a nonfamily member, 14 percent are employed by family members, and 13 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 (17 and 14 percent, respectively), while women who work in the nonagricultural sector are more often employed by a nonfamily member (73 and 68 percent, respectively). Seventy-four percent of employed women work all year round, and 26 percent work either seasonally (11 percent) or occasionally (15 percent). Continuity of employment varies by sector. Fifty-two percent of women who work in the agricultural sector work year round, compared with 79 percent of women engaged in nonagricultural work. Forty-eight percent of women who are employed in the agricultural sector work are seasonal or occasional workers. In contrast with women (74 percent), 95 percent of men work year round, while 5 percent work either seasonally or part of the year (Table 3.8). Small variations are observed in the employment patterns by background characteristics. As expected, men who completed secondary or higher education and men in the highest wealth quintile are more likely to work throughout the year than men in other groups. Characteristics of Survey Respondents • 45 Table 3.8 Continuity of employment: Men Percent distribution of ever-married men age 15-49 currently working by continuity of employment, according to background characteristics, Bangladesh 2011 Background characteristic Worked throughout the year Seasonally/ part of the year Once in a while Number of men Age 15-19 * * * 19 20-24 93.2 6.1 0.7 245 25-29 93.5 5.0 1.4 613 30-34 96.7 2.5 0.9 618 35-39 94.6 4.9 0.3 650 40-44 93.2 6.0 0.9 626 45-49 97.0 2.8 0.2 577 Marital status Married or living together 94.8 4.4 0.8 3,319 Divorced/separated/widowed (98.1) (1.9) (0.0) 29 Residence Urban 97.1 2.4 0.5 935 Rural 94.0 5.1 0.9 2,412 Division Barisal 94.7 4.9 0.4 172 Chittagong 91.3 7.5 1.2 508 Dhaka 96.8 2.6 0.5 1,078 Khulna 95.5 4.3 0.1 428 Rajshahi 93.5 5.5 1.0 550 Rangpur 96.5 1.9 1.3 439 Sylhet 91.1 8.1 0.8 172 Educational attainment No education 93.1 6.4 0.3 879 Primary incomplete 93.9 5.2 0.9 818 Primary complete1 96.2 3.3 0.5 298 Secondary incomplete 95.2 3.2 1.6 750 Secondary complete or higher2 97.4 2.3 0.3 602 Wealth quintile Lowest 90.7 8.7 0.4 645 Second 93.4 5.8 0.9 662 Middle 93.5 4.8 1.7 638 Fourth 97.6 2.0 0.5 716 Highest 98.5 1.0 0.4 686 Total 94.8 4.4 0.8 3,347 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 3.8 SUFFICIENCY OF EARNING The 2011 BDHS asked male respondents who usually work throughout the year whether their earnings from work were sufficient to provide for their family’s basic needs. The results are presented in Table 3.9. The majority of men (62 percent) say that their earnings are moderately sufficient, 10 percent say that they are sufficient, and 28 percent report earnings less than sufficient. There is no noticeable variation in earnings by age and rural-urban residence. 46 • Characteristics of Survey Respondents Men in Rajshahi are more likely than men in other divisions to say that their earnings are sufficient. As expected, sufficiency of earnings increases with the men’s education and wealth status. For example, 21 percent of men with secondary or higher-level schooling had sufficient earnings compared with 6 percent of men with no education. Similar patterns are observed in earnings by wealth quintile; 19 percent of men in the highest wealth quintile have sufficient earnings compared with 2 percent in the lowest wealth quintile. Table 3.9 Sufficiency of earnings: Men Percent distribution of ever-married men age 15-49 currently working by sufficiency of earnings, according to background characteristics, Bangladesh 2011 Background characteristic Sufficient Moderately sufficient Not sufficient Missing Total Number of men Age 15-19 * * * * * 19 20-24 8.8 74.0 17.2 0.0 100.0 245 25-29 12.0 61.0 27.0 0.0 100.0 613 30-34 8.3 66.0 25.8 0.0 100.0 618 35-39 10.6 63.5 25.9 0.1 100.0 650 40-44 11.2 58.7 30.0 0.0 100.0 626 45-49 10.8 54.6 34.7 0.0 100.0 577 Marital status Married or living together 10.4 61.9 27.6 0.0 100.0 3,319 Divorced/separated/widowed (5.6) (60.8) (33.7) (0.0) (100.0) 29 Residence Urban 12.8 62.5 24.7 0.0 100.0 935 Rural 9.5 61.7 28.8 0.0 100.0 2,412 Division Barisal 9.5 71.0 19.5 0.0 100.0 172 Chittagong 7.5 57.8 34.6 0.0 100.0 508 Dhaka 10.5 66.5 23.0 0.0 100.0 1,078 Khulna 8.7 65.3 26.0 0.0 100.0 428 Rajshahi 16.3 57.0 26.7 0.0 100.0 550 Rangpur 9.1 60.2 30.7 0.0 100.0 439 Sylhet 7.6 47.8 44.3 0.3 100.0 172 Educational attainment No education 6.0 53.7 40.2 0.1 100.0 879 Primary incomplete 6.9 64.3 28.9 0.0 100.0 818 Primary complete1 10.9 68.3 20.8 0.0 100.0 298 Secondary incomplete 10.6 66.1 23.3 0.0 100.0 750 Secondary complete or higher2 21.1 62.2 16.7 0.0 100.0 602 Wealth quintile Lowest 2.2 55.3 42.5 0.0 100.0 645 Second 7.4 61.4 31.1 0.1 100.0 662 Middle 9.2 64.5 26.3 0.0 100.0 638 Fourth 13.5 65.7 20.8 0.0 100.0 716 Highest 18.8 62.3 18.9 0.0 100.0 686 Total 10.4 61.9 27.7 0.0 100.0 3,347 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Marriage and Sexual Activity • 47 MARRIAGE AND SEXUAL ACTIVITY 4 4.1 INTRODUCTION his chapter focuses on the key factors other than contraception that affect women’s chances of becoming pregnant. These key factors include marriage, polygyny, and sexual activity. Marriage indicates the onset of exposure to the risk of pregnancy for most women, and thus it is an important fertility indicator. This chapter includes information on several direct measures of the beginning of exposure to pregnancy and level of exposure: for example, age at first marriage, age at first sexual intercourse, and recent sexual activity. Only women who had been married or were married were interviewed with the 2011 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 is equal to 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. A similar procedure is used for the sample of ever- married men. 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 2011 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 formal marriage. 4.2 CURRENT MARITAL STATUS Table 4.1 shows the current marital status of women and men age 15-49 by age. In Bangladesh, a substantially greater proportion of men than women age 15-49 have never married: 36 percent of men T Key Findings • There is evidence of a continuing rise in age at first marriage among women, while age of men at first marriage has not been changing rapidly. • The percentage of women age 25-49 who were married by age 15 has decreased from 52 percent among women age 45-49 to 17 percent among women age 15-19. • Bangladeshi men marry more than eight years later than women. The median age at first marriage among women age 25-49 is 15.5 years compared with 24.2 years for men the same age. • Seventy-seven percent of ever-married women were sexually active within the past four weeks and 12 percent were active within the past 1 to 12 months. • Twelve percent of currently married women reported that their husbands live elsewhere (due to migration). Forty-three percent of these women were not visited by their husbands in the last 12 months. 48 • Marriage and Sexual Activity compared with 15 percent of women. The proportion who have never married falls sharply with age among both women and men. Among women, the decline is from 54 percent in the age group 15-19 to less than 1 percent among women age 35 or older. Among men, it falls from 98 percent in the age group 15-19 to less than 1 percent among men age 40 or older. The low proportion of women age 25-29 who have never been married (3 percent) indicates that marriage is universal in Bangladesh and that more than nine in ten women marry before age 30. Similarly, only 2 percent of men age 35-39 have never been married, indicating that more than nine in ten men marry before age 35. Eight in ten women (80 percent) and more than six in ten men (63 percent) are currently married or cohabiting. Three percent of women and less than 1 percent of men age 15-49 are widowed. The proportion of women who are widowed increases sharply with age and is mostly limited to older age groups: 7 percent of women age 40-44 and 13 percent of women age 45-49 are widowed. Divorce and separation are uncommon in Bangladesh, with the proportion among women being slightly higher than among men. Two percent of women age 15-49 are either divorced or separated compared with less than 1 percent of men of the same age. The proportion divorced or separated does not vary markedly by age group among either women or men. Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Bangladesh 2011 Age Marital status Total Percentage of respondents currently in union Number of women and men Never married Married Divorced Separated Widowed WOMEN 15-19 54.3 44.7 0.6 0.4 0.0 100.0 44.7 4,306 20-24 13.4 83.7 1.3 1.2 0.4 100.0 83.7 4,058 25-29 3.0 93.2 1.0 1.4 1.3 100.0 93.2 3,501 30-34 1.2 94.3 1.0 1.7 1.8 100.0 94.3 2,686 35-39 0.8 91.9 1.4 1.3 4.6 100.0 91.9 2,264 40-44 0.3 89.8 0.8 1.9 7.2 100.0 89.8 2,158 45-49 0.2 82.3 1.5 2.7 13.3 100.0 82.3 1,824 Total 14.7 80.0 1.0 1.4 3.0 100.0 80.0 20,797 MEN 15-19 97.9 2.1 0.0 0.0 0.0 100.0 2.1 1,017 20-24 70.2 29.6 0.1 0.1 0.0 100.0 29.6 835 25-29 29.2 69.4 0.8 0.6 0.0 100.0 69.4 877 30-34 11.2 88.4 0.0 0.4 0.0 100.0 88.4 704 35-39 2.0 97.5 0.2 0.1 0.1 100.0 97.5 674 40-44 0.6 98.4 0.1 0.2 0.7 100.0 98.4 633 45-49 0.9 98.2 0.0 0.4 0.5 100.0 98.2 591 Total 15-49 36.4 63.0 0.2 0.3 0.2 100.0 63.0 5,331 50-54 0.3 99.2 0.0 0.4 0.1 100.0 99.2 607 Total 15-54 32.7 66.7 0.2 0.3 0.1 100.0 66.7 5,938 Table 4.2 shows trends in Bangladesh by age in the percentage of women who have never married, for the 1975-2011 period. The proportion of women who have never married affects fertility levels in a society like Bangladesh, where childbearing outside marriage is uncommon. The proportion of never-married women age 15-19 has increased from 30 percent in 1975 to 54 percent in 2011. Similarly, the proportion of never-married women age 20-24 first increased from 5 percent in 1975 to 19 percent in 1999-2000; then it declined steadily to 13 percent in 2011. Marriage and Sexual Activity • 49 Table 4.2 Trends in proportion never married Percentage of women who have never married, by age group, as reported in various surveys, Bangladesh 1975-2011 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 10-14 91.2 98.0 98.7 96.2 96.4 98.5 95.2 95.2 92.7 88.6 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 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 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 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 35-39 0.4 - - 0.1 0.5 0.1 0.3 0.0 0.2 0.4 0.6 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 45-49 0.0 0.1 - 0.1 0.1 - 0.2 0.0 0.0 0.0 0.8 0.2 - = Less than 0.1 percent u = Unknown/not available Sources: 1975 Bangladesh Fertility Survey (BFS) (MHPC, 1978:49); 1983, 1985, 1989, and 1991 Contraceptive Prevalence Surveys (CPSs) (Mitra et al., 1993:24); 1989 BFS (Huq and Cleland, 1990:43); 1993-1994 Bangladesh Demographic and Health Survey (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) 4.3 POLYGYNY There are predominantly two types of marital unions; monogamous and polygynous. The distinction between the two types has social significance and probable fertility implications, although the association between union type and fertility is complex and not well understood. Polygyny, the practice of having more than one wife, influences the frequency of sexual intercourse and thus may have an effect on fertility. The extent of polygyny was measured in the 2011 BDHS by asking all currently married female respondents whether their husband or partner had other wives (co-wives) and, if so, how many. Currently married men were also asked whether they had one or more wives or partners with whom they were living. Table 4.3 shows the proportion of currently married men who are in polygynous unions, by background characteristics. Overall, less than 1 percent of married men in Bangladesh are in a polygynous union, i.e., they have two or more wives. Polygyny is found among men age 30 years and over. There is no variation in the extent of polygyny by other background characteristics. 50 • Marriage and Sexual Activity Table 4.3 Number of men’s wives Percent distribution of currently married men age 15-49 by number of wives, according to background characteristics, Bangladesh 2011 Background characteristic Number of wives Total Number of men 1 2+ Age 15-19 * * 100.0 21 20-24 100.0 0.0 100.0 247 25-29 100.0 0.0 100.0 609 30-34 99.8 0.2 100.0 622 35-39 98.8 1.2 100.0 657 40-44 98.8 1.2 100.0 623 45-49 98.8 1.2 100.0 580 Residence Urban 99.2 0.8 100.0 941 Rural 99.3 0.7 100.0 2,420 Division Barisal 100.0 0.0 100.0 172 Chittagong 99.4 0.6 100.0 515 Dhaka 98.8 1.2 100.0 1,078 Khulna 99.6 0.4 100.0 425 Rajshahi 99.8 0.2 100.0 555 Rangpur 99.3 0.7 100.0 442 Sylhet 99.1 0.9 100.0 173 Educational attainment No education 98.7 1.3 100.0 885 Primary incomplete 99.0 1.0 100.0 812 Primary complete1 100.0 0.0 100.0 301 Secondary incomplete 99.5 0.5 100.0 751 Secondary complete or higher2 99.9 0.1 100.0 612 Wealth quintile Lowest 98.9 1.1 100.0 647 Second 99.3 0.7 100.0 658 Middle 99.2 0.8 100.0 640 Fourth 99.5 0.5 100.0 719 Highest 99.5 0.5 100.0 696 Total 15-49 99.3 0.7 100.0 3,360 50-54 98.6 1.4 100.0 602 Total 15-54 99.2 0.8 100.0 3,963 Note: An asterisk denotes a figure 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. 4.4 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. Because never-married men and 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 men and women and that there were no errors in the reporting of marital status, especially of young women and men. Table 4.4 shows, by current ages, the percentages of women and men 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, 74 percent married by age 18, and 86 percent married by age 20. Men in Bangladesh tend to marry later in life than women. Among men age 20-49, only 6 percent Marriage and Sexual Activity • 51 married by age 18, and 18 percent married by age 20. Overall, only 19 percent of men age 25-54 married at or before age 20, and more than half (56 percent) married at or before age 25. Within each age cohort, the proportion of women marrying by specific ages is substantially larger when compared with men. For example, in the 25-29 age cohort, almost three-quarters (73 percent) of women married by age 18 and 95 percent by age 25. In contrast, only 5 percent of men in the same age cohort are married by age 18 and 59 percent married by age 25. The proportion of women marrying in their early teens continues to decline. Across age cohorts, the proportion of women marrying by age 15 has declined by two-thirds over time, from 52 percent among women age 45-49 to 17 percent among women age 15-19. Similarly, the proportion of women marrying by age 18 and age 20 decreases substantially from the oldest cohort to the youngest cohort. Changes in the proportion of men marrying by specific ages over time are much smaller and do not follow a clear pattern. When looking at age cohorts, Table 4.4 shows a slow but steady increase over the past 25 years in the age at which Bangladeshi women first marry, from a median age of 14.9 years for women in their mid- to late forties to 16.6 years for those in their early twenties. The pattern differs for men. The median age at marriage among men decreases, but only slightly, from 24.5 years for men age 45-49 to 23.8 years for men age 25-29. Overall, men marry more than eight years later than women. The median age at first marriage among men age 25-49 is 24.2 years, and the median age at first marriage among women in the same age group is 15.5 years, indicating large differences in age between husbands and wives. Table 4.4 Age at first marriage Percentage of women and men age 15-49 who were first married, by specific exact ages and median age at first marriage, according to current age, Bangladesh 2011 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 17.2 na na na na 54.3 4,306 a 20-24 29.1 64.9 79.8 na na 13.4 4,058 16.6 25-29 35.2 72.8 86.1 91.2 95.3 3.0 3,501 16.0 30-34 39.3 74.4 87.4 92.7 95.8 1.2 2,686 15.8 35-39 42.4 77.6 88.1 92.7 96.4 0.8 2,264 15.5 40-44 48.8 81.4 90.8 95.8 97.3 0.3 2,158 15.1 45-49 51.9 82.4 92.8 96.6 98.5 0.2 1,824 14.9 20-49 39.0 74.0 86.4 na na 4.3 16,491 15.8 25-49 42.2 76.9 88.6 93.4 96.4 1.4 12,434 15.5 MEN 15-19 0.0 na na na na 97.9 1,017 a 20-24 0.0 4.4 12.2 na na 70.2 835 a 25-29 0.0 5.3 18.8 36.5 58.7 29.2 877 23.8 30-34 0.0 8.0 20.2 36.9 57.8 11.2 704 24.0 35-39 0.0 7.0 20.3 33.4 53.7 2.0 674 24.5 40-44 0.0 4.3 17.7 31.7 54.6 0.6 633 24.4 45-49 0.0 6.8 18.5 32.9 52.8 0.9 591 24.5 20-49 0.0 5.9 17.8 na na 21.9 4,314 a 25-49 0.0 6.3 19.1 34.5 55.8 10.3 3,479 24.2 20-54 0.0 6.2 18.2 na na 19.2 4,922 a 25-54 0.0 6.6 19.4 34.5 55.5 8.8 4,087 24.2 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50 percent of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group A comparison of the 2011 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 one and a half years over the past decade, from 14.2 years in 52 • Marriage and Sexual Activity 1996-1997 (Mitra et al., 1997) to the current figure of 15.8 years. On the other hand, comparing the results for men across surveys indicates that the median age at marriage among men has remained relatively stable since 2004 when the median age at marriage for men age 25-59 was 24.2 years (NIPORT et al., 2005). The legal age of marriage in Bangladesh for women is 18 years, but a large proportion of marriages still take place before the legal age. The 2011 BDHS found that 65 percent of women age 20-24 were married before age 18 (Figure 4.1). Over the past two decades, the proportion of women marrying before the legal age has decreased from 73 percent in 1989 to 65 percent in 2011. Figure 4.1 Trends in proportion of women age 20-24 who were first married by age 18 73 73 69 65 68 66 65 1989 BFS 1993-94 BDHS 1996-97 BDHS 1999-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Percent Table 4.5 examines the median age at first marriage for women age 20-49 and 25-49, and for men age 25-54, according to background characteristics. Urban women age 25-49 marry one year later than their rural counterparts (16.2 years versus 15.3 years). The median age at marriage shows a greater variation among administrative divisions; for women age 25-49, it ranges from 17.2 years in Sylhet to 14.7 years in Rangpur. Women’s education shows a strong positive association with age at marriage. For example, women who have completed secondary or higher education marry five years later than those with no education. Similarly, the median age at marriage increases with household wealth. Women from the highest wealth quintile marry two years later than those from the lowest wealth quintile. The median age at first marriage for men displays similar patterns and associations by educational attainment and household wealth to those observed for women. By administrative division, the highest median age at first marriage for men age 25-54 is observed in Dhaka (24.7 years), while the lowest is observed in Rajshahi (22.4 years). Men with no education get married almost two years earlier than men with some secondary education (20.7 years versus 23.2 years). The median age at marriage for men also increases with the wealth quintile. Marriage and Sexual Activity • 53 Table 4.5 Median age at first marriage by background characteristics Median age at first marriage among women age 20-49 and age 25-49, and median age at first marriage among men age 25-54, according to background characteristics, Bangladesh 2011 Background characteristic Women age Men age 25-54 20-49 25-49 Residence Urban 16.5 16.2 a Rural 15.6 15.3 23.6 Division Barisal 15.7 15.4 24.4 Chittagong 16.6 16.3 a Dhaka 15.8 15.6 24.7 Khulna 15.3 15.1 23.9 Rajshahi 15.2 15.1 22.4 Rangpur 15.0 14.7 22.7 Sylhet 17.5 17.2 a Educational attainment No education 14.8 14.7 20.7 Primary incomplete 14.9 14.8 21.6 Primary complete1 15.4 15.4 22.6 Secondary incomplete 16.3 16.2 23.2 Secondary complete or higher2 19.9 19.6 a Wealth quintile Lowest 15.1 15.0 22.3 Second 15.3 15.0 22.7 Middle 15.5 15.2 23.8 Fourth 16.0 15.6 24.8 Highest 17.4 17.0 a Total 15.8 15.5 24.2 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50 percent of the respondents began living with their spouses/partners 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. 4.5 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 2011 BDHS asked ever- married respondents how old they were when they first had sexual intercourse. It was recognized that the answers to this questions might be biased since respondents, especially female respondents, might be 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. However, the information for men show some Bangladeshi males are engaging in premarital sexual activity and are willing to report the activity. Table 4.6 shows the percentage of men 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 men interviewed in the BDHS and assuming that never-married men have not had intercourse. Given the conservative nature of the Bangladeshi society, that assumption is likely correct for many never-married men; however, it is clearly a source of potential for bias in the age at first intercourse results since at least some of the never- married population is likely to have initiated sexual activity. It also must be recognized that not all ever- married men who engaged in premarital sexual activity are likely to have reported that behavior in the BDHS, adding to the bias in the results in Table 4.6. Nevertheless, the results in Table 4.6 are useful since they document the information the BDHS was able to obtain on premarital sexual activity in Bangladeshi society. 54 • Marriage and Sexual Activity Table 4.6 shows that the median age at first sexual intercourse among men age 25-54 (23.7 years) is earlier than the median age at first marriage (24.2 years). The median age at first sexual intercourse is somewhat lower among men age 25-34 than among older men. Looking at specific ages, only 1 percent of men age 25-54 had sexual intercourse by age 15, which compares with 23 percent by age 20, 39 percent by age 22, and 58 percent by age 25. Men in younger age cohorts initiate sex later than their older counterparts. For example, 61 percent of men of age 25-29 had their first sexual intercourse by age 25 compared with 56 percent of men age 45-49. Table 4.6 Age at first sexual intercourse Percentage of women and men 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 2011 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse 15 18 20 22 25 15-19 0.1 na na na na 97.9 1,017 a 20-24 0.6 6.1 13.1 na na 70.2 835 a 25-29 1.2 8.1 22.8 40.2 60.5 29.4 877 23.3 30-34 1.2 11.0 25.3 42.1 61.4 11.2 704 23.0 35-39 1.0 10.6 24.9 38.2 57.1 2.0 674 24.0 40-44 0.8 7.5 21.2 36.2 56.9 0.6 633 24.0 45-49 1.0 9.5 21.8 36.4 55.5 0.9 591 23.9 20-49 1.0 8.7 21.3 a a 21.9 4,314 a 25-49 1.1 9.3 23.3 38.8 58.5 10.3 3,479 23.6 15-24 0.3 na na na na 85.4 1,852 a 20-54 1.0 8.9 21.5 a a 19.2 4,922 a 25-54 1.1 9.5 23.2 38.6 58.1 8.8 4,087 23.7 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group Table 4.7 examines the median age at first sexual intercourse by background characteristics. Because the median age at first marriage and the median age at first sexual intercourse for women are the same, the variation by background characteristics in age at first sexual intercourse is the same as that for age at first marriage (Table 4.5). For men age 25-54, the highest median age at first sexual intercourse is observed in Chittagong (25.0 years), while the lowest is observed in Rajshahi (22.2 years). Men with no education have their first sexual encounter more than two years earlier than men with secondary incomplete education (20.4 years versus 22.7 years). Median age at first sexual intercourse also increases with wealth quintile, from 21.9 years among the poorest men to 24.3 years among men in the highest wealth quintile. Marriage and Sexual Activity • 55 Table 4.7 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 20-49 and age 25-49, and median age at first sexual intercourse among men age 25-54, according to background characteristics, Bangladesh 2011 Background characteristic Women age Men age 25-54 20-49 25-49 Residence Urban 16.6 16.4 a Rural 15.6 15.4 23.0 Division Barisal 15.7 15.4 23.6 Chittagong 16.6 16.4 25.0 Dhaka 15.9 15.7 24.3 Khulna 15.4 15.2 23.4 Rajshahi 15.3 15.1 22.2 Rangpur 15.0 14.8 22.3 Sylhet 17.6 17.3 a Educational attainment No education 14.8 14.7 20.4 Primary incomplete 14.9 14.9 21.0 Primary complete1 15.5 15.4 21.8 Secondary incomplete 16.3 16.2 22.7 Secondary complete or higher2 a 19.7 a Wealth quintile Lowest 15.2 15.1 21.9 Second 15.3 15.1 22.3 Middle 15.5 15.3 23.3 Fourth 16.0 15.7 24.3 Highest 17.5 17.2 a Total 15.8 15.6 23.7 a = Omitted because less than 50 percent of the respondents had 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. 4.6 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 and men 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 4.8 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 77 percent of ever-married women age 15-49 were sexually active during the four weeks preceding the survey. An additional 12 percent had been sexually active in the 12 months preceding the survey, and 11 percent had their last sexual intercourse one or more years prior to the survey. There is no noticeable variation in recent sexual activity by marital duration or urban-rural residence. The oldest women, age 45-49, are the least likely to have had their last sexual intercourse in the past four weeks (61 percent) when compared with the youngest women. More than eight in ten married or cohabiting women (82 percent) had their last sexual encounter in the past four weeks preceding the survey whereas less than 1 percent of those previously married had an encounter within the past four weeks. There are large variations by administrative divisions in the timing of last sexual intercourse. The proportion of women who were sexually active in the past four weeks ranges from 83 to 85 percent in Rajshahi and Rangpur to 69 percent in Chittagong. 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 (74 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 other quintiles. 56 • Marriage and Sexual Activity Table 4.8 Recent sexual activity Percent distribution of ever-married women age 15-49 by timing of last sexual intercourse, according to background characteristics, Bangladesh 2011 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 81.7 13.3 4.1 0.0 0.8 100.0 1,970 20-24 78.7 12.5 8.5 0.1 0.1 100.0 3,514 25-29 80.0 10.0 9.9 0.1 0.0 100.0 3,394 30-34 81.2 9.4 9.2 0.1 0.0 100.0 2,654 35-39 78.5 10.2 11.0 0.1 0.1 100.0 2,246 40-44 73.7 11.9 14.1 0.2 0.0 100.0 2,152 45-49 61.1 16.6 22.2 0.1 0.0 100.0 1,820 Marital status Married or living together 82.4 11.8 5.6 0.1 0.1 100.0 16,635 Divorced/separated/ widowed 0.3 10.2 88.8 0.0 0.7 100.0 1,114 Marital duration2 0-4 years 80.3 14.9 4.1 0.1 0.6 100.0 3,088 5-9 years 83.2 10.5 6.3 0.0 0.0 100.0 3,011 10-14 years 83.5 9.5 6.8 0.2 0.0 100.0 2,823 15-19 years 86.0 8.9 5.0 0.1 0.0 100.0 2,269 20-24 years 84.6 10.6 4.6 0.2 0.0 100.0 1,830 25+ years 78.1 15.3 6.6 0.1 0.0 100.0 2,896 Married more than once 84.0 11.7 4.3 0.0 0.0 100.0 719 Residence Urban 78.3 10.5 11.0 0.0 0.2 100.0 4,619 Rural 76.9 12.2 10.7 0.1 0.1 100.0 13,130 Division Barisal 75.3 16.4 8.1 0.1 0.1 100.0 1,002 Chittagong 68.7 15.0 15.8 0.2 0.2 100.0 3,222 Dhaka 77.9 10.4 11.4 0.1 0.1 100.0 5,736 Khulna 78.8 11.1 9.7 0.1 0.3 100.0 2,139 Rajshahi 82.5 10.8 6.7 0.0 0.0 100.0 2,646 Rangpur 84.6 9.3 5.8 0.0 0.2 100.0 2,039 Sylhet 70.1 12.8 16.8 0.2 0.0 100.0 967 Educational attainment No education 74.0 11.6 14.3 0.0 0.0 100.0 4,912 Primary incomplete 80.2 10.2 9.5 0.1 0.0 100.0 3,264 Primary complete3 79.3 11.4 9.2 0.1 0.1 100.0 2,062 Secondary incomplete 76.9 12.8 10.0 0.1 0.2 100.0 5,383 Secondary complete or higher4 78.9 12.0 8.4 0.2 0.5 100.0 2,127 Wealth quintile Lowest 80.0 10.1 9.6 0.1 0.2 100.0 3,250 Second 79.5 11.5 8.7 0.1 0.2 100.0 3,487 Middle 76.5 12.6 10.7 0.1 0.1 100.0 3,567 Fourth 75.0 12.1 12.6 0.1 0.2 100.0 3,664 Highest 75.6 12.1 12.1 0.1 0.2 100.0 3,781 Total 77.2 11.7 10.8 0.1 0.1 100.0 17,749 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. Marriage and Sexual Activity • 57 Table 4.9 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, 12 percent of currently married women have a husband who lives elsewhere. Younger women, age 15-19 (18 percent), women who have been married for less than 5 years (20 percent), and rural women (13 percent) are most likely to have husbands who live elsewhere. Almost one in four women in Chittagong (23 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 19 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 16 percent of women in the highest quintiles. Table 4.9 Husband’s visits Percentage of currently married women age 15-49 whose husband lives elsewhere, and among currently married women whose husband lives elsewhere, percent distribution by frequency of husband’s visits to the household in the last 12 months, according to background characteristic, Bangladesh 2011 Background characteristic Percentage of women whose husband lives elsewhere Number of currently married women Among currently married women whose husband lives elsewhere, frequency of husband’s visits to the household in the past 12 months Total Number of women 0 1-5 6-11 12+ Missing Age 15-19 18.1 1,925 23.7 41.2 17.8 15.8 1.5 100.0 348 20-24 15.6 3,396 44.8 31.5 11.1 10.4 2.2 100.0 530 25-29 14.3 3,262 51.5 25.2 8.2 12.6 2.4 100.0 468 30-34 11.7 2,532 45.6 30.7 7.7 12.6 3.3 100.0 295 35-39 8.4 2,081 46.9 35.5 9.3 7.2 1.1 100.0 175 40-44 6.3 1,937 42.3 32.2 10.2 14.0 1.4 100.0 122 45-49 5.7 1,501 36.5 34.9 7.8 19.0 1.8 100.0 86 Marital duration1 0-4 years 19.5 3,088 28.5 36.7 16.0 17.0 1.8 100.0 602 5-9 years 14.9 3,011 46.7 31.7 10.0 9.9 1.7 100.0 450 10-14 years 12.9 2,823 56.6 24.5 7.5 7.9 3.5 100.0 364 15-19 years 10.7 2,269 47.6 34.6 4.9 9.4 3.6 100.0 242 20-24 years 7.7 1,830 48.7 29.4 11.1 9.9 0.9 100.0 140 25+ years 5.8 2,896 41.9 32.4 9.1 15.4 1.3 100.0 168 Married more than once 8.1 719 32.8 32.2 11.5 23.4 0.0 100.0 58 Residence Urban 10.1 4,292 42.3 35.9 7.5 13.1 1.1 100.0 435 Rural 12.9 12,343 42.6 31.1 11.6 12.3 2.4 100.0 1,590 Division Barisal 16.8 952 22.4 45.4 21.1 9.6 1.5 100.0 160 Chittagong 23.0 3,015 53.2 30.2 5.5 7.7 3.3 100.0 693 Dhaka 11.4 5,334 41.2 28.7 13.1 15.1 1.9 100.0 610 Khulna 7.8 1,996 38.5 34.6 14.7 10.8 1.3 100.0 156 Rajshahi 7.0 2,526 31.9 32.7 11.5 22.9 1.0 100.0 177 Rangpur 5.1 1,927 9.7 49.3 15.2 24.4 1.4 100.0 98 Sylhet 14.8 884 60.0 25.4 6.0 7.8 0.9 100.0 131 Educational attainment No education 6.1 4,379 45.6 28.3 6.9 16.2 2.9 100.0 268 Primary incomplete 8.5 3,056 45.0 29.8 12.6 10.8 1.8 100.0 260 Primary complete1 11.4 1,963 39.1 37.9 9.8 11.8 1.4 100.0 223 Secondary incomplete 17.2 5,176 44.6 31.3 12.5 9.3 2.4 100.0 889 Secondary complete or higher2 18.6 2,061 35.9 35.1 8.8 18.6 1.7 100.0 384 Wealth quintile Lowest 5.6 2,975 25.7 41.7 12.2 17.6 2.8 100.0 166 Second 9.2 3,267 33.0 28.0 17.8 18.6 2.6 100.0 302 Middle 13.1 3,372 40.4 33.7 13.0 10.7 2.2 100.0 443 Fourth 16.2 3,457 50.3 26.4 10.9 11.1 1.4 100.0 560 Highest 15.5 3,564 46.6 36.2 4.5 10.4 2.3 100.0 553 Total 15-49 12.2 16,635 42.5 32.2 10.8 12.5 2.1 100.0 2,024 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 58 • Marriage and Sexual Activity Women whose husbands live elsewhere were asked how often their husband came to visit in the past 12 months. Forty-three percent of women say that their husband did not come home in the past 12 months, 32 percent reported that their husband visited 1 to 5 times, 11 percent visited 6 to 11 times, and 13 percent visited 12 or more times. Women age 25-29 (52 percent) and those married 10 to 14 years (57 percent) 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. Number of visits varied widely by administrative division: only 10 percent of women in Rangpur were not visited by their husbands in the past 12 months compared with 60 percent of women in Sylhet. The percentage of women whose husbands did not visit in the past year has a negative association with wealth quintiles. Husbands of women in the two highest quintiles visit less often compared to those in the lower quintiles, possibly because they are more likely to be employed overseas rather than locally. Fertility • 59 FERTILITY 5 major objective of the 2011 BDHS was to examine fertility levels, trends, and differentials in Bangladesh. Bangladesh aims to reduce the total fertility rate (TFR) to 2.0 births per woman by 2016 through improved access to health and nutrition services for the poor and geographically marginalized population (MOHFW, 2011). Fertility is one of the three principal components of population dynamics that determine the size, structure, and composition of the population in any country. This chapter describes current and past fertility, cumulative fertility, birth intervals, age at first birth, and the reproductive behavior of adolescents. For the most part, fertility measures are based on the birth history data collected during interviews with ever-married women age 15-49. Each woman was asked a series of questions that could be used to construct a retrospective history of all of her births. To encourage complete reporting, the interviewer asked the respondent about the number of sons and daughters living with her, the number living elsewhere, and the number who had died. She then asked for a history of all births, including month and year, name, sex, and survival status of each birth. Interviewers were given extensive training in probing techniques designed to help respondents report this information accurately. The following measures of current fertility are derived from the birth history data: • 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 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 to 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. A Key Findings • The total fertility rate for the three years preceding the survey is 2.3 births per woman. • The rural-urban difference in fertility has narrowed over the past decade, from 1.1 births measured in the 1999-2000 BDHS to 0.5 births in the 2011 BDHS. • Khulna (with 1.9 births per woman) has already reached the HPNSDP target of 2.0 births per woman by 2016, and Rajshahi and Rangpur are very close behind. • After a decade-long plateau in fertility (1993-1994 to 2000) at around 3.3 children per woman, there has been a steady and encouraging decline in each subsequent BDHS. Between the 2007 and 2011 BDHS there has been almost a 15 percent decline in the total fertility rate, from 2.7 to 2.3 births per woman. • Childbearing begins early in Bangladesh, with almost half of women giving birth by age 18 and nearly 70 percent giving birth by age 20. 60 • Fertility women in a particular age group, divided by the number of woman-years lived in that age group during the specified period. • The total fertility rate (TFR) is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at currently observed ASFRs. The TFR is obtained by summing the ASFRs and multiplying by five. The various measures of current fertility are calculated for the three-year period preceding the survey, which roughly corresponds to the calendar years 2009-2011. A three-year period was chosen because it reflects the current situation without unduly increasing sampling error. Despite efforts to improve data quality, data from the BDHS are subject to the same types of errors that are inherent in all retrospective sample surveys: the possibility of omitting some births (especially births of children who died at a very young age) and the difficulty of accurately determining each child’s date of birth. These errors can bias estimates of fertility trends, which therefore have to be interpreted within the context of data quality and sample sizes. A summary of the quality of the BDHS data appears in the tables in Appendix C. 5.1 CURRENT FERTILITY The total fertility rate for the three-year period before the survey is 2.3 children per woman (Table 5.1). According to current fertility rates, on average, women will have 25 percent of their births before reaching age 20, 56 percent during their twenties, and 17 percent during their thirties. As expected, the TFR for rural women is higher than for urban women (2.5 compared with 2.0 births per woman). Bangladeshi women have a pattern of early childbearing (Figure 5.1). The rural-urban difference in fertility is greater in the age groups 15-19 and 20-24. Table 5.1 Current fertility Age-specific and total fertility rate, the general fertility rate, and the crude birth rate for the three years preceding the survey, by residence, Bangladesh 2011 Age group Residence Total Urban Rural 15-19 91 128 118 20-24 121 165 153 25-29 95 111 107 30-34 58 55 56 35-39 19 22 21 40-44 4 6 6 45-49 1 4 3 TFR(15-49) 2.0 2.5 2.3 GFR 76 97 91 CBR 20.6 23.3 22.6 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 • 61 Figure 5.1 Age-specific fertility rates by urban-rural residence 0 20 40 60 80 100 120 140 160 180 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group Urban Rural Births per 1,000 women BDHS 2011 5.2 FERTILITY DIFFERENTIALS Fertility varies widely by administrative divisions (Table 5.2). Fertility is lowest in Khulna division (1.9 births per woman), followed by Rajshahi and Rangpur at 2.1 births per woman, and highest in Sylhet (3.1 births per woman) and Chittagong (2.8 births per women). Bangladesh’s current Health, Population, and Nutrition Sector Development Program (HPNSDP) aims to reduce fertility to 2.0 births per woman by 2016. Khulna has reached that level already, and Rajshahi and Rangpur are very close. 62 • 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 years, by background characteristics, Bangladesh 2011 Background characteristic Total fertility rate Percentage women age 15- 49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 2.0 4.2 3.6 Rural 2.5 5.5 4.4 Division Barisal 2.3 5.3 4.5 Chittagong 2.8 5.4 4.9 Dhaka 2.2 5.3 4.1 Khulna 1.9 3.8 3.6 Rajshahi 2.1 4.8 3.7 Rangpur 2.1 5.0 4.0 Sylhet 3.1 7.3 4.9 Educational attainment No education 2.9 3.2 4.5 Primary incomplete 2.6 4.7 4.5 Primary complete1 2.3 6.7 4.1 Secondary incomplete 2.2 6.5 3.4 Secondary complete or higher2 1.9 4.7 2.5 Wealth quintile Lowest 3.1 6.0 4.4 Second 2.5 6.0 4.7 Middle 2.2 5.4 4.4 Fourth 2.1 4.4 4.1 Highest 1.9 4.2 3.4 Total 2.3 5.1 4.2 Note: Total fertility rates are for the period 1 to 36 months prior to interview. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Women’s education is strongly associated with fertility. The TFR decreases from 2.9 births for women with no education to 1.9 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 more than one child per woman. The percentage of women who reported being pregnant at the time of the survey is also presented in Table 5.2. This percentage may be underreported because some women may not be aware of a pregnancy, especially at the early stages, and some women who are early in their pregnancy may not want to reveal that they are pregnant. At the time of the survey, 5 percent of women age 15-49 reportedly were pregnant. Rural women are slightly more likely to be currently pregnant than urban women (6 percent and 4 percent, respectively). Among the divisions, the proportion of women who are currently pregnant is highest in Sylhet (7 percent). In five of the seven divisions, the percentage of currently pregnant women is 5 percent. The relationship between the percentage currently pregnant and education is an inverted U-shape, rising from a low of 3 percent among women with no education to a high of 7 percent among women with primary complete and some secondary education, and then dipping again to 5 percent among women who have completed secondary or higher education. Women in the lowest two wealth quintiles are somewhat more likely to be currently pregnant (6 percent) than women in the highest two quintiles (4 percent). Besides information on the TFR, 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. The former is a measure of current fertility, while the latter is a measure of past or completed fertility. Although comparing completed fertility among women age 40-49 with the TFR can provide an indication of fertility change, this change is subject to bias resulting from an understatement of parity by older women. Changes in age at marriage and Fertility • 63 contraceptive use also influence fertility trends. Unless there is evidence of increased age at marriage and/or an appreciable use of contraception, it is unlikely that fertility would decline. However, the comparison of past and present fertility indicators, together with corresponding increases in contraceptive use and women’s age at marriage, suggests a decline of almost two children per woman, from 4.2 to 2.3 children. There has been a decline in fertility in both urban and rural areas, in all regions, at all educational levels, and for all wealth quintiles. The difference between current and completed fertility is highest in Barisal (2.2 births), in rural areas (1.9 births), and among women in the second and middle wealth quintiles (2.2 births). 5.3 FERTILITY TRENDS In addition to the comparison of current and completed fertility, trends in fertility can be assessed in two other ways. First, fertility trends can be investigated using retrospective data from birth histories collected in the 2011 BDHS. Second, the TFR from the 2011 BDHS can be compared with estimates obtained in earlier surveys. Trends in fertility over time can be examined by comparing age-specific fertility rates from the 2011 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 in Table 5.3.1 show that fertility has dropped substantially among all age groups over the past two decades. The decline is steepest among the cohort age 30-34, with a 45 percent decline between the period 10 to 14 years before the survey and the period 0 to 4 years before the survey. 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 2011 Mother's age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 128 164 185 190 20-24 161 194 217 218 25-29 115 141 168 184 30-34 65 93 118 [140] 35-39 27 50 [72] - 40-44 7 [22] - - 45-49 [3] - - - Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. Since 1993, Bangladesh has undertaken demographic and health surveys regularly, in addition to other surveys, all of which have endowed the country with a wealth of data for examining fertility trends. Accordingly, changes in fertility levels over time can be tracked by examining fertility estimates from these surveys. Such data have been used to track fertility trends spanning the last three decades as summarized in Table 5.3.2 and Figure 5.2. 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 per woman during the current decade to reach 2.3 births per woman in 2009-2011. 64 • Fertility 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 2011 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) 15-19 109 182 179 140 147 144 135 126 118 20-24 289 260 230 196 192 188 192 173 153 25-29 291 225 188 158 150 165 135 127 107 30-34 250 169 129 105 96 99 83 70 56 35-39 185 114 78 56 44 44 41 34 21 40-44 107 56 36 19 18 18 16 10 6 45-49 35 18 13 14 6 3 3 1 3 TFR 15-49 6.3 5.1 4.3 3.4 3.3 3.3 3.0 2.7 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) Figure 5.2 Trends in total fertility rates, 1975-2011 6.3 5.1 4.3 3.4 3.3 3.3 3.0 2.7 2.3 1975 BFS 1989 BFS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Births per woman Figure 5.3 shows that in the 2007 BDHS and 2011 BDHS, Khulna Division continues to have the lowest TFR, and Sylhet Division has the highest TFR. Fertility • 65 Figure 5.3 Total fertility rates by division, 2007 and 2011 2.8 3.2 2.8 2.0 2.4 3.7 2.3 2.8 2.2 1.9 2.1 3.1 Barisal Chittagong Dhaka Khulna Rajshahi Sylhet Births per woman 2007 BDHS 2011 BDHS Note: TFR in Rangpur division in 2011 BDHS is 2.1 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 2.2, while currently married women have 2.6 births on average. Allowing for mortality of children, Bangladeshi women have, on average, 2.0 living children. Currently married women have an average of 2.3 living children. 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 2011 Age Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6 7 8 9 10+ ALL WOMEN 15-19 75.6 20.8 3.3 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 4,306 0.28 0.27 20-24 25.0 38.6 27.2 7.4 1.4 0.3 0.0 0.0 0.0 0.0 0.0 100.0 4,058 1.23 1.15 25-29 7.5 17.8 40.0 23.1 8.4 2.4 0.7 0.2 0.0 0.0 0.0 100.0 3,501 2.18 2.04 30-34 3.9 9.0 29.2 28.9 17.6 7.0 2.7 1.1 0.4 0.1 0.1 100.0 2,686 2.89 2.64 35-39 3.4 5.8 20.3 27.3 20.4 11.2 7.0 2.3 1.6 0.4 0.2 100.0 2,264 3.43 3.08 40-44 2.2 5.0 16.4 23.3 19.1 13.3 10.2 5.5 2.8 1.3 0.8 100.0 2,158 3.93 3.40 45-49 2.2 4.8 11.9 18.1 17.3 15.8 11.4 9.2 4.7 2.5 2.1 100.0 1,824 4.46 3.72 Total 23.1 17.6 21.4 16.1 9.7 5.4 3.3 1.8 0.9 0.4 0.3 100.0 20,797 2.21 1.98 CURRENTLY MARRIED WOMEN 15-19 45.9 46.1 7.3 0.7 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 1,925 0.63 0.59 20-24 12.7 44.5 31.9 8.7 1.7 0.4 0.0 0.0 0.0 0.0 0.0 100.0 3,396 1.43 1.35 25-29 4.0 17.8 42.2 24.0 8.9 2.4 0.7 0.2 0.0 0.0 0.0 100.0 3,262 2.27 2.12 30-34 2.3 8.0 29.6 29.7 18.3 7.3 2.9 1.1 0.5 0.1 0.1 100.0 2,532 2.98 2.72 35-39 1.9 4.9 20.5 27.9 21.5 11.6 7.2 2.2 1.6 0.5 0.2 100.0 2,081 3.52 3.16 40-44 1.7 3.8 16.6 23.7 18.9 13.4 10.8 5.8 3.0 1.4 0.9 100.0 1,937 4.02 3.49 45-49 1.6 3.4 10.8 17.7 17.5 16.7 12.1 9.8 5.0 3.0 2.2 100.0 1,501 4.64 3.89 Total 9.6 20.5 25.6 18.9 11.3 6.2 3.8 2.0 1.1 0.5 0.4 100.0 16,635 2.59 2.33 66 • Fertility Currently married women age 45-49 have given birth to an average of 4.6 children, of whom 3.9 have survived. Among all women age 15-49, the average number of children who have died per woman is 0.23. Among currently married women, it is 0.26; that is, 10 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 6 percent for women age 20-24 to 16 percent for women age 45-49. Nearly one-quarter (23 percent) of all women age 15-49 have never given birth. This proportion is far higher among women age 15-19, as 76 percent of women in this age group have never given birth. However, this proportion declines to 25 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 (2 to 3 percent) among all women age 35-44. These data indicate 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. Because voluntary childlessness is rare in Bangladesh, it is likely that married women with no births are unable to have children. Primary infertility is relatively low in Bangladesh at slightly more than 2 percent. 5.5 BIRTH INTERVALS Birth interval is the length of time between two successive live births. Information on birth intervals provides insight into birth spacing patterns, which affect fertility as well as maternal, infant, and childhood mortality. Studies have shown that short birth intervals are associated with increased risk of death for mother and baby, particularly when the birth interval is less than 24 months. 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 47 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. The length of the birth interval is closely associated with the survival status of the previous sibling. The median birth interval is 18 months shorter when the previous sibling has died than when the previous sibling is still alive (31 and 49 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 (55 months) than in rural (46 months) areas. There are marked differences in median birth intervals by administrative divisions. The median birth interval is longest in Khulna (61 months) and shortest in Sylhet (38 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 45 months among women with no education to 49 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 (57 months), whereas for the two lowest quintiles it is 45 months or less. The median number of months since a preceding birth increases significantly with age, from 26 months among mothers age 15-19 to 67 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. Fertility • 67 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 2011 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 21.6 20.8 37.8 15.9 3.9 0.0 100.0 162 26.4 20-29 4.9 7.7 22.2 21.0 16.7 27.5 100.0 3,625 44.5 30-39 3.3 4.5 15.1 14.9 12.5 49.8 100.0 1,635 59.8 40-49 3.6 2.8 15.4 11.9 7.4 59.0 100.0 231 67.4 Sex of preceding birth Male 5.4 6.8 20.0 17.3 15.1 35.4 100.0 2,810 48.4 Female 4.3 7.1 20.6 20.0 14.3 33.6 100.0 2,843 46.7 Survival of preceding birth Living 3.3 6.6 19.6 18.8 15.5 36.2 100.0 5,184 49.1 Dead 22.5 10.8 27.5 17.3 6.4 15.6 100.0 469 31.3 Birth order 2-3 4.6 6.6 19.2 18.5 15.2 35.9 100.0 4,045 48.9 4-6 5.4 7.4 22.6 19.2 13.7 31.7 100.0 1,400 45.1 7+ 6.6 11.7 26.5 18.2 12.3 24.7 100.0 209 37.9 Residence Urban 4.2 4.5 18.3 15.4 13.2 44.4 100.0 1,134 54.5 Rural 5.0 7.6 20.8 19.5 15.1 32.0 100.0 4,520 45.9 Division Barisal 4.4 5.3 15.2 18.9 16.1 40.1 100.0 303 52.9 Chittagong 5.4 8.7 25.1 21.0 14.4 25.4 100.0 1,348 41.5 Dhaka 4.8 6.2 20.5 19.3 15.1 34.0 100.0 1,715 47.3 Khulna 3.8 5.1 12.0 12.8 14.6 51.7 100.0 443 61.0 Rajshahi 3.9 5.3 13.6 17.1 14.6 45.5 100.0 753 56.6 Rangpur 3.7 6.1 19.4 16.3 15.0 39.5 100.0 587 52.1 Sylhet 7.7 10.9 27.9 20.6 13.6 19.3 100.0 505 37.6 Educational attainment No education 6.0 7.3 22.4 18.7 13.7 31.9 100.0 1,515 44.6 Primary incomplete 4.8 5.9 20.2 20.2 15.6 33.3 100.0 1,218 47.3 Primary complete1 4.0 9.4 22.4 17.8 14.3 32.1 100.0 714 45.7 Secondary incomplete 4.3 7.5 18.6 18.8 15.9 34.9 100.0 1,683 48.7 Secondary complete or higher2 4.9 3.6 16.8 15.9 12.6 46.3 100.0 523 56.4 Wealth quintile Lowest 5.1 8.3 24.4 22.2 15.9 24.1 100.0 1,570 41.0 Second 6.7 7.0 21.3 18.8 14.1 32.1 100.0 1,171 45.4 Middle 4.1 7.5 19.5 18.3 15.2 35.5 100.0 1,056 48.4 Fourth 4.7 5.3 18.2 16.1 13.4 42.2 100.0 1,011 52.7 Highest 3.0 5.8 14.8 15.7 14.4 46.4 100.0 846 57.3 Total 4.9 7.0 20.3 18.7 14.7 34.5 100.0 5,653 47.4 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. A comparison with earlier BDHS surveys shows that the median birth interval has increased markedly, rising from 35 months in 1993-1994 to 39 months in 2004, 44 months in 2007, and 47 months in 2011. Between 1993 and 2011, the median birth interval increased by 34 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 68 • Fertility 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. 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 2011 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 4.3 months, abstain for a median of 2.2 months, and are insusceptible to pregnancy for a median of 5.1 months. 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 2011 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 < 2 93.0 89.3 97.6 267 2-3 60.3 25.1 66.0 297 4-5 46.7 11.8 53.3 269 6-7 38.2 7.0 40.1 282 8-9 27.0 6.7 31.3 295 10-11 25.9 5.8 30.6 305 12-13 20.2 7.1 25.9 323 14-15 10.6 3.7 13.8 253 16-17 4.8 3.0 7.7 285 18-19 2.8 3.9 6.7 246 20-21 1.4 5.8 7.2 219 22-23 3.3 3.2 6.5 271 24-25 1.1 3.0 4.1 276 26-27 1.7 3.0 4.2 248 28-29 0.9 2.9 3.8 246 30-31 2.0 2.4 4.4 245 32-33 1.1 4.3 5.4 279 34-35 1.0 2.9 3.5 306 Total 19.6 10.7 23.6 4,913 Median 4.3 2.2 5.1 na Mean 7.1 4.1 8.5 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 Almost all women (98 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 93 percent in the first two months after birth to a low of less than 1 percent at 28-29 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 25 percent at 2 to 3 months and then drops to 12 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-third of all women are still amenorrheic, but only 7 percent are abstaining. At 16 to 17 months after birth, the proportion amenorrheic is 5 percent, while 3 percent of women are abstaining. Fertility • 69 A comparison of the 2011 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, and 4.3 months in 2011 (Mitra et al., 1994:77, Mitra et al., 1997:86; NIPORT et al., 2001:82; NIPORT et al., 2005:97). 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 there has been a slight decline in the duration of insusceptibility, from 6.5 months in 2007 to 5.1 months in 2011. Table 5.7 shows the median duration of postpartum amenorrhea, abstinence, and insusceptibility by background characteristics. The median duration of abstinence in Bangladesh varies little by background characteristics. The median duration of postpartum insusceptibility is almost two months longer among women age 30- 49 than among women age 15-29. Urban women have a shorter median duration of amenorrhea than rural women, and hence a shorter period of insusceptibility. There are considerable variations by administrative division for the period of insusceptibility. Postpartum insusceptibility is longer among women residing in Dhaka and Sylhet (5.8 and 5.7 months, respectively) than among women in the other divisions. The duration of postpartum amenorrhea is longer among women with no education than in women with some primary or secondary education. The median duration of postpartum amenorrhea also declines with household wealth. The poorest women have the longest duration of amenorrhea and postpartum insusceptibility. 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 2011 Background characteristic Postpartum amenorrhea Postpartum abstinence Postpartum insusceptibility1 Mother's age 15-29 4.2 2.2 4.8 30-49 5.6 2.3 6.6 Residence Urban 3.7 2.1 4.3 Rural 4.6 2.2 5.4 Division Barisal 4.8 1.8 4.9 Chittagong 3.8 2.3 4.6 Dhaka 5.2 2.3 5.8 Khulna 3.6 2.1 4.2 Rajshahi 3.9 2.0 4.0 Rangpur 4.1 2.0 4.7 Sylhet 5.2 2.3 5.7 Educational attainment No education 5.9 1.9 6.5 Primary incomplete 4.2 2.1 4.5 Primary complete2 5.6 2.6 7.2 Secondary incomplete 4.2 2.3 4.8 Secondary complete or higher3 3.3 2.2 4.3 Wealth quintile Lowest 6.2 1.9 6.4 Second 4.5 2.2 5.1 Middle 3.7 2.4 4.3 Fourth 4.5 2.1 5.0 Highest 3.6 2.3 4.5 Total 4.3 2.2 5.1 Note: Medians are based on the status at the time of the survey (current status). 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. 70 • Fertility 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 2011 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 presents data on menopause for women age 30 and older. Twenty percent of women age 30-49 are estimated to be menopausal. The proportion menopausal increases with age, from 7 percent among women age 30-34 to 62 percent among women age 48-49. These findings are similar to those in the 2007 BDHS. 5.8 AGE AT FIRST BIRTH Age at first birth has a direct effect on fertility. The onset of childbearing at an early age has a major effect on both the mother’s and the child’s health. 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 before age 15. The median age at first birth is about 18 years across all age cohorts, except for women age 20-24 and age 45-49, whose median age at first birth is 19 years. The proportion of women who had a child before age 15 has decreased; 11 percent of women in their late forties reported having had their first birth by age 15, compared with 4 percent of women age 15-19. About half of Bangladeshi women (49 percent) have given birth before reaching age 18, while 70 percent have given birth by age 20. A comparison of data from the 2007 and 2011 BDHS surveys shows a slight increase in the median age at first birth. 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 2011 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 3.5 na na na na 75.6 4,306 a 20-24 8.8 40.0 62.1 na na 25.0 4,058 18.9 25-29 11.3 49.1 70.4 82.9 89.6 7.5 3,501 18.1 30-34 12.7 49.3 69.5 82.0 90.6 3.9 2,686 18.1 35-39 11.6 50.9 69.8 81.9 90.3 3.4 2,264 17.9 40-44 10.8 48.9 71.0 82.8 91.4 2.2 2,158 18.1 45-49 11.1 44.5 65.5 79.4 90.3 2.2 1,824 18.5 20-49 10.9 46.6 67.7 na na 9.4 16,491 18.3 25-49 11.5 48.8 69.5 82.0 90.4 4.3 12,434 18.1 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 Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, by age, Bangladesh 2011 Age Percentage menopausal1 Number of women 30-34 6.7 2,654 35-39 10.4 2,246 40-41 15.6 1,075 42-43 25.8 753 44-45 34.5 759 46-47 50.1 680 48-49 61.8 705 Total 20.4 8,871 1 Percentage of women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey Fertility • 71 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 a year higher in urban areas than in rural areas. Among administrative divisions, it is highest in Sylhet (19.7 years). Median age at first birth is more than two years higher for women in the highest wealth quintile (19.8 years), compared with those in the lowest wealth quintile (17.6 years). Women who have some secondary education start childbearing later than those with little or no education. Table 5.10 Median age at first birth Median age at first birth among women age 20-49 and 25- 49, by background characteristics, Bangladesh 2011 Background characteristic Women age 20-49 Women age 25-49 Residence Urban 19.0 18.8 Rural 18.1 17.9 Division Barisal 18.2 18.0 Chittagong 18.8 18.5 Dhaka 18.5 18.3 Khulna 17.9 17.7 Rajshahi 17.8 17.6 Rangpur 17.5 17.5 Sylhet 19.7 19.5 Educational attainment No education 17.5 17.5 Primary incomplete 17.2 17.3 Primary complete1 17.7 17.7 Secondary incomplete 18.6 18.5 Secondary complete or higher2 a 22.2 Wealth quintile Lowest 17.6 17.7 Second 17.7 17.6 Middle 17.9 17.6 Fourth 18.5 18.1 Highest 19.8 19.6 Total 18.3 18.1 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. 5.9 TEENAGE PREGNANCY AND MOTHERHOOD Teenage pregnancy and motherhood is a major social and health concern. Early teenage pregnancy can cause severe health problems for both the mother and the child. The 2004 Bangladesh Population Policy focused on ensuring for adolescents adequate availability of and access to reproductive health services, especially family planning information, counselling, and services (MOHFW, 2009). 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 30 percent of adolescents age 15-19 have begun childbearing. About one- fourth of teenagers in Bangladesh 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 10 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 (33 versus 24 percent, respectively), and in Rangpur (41 percent) compared with other divisions. Childbearing begins 72 • Fertility later in Sylhet than in other divisions, mainly because of the later age at marriage in Sylhet. Delayed childbearing is strongly related to education among women age 15-19. Only 11 percent of the teenagers who completed secondary or higher education have begun childbearing, compared with almost half of those with no education (47 percent). Childbearing begins earlier in the lowest wealth quintile: 42 percent of adolescents in this group have begun childbearing, compared with 19 percent of adolescents 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. However, early childbearing among teenage women has slightly declined to 30 percent in 2011. 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 2011 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 6.0 3.8 9.8 888 16 11.5 4.6 16.1 818 17 22.3 6.6 28.9 825 18 31.7 7.1 38.8 971 19 51.4 6.9 58.3 804 Residence Urban 19.1 4.9 24.0 1,140 Rural 26.3 6.1 32.5 3,167 Division Barisal 24.6 5.5 30.2 264 Chittagong 21.9 5.5 27.4 913 Dhaka 23.7 5.1 28.8 1,365 Khulna 26.9 6.0 32.9 480 Rajshahi 24.8 8.0 32.8 519 Rangpur 35.1 5.9 41.0 473 Sylhet 13.6 5.8 19.5 293 Educational attainment No education 41.6 5.1 46.7 249 Primary incomplete 33.9 5.3 39.3 537 Primary complete1 31.5 8.3 39.8 430 Secondary incomplete 25.3 6.3 31.6 2,262 Secondary complete or higher2 7.2 3.9 11.1 816 Wealth quintile Lowest 34.9 6.7 41.6 606 Second 27.0 6.7 33.8 945 Middle 24.9 5.9 30.8 956 Fourth 22.5 6.1 28.6 952 Highest 15.6 3.7 19.3 849 Total 24.4 5.8 30.2 4,306 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Fertility Preferences • 73 FERTILITY PREFERENCES 6 nformation on fertility preferences is of considerable importance to family planning programs because it allows planners to assess the desire for children and also to assess the extent of unwanted and mistimed pregnancies. Data on fertility preferences also indicate the direction that future fertility efforts of a country’s citizens may take. As in previous BDHS surveys, the 2011 BDHS asked women a series of questions to ascertain their fertility preferences. The resulting data are used to quantify fertility 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—in combination 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 or man would want in total if she or he could start afresh. The information on ideal family size provides two measures. First, for men and women who have not yet started a family the data provide an idea of future fertility (to the extent that couples are able to realize their fertility desires). Second, 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 since it is understood that 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 2011 BDHS, currently married women (whether pregnant or not) and men 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 in the case of pregnant women to ensure the wantedness of subsequent children after completion of the current pregnancy. Sterilized women and men were considered to want no more children, and therefore they were not asked questions about their desire I Key Findings • Sixty-five percent of currently married women in Bangladesh want to limit child bearing—59 percent want no more children, and 6 percent have been sterilized. • The desire to stop childbearing among currently married women with two children has increased rapidly over the past decade, from 66 percent in 1999-2000 to 82 percent in 2011. • Women and men prefer to have the same family size of about two children (2.2). Since 1999-2000, the mean ideal number of children has decreased from 2.5 children to 2.2 children in 2011. • Bangladeshi women have 0.7 children more than their desired number. This implies that the TFR would be 30 percent lower if unwanted births were avoided. The gap between wanted and actual fertility rates has narrowed over the years; from 1.1 children in 1999-2000 to 0.7 children in 2011. 74 • Fertility Preferences for more children. Figure 6.1 shows the overall fertility preferences among currently married women in Bangladesh. There is widespread desire among Bangladeshi women to control the timing and number of births they have. Overall, 65 percent of currently married women in Bangladesh want to limit child bearing—59 percent say they want no more children, and an additional 6 percent have been sterilized. Thirty-one percent of married women want to have a child at some time in the future, but only 11 percent of married women want a child within two years, and 20 percent would prefer to wait two or more years Thus, the vast majority of married women want to either space their next birth or cease childbearing altogether. Figure 6.1 Fertility preferences among currently married women age 15-49 Want no more children* 65% Undecided** 2% Want child soon 11% Want child later 20% Infecund 2% * Includes male and female sterilization ** Includes undecided about when or if to have a child BDHS 2011 Table 6.1 shows the percent distribution of currently married women by desire for another child, according to the number of living 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 82 percent of women with two living children and over 90 percent of women with three or more children. The proportion of women who want to have another child decreases with the number of living children. Two in three women with no children want to have a child soon, while 62 percent of women with one child want to space the next birth and wait for two or more years. There have been some changes in fertility preferences among married women since 2007. The proportion of currently married women who either want no more children or who have been sterilized increased from 62 percent in 2007 to 65 percent in 2011, while the proportion of married women who want another child soon or later has decreased from 33 percent in 2007 to 31 percent in 2011 (NIPORT, Mitra and Associates, and Macro International, 2009). Fertility Preferences • 75 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 2011 Desire for children Number of living children1 Total 15-49 0 1 2 3 4 5 6+ Have another soon2 65.8 17.4 4.9 1.6 1.1 0.5 0.3 10.9 Have another later3 27.4 62.3 10.2 2.7 1.1 0.2 0.0 19.8 Have another, undecided when 1.6 1.5 0.3 0.0 0.1 0.1 0.7 0.6 Undecided 1.5 2.1 1.5 1.2 0.3 0.5 0.4 1.4 Want no more 0.9 14.5 76.2 80.7 81.4 80.7 86.3 58.7 Sterilized4 0.5 1.0 5.3 11.1 11.4 12.1 6.1 6.2 Declared infecund 2.3 1.1 1.3 2.4 4.1 5.9 5.9 2.3 Missing 0.0 0.1 0.3 0.2 0.4 0.0 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,268 3,740 4,886 3,365 1,836 853 688 16,635 1 The number of living children includes current pregnancy for women. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 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. The National Population Policy promotes a two-child family norm and emphasizes a dissemination of the message—not more than two children, one is better (MOHFW, 2009). Figure 6.2 shows that the desire to limit childbearing has increased rapidly in Bangladesh over the past decade. The percentage of currently married women with two children who desire to stop childbearing increased by 16 percentage points in the last decade, from 66 percent in 1999-00 to 82 percent in 2011. Figure 6.2 Trends in currently married women with two children who want no more children, 1993-2011 58 64 66 67 74 82 1993-94 BDHS 1996-97 BDHS 1999-00 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Percent Includes male and female sterilization. 76 • Fertility Preferences Table 6.2 shows the percentage of currently married women who desire to stop childbearing by urban-rural residence, division, education, and household wealth, by the number of living children the women have. Overall, rural women are more likely than urban women to want no more children because rural women already have more children than urban women do. With fewer numbers of living children, the pattern is reversed, that is, urban women are more likely than rural women to want no more children. For example, among women with two children, 86 percent of urban women want no more children compared with 80 percent of rural women. 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 2011 Background characteristic Number of living children1 Total 0 1 2 3 4 5 6+ Residence Urban 1.7 18.9 86.3 93.5 93.4 85.9 88.9 62.4 Rural 1.2 14.0 79.7 91.3 92.7 94.1 93.0 65.8 Division Barisal 1.7 14.7 82.5 92.6 96.5 95.2 98.6 66.7 Chittagong 0.0 9.4 69.5 86.5 93.4 95.0 92.5 62.1 Dhaka 1.5 15.1 81.0 94.1 93.9 92.0 93.5 64.0 Khulna 1.7 20.4 88.6 93.2 95.6 89.3 93.5 66.9 Rajshahi 1.7 21.7 85.8 92.8 88.4 89.1 88.2 66.3 Rangpur 0.3 13.1 87.0 93.6 91.6 95.4 90.6 67.6 Sylhet 4.5 12.2 66.9 83.3 89.1 91.6 90.6 63.9 Education No education 7.2 29.8 83.2 91.3 91.8 93.3 91.3 81.6 Primary incomplete 1.0 16.4 79.8 93.2 93.3 89.9 95.1 73.6 Primary complete2 0.8 12.1 79.6 90.3 94.1 93.9 94.5 65.6 Secondary incomplete 0.4 11.7 80.1 91.9 93.3 95.1 90.2 51.2 Secondary complete or higher3 0.7 18.1 86.4 91.7 96.8 100.0 100.0 50.4 Wealth quintile Lowest 3.7 15.1 77.5 89.6 92.6 95.0 91.1 69.6 Second 0.3 15.1 80.5 92.8 92.8 92.2 94.0 67.0 Middle 2.3 13.9 82.4 92.1 93.3 96.9 92.5 65.9 Fourth 0.3 14.6 81.9 92.8 91.1 89.4 90.3 62.1 Highest 1.2 18.1 83.7 91.8 94.6 86.3 95.8 60.8 Total 1.3 15.5 81.5 91.8 92.8 92.8 92.4 64.9 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. Overall, differences among women in their desire to limit childbearing are relatively small by administrative division. This difference has narrowed over time. For example, the percentage of women who want to stop childbearing in Sylhet increased from 54 percent in 2007 to 64 percent in 2011. However, the desire to limit childbearing varies somewhat among currently married women with two children. While the proportion of women with two children who want no more children has increased substantially in Sylhet, Barisal, and Chittagong divisions since 2007, this proportion remains lower than average in Sylhet (67 percent) and Chittagong (70 percent) (NIPORT, Mitra and Associates, and Macro International, 2009). 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, 82 percent of currently married women with no education want to stop childbearing compared with 50 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 (70 percent) while women in the highest wealth quintile are least likely to want no more children (61 percent). The Fertility Preferences • 77 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. 6.3 IDEAL FAMILY SIZE Women and men who were interviewed in the 2011 BDHS were asked two questions for determining ideal family size. Respondents who did not have any living children were asked, “If you could choose exactly the number of children to have in your lifetime, how many would that be?” For respondents who had living children, the question was rephrased as follows, “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your lifetime, how many would that be?” The results for women are presented in Table 6.3. Women in Bangladesh prefer a small family size (2.2 children on average). Three in four women want to have two children, while 5 percent want to have only one child. Twelve percent of women prefer a three-child family. 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 2011 Ideal number of children Number of living children1 Total 0 1 2 3 4 5 6+ 0 1.0 0.1 0.0 0.0 0.1 0.2 0.3 0.2 1 11.3 10.9 3.7 2.5 1.3 0.6 0.3 5.1 2 79.9 83.0 84.4 70.2 65.5 52.4 45.8 75.5 3 4.4 4.5 9.2 21.1 16.5 24.8 21.5 12.2 4 1.7 1.1 2.2 5.1 13.8 16.7 22.7 5.4 5 0.3 0.1 0.1 0.2 1.1 2.3 1.9 0.4 6+ 0.1 0.0 0.0 0.0 0.3 0.8 2.6 0.2 Non-numeric responses 1.3 0.4 0.3 0.7 1.4 2.1 4.9 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,447 4,011 5,115 3,568 1,954 918 737 17,749 Mean ideal number children for:2 Ever-married women 2.0 2.0 2.1 2.3 2.5 2.7 2.9 2.2 Number 1,428 3,996 5,099 3,542 1,927 898 700 17,590 Currently married women 2.0 2.0 2.1 2.3 2.5 2.7 2.9 2.2 Number 1,254 3,725 4,874 3,338 1,812 836 654 16,493 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. There has been a decline in the mean ideal number of children among women since 1999-2000. The mean ideal number of children decreased by 0.1 in each subsequent survey, from 2.5 children in 1999- 2000 to 2.2 in 2011. This finding could explain the declining total fertility rates in the same period. 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 2.9, 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. Both women and men in Bangladesh prefer to have the same number of children (2.2). Table 6.4 presents data on the mean ideal number of children for ever-married women and men age 15-49, by background characteristics. The ideal family size for both women and men increases with age. For women, 78 • Fertility Preferences it rises from 2.0 children in the youngest age group (15-19 years) to 2.5 children in the oldest age group (45-49 years). For men, it rises from 2.0 children among men age 20-24 to 2.2 children in the older age groups (30-49 years). Ideal family size for both women and men is slightly higher in rural areas than urban areas, and it is inversely related to education and household wealth. Divisional variations in ideal family size among both women and men are modest, ranging from 2.0 to 2.5 children. Ideal family size for both women and men is highest in Sylhet and Chittagong (2.5 children and 2.4 children, respectively) and is lowest among men in Khulna (2.0 children) and among women in Khulna, Rajshahi, and Rangpur (2.1 children). Table 6.4 Mean ideal number of children Mean ideal number of children for ever-married women age 15-49 and ever-married men age 15-49 by background characteristics, Bangladesh 2011 Background characteristic Mean Number of women1 Mean Number of men1 Age 15-19 2.0 1,961 * 21 20-24 2.1 3,497 2.0 247 25-29 2.1 3,380 2.0 620 30-34 2.2 2,632 2.2 620 35-39 2.3 2,217 2.2 656 40-44 2.4 2,119 2.2 625 45-49 2.5 1,785 2.2 580 Residence Urban 2.1 4,600 2.0 944 Rural 2.2 12,991 2.2 2,425 Division Barisal 2.2 990 2.1 173 Chittagong 2.4 3,173 2.4 511 Dhaka 2.2 5,724 2.1 1,092 Khulna 2.1 2,131 2.0 430 Rajshahi 2.1 2,633 2.1 552 Rangpur 2.1 2,026 2.1 440 Sylhet 2.5 914 2.5 170 Education No education 2.4 4,835 2.3 883 Primary incomplete 2.3 3,231 2.2 818 Primary complete2 2.2 2,034 2.1 304 Secondary incomplete 2.1 5,369 2.1 753 Secondary complete or higher3 2.0 2,121 2.0 611 Wealth quintile Lowest 2.3 3,211 2.3 650 Second 2.2 3,449 2.2 662 Middle 2.2 3,529 2.2 638 Fourth 2.2 3,639 2.1 721 Highest 2.1 3,762 2.0 698 Total 15-49 2.2 17,590 2.2 3,369 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Number of women/men who gave a numeric response 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 6.4 FERTILITY PLANNING Information collected in the 2011 BDHS can be used to estimate levels of unwanted fertility. This information provides some insight into the degree to which couples are able to control fertility. Women age 15-49 were asked a series of questions about each child born to them in the preceding five years, as well as any current pregnancy, to determine whether the birth or pregnancy was wanted then (planned), wanted later (mistimed), or not wanted at all (unplanned) at the time of conception. In assessing these results, it is important to recognize that women may declare a previously unwanted birth or current pregnancy as wanted, and this rationalization results in an underestimate of the true extent of unwanted births. Fertility Preferences • 79 Table 6.5 shows that almost three in four births in the five years preceding the survey were planned, 15 percent were mistimed, and 13 percent were unwanted. These figures are almost unchanged since the 2007 BDHS. The proportion of wanted births decreases and the proportion of unwanted births increases with increasing birth order, a pattern similar to that found in the 2004 and 2007 BDHS surveys. Eighty-seven percent of first-order births are wanted then, and 46 percent of fourth and higher-order births are unwanted. The proportion of mistimed births is highest for second-order births (23 percent) and then declines with birth order. 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 2011 Birth order and mother’s age at birth Planning status of birth Total Number of births Wanted then Wanted later Wanted no more Missing Birth order 1 87.1 12.8 0.1 0.1 100.0 3,512 2 74.6 23.2 2.2 0.0 100.0 2,866 3 63.7 14.7 21.6 0.0 100.0 1,717 4+ 47.5 6.2 46.1 0.2 100.0 1,763 Mother’s age at birth <20 79.2 19.8 0.9 0.1 100.0 3,105 20-24 75.0 17.9 7.1 0.0 100.0 3,418 25-29 68.6 9.7 21.6 0.1 100.0 2,009 30-34 59.4 4.5 36.1 0.0 100.0 903 35-39 46.6 2.0 51.0 0.3 100.0 335 40-44 36.2 5.7 58.1 0.0 100.0 72 45-49 * * * * * 15 Total 72.3 15.0 12.7 0.1 100.0 9,857 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. A similar pattern is observed for the mother’s age at birth. The proportion of planned births is highest (79 percent) among mothers in the youngest age group (<20) and then decreases with mother’s age. 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 1 percent among mothers below age 20 to 58 percent among mothers age 40-44. 80 • Fertility Preferences 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 intentions. This measure also may be an underestimate to the extent that women may not report an ideal family size lower than their actual family size. The total wanted fertility rates 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 total wanted fertility rate for Bangladesh is 1.6 children, a 16 percent decline from the 1.9 children estimated in the 2007 BDHS. The total fertility rate (TFR) is estimated as 2.3 children, which shows the same decline (15 percent) in the same period. 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. The gap between wanted and actual fertility rates has narrowed over the years; from 1.1 children in 1999-2000 to 0.7 children in 2011 (Figure 6.3). Figure 6.3 Trends in gap between wanted and unwanted fertility rates, 1993-2011 2.1 2.1 2.2 2.0 1.9 1.6 3.4 3.3 3.3 3.0 2.7 2.3 1993-94 BDHS 1996-97 BDHS 1999-00 BDHS 2004 BDHS 2007 BDHS 2011 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 2011 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 1.5 2.0 Rural 1.6 2.5 Division Barisal 1.6 2.3 Chittagong 1.7 2.8 Dhaka 1.6 2.2 Khulna 1.5 1.9 Rajshahi 1.6 2.1 Rangpur 1.5 2.1 Sylhet 1.8 3.1 Education No education 1.8 2.9 Primary incomplete 1.6 2.6 Primary complete1 1.6 2.3 Secondary incomplete 1.7 2.2 Secondary complete or higher2 1.5 1.9 Wealth quintile Lowest 1.8 3.1 Second 1.7 2.5 Middle 1.6 2.2 Fourth 1.5 2.1 Highest 1.5 1.9 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. Fertility Preferences • 81 There is a wide gap between wanted and observed fertility rates by characteristics of women. The gap is higher among women who live in rural areas (0.9 children) than among women who live in urban areas (0.5 children). The gap is also higher among women residing in Sylhet (1.3 children) and Chittagong (1.1 children) than women residing in Khulna (0.4 children) and Rajshahi (0.5 children). The gap between wanted and observed total fertility rates decreases with increasing education and wealth. Women with no education have 1.1 children more than they want, compared to 0.4 children among women with 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 1.3 children among women in the lowest wealth quintile. 6.6 SPOUSAL AGREEMENT IN DESIRED NUMBER OF CHILDREN Currently married women who were not sterilized in the 2011 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 of desired number of children Percent distribution of currently married women age 15-49 by husband’s desired number of children, by background characteristics, Bangladesh 2011 Background characteristic Husband wants Total Number of women Same number More children Fewer children Don’t know Missing Residence Urban 83.2 9.0 5.8 1.8 0.2 100.0 4,292 Rural 79.8 10.0 7.2 2.9 0.2 100.0 12,343 Division Barisal 81.3 9.3 5.5 3.8 0.1 100.0 952 Chittagong 79.0 10.8 6.7 3.3 0.2 100.0 3,015 Dhaka 82.7 9.6 5.3 2.2 0.2 100.0 5,334 Khulna 79.8 9.6 8.8 1.9 0.1 100.0 1,996 Rajshahi 81.1 7.6 8.7 2.3 0.3 100.0 2,526 Rangpur 81.5 8.9 7.2 2.1 0.3 100.0 1,927 Sylhet 72.2 15.3 6.7 5.5 0.3 100.0 884 Education No education 78.6 11.6 5.8 3.7 0.3 100.0 4,379 Primary incomplete 79.2 11.2 6.6 2.8 0.2 100.0 3,056 Primary complete1 81.1 9.3 6.9 2.6 0.2 100.0 1,963 Secondary incomplete 82.1 8.1 7.5 2.1 0.2 100.0 5,176 Secondary complete or higher2 83.2 8.1 7.3 1.4 0.1 100.0 2,061 Wealth quintile Lowest 77.2 12.6 6.0 3.9 0.3 100.0 2,975 Second 80.5 9.8 6.5 2.9 0.3 100.0 3,267 Middle 81.3 8.6 7.2 2.7 0.2 100.0 3,372 Fourth 80.7 9.1 7.7 2.3 0.1 100.0 3,457 Highest 83.0 8.8 6.5 1.5 0.2 100.0 3,564 Total 80.7 9.7 6.8 2.6 0.2 100.0 16,635 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Overall, four in five women report having spousal agreement in the desired number of children. Ten percent of women say their husband wants more children than they want, and 7 percent say he wants fewer children. There are relatively small variations in spousal agreement in the desired number of children by residence and education. Urban women are slightly more likely to report spousal agreement than rural women (83 percent and 80 percent respectively). There is a tendency towards increased spousal agreement in desired number of children with household wealth. The proportion of women having spousal agreement ranges from 77 percent among women in the lowest quintile to 83 percent in the highest quintle. Divisional variations in spousal agreement in desired number of children are modest, ranging from 79 to 83 percent, except in Sylhet where agreement is only 72 percent. Fertility Regulation • 83 FERTILITY REGULATION 7 his chapter presents results on contraceptive use and related information from the 2011 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, contact with family planning workers, exposure to family planning messages in the media, discussion of family planning with the spouse, 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, 61 percent of currently married Bangladeshi women age 15-49 are currently using a contraceptive method (Table 7.1). More than half (52 percent) use a modern method, and 9 percent use a traditional method. The pill is by far the most widely used method (27 percent), followed by injectables (11 percent), periodic abstinence (7 percent), male condoms (6 percent), and female sterilization (5 percent). About 1 percent each uses the IUD, male sterilization, implants, and withdrawal. Current use of contraception varies by age. Among young women, the use of any method increases with age, rising from usage among 47 percent of currently married women age 15-19 to a peak usage of 72 percent at age 35-39. Then usage among currently married women decreases to 64 percent at age 40-44 and to 43 percent at age 45-49. This inverted U-shaped pattern of contraceptive use by age is typical of most countries. The drop in current use among older women is usually attributed to their declining fecundity—whether perceived or real—while T Key Findings • Three in five married women in Bangladesh use a method of contraception, and more than half use a modern method of contraception (52 percent). Use of contraception increased from 56 to 61 percent between 2007 and 2011. • The four most popular modern methods used by married women are the pill (27 percent), injectables (11 percent), the male condom (6 percent), and female sterilization (5 percent). • Only 8 percent of currently married couples use a long-term or permanent method, such as sterilization, an IUD, or an implant. • More than one in three users of contraception has discontinued a method within 12 months of starting its use (36 percent). • The government sector remains the major provider of contraceptive methods, catering to more than half of all users (52 percent); government fieldworkers supply 23 percent. The private sector provides contraceptives to 43 percent of all users, with pharmacies supplying 33 percent. About two in five pill users (38 percent) and three in five condom users (60 percent) use a socially marketed brand. • Fourteen percent of currently married women in Bangladesh have an unmet need for family planning services; 8 percent have an unmet need for limiting births and 5 percent have an unmet need for spacing births. • Television is the most popular source of family planning messages in Bangladesh, with 24 percent of ever-married women and 37 percent of ever-married men having seen a family planning message in this media in the past six months. 84 • Fertility Regulation lower levels of use among younger women are usually attributed to their desire to have more children. Contraceptive use among women age 15-19 has increased from 42 percent in 2007 to 47 percent in 2011 (NIPORT et al, 2009). There are also variations in the use of specific methods by age. The pill is the most popular method among married women in all age groups, with one exception: women in the oldest age group, who are more likely to be sterilized. Injectables are the second most popular modern method after the pill for women age 20-34, while periodic abstinence is the second most popular method for women age 35-49. 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 2011 Age Any method Any modern method Modern method Any tradi- tional method Traditional method Not cur- rently using Total Number of women Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Male condom Periodic absti- nence With- drawal Other 15-19 47.1 42.4 0.0 0.0 26.0 0.0 8.9 0.7 6.8 4.7 2.8 1.9 0.1 52.9 100.0 1,925 20-24 57.9 53.4 0.8 0.5 31.9 0.6 12.8 1.2 5.6 4.5 3.1 1.2 0.2 42.1 100.0 3,396 25-29 65.8 60.0 3.5 1.2 32.3 0.8 14.1 1.7 6.3 5.8 4.1 1.7 0.0 34.2 100.0 3,262 30-34 70.7 61.0 5.2 2.1 32.6 1.0 13.2 1.2 5.7 9.8 7.1 2.2 0.5 29.3 100.0 2,532 35-39 71.7 56.9 7.9 1.5 27.6 1.3 10.7 1.7 6.2 14.8 11.3 2.8 0.7 28.3 100.0 2,081 40-44 63.6 46.0 9.2 2.5 18.5 0.9 9.4 0.7 4.8 17.7 14.5 2.0 1.1 36.4 100.0 1,937 45-49 43.1 30.4 13.7 1.3 9.0 0.2 3.9 0.1 2.1 12.8 10.8 1.6 0.3 56.9 100.0 1,501 Total 61.2 52.1 5.0 1.2 27.2 0.7 11.2 1.1 5.5 9.2 6.9 1.9 0.4 38.8 100.0 16,635 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 Use of contraceptives varies by the woman’s number of living children (Table 7.2 and Figure 7.1). Contraceptive use increases sharply as the number goes up, from 24 percent among married women with no children to 65 percent among women with one or two children. It continues to increase to 69 percent among women with three or four children but decreases to 58 percent after five or more children. This decrease in use may be caused by declining fecundity associated with the older age of high-parity women. The pill is the most widely used method among all categories of women. Contraceptive use varies by place of residence. While use of contraception continues to be higher in urban (64 percent) than in rural areas (60 percent), the gap is narrowing; in the 2007 BDHS it was 62 percent in urban areas and 54 percent in rural areas (NIPORT et al, 2009). The urban-rural differential in contraceptive use is primarily the result of greater use of condoms in urban areas than in rural areas (10 percent compared with 4 percent). Contraceptive use among geographic divisions ranges from a high of 69 percent in Rangpur to a low of 45 percent in Sylhet. There is a small variation in contraceptive use by women’s education. Contraceptive pills are favored by women of all educational levels (21 to 32 percent). Women with no education are more likely to use female sterilization than educated women. Women in the lowest two educational quintiles are the most likely to report using male sterilization. After the pill, injectables are favored by women (no education through secondary incomplete level) (10 to 14 percent). In contrast, male condom use is the second most popular method among women with secondary or higher education (18 percent). There is no significant variation in overall contraceptive use by economic status of women (61 percent of women in the highest wealth quintile use contraceptives compared with 62 percent of women in the lowest wealth quintile). Use of condoms increases with wealth quintile, while use of injectables declines as wealth increases. Fertility Regulation • 85 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 2011 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not cur- rently using Total Number of women Female sterili- zation Male sterili- zation Pill IUD Inject- ables Im- plants Male condom Periodic absti- nence With- drawal Other Number of living children 0 24.4 20.2 0.1 0.3 13.2 0.0 0.1 0.0 6.5 4.2 2.6 1.7 0.0 75.6 100.0 1,688 1-2 64.7 57.3 2.7 0.9 32.4 0.7 12.4 1.3 7.0 7.4 5.4 1.8 0.2 35.3 100.0 8,389 3-4 68.8 56.9 9.7 1.9 26.3 1.0 12.7 1.4 4.0 11.9 9.1 2.2 0.7 31.2 100.0 5,037 5+ 57.5 42.2 7.4 2.1 17.5 0.8 11.9 0.7 1.8 15.2 12.9 1.4 0.9 42.5 100.0 1,521 Residence Urban 64.0 54.0 3.9 1.0 28.1 0.7 9.2 0.9 10.3 10.0 7.8 2.0 0.3 36.0 100.0 4,292 Rural 60.3 51.4 5.3 1.3 26.9 0.7 11.9 1.2 3.9 8.9 6.6 1.8 0.4 39.7 100.0 12,343 Division Barisal 64.7 54.5 2.8 1.5 26.6 0.7 18.4 1.2 3.3 10.1 8.5 1.4 0.3 35.3 100.0 952 Chittagong 51.4 44.5 4.5 0.8 22.3 0.6 11.5 1.0 3.8 6.9 4.9 1.3 0.6 48.6 100.0 3,015 Dhaka 61.0 51.1 4.6 1.0 27.7 0.5 9.1 1.1 6.9 9.9 7.8 1.8 0.2 39.0 100.0 5,334 Khulna 66.7 56.1 5.8 1.0 28.9 0.9 11.6 1.1 6.8 10.6 6.9 3.3 0.4 33.3 100.0 1,996 Rajshahi 67.3 58.3 5.3 1.5 31.2 1.4 10.7 1.5 6.8 9.1 6.3 2.2 0.6 32.7 100.0 2,526 Rangpur 69.4 60.7 6.6 2.5 30.8 0.5 16.1 1.1 3.0 8.7 7.0 1.3 0.4 30.6 100.0 1,927 Sylhet 44.8 35.2 4.6 0.9 19.0 0.6 4.9 0.6 4.6 9.6 8.1 1.1 0.3 55.2 100.0 884 Education No education 61.4 50.2 9.6 1.9 21.4 0.8 13.5 1.1 1.9 11.2 9.1 1.3 0.8 38.6 100.0 4,379 Primary incomplete 64.2 53.5 5.5 2.0 26.8 0.6 14.4 1.5 2.7 10.7 8.2 2.0 0.5 35.8 100.0 3,056 Primary complete1 59.6 50.5 4.0 1.7 27.1 0.6 12.4 1.2 3.4 9.1 7.5 1.3 0.3 40.4 100.0 1,963 Secondary incomplete 59.0 52.9 2.1 0.5 32.1 0.8 10.0 1.1 6.4 6.1 3.9 2.0 0.2 41.0 100.0 5,176 Secondary complete or higher2 63.4 53.2 2.5 0.2 28.2 0.8 3.4 0.5 17.5 10.3 7.3 2.9 0.1 36.6 100.0 2,061 Wealth quintile Lowest 61.5 52.9 6.7 2.5 24.3 0.7 16.0 1.2 1.3 8.6 7.1 1.0 0.5 38.5 100.0 2,975 Second 62.9 53.8 5.3 1.7 27.8 0.7 13.7 1.9 2.6 9.2 7.0 1.6 0.5 37.1 100.0 3,267 Middle 61.4 52.1 5.2 1.0 28.8 0.9 11.4 1.2 3.8 9.3 7.1 1.7 0.4 38.6 100.0 3,372 Fourth 59.5 50.6 4.3 0.8 27.8 0.6 10.2 0.9 6.1 8.9 6.2 2.3 0.3 40.5 100.0 3,457 Highest 60.8 51.1 3.6 0.4 27.2 0.8 5.7 0.6 12.9 9.8 7.1 2.5 0.1 39.2 100.0 3,564 Total 61.2 52.1 5.0 1.2 27.2 0.7 11.2 1.1 5.5 9.2 6.9 1.9 0.4 38.8 100.0 16,635 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. Figure 7.1 Contraceptive use by background characteristics 64 60 65 51 61 67 67 69 45 61 64 60 59 63 62 63 61 60 61 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 * Primary complete is defined as completing grade 5. ** Secondary complete is defined as completing grade 10. 86 • Fertility Regulation 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 61 percent in 2011, a greater than sevenfold increase in fewer than four decades (Table 7.3 and Figure 7.2). Over the past four years alone, contraceptive use has increased by five percentage points, from 56 percent in 2007 to 61 percent in 2011. The use of oral pills declined slightly between 2007 and 2011, but the decline in injectable use seen in 2007 reversed in 2011, showing an increase from 7 percent to 11 percent of married women. It should be noted that the decline in injectable use, from 10 percent in 2004 to 7 percent in 2007, was due to a nationwide stock-out just before the survey. The 2008 Utilization of Essential Service Delivery survey (UESD) found a return to 11 percent as soon as the stock- out was resolved (Al-Sabir et al, 2009). While female sterilization has stalled, holding steady at about 5 percent of married women since 2004, there is a hint that use of male sterilization may have increased slightly since 2007. Use of traditional methods also declined, from 11 percent in 2004 to 8 percent in 2007, but then usage increased slightly to 9 percent in 2011. 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 1975-2011 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 Any method 7.7 19.1 25.3 30.8 39.9 44.6 49.2 53.8 58.1 55.8 61.2 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 Pill 2.7 3.3 5.1 9.6 13.9 17.4 20.8 23.0 26.2 28.5 27.2 IUD 0.5 1.0 1.4 1.4 1.8 2.2 1.8 1.2 0.6 0.9 0.7 Injectables u 0.2 0.5 0.6 2.6 4.5 6.2 7.2 9.7 7.0 11.2 Implants u u u u u u 0.1 0.5 0.8 0.7 1.1 Vaginal methods 0.0 0.3 0.2 0.1 u u u u u u u Condom 0.7 1.5 1.8 1.8 2.5 3.0 3.9 4.3 4.2 4.5 5.5 Female sterilization 0.6 6.2 7.9 8.5 9.1 8.1 7.6 6.7 5.2 5.0 5.0 Male sterilization 0.5 1.2 1.5 1.2 1.2 1.1 1.1 0.5 0.6 0.7 1.2 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 Periodic abstinence 0.9 2.4 3.8 4.0 4.7 4.8 5.0 5.4 6.5 4.9 6.9 Withdrawal 0.5 1.3 0.9 1.8 2.0 2.5 1.9 4.0 3.6 2.9 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 Number of women u 7,662 7,822 10,907 9,745 8,980 8,450 9,720 10,582 10,192 16,635 u = Unknown (not available) 1 Data from 2007 and 2011 are restricted to currently married women age 15-49. 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 at., 2005:67), and 2007 BDHS (NIPORT et al., 2008: 52) Fertility Regulation • 87 Figure 7.2 Trends in contraceptive use among currently married women age 10-49, 1975-2011 8 19 25 31 40 45 49 54 58 56 61 1975 BFS 1983 CPS 1985 CPS 1989 BFS 1991 CPS 1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Traditional methods Modern methods Percent Note: Contraceptive use in 2007 and 2011 is for women age 15-49. Between 1991 and 2011 use of female sterilization among currently married women declined from 9 to 5 percent. At the same time, two methods gained popularity; the pill is being used by 27 percent of women, almost double the level in 1991 (14 percent). Use of injectables increased from 3 percent in 1991 to 11 percent in 2011, a fourfold increase. However, the usage rate of injectables has stagnated at around 11 percent since 2008, a matter that may need further attention by program planners and policy makers. 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, and hints at a slight increase in 2011. 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. 88 • Fertility Regulation Figure 7.3 Trends in contraceptive method mix among currently married women, age 10-49, from1991-2011 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1991 CPS 1993-94 BDHS 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Any traditional Sterilization Condom Injectables Implants IUD Pill Note: Contraceptive use in 2007 and 2011 is for women age 15-49. Under the Health Population Nutrition Sector Development Program (HPNSDP), Bangladesh aims to increase overall use of contraception to 72 percent by 2016. This means an increase of 11 percentage points would need to occur in the next 5 years, or an average of a 2.2 percentage point increase per year. During 2004-2011, all-method contraceptive use increased from 58 to 61 percent, a 3-percentage- point increase in seven years. The HPNSDP for 2011-2016 also focuses on reducing regional differences in contraceptive use. Its plan is to increase modern method contraceptive use in Sylhet and Chittagong (the two divisions lagging behind in the adoption of family planning) to 50 percent by 2016. To reach this level, modern contraceptive method use in Chittagong and Sylhet must increase by 5 and 15 percentage points, respectively. 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 three in ten women were sterilized before age 25. The median age of sterilization is 28 years, which is one year higher than reported in the 2007 BDHS (NIPORT et al, 2009). Fertility Regulation • 89 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 2011 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 8.5 39.8 23.6 17.6 6.1 4.3 100.0 148 29.6 2-3 23.6 24.0 24.6 19.1 7.7 0.9 100.0 135 29.2 4-5 24.7 25.8 17.3 23.2 7.7 1.2 100.0 80 28.2 6-7 17.7 28.2 39.7 10.0 4.5 0.0 100.0 82 30.4 8-9 17.2 30.3 26.1 25.9 0.6 0.0 100.0 50 31.2 10+ 46.3 28.6 19.9 5.2 0.0 0.0 100.0 331 a Total 29.1 29.6 23.4 13.2 3.6 1.0 100.0 825 28.2 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. According to Bangladesh government policy, the MR procedure can be performed within 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 2011 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. Seven in ten ever-married and currently married women know about MR (Table 7.5). Among those who have ever heard of MR, 9 percent of ever-married and currently married women have ever used it. The use of MR increases among the ever-married and currently married women up to age 39 and then decreases slightly. Table 7.5 Menstrual regulation Percentage of ever-married and currently married women who know of menstrual regulation (MR) and percentage who ever used MR, by age group, Bangladesh 2011 Age Ever-married women Currently married women Percent of ever-married women who have ever heard of MR Number of ever-married women Among women who have ever heard of MR Percent of currently married women who have ever heard of MR Number of currently married women Among women who have ever heard of MR Percent ever used MR Number of ever-married women Percent ever used MR Number of currently married women 15-19 58.2 1,970 2.7 1,147 58.5 1,925 2.6 1,126 20-24 69.3 3,514 5.4 2,435 69.4 3,396 5.5 2,356 25-29 74.6 3,394 9.3 2,530 75.1 3,262 9.6 2,450 30-34 73.6 2,654 12.0 1,954 74.3 2,532 12.2 1,882 35-39 73.5 2,246 13.5 1,650 74.5 2,081 14.1 1,549 40-44 69.5 2,152 10.9 1,496 69.9 1,937 11.5 1,355 45-49 63.1 1,820 9.7 1,147 64.6 1,501 10.1 970 Total 69.6 17,749 9.1 12,360 70.3 16,635 9.4 11,689 90 • Fertility Regulation The major source of MR among the ever-married women who have used MR in the last three years is public sector facilities (43 percent), followed by private medical sector (32 percent) and NGO sector (9 percent) facilities (Table 7.6). Private hospitals and clinics are the major sources of MR (21 percent), followed by the Upazila health complex (20 percent) and the health and family welfare center (11 percent). 7.6 SOURCES OF FAMILY PLANNING METHODS To ascertain the sources of family planning methods in Bangladesh, the 2011 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 (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 government hospitals, Upazila health complexes, family welfare centers, satellite/EPI clinics, maternal and child welfare centers, and government fieldworkers), NGO-sector sources (including static clinics, satellite clinics, depot holders, and fieldworkers), private medical sources (including private hospitals and clinics, qualified or traditional doctors, and pharmacies), and other private sources (including shops and friends or relatives). Table 7.7 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 2011 Source Female sterilization Male sterilization Pill IUD Injectables Implants Male condom Total Public sector 74.9 87.7 44.9 89.3 66.4 93.3 16.7 52.1 Medical college hospital 4.2 1.5 0.1 0.5 0.1 0.8 0.0 0.5 Specialized government hospital 0.1 2.4 0.0 0.0 0.0 0.0 0.0 0.1 District hospital 15.9 19.9 0.1 8.8 0.6 8.6 0.1 2.5 Maternal and child welfare center 7.3 6.9 0.4 10.1 2.0 13.1 0.5 2.0 Upazilla health complex 41.8 51.5 2.1 28.1 5.2 42.8 0.9 8.8 Health and family welfare center 5.1 5.5 5.5 35.3 17.7 26.5 2.8 8.7 Satellite clinic/Epi outreach 0.0 0.0 3.2 0.0 11.1 0.0 0.4 4.1 Community clinic 0.0 0.0 2.1 6.0 6.0 1.5 0.8 2.6 Government field worker (FWA) 0.0 0.0 31.3 0.5 23.5 0.0 11.2 22.7 Other public sector 0.5 0.0 0.1 0.0 0.2 0.0 0.0 0.2 Private medical sector 21.1 3.9 45.0 3.8 24.5 1.8 69.3 38.4 Private hospital/clinic 20.5 3.9 0.1 3.5 1.8 1.4 0.2 2.6 Qualified doctor’s chamber 0.3 0.0 0.2 0.3 2.1 0.0 0.0 0.6 Non-qualified doctor’s chamber 0.0 0.0 0.6 0.0 6.9 0.3 0.1 1.8 Pharmacy 0.0 0.0 44.1 0.0 13.7 0.0 69.0 33.3 Other private medical sector 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NGO sector 2.5 4.7 3.4 6.9 8.1 4.9 2.2 4.3 Static clinic 2.5 4.7 1.2 6.9 5.5 4.9 1.6 2.5 Satellite clinic 0.0 0.0 0.1 0.0 0.8 0.0 0.1 0.2 Depot holder 0.0 0.0 0.5 0.0 0.1 0.0 0.1 0.3 Field worker 0.0 0.0 1.5 0.0 1.5 0.0 0.4 1.2 Other NGO 0.0 0.0 0.1 0.0 0.2 0.0 0.0 0.1 Other source 0.0 0.0 6.6 0.0 0.9 0.0 11.8 4.9 Grocery 0.0 0.0 4.3 0.0 0.3 0.0 10.2 3.4 Friends/relatives 0.0 0.0 1.9 0.0 0.1 0.0 0.8 1.1 Other 0.0 0.0 0.5 0.0 0.5 0.0 0.8 0.4 Don’t know 0.4 2.6 0.0 0.0 0.0 0.0 0.0 0.1 Missing 1.0 1.1 0.2 0.0 0.2 0.0 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 825 207 4,531 122 1,863 189 921 8,659 Table 7.6 Use of menstrual regulation Percent distribution of ever-married women age 15-49 who have ever used menstrual regulation in the last three years by source of service, Bangladesh 2011 Source of service Percent Public sector 43.3 Medical college hospital 1.0 District hospital 3.6 Maternal and child welfare center 6.1 Upazila health complex 19.5 Health and family welfare center 10.8 Satellite clinic/EPI outreach 0.1 Community clinic 0.3 Government field worker (FWA) 1.7 Private medical sector 32.0 Private hospital/clinic 20.8 Qualified doctor’s chamber 6.2 Non-qualified doctor’s chamber 2.7 Pharmacy 2.2 Other private medical sector 0.1 NGO sector 8.8 Static clinic 7.6 Depot holder 0.2 Field worker 0.9 Other 3.3 Don’t know 2.3 Missing 10.3 Total 100.0 Number of women 378 Fertility Regulation • 91 Table 7.7 and Figure 7.4 show the percentage of current users of modern methods who obtained their method from a specific source. The table shows that the public sector remains the predominant source, providing contraceptive methods to more than half of users (52 percent), with government fieldworkers the most important public sector source, supplying 23 percent of users. The contribution of the public sector in providing modern family planning methods declined from 57 percent in 2004 to 50 percent in 2007, and increased slightly to 52 percent in 2011. The rise in public sector contribution is mainly due to increased use of fieldworkers and community clinics for family planning supplies. In recent years the government of Bangladesh has recruited new health workers to fill vacant positions and has increased efforts to make the community clinics functional. Thirty-eight percent of modern contraceptive users get their supplies from a private medical source, with pharmacies being the most important source, serving 33 percent of users. An additional 5 percent use non-medical private sources, mainly groceries. Non-governmental organizations (NGOs) supply contraceptives to 4 percent of users. Between 2007 and 2011, the contribution of the private sector (medical and non-medical) as a source of contraceptive supply declined slightly, from 44 to 43 percent. Although use of private medical practitioners or clinics has increased slightly, the share of pharmacies and shops in providing contraceptives has declined (from 40 to 37 percent). Figure 7.4 Distribution of current users of modern methods by source of supply Public sector 52 Private medical sector 38 NGO sector 4 Other source 5 BDHS 2011 % % % % 92 • Fertility Regulation There are large differences by specific method in the source used. The public sector is the predominant source for sterilizations, IUDs, implants, and injectables. The Upazila health complex accounts for the largest share of sterilizations and implants. The government fieldworkers are becoming increasingly important for delivering injectables (now that they are authorized to dispense them). Their share in the provision of injectables increased from 8 percent in 2007 to 24 percent in 2011. Pharmacies are the predominant source for pills and condoms. The government fieldworker is also an important source for pills. The 2011 BDHS asked women who have never used family planning whether they know a source of services for family planning. Table 7.8 shows the knowledge level in different sectors as a source of family planning services. Seven in ten know a public sector source, while almost half know a private medical sector source of family planning services. Eight percent of never users know about an NGO source. However, one in five doesn’t know any source of family planning method. 7.7 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), micronutrition powder, zinc tablets, 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, C-3, and the Progestin-only pill Minicon. Another oral pill, Nordette-28, has been discontinued. To obtain information on the number of users purchasing the social marketing brands, the 2011 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. Table 7.8 Knowledge of specific sources of family planning services Percentage of ever-married women age 15-49 who have never used family planning who know sources of family planning, Bangladesh 2011 Source known Percent Public sector 71.0 Medical college hospital 0.6 Specialized government hospital 0.6 District hospital 6.4 Maternal and child welfare center 3.8 Upazila health complex 22.5 Health and family welfare center 21.3 Satellite clinic/EPI outreach 12.2 Community clinic 5.6 Government field worker (FWA) 41.1 Private medical sector 49.5 Private hospital/clinic 2.9 Qualified doctor’s chamber 1.2 Non-qualified doctor’s chamber 1.8 Pharmacy 46.8 Private medical college hospital 0.2 NGO sector 7.6 Static clinic 4.1 Satellite clinic 0.5 Depot holder 0.2 Field worker 3.3 Other NGO 0.1 Other source 11.6 Grocery 11.5 Friends/relatives 0.1 Don’t know 20.7 Missing 0.2 Any source 79.1 Number of women 3,159 Fertility Regulation • 93 As shown in Table 7.9, 38 percent of pill users use social marketing brands compared with 55 percent who use the government-supplied brand, Shuki. Shuki is provided free of charge through government fieldworkers and clinics and at a nominal charge through nongovernmental service providers. One in four pill users uses Femicon, the most popular social marketing brand of pill. Femicon is more common in urban (33 percent) than in rural (23 percent) areas. The next most widely used social marketing brand is Femipil (8 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 2 percent of pill users. The percentage of pill users using a social marketing brand has risen consistently from 14 percent in 1993-94 to 40 percent in 2004, and to 45 percent in 2007; use then declined to 38 percent in 2011. The use of Femicon decreased by nine percentage points, from 35 percent in 2007 to 26 percent in 2011. The supply of Femicon and Nordette-28 was interrupted in 2010 because the plant was closed by the manufacturer (Wyeth, USA). To assess the social marketing program’s reach in condom use, the 2011 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, because of the larger sample of women than men in the BDHS survey, the data shown in Table 7.10 are derived from women. Three in five condom users buy social marketing brands; 24 percent use Panther, 14 percent use Hero, 13 percent use Sensation, and another 3 percent use U&ME. The Panther, Sensation, and U&ME brands are more popular in urban than rural areas, while Raja and Hero brands are more popular in rural areas. The percentage of condom users who obtain their supplies from the SMC has increased over the past four years, from 57 percent in 2007 to 60 percent in 2011. The SMC distributes the injectable brand Somaject 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 2011 BDHS, information in Table 7.7 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 7.7 shows that about one fifth of married women age 15-49 years who currently use injectables obtained the injection from either nonqualified doctor’s chambers or pharmacies, which are the sources of Somaject distribution. Table 7.9 Use of pill brands Percent distribution of currently married pill users by brand of pill used, according to urban-rural residence, Bangladesh 2011 Background characteristic Residence Total Urban Rural Social marketing 48.8 34.2 38.1 Nordette-28 3.8 0.7 1.5 Femicon 33.0 22.8 25.5 Minicon 1.7 1.5 1.6 Femipil 8.6 8.3 8.4 Noret-28 1.5 0.8 1.0 Combination-3 0.2 0.1 0.1 Government 40.8 60.3 55.1 Shuki 40.8 60.3 55.1 Private 10.0 4.9 6.3 Ovostat 6.2 3.1 4.0 Desolon 0.7 0.2 0.3 Bredicon 0.2 0.2 0.2 Lynes 0.3 0.1 0.2 Marvelon 2.0 1.0 1.3 Aco 0.4 0.3 0.4 Regumen 0.1 0.0 0.1 Other 0.4 0.5 0.5 Total 100.0 100.0 100.0 Number of women 1,201 3,318 4,519 Note: Pill users who do not know the brand name are excluded from the table. 94 • Fertility Regulation Table 7.10 Use of condom brands Percent distribution of currently married condom users by brand of condom used, according to urban-rural residence, Bangladesh 2011 Condom brand Residence Total Urban Rural Social marketing 65.2 55.5 60.1 Raja 3.4 8.3 6.0 Panther 26.5 21.5 23.9 Hero 11.6 16.0 13.9 Sensation 19.0 8.0 13.3 U & ME 4.6 1.7 3.1 Government 8.6 21.9 15.5 Nirapad 8.6 21.9 15.5 Private 21.0 15.7 18.2 Moods 0.3 0.3 0.3 Gamy 1.2 0.9 1.1 Wonder life 0.1 0.3 0.2 Romantex 0.8 1.3 1.1 Durex 1.7 0.2 0.9 Love guard 0.9 1.2 1.1 Coral 3.8 2.5 3.1 Jippy 0.4 0.6 0.5 Green love 3.0 3.1 3.1 Carex 6.5 3.9 5.2 Long love 1.4 0.9 1.1 Luxury 0.6 0.0 0.3 Care free 0.2 0.0 0.1 Feelings 0.1 0.2 0.2 Sweet love 0.0 0.3 0.2 Other 5.2 6.9 6.1 Total 100.0 100.0 100.0 Number of women 405 445 850 Note: Table excludes condom users who do not know the brand name. Table is based on women's reports. 7.8 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 7.11. These rates are based on information collected in the 5-year, month-by-month 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 7.11 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. Fertility Regulation • 95 Table 7.11 12-month 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, 2011 Method Method failure Desire to become pregnant Other fertility- related reasons2 Side effects/ health concerns Wanted more effective method Other method- related reasons3 Other reason Any reason4 Switched to another method5 Number of episodes of use6 Female sterilization 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.0 331 Pill 4.3 8.9 9.5 11.6 1.3 1.5 1.9 39.0 11.1 7,109 IUD (1.6) (0.8) (0.0) (16.5) (1.0) (0.7) (1.8) (22.4) (15.0) 134 Injectables 1.2 3.4 3.8 22.9 0.5 2.6 1.6 36.1 20.3 2,656 Implants (1.1) (1.0) (0.0) (5.7) (0.0) (0.0) (0.0) (7.8) (4.0) 203 Condom 7.8 9.1 4.1 4.9 6.4 10.1 4.7 47.0 24.5 1,549 Periodic abstinence 5.3 5.6 1.4 0.8 7.8 0.7 1.4 23.1 10.0 1,106 Withdrawal 8.0 3.1 0.9 1.5 5.7 4.3 1.7 25.3 11.5 346 All methods1 4.1 7.0 6.3 11.4 2.3 2.6 2.0 35.7 13.8 13,614 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months prior to the survey. Figures in parentheses are based on 125-249 unweighted episodes of use. 1 Includes male sterilization 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 36 percent of users of contraceptive methods stop using the method within 12 months of starting. Not surprisingly, discontinuation rates are much higher for more temporary methods like condoms (47 percent) and the pill (39 percent) than for longer-term methods like the IUD and implants. There has been a decline in discontinuation rates from 57 percent in 2007 to 36 percent in 2011. While the decline occurred for all methods in the past four years, it has been particularly large for withdrawal and periodic abstinence. Figure 7.5 shows the trend in discontinuation rates from 1996-97 to 2011. The all-method discontinuation rate for any reason fluctuated between 47 and 49 percent between 1996-97 and 2004, increased to 57 percent in 2007, and then sharply declined to 36 percent in 2011. The reasons for this decline in discontinuation rate need further investigation. 96 • Fertility Regulation Figure 7.5 Twelve-month contraceptive discontinuation rates for any reason 47 49 49 57 36 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Percent Further information on reasons for contraceptive discontinuation is presented in Table 7.12. This table shows the percent distribution of all discontinuations occurring during the five years preceding the survey, regardless of whether they occurred during the first 12 months of use or not. Side effects/health concerns are the most common reason for discontinuation, accounting for 29 percent of all discontinuations. The next most common reason for discontinuation is the desire to become pregnant (26 percent), followed by accidental pregnancies (15 percent). Table 7.12 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 2011 Reason Pill IUD Inject- ables Implants Male condom Periodic absti- nence With- drawal All methods Became pregnant while using 15.2 2.4 5.2 1.4 19.4 29.5 29.4 15.0 Wanted to become pregnant 29.9 11.6 17.2 8.6 25.7 24.5 21.1 26.2 Husband disapproved 0.6 0.3 0.9 0.0 5.9 1.4 8.4 1.4 Wanted a more effective method 3.3 4.5 2.2 8.3 11.3 19.8 18.9 5.4 Side effects/health concerns 28.3 64.2 53.2 64.9 10.3 1.5 2.3 29.3 Lack of access/too far 0.8 0.4 4.4 3.3 0.8 0.0 0.0 1.4 Cost too much 0.4 0.0 0.5 0.0 0.5 0.0 0.0 0.4 Inconvenient to use 2.4 2.5 1.7 1.7 14.3 2.3 7.8 3.5 Up to God/fatalistic 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 Difficult to get pregnant/ menopausal 2.1 3.0 5.2 2.7 1.6 7.9 2.5 3.0 Infrequent sex/husband away 12.7 1.3 4.8 2.8 6.8 3.9 3.0 9.6 Marital dissolution/separation 1.1 0.0 1.1 3.1 0.8 1.4 1.4 1.1 Other 0.4 7.8 0.7 2.8 0.3 0.7 1.3 0.6 Don’t know 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Missing 2.7 2.0 2.9 0.3 2.2 7.2 3.8 3.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 6,847 85 2,114 112 1,125 810 232 11,360 Note: Total includes 4 women and 5 men who had been sterilized and 26 women who used other methods. Fertility Regulation • 97 There are variations in reasons for discontinuation by method. Side effects are the most common reason for discontinuation of the injectables (53 percent), implant (65 percent), and IUD (64 percent), while desire to become pregnant is the most common reason for discontinuation of the pill (30 percent) and male condom (26 percent). Method failure (“became pregnant while using”) is the most common reason for discontinuation of periodic abstinence (30 percent) and withdrawal (29 percent). Desire to become pregnant is an important reason for discontinuation of reversible methods such as condom (26 percent), periodic abstinence (25 percent), withdrawal (21 percent), injectables (17 percent), and the IUD (12 percent). 7.9 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, which led to unmet need being calculated inconsistently. The revised definition 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. 98 • Fertility Regulation Unmet need, total demand, percentage of demand satisfied, 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, 14 percent of currently married women in Bangladesh have an unmet need for family planning services, 8 percent for limiting and 5 percent for spacing of births (Table 7.13). Unmet need for family planning decreases with increasing age, ranging from 17 percent among women age 15-19 to 8 percent among women age 45-49. Women in rural areas have a higher unmet need (14 percent) than women in urban areas (11 percent). By division, unmet need is highest in Chittagong (21 percent) and lowest in Khulna and Rangpur (both 10 percent). Unmet need increased from 15 percent of currently married women in 2004 to 17 percent in 2007 and then decreased to 14 percent in 2011 (Figure 7.6). The Health Population Nutrition Sector Development Programme (HPNSDP) has set as a target reducing unmet need for family planning services to 9 percent by 2016. Demand for family planning services is defined as the sum of total unmet need and total contraceptive use. The 2011 BDHS shows that demand for family planning services is 75 percent and proportion of demand satisfied (total contraceptive use divided by the sum of total unmet need and total contraceptive use) is 82 percent. Fertility Regulation • 99 Table 7.13 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 2011 Background characteristic Unmet need for family planning1 Met need for family planning (currently using)2 Total demand for family planning Percentage of demand satisfied Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 15.7 1.3 17.0 42.0 5.1 47.1 57.7 6.4 64.1 73.5 1,925 20-24 10.9 4.4 15.3 34.2 23.6 57.9 45.1 28.1 73.2 79.1 3,396 25-29 5.1 10.1 15.2 16.2 49.5 65.8 21.4 59.6 81.0 81.2 3,262 30-34 1.8 11.7 13.5 5.3 65.4 70.7 7.2 77.1 84.2 83.9 2,532 35-39 0.5 11.0 11.5 1.5 70.3 71.7 1.9 81.3 83.2 86.2 2,081 40-44 0.1 10.2 10.3 0.3 63.4 63.6 0.4 73.5 74.0 86.0 1,937 45-49 0.1 7.6 7.8 0.3 42.8 43.1 0.4 50.5 50.9 84.8 1,501 Residence Urban 4.2 6.9 11.1 19.2 44.8 64.0 23.4 51.7 75.0 85.3 4,292 Rural 5.8 8.5 14.3 15.0 45.2 60.3 20.9 53.7 74.6 80.8 12,343 Division Barisal 5.3 6.9 12.1 18.5 46.1 64.7 23.8 53.0 76.8 84.2 952 Chittagong 8.4 12.3 20.7 14.6 36.8 51.4 23.0 49.1 72.1 71.3 3,015 Dhaka 5.0 8.0 13.0 16.6 44.4 61.0 21.6 52.4 74.0 82.4 5,334 Khulna 3.7 5.8 9.5 17.2 49.5 66.7 21.0 55.3 76.2 87.5 1,996 Rajshahi 4.6 6.4 11.0 16.8 50.6 67.3 21.4 57.0 78.4 85.9 2,526 Rangpur 4.1 5.5 9.7 16.7 52.7 69.4 20.8 58.2 79.0 87.8 1,927 Sylhet 6.6 10.7 17.3 9.8 34.9 44.8 16.4 45.7 62.1 72.1 884 Educational attainment No education 2.2 9.8 12.0 5.0 56.4 61.4 7.2 66.2 73.4 83.6 4,379 Primary incomplete 4.2 8.7 12.9 11.6 52.6 64.2 15.8 61.3 77.1 83.2 3,056 Primary complete3 5.4 7.5 12.9 15.1 44.5 59.6 20.5 52.0 72.5 82.2 1,963 Secondary incomplete 8.5 7.1 15.6 24.3 34.7 59.0 32.8 41.8 74.6 79.1 5,176 Secondary complete or higher4 6.2 6.3 12.5 26.7 36.7 63.4 32.9 43.0 76.0 83.5 2,061 Number of living children1 0 4.4 8.2 12.6 16.6 46.0 62.7 21.1 54.2 75.3 83.2 2,303 1 4.9 7.6 12.6 15.3 46.6 61.9 20.2 54.2 74.4 83.1 4,349 2 5.3 8.6 13.9 16.0 45.3 61.3 21.3 53.9 75.2 81.6 3,980 3 5.4 8.0 13.5 16.8 45.2 62.0 22.3 53.3 75.5 82.2 2,792 4+ 6.9 8.0 14.8 16.4 42.1 58.4 23.2 50.0 73.3 79.8 3,212 Wealth quintile Lowest 5.2 8.6 13.8 12.9 48.6 61.5 18.1 57.2 75.3 81.6 2,975 Second 5.4 7.0 12.4 15.3 47.7 62.9 20.7 54.7 75.4 83.5 3,267 Middle 5.4 8.1 13.4 15.4 46.1 61.4 20.7 54.1 74.9 82.1 3,372 Fourth 6.3 8.8 15.1 17.0 42.5 59.5 23.3 51.4 74.6 79.7 3,457 Highest 4.8 7.8 12.6 19.4 41.5 60.8 24.1 49.3 73.4 82.9 3,564 Total 5.4 8.1 13.5 16.1 45.1 61.2 21.5 53.2 74.7 82.0 16,635 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 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. 100 • Fertility Regulation Figure 7.6 Trends in unmet need for family planning among currently married women age 15-49, 2007 and 2011 BDHS 17 56 73 77 14 61 75 82 Unmet need Current use Total demand Proportion of total demand satisfied 2007 BDHS 2011 BDHS 7.10 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 survey—defined as nonusers—were asked about their intention to use family planning in the future. The results are presented in Table 7.14, according to the number of living children the women had. Approximately two-thirds of nonusers said they intend to use family planning methods, and one- third said that they do not intend to use contraceptives. Only a few nonusers (2 percent) say they are unsure of their intention. Intention to use varies with the number of children. The proportion of nonusers who say they intend to use family planning in the future peaks at 84 percent for women with one child and falls sharply to 34 percent among women with four or more children. The proportion of nonusers intending to use family planning in the future has been decreasing gradually, dropping from 73 percent in 2004 to 70 percent in 2007 and to 65 percent in 2011. Table 7.14 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 2011 Intention to use in the future Number of living children1 Total 0 1 2 3 4+ Intends to use 76.5 83.5 71.6 58.6 34.3 65.4 Unsure 3.3 2.2 1.2 0.7 1.1 1.6 Does not intend to use 20.2 13.8 26.8 40.2 63.8 32.5 Missing 0.0 0.5 0.3 0.6 0.8 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 856 1,657 1,538 1,066 1,336 6,452 1 Includes current pregnancy Percent Fertility Regulation • 101 Another question assessed future demand for specific contraceptive methods among currently married women who were not using contraception but who said they intended to use a method in the future. They were asked which method they would prefer to use. The results are presented in Table 7.15. More than half of the prospective users prefer the pill (51 percent), while 19 percent prefer injectables. Table 7.15 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 2011 Method Age 15-29 Age 30-49 Total Female sterilization 2.3 3.9 2.6 Male sterilization 0.1 0.1 0.1 Pill 50.4 50.9 50.5 IUD 0.4 0.5 0.4 Injectables 19.7 18.2 19.3 Implants 0.9 0.5 0.8 Male condom 3.7 4.8 4.0 Periodic abstinence 1.0 3.9 1.6 Withdrawal 0.1 0.5 0.2 Other 0.2 0.2 0.2 Unsure 21.2 16.7 20.2 Total 100.0 100.0 100.0 Number of women 3,289 933 4,222 7.11 REASONS FOR NOT INTENDING TO USE CONTRACEPTION Table 7.16 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). More than three-quarters 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 35 percent of nonintenders, followed by those are subfecund or infecund (24 percent). Sixteen percent of women do not intend to use a contraceptive method because of infrequent sex or no sex. Two percent of nonintenders, mostly women age 15-29, do not intend to use contraception because they want more children. Fourteen percent of married women do not intend to use because of method-related reasons, mainly health concerns. Other major reasons for nonuse are opposition to family planning and lack of knowledge. Six percent of nonintenders do not intend to use contraceptives because of opposition to family planning, either by themselves, their husband, or others, or because of religious prohibitions. 102 • Fertility Regulation Table 7.16 Reason for not intending to use contraception in the future Percent distribution of currently married women age 15-49 who are not using contraception and who do not intend to use in the future by main reason for not intending to use, according to age, Bangladesh 2011 Reason Age 15-29 Age 30-49 Total Fertility-related reasons 47.2 80.6 77.2 Infrequent sex/no sex 16.0 16.1 16.1 Menopausal/had hysterectomy 5.8 37.8 34.6 Subfecund/infecund 13.9 24.6 23.5 Wants as many children as possible 9.9 1.1 1.9 Up to God/fatalistic 1.5 1.0 1.0 Opposition to use 20.3 4.6 6.1 Respondent opposed 7.1 2.1 2.6 Husband/partner opposed 10.8 1.2 2.2 Religious prohibition 2.4 1.3 1.4 Lack of knowledge 0.4 0.2 0.3 Knows no method 0.4 0.1 0.1 Knows no source 0.0 0.1 0.1 Method-related reasons 23.6 12.5 13.7 Health concerns 10.3 5.2 5.7 Fear of side effects 3.9 2.8 2.9 Inconvenient to use 1.0 0.1 0.2 Interfere with body’s normal process 8.4 4.5 4.9 Other 6.2 0.9 1.5 Don’t know 0.9 0.5 0.5 Missing 1.3 0.7 0.7 Total 100.0 100.0 100.0 Number of women 211 1,886 2,096 7.12 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 2011 BDHS asked women and men 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 7.17.1 presents the proportion of ever-married women and Table 7.17.2 presents the proportion of ever-married men who had heard or seen such a message from a media source, by background characteristics. Television is the most popular source for family planning messages in Bangladesh, with 24 percent of ever-married women age 15-49 and 37 percent of ever-married men age 15-49 having seen a family planning message in this media. Six percent of women and 24 percent of men saw a family planning message in either a poster billboard, or leaflet, and 3 percent of women and 16 percent of men read about family planning in a newspaper or magazine. Overall, 74 percent of women and 59 percent of men 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. In the case of radio broadcasts, women and men residing in rural areas are more exposed to family planning messages on radio than those living in urban areas. Education has a positive influence on media exposure. For example, 12 percent of uneducated women have exposure to family planning information on television compared with 45 percent of women with a secondary or higher education. A similar pattern is observed for men. Among both women and men, exposure to family planning messages increases with wealth. Fertility Regulation • 103 Table 7.17.1 Exposure to family planning messages: Women Percentage of ever-married 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 2011 Background characteristic 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 Govern- ment Non- government Age 15-19 4.2 26.1 2.2 71.6 5.5 1.2 5.4 1.6 34.5 1,970 20-24 3.0 27.1 2.5 70.7 7.3 1.2 6.1 1.5 36.7 3,514 25-29 3.1 28.1 3.9 70.0 6.3 1.4 6.9 1.5 36.7 3,394 30-34 2.8 24.3 2.9 73.8 5.1 1.3 6.5 1.2 33.2 2,654 35-39 3.5 21.8 3.5 75.4 5.0 1.3 7.9 0.8 32.3 2,246 40-44 1.9 21.6 3.3 76.6 4.5 0.9 4.4 0.8 28.1 2,152 45-49 1.5 17.5 2.2 81.3 3.4 1.1 3.4 0.4 22.0 1,820 Residence Urban 1.6 35.1 6.5 63.3 9.7 1.4 3.1 1.5 41.7 4,619 Rural 3.4 20.7 1.7 77.1 4.1 1.2 7.0 1.1 29.7 13,130 Division Barisal 6.5 18.7 2.4 76.8 5.3 1.0 6.5 0.8 29.9 1,002 Chittagong 2.9 27.2 2.8 71.1 4.9 1.3 4.3 0.7 33.5 3,222 Dhaka 2.2 25.6 3.8 72.6 6.4 0.8 5.1 1.1 33.4 5,736 Khulna 3.0 21.3 2.0 76.4 5.8 1.4 6.8 0.9 30.9 2,139 Rajshahi 3.1 23.7 2.5 74.0 4.5 1.6 8.5 0.9 33.4 2,646 Rangpur 3.3 22.5 2.9 75.2 5.5 1.8 7.9 2.6 33.4 2,039 Sylhet 1.8 26.9 2.9 72.3 5.0 1.2 3.1 1.6 31.6 967 Educational attainment No education 1.4 11.6 0.0 87.6 1.6 0.8 5.0 0.8 18.0 4,912 Primary incomplete 2.3 17.3 0.1 80.9 2.7 0.7 6.5 1.1 25.7 3,264 Primary complete1 2.9 23.4 1.2 74.6 3.7 0.7 6.4 0.9 31.3 2,062 Secondary incomplete 3.9 32.7 3.1 64.9 6.9 1.4 6.6 1.8 41.9 5,383 Secondary complete or higher2 4.8 45.1 15.7 50.5 17.3 2.8 5.4 0.8 56.2 2,127 Wealth quintile Lowest 1.7 6.0 0.2 92.9 1.9 1.0 5.9 1.0 14.2 3,250 Second 3.4 10.7 0.6 86.7 3.3 1.2 6.9 1.1 21.0 3,487 Middle 3.7 22.0 1.4 75.2 3.9 1.3 7.7 1.2 32.3 3,567 Fourth 3.6 36.3 2.6 61.8 6.0 1.1 6.7 1.3 43.9 3,664 Highest 2.1 43.7 9.4 54.5 11.9 1.5 2.9 1.2 49.5 3,781 Total 15-49 2.9 24.4 3.0 73.5 5.5 1.2 6.0 1.2 32.8 17,749 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 104 • Fertility Regulation Table 7.17.2 Exposure to family planning messages: Men Percentage of ever-married men age 15-49 who heard or saw a family planning message on radio, television or in a newspaper in the last month, according to background characteristics, Bangladesh 2011 Background characteristic 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 men Govern- ment Non- government Age 15-19 11.6 47.7 4.8 52.3 20.9 9.6 5.6 4.7 58.0 21 20-24 5.9 33.1 16.1 61.4 25.5 2.8 5.4 1.0 47.1 249 25-29 6.5 42.1 16.8 54.3 27.0 6.2 4.3 0.7 55.4 621 30-34 5.8 36.1 13.9 59.9 23.6 5.5 3.6 1.7 50.4 625 35-39 4.6 36.1 15.0 59.2 25.0 7.0 5.3 1.0 50.1 660 40-44 4.9 34.2 17.3 61.3 23.3 7.0 6.1 0.5 48.8 629 45-49 6.4 40.2 15.0 56.7 22.0 6.9 6.0 0.9 51.5 586 Residence Urban 2.9 38.9 22.3 57.1 27.9 7.2 3.2 1.0 52.1 949 Rural 6.8 36.8 13.0 59.0 22.9 5.9 5.8 0.9 50.5 2,442 Division Barisal 9.2 37.5 12.1 58.2 25.5 8.7 7.2 0.0 51.9 174 Chittagong 3.7 40.6 14.7 54.9 23.0 7.0 6.2 1.2 53.1 519 Dhaka 5.5 34.9 16.6 61.6 21.7 5.5 4.0 0.3 47.1 1,095 Khulna 4.7 32.3 15.3 63.7 21.5 3.8 2.4 0.8 46.1 430 Rajshahi 8.9 39.2 15.9 54.9 26.1 6.3 5.5 1.7 54.6 556 Rangpur 4.3 42.7 15.4 54.6 29.4 5.6 7.5 1.5 57.2 442 Sylhet 4.9 37.3 14.7 58.7 31.5 14.3 5.9 2.2 52.1 175 Educational attainment No education 4.5 26.9 0.3 71.1 9.4 3.4 2.4 0.7 36.3 890 Primary incomplete 6.3 32.4 3.9 64.5 15.3 4.0 3.8 0.6 45.2 823 Primary complete1 7.6 39.4 14.4 55.5 27.4 7.1 3.8 0.6 52.8 305 Secondary incomplete 6.5 43.4 22.9 51.7 33.4 7.5 6.3 0.9 59.7 758 Secondary complete or higher2 4.7 51.0 44.7 42.1 45.1 11.6 9.8 1.9 68.1 615 Wealth quintile Lowest 4.9 24.9 2.3 72.5 14.4 4.4 3.0 1.0 36.1 654 Second 7.2 31.8 7.2 63.8 19.1 5.0 4.4 0.9 48.1 666 Middle 8.7 38.9 10.9 56.5 21.6 4.8 5.3 1.2 51.8 647 Fourth 4.7 43.5 23.2 52.3 29.5 7.7 6.8 0.7 55.2 726 Highest 3.2 46.8 32.3 48.6 35.5 9.1 5.7 1.1 62.3 699 Total 15-49 5.7 37.4 15.6 58.5 24.3 6.3 5.1 1.0 50.9 3,392 50-54 6.3 29.8 12.3 65.8 19.2 5.3 5.3 0.8 43.6 605 Total 15-54 5.8 36.3 15.1 59.6 23.5 6.1 5.1 0.9 49.8 3,997 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Exposure to family planning messages in the mass media for men and women age 15-49 has declined over the last four years. Among women, exposure to family planning messages in radio has declined from 13 percent in the 2007 BDHS to 3 percent in the 2011 BDHS, exposure through television has declined from 31 percent in 2007 to 24 percent in 2011, and exposure through poster, bill board, or leaflet has declined from 10 percent in 2007 to 6 percent in 2011. Among men age 15-49, exposure through the radio has decreased from 19 percent in 2007 to 6 percent in 2011, through television from 39 percent to 37 percent, and through poster, billboard, or leaflet from 35 percent to 24 percent in the same period. 7.13 FIELDWORKER VISITS In the 2011 BDHS, women were asked whether a family planning fieldworker had visited them in the six months prior to the survey. Table 7.18 shows that only 15 percent of currently married women said they were visited by a fieldworker in the six months before the survey, down from 21 percent in 2007. One-third of women visited by a fieldworker received a family planning method from the worker. The decline in household visits by fieldworkers may be a consequence of the decision that fieldworkers will provide services from community clinics for three days a week. Fertility Regulation • 105 Table 7.18 Contact with family planning providers: type of service Percentage of currently married women age 15-49 who reported having been visited by a fieldworker in the past six months and among women who were visited by a family planning fieldworker, the percent distribution of various types of services provided by the fieldworker, by background characteristics, Bangladesh 2011 Background characteristic Percentage of women who reported being visited by fieldworker in the past 6 months Number of women Among women who were visited by a family planning fieldworker, services provided by the fieldworker: Total Number of women Talked Gave family planning method Talked and gave family planning method Age 15-19 12.1 1,925 71.1 22.3 6.7 100.0 233 20-24 15.5 3,396 59.4 28.2 12.5 100.0 525 25-29 17.8 3,262 54.3 33.5 12.2 100.0 581 30-34 16.7 2,532 48.2 38.7 13.1 100.0 422 35-39 16.6 2,081 46.4 41.4 12.2 100.0 346 40-44 10.7 1,937 52.3 36.7 11.0 100.0 208 45-49 6.9 1,501 54.1 28.6 17.2 100.0 104 Contraceptive use Not using 8.7 6,452 82.5 10.1 7.4 100.0 560 Using 18.3 10,183 46.2 40.4 13.4 100.0 1,858 Residence Urban 10.4 4,292 62.0 27.7 10.3 100.0 445 Rural 16.0 12,343 53.0 34.7 12.4 100.0 1,973 Division Barisal 12.7 952 56.7 30.8 12.5 100.0 121 Chittagong 9.7 3,015 68.8 17.8 13.4 100.0 293 Dhaka 13.7 5,334 55.5 32.0 12.5 100.0 732 Khulna 14.7 1,996 48.5 36.6 14.9 100.0 292 Rajshahi 18.6 2,526 44.3 46.1 9.6 100.0 471 Rangpur 20.8 1,927 56.1 34.2 9.7 100.0 401 Sylhet 12.1 884 64.6 20.5 14.9 100.0 107 Education No education 13.0 4,379 46.5 41.1 12.4 100.0 568 Primary incomplete 15.2 3,056 51.5 36.9 11.6 100.0 464 Primary complete1 16.0 1,963 58.2 28.2 13.5 100.0 315 Secondary incomplete 16.0 5,176 58.4 30.6 10.9 100.0 827 Secondary complete or higher2 11.9 2,061 62.0 24.6 13.4 100.0 245 Wealth quintile Lowest 15.5 2,975 52.3 36.2 11.5 100.0 461 Second 15.9 3,267 48.3 40.6 11.0 100.0 521 Middle 17.1 3,372 52.9 32.1 15.0 100.0 575 Fourth 15.6 3,457 58.1 30.9 10.9 100.0 541 Highest 9.0 3,564 65.5 24.1 10.5 100.0 321 Total 14.5 16,635 54.6 33.4 12.0 100.0 2,418 Ten percent of women said they were visited by a government family planning fieldworker (down from 16 percent in 2007), while 2 percent were visited by a government health worker and 2 percent by an NGO fieldworker (Table 7.19). Married women who live in rural areas are twice as likely to be visited by a government family planning worker than women in urban areas. Users of family planning are more than twice as likely to be visited by a government family planning worker than nonusers. 106 • Fertility Regulation Table 7.19 Contact with family planning providers: type of fieldworker Percent distribution of currently-married women age 15-49 according to visit by a fieldworker in the past six months, by type of fieldworker, according to background characteristics, Bangladesh 2011 Background characteristic Not visited by a field worker Visited in the last six months by a Government family planning worker Government health worker NGO worker Other Don’t know/ missing Total Number of women Age 15-19 87.9 7.6 1.7 2.8 0.0 0.0 100.0 1,925 20-24 84.5 9.7 2.7 3.0 0.1 0.1 100.0 3,396 25-29 82.2 13.0 2.6 2.2 0.2 0.0 100.0 3,262 30-34 83.3 11.5 2.5 2.7 0.1 0.0 100.0 2,532 35-39 83.4 12.0 2.6 1.9 0.3 0.1 100.0 2,081 40-44 89.3 8.5 1.1 1.1 0.0 0.1 100.0 1,937 45-49 93.1 5.6 1.1 0.5 0.0 0.0 100.0 1,501 Residence Urban 89.6 5.7 1.5 3.1 0.2 0.1 100.0 4,292 Rural 84.0 11.7 2.4 1.9 0.1 0.0 100.0 12,343 Division Barisal 87.3 9.8 2.0 1.2 0.0 0.0 100.0 952 Chittagong 90.3 6.1 1.8 1.6 0.1 0.1 100.0 3,015 Dhaka 86.3 9.8 1.6 2.2 0.1 0.1 100.0 5,334 Khulna 85.3 10.8 1.2 2.5 0.1 0.1 100.0 1,996 Rajshahi 81.4 14.8 2.8 1.2 0.1 0.0 100.0 2,526 Rangpur 79.2 12.2 4.4 4.5 0.0 0.0 100.0 1,927 Sylhet 87.9 7.3 3.2 1.7 0.2 0.0 100.0 884 Educational attainment No education 87.0 9.5 1.8 1.5 0.2 0.1 100.0 4,379 Primary incomplete 84.8 11.1 1.9 2.3 0.0 0.0 100.0 3,056 Primary complete1 84.0 10.8 3.0 2.4 0.2 0.1 100.0 1,963 Secondary incomplete 84.0 10.8 2.5 2.7 0.0 0.0 100.0 5,176 Secondary complete or higher2 88.1 8.1 1.9 1.9 0.1 0.0 100.0 2,061 Wealth quintile Lowest 84.5 11.7 1.7 2.0 0.1 0.1 100.0 2,975 Second 84.1 11.3 2.7 1.9 0.1 0.0 100.0 3,267 Middle 82.9 12.0 3.0 2.2 0.1 0.0 100.0 3,372 Fourth 84.4 10.9 2.3 2.4 0.1 0.1 100.0 3,457 Highest 91.0 5.4 1.4 2.3 0.1 0.0 100.0 3,564 Contraceptive use Not using 91.3 5.3 1.5 1.9 0.1 0.0 100.0 6,452 Using 81.7 13.2 2.7 2.3 0.1 0.1 100.0 10,183 Total 85.5 10.2 2.2 2.2 0.1 0.1 100.0 16,635 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 7.14 SATELLITE CLINICS As shown in Table 7.20, three in four 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, Chittagong and Sylhet divisions, women who completed secondary or higher education, and women in the highest wealth quintile. Sixteen percent of women who were aware of satellite clinics 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-fifth of women received family planning methods or visited to obtain vitamin A for their children. Other reasons for visiting satellite clinics include receiving tetanus toxoid injections (6 percent), medicine for general health (3 percent), antenatal care services (2 percent), child growth monitoring (1 percent) and deworming medicine (1 percent). Fe rti lit y R eg ul at io n • 1 07 Ta bl e 7. 20 S at el lit e cl in ic s P er ce nt ag e of e ve r- m ar rie d w om en a ge 1 5- 49 w ho r ep or te d a sa te llit e cl in ic in th ei r co m m un ity in th e pa st th re e m on th s, th e pe rc en ta ge w ho v is ite d a sa te lli te c lin ic , a nd a m on g th os e w ho v is ite d th e cl in ic th e pe rc en ta ge w ho re po rte d va rio us ty pe s of s er vi ce s re ce iv ed a t t he c lin ic , b y ba ck gr ou nd c ha ra ct er is tic s, B an gl ad es h 20 11 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e re po rti ng a sa te lli te cl in ic in th e co m m un ity N um be r o f w om en O f t ho se w ho re po rte d a sa te lli te c lin ic in th e co m m un ity O f t ho se w ho v is ite d a sa te llit e cl in ic , p er ce nt ag e re po rti ng re ce iv in g of v ar io us s er vi ce s N um be r o f w om en P er ce nt ag e w ho v is ite d cl in ic N um be r o f w om en Fa m ily pl an ni ng m et ho ds Im m un i- za tio ns C hi ld g ro w th m on ito rin g Te ta nu s to xo id in je ct io ns A nt en at al ca re V ita m in A fo r c hi ld re n D ew or m in g m ed ic in e M ed ic in e fo r ge ne ra l he al th O th er s D on ’t kn ow / m is si ng A ge 15 -1 9 72 .0 1, 97 0 25 .1 1, 41 8 10 .5 69 .7 0. 6 12 .1 3. 2 10 .7 0. 1 1. 3 0. 1 0. 0 35 6 20 -2 4 75 .4 3, 51 4 22 .7 2, 65 0 15 .0 63 .9 1. 2 6. 7 1. 1 21 .7 0. 9 0. 6 1. 3 0. 0 60 1 25 -2 9 74 .2 3, 39 4 20 .1 2, 51 9 20 .3 53 .6 0. 7 6. 0 1. 4 23 .8 2. 1 3. 0 2. 5 0. 1 50 6 30 -3 4 75 .8 2, 65 4 14 .9 2, 01 2 28 .1 44 .8 1. 8 3. 7 1. 1 18 .8 1. 1 4. 4 2. 2 0. 2 30 0 35 -3 9 76 .9 2, 24 6 9. 2 1, 72 8 43 .5 33 .2 0. 7 2. 7 2. 0 21 .1 2. 8 1. 9 3. 3 1. 7 15 9 40 -4 4 75 .4 2, 15 2 8. 3 1, 62 1 39 .0 42 .5 3. 3 2. 7 0. 0 22 .1 0. 3 3. 0 1. 0 0. 0 13 5 45 -4 9 75 .1 1, 82 0 5. 6 1, 36 6 17 .2 37 .6 0. 5 4. 8 1. 7 26 .4 2. 6 12 .4 5. 2 2. 6 77 R es id en ce U rb an 66 .2 4, 61 9 12 .6 3, 05 8 24 .3 52 .4 1. 6 5. 2 2. 4 15 .4 2. 0 3. 0 1. 7 0. 0 38 4 R ur al 78 .1 13 ,1 30 17 .1 10 ,2 56 20 .4 55 .7 1. 0 6. 6 1. 4 21 .1 1. 1 2. 4 1. 8 0. 3 1, 75 0 D iv is io n B ar is al 80 .6 1, 00 2 17 .5 80 8 33 .2 46 .4 1. 9 8. 1 1. 8 12 .9 1. 0 1. 7 2. 4 0. 5 14 2 C hi tta go ng 72 .0 3, 22 2 19 .6 2, 32 1 17 .7 58 .9 1. 5 4. 7 1. 5 23 .2 2. 4 1. 5 2. 6 0. 0 45 5 D ha ka 75 .2 5, 73 6 13 .7 4, 31 1 18 .3 59 .5 1. 2 6. 5 1. 3 14 .4 0. 3 3. 1 1. 6 0. 3 59 2 K hu ln a 84 .3 2, 13 9 13 .2 1, 80 3 25 .3 49 .3 1. 2 10 .1 0. 1 16 .8 0. 9 2. 9 0. 8 0. 0 23 8 R aj sh ah i 67 .9 2, 64 6 18 .2 1, 79 5 24 .6 46 .3 0. 8 4. 6 2. 0 26 .7 2. 6 4. 2 2. 9 0. 0 32 8 R an gp ur 77 .3 2, 03 9 16 .6 1, 57 5 25 .6 57 .9 0. 4 6. 7 2. 4 17 .5 0. 1 1. 1 0. 7 0. 4 26 1 S yl he t 72 .5 96 7 17 .0 70 1 5. 5 59 .1 1. 2 7. 3 2. 3 39 .2 1. 1 2. 5 0. 5 1. 8 11 9 Ed uc at io na l a tta in m en t N o ed uc at io n 76 .2 4, 91 2 12 .5 3, 74 5 23 .5 52 .8 1. 3 5. 7 1. 9 20 .9 1. 7 2. 9 1. 3 0. 5 47 0 P rim ar y in co m pl et e 77 .2 3, 26 4 16 .9 2, 51 9 26 .0 48 .8 0. 7 5. 8 1. 9 23 .7 1. 1 2. 5 0. 7 0. 3 42 5 P rim ar y co m pl et e1 78 .1 2, 06 2 16 .6 1, 61 1 18 .0 54 .1 1. 5 10 .5 1. 1 19 .1 0. 6 0. 4 2. 7 0. 0 26 7 S ec on da ry in co m pl et e 75 .4 5, 38 3 19 .1 4, 05 7 18 .9 60 .5 1. 3 6. 0 1. 3 16 .4 1. 2 3. 6 1. 7 0. 3 77 7 S ec on da ry c om pl et e or hi gh er 2 64 .9 2, 12 7 14 .1 1, 38 1 17 .3 54 .6 0. 8 5. 2 1. 4 26 .6 1. 4 0. 0 4. 7 0. 0 19 5 W ea lth q ui nt ile Lo w es t 79 .7 3, 25 0 19 .7 2, 58 9 22 .4 54 .5 0. 8 6. 7 1. 6 21 .4 1. 9 2. 5 0. 6 0. 0 50 9 S ec on d 75 .9 3, 48 7 16 .5 2, 64 8 20 .5 56 .6 0. 4 7. 5 1. 4 19 .8 0. 3 1. 9 1. 7 0. 7 43 7 M id dl e 79 .1 3, 56 7 17 .0 2, 82 1 24 .8 49 .9 1. 6 6. 3 1. 5 20 .1 0. 9 3. 0 2. 4 0. 3 48 1 Fo ur th 74 .6 3, 66 4 14 .8 2, 73 2 19 .2 61 .0 1. 4 4. 2 0. 9 19 .9 1. 7 2. 4 1. 7 0. 3 40 4 H ig he st 66 .8 3, 78 1 12 .0 2, 52 5 16 .1 54 .6 1. 7 7. 5 2. 6 18 .7 1. 3 2. 8 3. 2 0. 0 30 3 To ta l 75 .0 17 ,7 49 16 .0 13 ,3 14 21 .1 55 .1 1. 1 6. 4 1. 5 20 .1 1. 2 2. 5 1. 8 0. 3 2, 13 4 1 P rim ar y co m pl et e is d ef in ed a s co m pl et in g gr ad e 5. 2 S ec on da ry c om pl et e is d ef in ed a s co m pl et in g gr ad e 10 . • 107Fertility Regulation 108 • Fertility Regulation 7.15 COMMUNITY CLINICS The government of Bangladesh has planned to establish one community clinic for each 6,000 people that would provide health care services to the community. These clinics are to 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 7.21, about one in five ever-married women are aware of the community clinic in their area. Awareness of community clinics is lower among older women, women in urban areas, women in Dhaka, Sylhet, and Khulna divisions, and women with higher education and wealth status. Sixteen percent of women who were aware of community clinics reported visiting such a clinic in the three months before the 2011 BDHS. Thirty-nine percent of women who visited a community clinic went to obtain medicine for general health, while one-third visited for family planning services and 15 percent visited for immunization services for their children. Other reasons for visiting community clinics are vitamin A for children (5 percent), tetanus toxoid injections (3 percent), antenatal care services (3 percent), and child growth monitoring (1 percent). Fe rti lit y R eg ul at io n • 1 09 Ta bl e 7. 21 C om m un ity c lin ic s P er ce nt ag e of e ve r- m ar rie d w om en a ge 1 5- 49 w ho re po rte d a co m m un ity c lin ic in th ei r v ill ag e/ m ah al la , t he p er ce nt ag e w ho v is ite d a co m m un ity c lin ic in th e pa st th re e m on th s, a nd th e pe rc en ta ge w ho re po rte d va rio us ty pe s of s er vi ce s re ce iv ed a t t he c lin ic , b y ba ck gr ou nd c ha ra ct er is tic s, B an gl ad es h 20 11 B ac kg ro un d ch ar ac te ris tic P er ce nt ag e re po rti ng a co m m un ity cl in ic in th e co m m un ity N um be r o f w om en A m on g th os e w ho re po rte d kn ow in g a co m m un ity c lin ic in th ei r ar ea : A m on g th os e w ho v is ite d a co m m un ity c lin ic , p er ce nt ag e re ce iv in g se rv ic es in : N um be r o f w om en P er ce nt ag e w ho v is ite d cl in ic N um be r o f w om en Fa m ily pl an ni ng m et ho ds Im m un i- za tio ns C hi ld g ro w th m on ito rin g Te ta nu s to xo id in je ct io ns A nt en at al ca re V ita m in A fo r c hi ld re n M ed ic in e fo r ge ne ra l he al th O th er s D on ’t kn ow / m is si ng A ge 15 -1 9 18 .1 1, 97 0 12 .2 35 7 18 .2 36 .3 1. 3 8. 5 4. 9 10 .0 20 .7 6. 4 0. 0 43 20 -2 4 18 .3 3, 51 4 18 .8 64 5 32 .2 20 .4 3. 0 1. 9 6. 7 8. 4 23 .6 11 .2 0. 0 12 1 25 -2 9 19 .7 3, 39 4 18 .7 66 8 38 .2 14 .2 0. 0 5. 4 1. 0 4. 8 37 .5 1. 3 2. 9 12 5 30 -3 4 18 .0 2, 65 4 18 .1 47 9 43 .5 13 .4 1. 2 2. 2 0. 0 4. 3 31 .3 5. 0 0. 0 87 35 -3 9 17 .2 2, 24 6 16 .8 38 6 36 .5 5. 2 0. 9 0. 0 3. 7 1. 5 51 .4 3. 1 0. 0 65 40 -4 4 17 .2 2, 15 2 12 .1 36 9 31 .9 5. 7 0. 0 0. 0 0. 0 0. 6 55 .0 7. 4 0. 0 45 45 -4 9 16 .6 1, 82 0 12 .0 30 2 13 .6 6. 3 0. 0 3. 3 0. 0 3. 0 88 .0 1. 5 0. 0 36 R es id en ce U rb an 6. 7 4, 61 9 10 .5 30 9 26 .3 17 .6 0. 0 8. 4 8. 6 1. 7 42 .0 0. 0 0. 0 32 R ur al 22 .1 13 ,1 30 16 .9 2, 89 7 34 .1 14 .8 1. 2 2. 7 2. 3 5. 3 38 .3 5. 8 0. 7 49 0 D iv is io n B ar is al 23 .1 1, 00 2 16 .0 23 1 51 .0 11 .9 1. 7 0. 0 0. 7 4. 0 32 .2 1. 6 0. 0 37 C hi tta go ng 20 .2 3, 22 2 12 .3 65 1 31 .4 21 .1 0. 0 5. 0 1. 7 5. 0 30 .2 8. 2 0. 0 80 D ha ka 10 .8 5, 73 6 16 .2 62 2 27 .1 13 .3 0. 0 1. 8 3. 8 1. 9 43 .4 6. 8 1. 9 10 0 K hu ln a 19 .3 2, 13 9 19 .4 41 2 36 .0 5. 5 0. 0 1. 2 3. 1 1. 2 53 .5 2. 4 0. 0 80 R aj sh ah i 23 .9 2, 64 6 15 .5 63 2 40 .9 16 .9 2. 6 6. 2 0. 0 5. 0 33 .4 4. 7 1. 1 98 R an gp ur 25 .4 2, 03 9 19 .2 51 9 30 .6 16 .0 2. 1 1. 7 4. 9 9. 3 36 .6 6. 2 0. 0 10 0 S yl he t 14 .3 96 7 20 .1 13 8 17 .8 24 .0 2. 1 4. 7 4. 1 15 .3 36 .0 5. 9 2. 0 28 Ed uc at io na l a tta in m en t N o ed uc at io n 17 .0 4, 91 2 14 .6 83 7 35 .2 9. 3 0. 5 1. 4 0. 4 6. 7 46 .4 6. 6 0. 0 12 2 P rim ar y in co m pl et e 18 .1 3, 26 4 22 .0 59 1 38 .9 15 .7 1. 6 3. 9 0. 4 5. 9 35 .5 1. 9 0. 4 13 0 P rim ar y co m pl et e1 20 .6 2, 06 2 15 .4 42 5 36 .1 14 .8 0. 0 1. 8 1. 5 3. 4 38 .8 8. 9 0. 0 65 S ec on da ry in co m pl et e 19 .2 5, 38 3 14 .6 1, 03 5 31 .1 18 .8 1. 2 2. 3 2. 3 5. 0 36 .3 6. 3 2. 0 15 1 S ec on da ry c om pl et e or hi gh er 2 14 .9 2, 12 7 17 .0 31 7 20 .9 15 .4 2. 3 8. 1 15 .3 1. 8 34 .4 4. 4 0. 0 54 W ea lth q ui nt ile Lo w es t 19 .8 3, 25 0 19 .4 64 4 41 .6 11 .1 1. 4 3. 4 1. 6 6. 5 35 .2 4. 2 0. 0 12 5 S ec on d 21 .3 3, 48 7 19 .3 74 4 33 .5 11 .3 1. 1 0. 7 1. 2 5. 2 43 .6 7. 9 0. 0 14 3 M id dl e 21 .2 3, 56 7 17 .7 75 5 36 .7 17 .1 0. 0 2. 4 3. 8 3. 4 37 .1 2. 9 2. 7 13 3 Fo ur th 17 .4 3, 66 4 13 .0 63 9 25 .3 17 .8 3. 1 7. 0 2. 3 2. 8 36 .6 7. 6 0. 0 83 H ig he st 11 .2 3, 78 1 8. 9 42 4 14 .5 27 .4 0. 0 4. 0 8. 4 11 .0 40 .2 3. 5 0. 0 38 To ta l 18 .1 17 ,7 49 16 .3 3, 20 5 33 .6 14 .9 1. 1 3. 0 2. 7 5. 1 38 .6 5. 4 0. 7 52 3 1 P rim ar y co m pl et e is d ef in ed a s co m pl et in g gr ad e 5. 2 S ec on da ry c om pl et e is d ef in ed a s co m pl et in g gr ad e 10 . • 109Fertility Regulation Infant and Child Mortality • 111 INFANT AND CHILD MORTALITY 8 nfant and child mortality rates reflect a country’s level of socioeconomic development and quality of life. They are used to monitor and evaluate population and health programs and policies. The rates are also useful in identifying promising directions for health and nutrition programs in Bangladesh. This chapter provides information on the mortality of children under age 5. Specifically, it presents information on levels, trends, and differentials in neonatal, postneonatal, infant, and child 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 2011 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. In this chapter, the following direct estimates of infant and child mortality1 were used: Neonatal mortality: the probability of dying within the first month of life; Postneonatal mortality: the difference between infant and neonatal mortality; 1 A detailed description of the method for calculating the probabilities presented here is given in Rutstein (1984). The mortality estimates are not rates but are true probabilities calculated according to the conventional life-table approach. Deaths and exposure in any calendar period are first tabulated for the age intervals 0, 1-2, 3-5, 6-11, 12-23, 24-35, 36-47, and 48-59 months. Then age-interval-specific probabilities of survival are calculated. Finally, probabilities of mortality for larger age segments are produced by multiplying the relevant age-interval survival probabilities together and subtracting the product from one:  −−= += nxi ixn )q1(1q I Key Findings • Infant and under-5 mortality rates for the past five years are 43 and 53 deaths per 1,000 live births, respectively. At these mortality levels, one in every 23 Bangladeshi children dies before reaching his or her first birthday, and one in every 19 children does not survive to his or her fifth birthday. • As under-5 mortality continues to decline, Bangladesh is on track to achieve the Millennium Development Goal (MDG) 4 target of 48 deaths per 1,000 live births by the year 2015. • Infant mortality has declined by 51 percent over the last 18 years, while child mortality and under-5 mortality have declined by 78 percent and 60 percent, respectively, over the same period. • The neonatal mortality rate for the past five years has been 32 deaths per 1,000 live births, which is three times the postneonatal mortality rate (10 deaths per 1,000 live births). The perinatal mortality rate is 50 deaths per 1,000 pregnancies. • Sylhet has the highest mortality rates for all mortality indicators except child mortality. 112 • Infant and Child 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 completeness with which deaths of children are reported and the extent to which birth dates and ages at death are accurately reported and recorded. Estimated rates of infant and child mortality are subject to both sampling and nonsampling errors. 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 under seven days to all neonatal deaths and an abnormally low ratio of neonatal to infant mortality. Changes in these ratios over time can be examined to test the hypothesis that underreporting of early infant deaths is more common for births that occurred further in the past than for births that occurred more recently. Failure to report deaths will result in mortality figures that are low, and if underreporting is more severe for children born longer ago than for children born recently, any 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 2011 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 72 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 66 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 77 percent) for the various periods preceding the survey. Another problem inherent in most retrospective surveys is heaping of age at death on certain digits (e.g., 6, 12, and 18 months). If the net result of misreporting is the transference of deaths between age segments for which the rates are calculated, misreporting of the age at death will bias estimates of the age pattern of mortality. For instance, an overestimate of child mortality relative to infant mortality may result if children dying during the first year of life are reported as having died at age 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., at age 0-11 months). In such cases, heaping would bias infant mortality (1q0) downward and child mortality (4q1) upward. In the 2011 BDHS, there appears to be a preference for reporting age at death at 3, 7, 15, and 21 days (Appendix Table C.5). An examination of the distribution of deaths under age 2 during the 15 years preceding the survey by month of death (Appendix Table C.6) indicates some heaping of deaths at 6, 12, and 18 months of age. Some heaping on 12 months and recording of deaths at “1 year” is found despite the strong emphasis 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 • 113 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 2006 to 2005. 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 2006 to date of interview for the 2011 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 births to younger women, the mortality rates for the period may be slightly underestimated. Estimates for more recent periods are less affected by truncation bias because fewer older women are excluded. However the extent of this bias depends on the proportion of births omitted. Table 6.5 (Chapter 6) shows that very few children born in the five years before the survey were born to women age 35 and above. Given the small proportion of births excluded, selection bias for infant and child mortality statistics as far back as 15 years before the survey should be negligible. 8.2 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 2011 BDHS show that under-5 mortality during the five years preceding the survey (which roughly corresponds to the years 2007-2011) is 53 deaths per 1,000 live births. This means that one in nineteen children born in Bangladesh dies before reaching the fifth birthday. The infant mortality rate is 43 deaths per 1,000 live births, and the child mortality rate is 11deaths per 1,000 children surviving to 12 months of age, but not to their fifth birthday. During infancy, the risk of dying in the first month of life (32 deaths per 1,000 live births) is three times greater than in the subsequent 11 months (10 deaths per 1,000 live births). Deaths in the neonatal period account for 60 percent of all under-5 deaths. Table 8.1 Early childhood mortality rates Neonatal, post-neonatal, infant, child, and under-5 mortality rates for five-year periods preceding the survey, Bangladesh 2011 Years preceding the survey Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 0-4 32 10 43 11 53 5-9 40 17 56 17 73 10-14 43 22 65 24 87 1 Computed as the difference between the infant and neonatal mortality rates 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.” 114 • Infant and Child Mortality Childhood mortality rates obtained for the five years preceding successive DHS surveys conducted in Bangladesh since 1993-1994 confirm a declining trend in mortality (Table 8.2 and Figure 8.1). Between the periods 1989-1993 and 2007-2011, infant mortality declined by half, from 87 deaths per 1,000 live births to 43 deaths per 1,000 live births. Even more impressive are the 71 percent decline in postneonatal mortality and the 60 percent decline in under-5 mortality over the same period. The corresponding decline in neonatal mortality was 38 percent. Comparison of mortality rates over the last two surveys show that infant, child, and under-5 mortality have declined by about 20 percent. As a consequence of this rapid rate of decline, Bangladesh is on track to achieve the MDG 4 target of an under-5 mortality rate of 48 deaths per 1,000 live births by 2015. An examination of neonatal, infant, and under-5 mortality rates in Bangladesh over the last 18 years reveals that neonatal mortality declined at a slower pace than infant and child mortality, with the result that neonatal deaths have increased from 60 percent of all infant deaths in 1989-1993 to 74 percent in 2007-2011, and from 39 percent of under-5 deaths in 1989-1993 to 60 percent in 2007-2011. Table 8.2 Trends in early childhood mortality Neonatal, postneonatal, infant, child, and under-5 mortality rates for five-year periods preceding the BDHS surveys Data source Approxi- mate reference period Neonatal mortality (NN) Post- neonatal mortality1 (PNN) Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) 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 Figure 8.1 Trends in childhood mortality, 1989-2011 52 87 133 48 82 116 42 66 94 41 65 88 37 52 65 32 43 53 Neonatal mortality Infant mortality Under-5 mortality Deaths per 1,000 live births BDHS 1989-93 BDHS 1992-96 BDHS 1995-99 BDHS 1999-2003 BDHS 2002-2006 BDHS 2007-2011 Infant and Child Mortality • 115 8.3 SOCIOECONOMIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY Differentials in childhood mortality by selected background characteristics 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. There is no significant difference in mortality levels in urban and rural areas among children under age 1. Child mortality is somewhat higher in rural areas than in urban areas. Over the years, mortality levels among children under age 5 have declined faster in the rural areas than in the urban areas, reducing the gap between urban and rural childhood mortality rates. The 2011 BDHS data show wide variations in mortality by division. Infant mortality rates range from 35 deaths per 1,000 live births in Chittagong to 59 deaths per 1,000 live births in Sylhet. Khulna has the lowest child and under-5 mortality rates, while Sylhet has the highest neonatal, postneonatal, infant, and under-5 mortality rates. Whereas Chittagong has the lowest infant mortality rate (35 deaths per 1,000 live births), it has the highest child mortality (16 deaths per 1,000 live 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 pregnancy and child health care. For example, infant mortality is 40 percent lower for children whose mothers have completed secondary education than for those with no education (33 and 55 deaths per 1,000 live births, respectively). A child’s risk of dying is also associated with the economic status of the household. All childhood mortality rates are lowest for children in the highest wealth quintile. For instance, the risk of dying by age 5 for children in the highest quintile is 37 deaths per 1,000 live births compared with 64 deaths per 1,000 live births for children in the lowest quintile. Table 8.3 Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, infant, child, and under-5 mortality rates for the 5-year period preceding the survey, by background characteristic, Bangladesh 2011 Background characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Residence Urban 32 10 42 8 50 Rural 33 10 43 12 55 Division Barisal (38) (11) (49) (14) (62) Chittagong 21 13 35 16 50 Dhaka 36 8 44 11 54 Khulna 32 4 36 4 40 Rajshahi 39 13 51 13 63 Rangpur 27 9 36 6 42 Sylhet 45 14 59 12 71 Mother’s education No education 32 23 55 18 71 Primary incomplete 38 11 49 13 61 Primary complete2 32 8 40 5 45 Secondary incomplete 30 6 36 10 46 Secondary complete or higher3 33 1 33 6 39 Wealth quintile Lowest 34 16 50 15 64 Second 38 13 51 15 64 Middle 32 9 41 9 49 Fourth 33 5 38 10 48 Highest 23 7 29 8 37 Note: Figures in parentheses have 250-499 years of exposure for that group. 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. 116 • Infant and Child Mortality Figure 8.2 Under-5 mortality rates by socioeconomic characteristics 50 55 (62) 50 54 40 63 42 71 71 61 45 46 39 64 64 49 48 37 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 Under-five mortality (5q0) Notes: Rates are for the 5-year period preceding the survey. Figures in parentheses have 250-499 years of exposure for that group. BDHS 2011 8.4 DEMOGRAPHIC DIFFERENTIALS IN INFANT AND CHILD MORTALITY This section examines differentials in early childhood mortality by demographic characteristics of the child and the mother. Table 8.4 and Figure 8.3 present mortality rates for the five-year period preceding the survey by sex of the child, age of the mother at birth, birth order, previous birth interval, and birth size. Table 8.4 Early childhood mortality rates by demographic characteristics Neonatal, postneonatal, infant, child, and under-5 mortality rates for the 5-year period preceding the survey, by demographic characteristics, Bangladesh 2011 Demographic characteristic Neonatal mortality (NN) Post- neonatal mortality (PNN)1 Infant mortality (1q0) Child mortality (4q1) Under-5 mortality (5q0) Child’s sex Male 39 9 48 10 57 Female 26 11 37 13 50 Mother’s age at birth <20 45 11 57 10 66 20-29 26 8 34 9 43 30-39 26 16 42 22 63 40-49 * * * * * Birth order 1 43 8 52 8 60 2-3 29 8 37 10 47 4-6 21 17 38 15 53 7+ * * * * * Previous birth interval2 <2 years 45 22 66 17 82 2 years 16 11 28 23 50 3 years 20 13 33 10 43 4+ years 27 8 35 8 42 Birth size3 Small/very small 41 16 57 na na Average or larger 30 9 38 na na Note: An asterisk indicates that the exposure years for the age group are fewer than 250. na = Not applicable 1 Computed as the difference between the infant and neonatal mortality rates 2 Excludes first-order births Infant and Child Mortality • 117 Figure 8.3 Under-5 mortality rates by demographic characteristics 66 43 63 * 60 47 53 * 82 50 43 42 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 Under-five mortality (5q0) Notes: Rates are for the 5-year period preceding the survey. Previous birth interval excludes first-order births. An asterisk indicates that the exposure years for the age group are less than 250. BDHS 2011 Male children have higher neonatal mortality than female children, while female children experience higher postneonatal and child mortality than males. Neonatal mortality is expected to be higher for boys than for girls because baby boys are more vulnerable than baby girls from the time of conception. With the exception of the 2004 and 2007 BDHS, all BDHS surveys reported both higher postneonatal and child mortality for females than for males—a pattern that has been observed in other countries of South Asia where strong son preference is thought to result in relative nutritional and medical neglect of female children (Das Gupta, 1987; Basu, 1989). The 2011 BDHS indicates that infant and under-5 mortality of male children is now higher than that of female children. 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 2011 BDHS shows a similar pattern for all mortality estimates except for neonatal mortality rates. Infant and under- 5 mortality rates also have a U-shaped relationship with birth order (Table 8.3). In contrast, neonatal mortality decreases linearly, and child mortality increases linearly with birth order. Short birth intervals are associated with an increased risk of dying. Retherford and others (1989) observe an association between short birth intervals (less than 2 years) and increased mortality, even after controlling for other demographic and socioeconomic variables. As shown in Table 8.4, all childhood mortality rates are lower at longer birth intervals. Neonatal, postneonatal, infant, child, and under-5 mortality rates are almost two times higher for children born after an interval of less than two years compared with children who are born after an interval of four years or longer. Studies have shown that children’s birth weight is an important determinant of their survival chances (UNICEF and WHO, 2004). Because most births in Bangladesh occur at home, where children often are not weighed at birth, data on birth weight are available for only a few children. However, mothers in the 2011 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. As expected, the size of the baby at birth and mortality were negatively associated. For example, 1 in 18 children regarded by their mothers as very small or small did not survive to the first year compared with 1 in 26 children perceived as average or larger at birth. 118 • Infant and Child Mortality 8.5 PERINATAL MORTALITY Perinatal deaths are composed of pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths within the first seven days of life (early neonatal deaths). The perinatal 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 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 2011 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 shows that the perinatal mortality rate in Bangladesh is 50 deaths per 1,000 pregnancies, which is 9 percent lower than the level observed in the 2007 BDHS (55 deaths per 1,000 pregnancies). Perinatal mortality is high among teenage mothers and mothers age 40-49. Perinatal mortality is highest among first pregnancies (71 deaths per 1,000 pregnancies). Rural areas have higher perinatal mortality than urban areas, and Barisal has the highest perinatal mortality rate of all divisions. Perinatal mortality has a negative association with the mother’s education and wealth status; it is lowest for women who have completed secondary or higher education and for women in the highest wealth quintile. 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 2011 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 81 103 63 2,895 20-29 108 95 41 4,903 30-39 40 20 53 1,138 40-49 4 2 62 85 Previous pregnancy interval in months4 First pregnancy 106 105 71 2,955 <15 7 14 53 390 15-26 19 25 41 1,087 27-38 28 11 32 1,231 39+ 71 66 41 3,359 Residence Urban 39 55 47 1,994 Rural 194 165 51 7,027 Division Barisal 17 15 62 507 Chittagong 44 31 36 2,061 Dhaka 72 80 54 2,798 Khulna 16 21 45 812 Rajshahi 30 38 58 1,180 Rangpur 30 18 50 956 Sylhet 24 18 60 706 Mother’s education No education 69 36 57 1,854 Primary incomplete 37 49 52 1,650 Primary complete5 30 29 52 1,124 Secondary incomplete 79 78 47 3,323 Secondary complete or higher6 17 29 43 1,070 Wealth quintile Lowest 48 55 49 2,116 Second 62 50 60 1,861 Middle 55 39 53 1,758 Fourth 42 46 51 1,728 Highest 26 30 36 1,559 Total 232 220 50 9,021 1 Stillbirths are fetal deaths in pregnancies lasting seven or more months. 2 Early neonatal deaths are deaths at age 0 to 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 1000. 4 Categories correspond to birth intervals of <24 mos., 24-35 mos., 36-47 mos., and 48+ mos. 5 Primary complete is defined as completing grade 5. 6 Secondary complete is defined as completing grade 10. Infant and Child Mortality • 119 8.6 HIGH-RISK FERTILITY BEHAVIOR Many studies have found a strong relationship between children’s chances of dying and certain fertility behaviors. In general, the probability of dying in early childhood is much greater if children are born to mothers who are too young or too old, if they are born after a short birth interval, or if they are born to mothers with high parity. For this analysis, mothers are classified as too young if they are less than age 18 and too old if they are over age 34 at the time of delivery. A short birth interval is defined as a birth occurring within two years of a previous birth, and a high birth order is defined as a birth occurring after three or more previous births (birth order four or higher). After cross-classification of births by combinations of all three characteristics, a birth may have from zero to three high-risk characteristics. All risk categories are potentially avoidable except for first births to mothers age 18-34. Table 8.6 shows the percent distribution of births in the five-year period preceding the survey and the distribution of all currently married women across various risk categories. It also shows the relative risk of children dying across the various risk categories. 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. The “risk ratio” is the ratio of the proportion of dead children in a given high-risk category to the proportion of dead children not in any high-risk category. 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 2011 Risk category Births in the 5 years preceding the survey Percentage of currently married women1 Percentage of births Risk ratio Not in any high risk category 39.2 1.00 34.5a Unavoidable risk category First order births between ages 18 and 34 years 21.4 1.44 6.9 Single high-risk category Mother’s age <18 15.0 1.37 2.3 Mother’s age >34 0.8 2.19 7.5 Birth interval <24 months 4.2 1.92 7.5 Birth order >3 12.5 1.14 12.2 Subtotal 32.6 1.37 29.5 Multiple high-risk category Age <18 and birth interval <24 months2 0.9 2.33 0.9 Age >34 and birth interval <24 months 0.0 * 0.0 Age >34 and birth order >3 3.3 0.75 23.8 Age >34 and birth interval <24 months and birth order >3 0.2 (4.09) 0.5 Birth interval <24 months and birth order >3 2.2 1.43 3.8 Subtotal 6.7 1.30 29.0 In any avoidable high-risk category 39.3 1.36 58.6 Total 100.0 na 100.0 Number of births/women 8,789 na 16,635 Note: Risk ratio is the ratio of the proportion dead among births in a specific high-risk category to the proportion dead among births not in any high-risk category. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. na = Not applicable 1 Women are assigned to risk categories according to the status they would have at the birth of a child if they were to conceive at the time of the survey: current age less than 17 years and 3 months or older than 34 years and 2 months, latest birth less than 15 months ago, or latest birth being of order 3 or higher. 2 Includes the category age <18 and birth order >3 a Includes sterilized women 120 • Infant and Child Mortality Among children born in the five years preceding the survey, 39 percent are not in any high-risk categories, another 39 percent of births are in one of the avoidable high-risk categories, 33 percent are in a single high-risk category, and 7 percent are in a multiple high-risk category. The remainder (21 percent) fall in the category of unavoidable risk, that is, first order births to women age 18-34. Thus, 61 percent of births in Bangladesh are in some high-risk category. The most common risk categories are mother’s young age (younger than 18 years) and 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. Children born to mothers age 34 or older are more than twice as likely to die as those born to mothers who are not in any high-risk category. Children whose preceding birth interval is less than 24 months are about twice as likely to die as children who are not in any high-risk category. Children are more than two times as likely to die when their mothers are under age 18 and the preceding birth interval is less than 24 months. However, less than 1 percent of the births fall in this category. The last column in Table 8.6 shows the distribution of currently married women by the risk category into which a birth would fall if conceived at the time of the survey. This column is based on assumptions that do not take into account family planning, postpartum infecundity, and prolonged abstinence. Among married woman who gave birth in the five years preceding the survey, 35 percent are not at any elevated risk of mortality, and 59 percent are in at least one of the avoidable high-risk categories; 30 percent have a single high-risk factor and 29 percent have multiple high-risk factors. Maternal and Newborn Health • 121 MATERNAL AND NEWBORN HEALTH 9 health care system aiming 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 Millennium Development Goal (MDG) 5, to improve maternal health, by reducing the maternal mortality ratio from 574 to 143 deaths per 100.000 live births by 2015 (UNDP, 2011). The MDG 4 target for Bangladesh has been set to reduce the under-5 mortality ratio from 146 per 1,000 live births in 1990 to 48 per 1,000 live births in 2015. Accordingly, the Ministry of Health and Family Welfare has developed various policies and strategies to improve maternal and newborn health. In a new Health Population and Nutrition Sector Development Programme (HPNSDP) for 2011-16, two operational plans have been implemented under the Directorate General of Health Services and the Directorate General of Family Planning. The new sector program strongly emphasizes improving access and equity in the utilization of essential maternal and neonatal health services (MOHFW, 2011). This chapter provides information from the 2011 BDHS on several aspects of maternal and newborn health, including antenatal care, delivery, postnatal care, and newborn care. In the 2011 BDHS, women who had given birth in the five 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 five years preceding the survey. In addition, questions on newborn care, such as cord care and the practice of drying, wrapping, and bathing newborns, were asked about the most recent live birth in the five years preceding the survey. Tables present findings from the most recent pregnancies and births in the A Key Findings • Fifty-five percent of women who gave birth in the three years preceding the survey received antenatal care from a medically-trained provider, up from 52 percent in 2007. • One in every four women (26 percent) has four or more antenatal care visits during the course of her pregnancy, which demonstrates improvement from 22 percent in 2007. • Nine in ten mothers had their last live birth protected against neonatal tetanus. • Thirty-two percent of births in the past three years have been assisted by a skilled provider. Birth attendance by skilled provider has doubled since 2004. • In the three years before the survey, 27 percent of women received postnatal care for their last birth from a medically-trained provider within two days of their delivery, up from 20 percent in 2007. • Newborn care practices have improved considerably since 2007 in Bangladesh. Among the noninstitutional births in the three years preceding the survey, a boiled instrument was used to cut the umbilical cord in 84 percent of cases. About half of the newborns were dried, and one-third were wrapped within five minutes of birth. The practice of waiting at least 72 hours after birth to bathe the newborn is more common in 2011 than in 2007, having increased from 17 percent to 28 percent. 122 • Maternal and Newborn Health three years preceding the survey. To allow for comparison with data from previous surveys, data from the 2004 and 2007 BDHS reports have been re-tabulated to refer to births in the three years prior to the surveys. This information will assist planners and other collaborators in the health sector to formulate appropriate strategies and interventions to provide 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 antenatal care 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. Sixty-eight percent of women with a birth in the three years preceding the survey received antenatal care at least once from a provider. The majority of women (55 percent) received care from a medically-trained provider, that is, a qualified doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendant (CSBA), medical assistant (MA), or sub-assistant community medical officer (SACMO). The likelihood of receiving ANC from a medically-trained provider declines rapidly with increasing age and birth order. For example, 57 percent of women who were younger than age 20 at their last birth received antenatal care from a medically-trained provider compared with 40 percent of women age 35 or older. The urban-rural differential in ANC coverage continues to be large: 74 percent of urban women received ANC from a medically-trained provider compared with 49 percent of rural women. Mothers in Khulna are most likely to receive antenatal care from a medically-trained provider (65 percent), while those in Sylhet are least likely to receive care (47 percent). The likelihood of receiving care from a medically-trained provider increases substantially with the mother’s education level and wealth status. Twenty-six percent of mothers with no education received ANC from a trained provider compared with 88 percent of mothers with a secondary school or higher education. Similarly, the proportion of women who received ANC from a medically-trained provider is lowest among those in the lowest wealth quintile (30 percent), and increases with each wealth quintile to a high of 87 percent among women in the highest wealth quintile. Comparable data from the 2004 and 2007 BDHS surveys show that while ANC from any provider has increased by 17 percent since 2004 (from 58 percent in 2004 to 63 percent in 2007 and to 68 percent in 2011), ANC from a medically-trained provider during the same period has increased by only 8 percent (from 51 percent in 2004 to 53 percent in 2007 and to 55 percent in 2011). Inequity in the use of maternal health services is a concern in Bangladesh, and there are programs targeted to reduce the gap. In 2007 and 2011, women in the highest wealth quintile were three times more likely than women in the lowest wealth quintile to receive ANC from a medically-trained provider. The gap remains, as similar percentages of women in the lowest wealth quintile received ANC from a medically-trained provider in 2007 and 2011: 32 percent in 2007 and 30 percent in 2011. Likewise, 85 percent of women in the highest wealth quintile received ANC from a medically-trained provider in 2007 compared with 87 percent in 2011. Between 2007 and 2011, antenatal care from a trained provider has declined among women without any education, women in the lowest wealth quintile, and women in Sylhet and Khulna divisions. Figure 9.1 shows the trend in ANC utilization from a medically-trained provider by division. The changes in ANC from a medically-trained provider between 2007 and 2011 are small and go in both directions. M at er na l a nd N ew bo rn H ea lth • 1 23 Ta bl e 9. 1 A nt en at al c ar e P er ce nt d is tri bu tio n of w om en a ge 1 5- 49 w ho h ad a li ve b irt h in th e th re e ye ar s pr ec ed in g th e su rv ey , b y an te na ta l c ar e (A N C ) p ro vi de r d ur in g pr eg na nc y fo r t he m os t r ec en t b irt h, a nd th e pe rc en ta ge re ce iv in g an te na ta l ca re fr om a s ki lle d pr ov id er fo r t he m os t r ec en t b irt h, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, B an gl ad es h 20 11 B ac kg ro un d ch ar ac te ris tic M ed ic al ly tr ai ne d pr ov id er H A/ FW A Tr ai ne d bi rth at te nd an t U nt ra in ed bi rth at te nd an t U n- qu al ifi ed pr ov id er N G O w or ke r O th er N o on e M is si ng To ta l A ny A N C AN C fr om m ed ic al ly tra in ed pr ov id er 1 N um be r of w om en Q ua lif ie d do ct or N ur se / m id w ife / pa ra - m ed ic FW V C SB A M A/ SA C M O M ot he r’s a ge a t b irt h <2 0 41 .9 8. 8 5. 5 0. 6 0. 3 5. 9 0. 3 0. 2 1. 1 6. 7 0. 2 28 .5 0. 0 10 0. 0 71 .5 57 .1 1, 41 4 20 -3 4 44 .1 5. 9 3. 6 0. 3 0. 3 5. 0 0. 3 0. 2 1. 0 6. 2 0. 1 32 .8 0. 2 10 0. 0 67 .0 54 .3 3, 06 0 35 -4 9 34 .1 2. 3 4. 0 0. 0 0. 0 3. 0 0. 3 0. 0 0. 1 6. 9 0. 0 49 .2 0. 0 10 0. 0 50 .8 40 .4 17 8 B irt h or de r 1 51 .2 8. 8 5. 2 0. 4 0. 4 5. 4 0. 2 0. 2 0. 9 5. 6 0. 2 21 .4 0. 0 10 0. 0 78 .6 66 .1 1, 68 1 2- 3 43 .1 6. 0 3. 8 0. 2 0. 3 4. 6 0. 3 0. 2 1. 1 7. 1 0. 1 32 .9 0. 2 10 0. 0 66 .9 53 .4 2, 17 4 4- 5 26 .8 4. 3 3. 8 0. 9 0. 2 7. 2 0. 4 0. 0 1. 2 6. 0 0. 0 48 .8 0. 5 10 0. 0 50 .7 35 .9 60 1 6+ 23 .0 2. 9 0. 6 0. 0 0. 0 3. 3 0. 6 0. 0 0. 1 5. 2 0. 0 64 .2 0. 0 10 0. 0 35 .8 26 .5 19 6 R es id en ce U rb an 62 .3 10 .1 1. 7 0. 0 0. 0 2. 9 0. 1 0. 0 0. 3 5. 4 0. 0 16 .9 0. 0 10 0. 0 83 .1 74 .3 1, 06 8 R ur al 37 .3 5. 6 4. 9 0. 5 0. 4 5. 9 0. 3 0. 2 1. 2 6. 6 0. 1 36 .6 0. 2 10 0. 0 63 .1 48 .7 3, 58 4 D iv is io n B ar is al 40 .1 5. 5 4. 0 0. 5 0. 7 10 .2 1. 2 0. 0 1. 1 4. 4 0. 0 31 .6 0. 7 10 0. 0 67 .7 50 .8 26 0 C hi tta go ng 45 .8 5. 7 3. 4 0. 0 0. 2 3. 2 0. 5 0. 0 1. 2 2. 5 0. 2 37 .1 0. 1 10 0. 0 62 .8 55 .1 1, 08 3 D ha ka 45 .2 6. 0 2. 6 0. 5 0. 1 4. 2 0. 1 0. 5 0. 7 7. 4 0. 1 32 .4 0. 0 10 0. 0 67 .6 54 .5 1, 41 8 K hu ln a 47 .2 10 .3 6. 4 0. 8 0. 8 5. 7 0. 3 0. 0 0. 6 4. 7 0. 1 23 .0 0. 0 10 0. 0 77 .0 65 .4 44 1 R aj sh ah i 40 .5 6. 5 8. 3 0. 8 0. 0 6. 9 0. 0 0. 0 1. 6 6. 7 0. 0 28 .5 0. 2 10 0. 0 71 .3 56 .1 61 8 R an gp ur 33 .6 11 .1 4. 5 0. 0 0. 4 9. 2 0. 3 0. 0 0. 8 17 .3 0. 0 22 .2 0. 6 10 0. 0 77 .1 49 .6 49 1 S yl he t 40 .6 2. 7 2. 6 0. 3 0. 5 1. 8 0. 1 0. 0 1. 5 1. 5 0. 1 48 .2 0. 0 10 0. 0 51 .8 46 .7 34 2 Ed uc at io n N o ed uc at io n 17 .2 5. 8 2. 2 0. 5 0. 4 5. 4 0. 3 0. 0 0. 9 6. 5 0. 0 60 .6 0. 1 10 0. 0 39 .3 26 .2 81 9 P rim ar y in co m pl et e 28 .7 6. 1 4. 6 0. 2 0. 2 5. 2 0. 2 0. 9 1. 9 7. 8 0. 2 43 .5 0. 3 10 0. 0 56 .2 39 .9 85 3 P rim ar y co m pl et e2 33 .3 4. 3 3. 2 0. 7 0. 5 8. 9 0. 2 0. 0 1. 9 10 .3 0. 1 36 .5 0. 2 10 0. 0 63 .3 41 .9 54 5 S ec on da ry in co m pl et e 52 .8 8. 2 5. 5 0. 5 0. 2 4. 9 0. 4 0. 0 0. 7 5. 7 0. 1 21 .0 0. 1 10 0. 0 78 .8 67 .1 1, 84 4 S ec on da ry c om pl et e or hi gh er 3 78 .3 6. 1 3. 1 0. 0 0. 4 2. 5 0. 1 0. 0 0. 2 2. 5 0. 0 6. 8 0. 0 10 0. 0 93 .2 87 .8 59 1 W ea lth q ui nt ile Lo w es t 18 .7 6. 5 3. 9 0. 9 0. 3 7. 5 0. 0 0. 0 1. 2 8. 9 0. 0 51 .6 0. 4 10 0. 0 48 .0 30 .4 1, 06 2 S ec on d 27 .8 6. 2 5. 1 0. 1 0. 4 5. 5 0. 7 0. 3 1. 0 8. 0 0. 2 44 .5 0. 1 10 0. 0 55 .4 39 .6 92 0 M id dl e 40 .4 7. 1 6. 1 0. 3 0. 3 5. 9 0. 2 0. 6 1. 1 6. 0 0. 1 31 .8 0. 1 10 0. 0 68 .1 54 .2 91 9 Fo ur th 56 .2 7. 1 4. 2 0. 5 0. 2 4. 1 0. 4 0. 0 1. 1 5. 5 0. 1 20 .5 0. 1 10 0. 0 79 .5 68 .1 91 1 H ig he st 79 .2 6. 5 1. 5 0. 0 0. 2 2. 3 0. 0 0. 0 0. 6 2. 6 0. 2 7. 0 0. 0 10 0. 0 93 .0 87 .4 84 1 To ta l 43 .1 6. 7 4. 2 0. 4 0. 3 5. 2 0. 3 0. 2 1. 0 6. 4 0. 1 32 .1 0. 2 10 0. 0 67 .7 54 .6 4, 65 2 N ot e: If m or e th an o ne s ou rc e of A N C w as m en tio ne d, o nl y th e pr ov id er w ith th e hi gh es t q ua lif ic at io ns is c on si de re d in th is ta bu la tio n. FW V = fa m ily w el fa re v is ito r; C SB A = c om m un ity s ki lle d bi rth a tte nd an t; M A = m ed ic al a ss is ta nt ; S A C M O = s ub -a ss is ta nt c om m un ity m ed ic al o ffi ce r; H A = he al th a ss is ta nt ; F W A = fa m ily w el fa re a ss is ta nt . 1 M ed ic al ly tr ai ne d pr ov id er in cl ud es q ua lif ie d do ct or , n ur se , m id w ife , p ar am ed ic , F W V, C SB A, a nd M A/ SA C M O . 2 P rim ar y co m pl et e is d ef in ed a s co m pl et in g gr ad e 5. 3 S ec on da ry c om pl et e is d ef in ed a s co m pl et in g gr ad e 10 . • 123Maternal and Newborn Health 124 • Maternal and Newborn Health Figure 9.1 Trend in utilization of antenatal care from a medically-trained provider by division, 2007-2011 45 53 51 68 55 5051 55 55 65 56 47 Barisal Chittagong Dhaka Khulna Rajshahi Sylhet Percent 2007 BDHS 2011 BDHS Note: Rangpur was part of Rajshahi in 2007. 9.1.2 Place of Antenatal Care The place where a woman receives ANC influences the frequency and quality of care received. Information on the ANC source 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 (43 percent), followed by the public sector (41 percent), and the nongovernmental organization (NGO) sector (9 percent). Sixteen percent of women received ANC at home. The place where a woman receives care varies according to age at birth. Young women under age 20 and women age 35 and older at the time of birth are more likely than other women to receive ANC from the public sector. 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, 61 percent of women who completed secondary or higher education received ANC from the private sector compared with 27 percent of women with no education. Women in the lower three wealth quintiles are more likely to seek ANC from the public sector than from the private sector. Comparable data from the 2007 BDHS survey shows a decrease in the proportion of women who received ANC from the public sector and the NGO sector. In 2007 the public sector was the leading source of ANC for women (43 percent), followed by the private sector (38 percent) and the NGO sector (17 percent), while the rest of women received ANC at home. Maternal and Newborn Health • 125 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 2011 Background characteristic Place of antenatal care. Number of women Home Public sector Private sector NGO sector Other Mother’s age at birth <20 19.7 43.6 38.3 9.8 0.0 1,011 20-34 14.5 39.4 45.2 9.0 0.4 2,056 35-49 14.7 45.0 35.5 9.3 0.0 91 Birth order 1 15.2 42.2 44.1 10.2 0.2 1,322 2-3 16.1 38.9 44.2 8.8 0.3 1,458 4-5 19.3 45.0 31.6 7.4 0.4 308 6+ 22.8 39.2 34.9 9.7 0.0 70 Residence Urban 9.6 36.0 46.0 19.3 0.4 887 Rural 18.7 42.8 41.4 5.3 0.3 2,270 Division Barisal 15.1 50.6 36.3 7.3 0.8 178 Chittagong 6.5 36.1 55.7 7.3 0.6 681 Dhaka 19.5 37.1 43.2 10.8 0.0 959 Khulna 12.5 46.9 40.4 10.9 0.4 340 Rajshahi 18.2 47.4 38.7 5.9 0.5 442 Rangpur 31.4 45.1 20.5 13.6 0.0 381 Sylhet 5.9 33.5 58.7 6.4 0.0 177 Education No education 24.9 42.4 27.4 10.5 0.2 323 Primary incomplete 24.2 41.9 31.0 8.0 0.7 482 Primary complete1 27.1 42.2 29.0 8.7 0.0 346 Secondary incomplete 13.1 41.7 46.3 10.0 0.1 1,457 Secondary complete or higher2 5.2 36.3 61.1 8.2 0.7 551 Wealth quintile Lowest 28.9 47.0 22.0 6.5 0.3 514 Second 23.1 46.8 31.1 6.3 0.5 511 Middle 17.5 46.3 38.4 7.6 0.0 626 Fourth 13.3 38.7 49.1 11.6 0.5 724 Highest 4.9 30.7 61.4 12.3 0.2 782 Total 16.2 40.9 42.7 9.3 0.3 3,158 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 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 ANC 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. Twenty-six 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 are more than twice as likely as rural women to have made four or more antenatal visits (45 percent versus 20 percent). Women residing in urban areas, on average, had 1.3 more visits than rural women. The HPNSDP 2011-2016 specifies a target of at least four antenatal care visits to be achieved by 50 percent of women who have a live birth (MOHFW, 2011). A comparison with the 2004 and 2007 BDHS surveys shows that not only are more women receiving antenatal care, but women are also receiving care more often. The percentage of women who had no ANC visit has declined from 44 percent in 2004 to 32 percent in 2011. At the same time, the percentage of pregnant women who made four or more antenatal visits has increased from 16 percent in 2004 to the current level of 26 percent (Figure 9.2). 126 • Maternal and Newborn Health 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 2011 Number of ANC visits Residence Total Urban Rural None 16.9 36.6 32.1 1 11.9 16.4 15.3 2 12.5 14.9 14.4 3 13.8 12.2 12.5 4+ 44.7 19.8 25.5 Don’t know/missing 0.2 0.1 0.1 Median number of visits (for those with ANC) 4.3 3.0 3.3 Total 100.0 100.0 100.0 Number of women 1,068 3,584 4,652 Figure 9.2 Trend in antenatal care visits, 2004-2011 42 17 37 22 32 26 None 4+ ANC visits 2004 BDHS 2007 BDHS 2011 BDHS Percent 9.1.4 Tetanus Toxoid Injections Neonatal tetanus is a leading cause of neonatal deaths, especially in developing countries where a high proportion of deliveries are conducted at home or in places where unhygienic conditions prevail. Tetanus toxoid (TT) injections are given to pregnant women during pregnancy to prevent neonatal tetanus, which can occur when sterile procedures are not followed in cutting the umbilical cord after delivery. If a woman has received no previous TT injections, she needs two doses of TT during pregnancy for full protection. However, a woman may require only one or no TT injections during pregnancy if she has been vaccinated before, depending on the number and timing of past injections. A total of five doses is considered to provide lifetime protection. The 2011 BDHS collected data on whether or not the women received any TT vaccinations during pregnancy and whether or not the pregnancy was protected against neonatal tetanus. Table 9.4 presents the percentage of women who had a live birth in the three years preceding the survey whose last birth was protected against neonatal tetanus. The last birth for nine out of ten mothers was protected against neonatal tetanus. In addition, 42 percent of mothers received two or more tetanus injections during their last pregnancy. Maternal and Newborn Health • 127 Younger mothers and women with fewer previous live births are more likely than other women to have received two or more tetanus injections during their last pregnancy. The association between education and wealth on receiving two doses of tetanus toxoid during pregnancy is not strong. However, when prior vaccination is taken into account, the proportion of women whose pregnancy was protected against TT increased with both education and wealth. For example, the percentage of women whose last birth was protected against neonatal tetanus ranges from a low of 78 percent among mothers with no education to a high of 96 percent among mothers who have completed secondary education. Between 2007 and 2011, the percentage of mothers who received at least two tetanus toxoid injections for their last birth in the three years preceding the survey decreased by 24 percent (from 55 to 42 percent, respectively), and the percentage whose last birth was protected against neonatal tetanus has remained almost the same (91 and 90 percent, respectively). Table 9.4 Tetanus toxoid injections Among mothers age 15-49 with a live birth in the three years preceding the survey, the percentage receiving two or more tetanus toxoid injections (TTI) during the pregnancy for the last live birth, and the percentage whose last live birth was protected against neonatal tetanus, according to background characteristics, Bangladesh 2011 Background characteristic Percentage receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus1 Number of mothers Mother’s age at birth <20 47.5 93.6 1,414 20-34 39.7 89.5 3,060 35-49 29.7 67.9 178 Birth order 1 50.4 95.4 1,681 2-3 38.6 89.6 2,174 4-5 34.0 83.5 601 6+ 24.2 66.8 196 Residence Urban 46.5 93.5 1,068 Rural 40.2 88.8 3,584 Division Barisal 55.3 88.9 260 Chittagong 40.9 88.8 1,083 Dhaka 44.5 92.4 1,418 Khulna 33.7 90.5 441 Rajshahi 42.6 87.9 618 Rangpur 42.8 92.1 491 Sylhet 29.3 83.7 342 Education No education 41.6 78.1 819 Primary incomplete 45.5 87.9 853 Primary complete1 45.8 90.8 545 Secondary incomplete 39.5 93.8 1,844 Secondary complete or higher2 39.3 96.3 591 Wealth quintile Lowest 40.3 82.2 1,062 Second 44.3 89.9 920 Middle 42.1 91.9 919 Fourth 36.4 92.4 911 Highest 45.8 94.7 841 Total 41.7 89.9 4,652 1 Includes mothers with two injections during the pregnancy of her last birth, or two or more injections (the last within 3 years of the last live birth), or three or more injections (the last within 5 years of the last birth), or four or more injections (the last within 10 years of the last live birth), or five or more injections at any time prior to the last birth. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 128 • Maternal and Newborn Health 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 skilled birth attendants (SBAs). Women interviewed in the 2011 BDHS reported on the place and type of assistance during delivery of all children born in the five 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. Twenty-nine percent of births in Bangladesh are delivered at a health facility: 15 percent in a private facility, 12 percent in a public facility, and 2 percent in an NGO facility. Seventy-one percent of births are delivered at home. The likelihood of delivering in a health facility is considerably lower for women age 35 and older (20 percent) compared with those who are younger (29 percent). Facility delivery decreases sharply as the number of live births by a woman increases. On the other hand, the number of antenatal care visits, education level, and wealth status have a positive relationship on the likelihood of delivering in a health facility. For example, only 11 percent of women with no education deliver in a health facility compared with 67 percent of women with completed secondary education. Among divisions, Khulna has the highest proportion of births delivered at a health facility (46 percent), while Sylhet has the lowest (21 percent). Although still low, the proportion of births delivered at health facilities has been increasing since 2004, from 12 percent in 2004 to 17 percent in 2007 and to 29 percent in 2011. 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 a less significant increase in deliveries in public facilities (from 8 percent in 2007 to 12 percent in 2011). In the effort to achieve equity in delivery in a health facility, the HPNSDP 2011-2016 sets a ratio of less than 1 to 4 between women in the lowest and the highest quintiles (MOHFW, 2011). Bangladesh has been making progress in reducing the gap between the poorest and the richest women in the use of facilities for delivery, as shown by the BDHS findings. In the 2011 BDHS, 10 percent of births in the past three years to women in the lowest wealth quintile were delivered in a health facility compared with 60 percent of births in the highest wealth quintile (Figure 9.3). This translates to a ratio of 1 to 6. The corresponding ratios in the 2004 BDHS and the 2007 BDHS among births in the three years before the survey are 1 to 13 and 1 to 8, respectively. 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. According to the 2011 BDHS, 17 percent of live births in the three years preceding the survey were delivered by C-section. Delivery by Caesarean section is highest among births to mothers who completed secondary education (49 percent), births to mothers in the highest wealth quintile (41 percent), births to women who live in urban areas (29 percent), and first births (24 percent). Deliveries by C-section increased from 9 percent in 2007 to 17 percent in 2011. Maternal and Newborn Health • 129 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 2011 Background characteristic Health facility Home Other/ missing Total Percentage delivered in a health facility Percentage delivered by C-section Number of births Public sector Private sector NGO Mother’s age at birth <20 13.4 13.6 2.0 70.8 0.2 100.0 29.0 14.6 1,539 20-34 11.4 16.0 1.9 70.5 0.2 100.0 29.3 18.6 3,233 35-49 7.4 11.9 0.2 80.4 0.0 100.0 19.6 11.7 183 Birth order 1 16.0 21.4 2.4 60.0 0.3 100.0 39.8 24.1 1,830 2-3 11.0 13.6 2.1 73.2 0.1 100.0 26.7 15.8 2,294 4-5 5.3 6.1 0.5 87.8 0.3 100.0 12.0 5.9 624 6+ 3.9 3.2 0.0 92.9 0.0 100.0 7.1 2.9 208 Antenatal care visits1 None 4.1 4.5 0.2 91.1 0.1 100.0 8.8 5.0 1,496 1-3 13.1 13.6 1.9 71.1 0.2 100.0 28.7 15.8 1,966 4+ 20.0 31.0 4.1 44.6 0.3 100.0 55.1 34.7 1,188 Residence Urban 17.8 25.2 6.3 50.5 0.2 100.0 49.3 28.9 1,121 Rural 10.1 12.1 0.6 77.0 0.2 100.0 22.8 13.6 3,835 Division Barisal 9.7 11.5 1.0 77.6 0.1 100.0 22.3 13.2 273 Chittagong 11.5 12.1 1.3 75.0 0.2 100.0 24.8 14.0 1,176 Dhaka 10.8 16.2 2.9 70.0 0.1 100.0 29.9 20.2 1,510 Khulna 18.4 25.2 2.2 54.1 0.1 100.0 45.8 26.2 463 Rajshahi 9.9 19.1 0.8 69.9 0.3 100.0 29.8 17.6 646 Rangpur 15.1 10.6 1.9 71.9 0.4 100.0 27.6 11.6 513 Sylhet 9.5 9.7 1.8 78.7 0.3 100.0 21.0 12.0 375 Education No education 4.9 4.7 1.5 88.8 0.0 100.0 11.2 4.5 892 Primary incomplete 8.2 6.2 1.4 84.0 0.3 100.0 15.7 6.8 904 Primary complete2 9.8 11.0 1.1 78.0 0.1 100.0 21.9 12.8 581 Secondary incomplete 13.5 17.1 2.3 66.8 0.2 100.0 33.0 18.8 1,956 Secondary complete or higher3 23.8 40.3 2.5 33.1 0.4 100.0 66.6 48.5 623 Wealth quintile Lowest 6.9 2.8 0.3 90.1 0.0 100.0 9.9 2.7 1,135 Second 7.8 9.4 0.3 82.4 0.1 100.0 17.5 9.6 1,003 Middle 11.4 11.3 1.4 75.6 0.3 100.0 24.1 14.3 974 Fourth 15.7 20.7 3.1 60.2 0.4 100.0 39.4 22.6 963 Highest 19.1 35.6 5.1 40.0 0.2 100.0 59.8 41.1 881 Total 11.8 15.1 1.9 71.0 0.2 100.0 28.8 17.1 4,956 Note: Total includes 3 births with missing information on number of antenatal care visits. 1 Includes only the most recent birth in the five years preceding the survey 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 130 • Maternal and Newborn Health Figure 9.3 Place of delivery by wealth quintile 3 6 10 3 6 18 7 10 24 15 20 3938 49 60 2004 BDHS 2007 BDHS 2011 BDHS Percent deliveries in last 3 years Lowest Second Middle Fourth Highest 1:13 1:8 1:6 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 9.6 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. Thirty-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 11 percent of deliveries. However, more than half of births in Bangladesh were assisted by dais or untrained traditional birth attendants (53 percent), and 4 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. Maternal and Newborn Health • 131 Table 9.6 Assistance during delivery Percent distribution of live births in the three years preceding the survey by person providing assistance during delivery (skilled and unskilled) and percentage of births assisted by a skilled provider, according to background characteristics, Bangladesh 2011 Background characteristic Assistance during delivery Total Percent- age deliv- ered by a medically trained provider1 Number of births Quali- fied doctor Nurse/ mid- wife/ para- medic FWV CSBA HA/ FWA Trained tradi- tional birth atten- dant Un- trained tradi- tional birth atten- dant Un- quali- fied doctor Rela- tives and friends NGO worker No one Missing Mother’s age at birth <20 20.3 11.6 0.2 0.2 0.4 11.1 52.3 0.2 3.5 0.0 0.2 0.0 100.0 32.3 1,539 20-34 23.5 7.8 0.3 0.3 0.5 10.5 52.4 0.2 3.9 0.1 0.6 0.0 100.0 31.9 3,233 35-49 15.0 5.8 0.2 0.7 0.0 17.9 56.2 0.3 3.9 0.0 0.0 0.0 100.0 21.7 183 Birth order 1 31.4 11.4 0.3 0.1 0.4 10.2 43.2 0.2 2.5 0.0 0.0 0.0 100.0 43.3 1,830 2-3 20.3 8.5 0.3 0.3 0.2 10.6 55.3 0.2 4.0 0.1 0.4 0.0 100.0 29.2 2,294 4-5 8.3 5.0 0.4 0.8 1.4 13.1 61.5 0.1 7.5 0.0 1.9 0.0 100.0 14.4 624 6+ 4.0 3.2 0.0 0.6 0.0 14.4 76.3 0.3 1.3 0.0 0.0 0.0 100.0 7.8 208 Place of delivery Public 64.6 33.9 0.9 0.0 0.3 0.0 0.1 0.0 0.2 0.0 0.0 0.0 100.0 99.4 587 Private 88.7 11.1 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 99.8 749 NGO 46.2 41.6 0.0 0.0 0.0 1.9 0.0 0.0 7.8 2.5 0.0 0.0 100.0 87.7 94 Home 0.3 3.4 0.2 0.4 0.5 15.3 73.9 0.3 5.1 0.0 0.6 0.0 100.0 4.3 3,517 Residence Urban 38.4 14.9 0.4 0.1 0.1 9.8 34.0 0.1 1.8 0.2 0.2 0.1 100.0 53.7 1,121 Rural 17.5 7.2 0.3 0.4 0.5 11.3 57.9 0.2 4.4 0.0 0.5 0.0 100.0 25.2 3,835 Division Barisal 19.1 9.3 0.1 0.0 0.4 9.3 58.6 0.2 2.4 0.1 0.4 0.0 100.0 28.4 273 Chittagong 20.4 8.4 0.2 0.7 0.4 9.5 57.7 0.1 2.3 0.0 0.3 0.0 100.0 29.7 1,176 Dhaka 24.4 6.6 0.5 0.1 0.5 10.6 54.3 0.0 2.2 0.1 0.6 0.0 100.0 31.5 1,510 Khulna 30.6 17.7 0.3 0.4 0.2 11.7 37.4 0.2 1.5 0.1 0.0 0.0 100.0 49.0 463 Rajshahi 22.1 8.6 0.2 0.0 0.6 10.4 50.4 0.6 6.3 0.0 0.6 0.1 100.0 30.9 646 Rangpur 17.8 10.7 0.1 0.2 0.1 14.6 44.0 0.4 11.6 0.0 0.6 0.0 100.0 28.7 513 Sylhet 17.1 6.8 0.2 0.3 0.4 13.0 58.5 0.3 3.2 0.0 0.2 0.0 100.0 24.4 375 Education No education 6.6 5.4 0.0 0.6 0.5 9.6 70.0 0.1 6.2 0.2 0.7 0.0 100.0 12.6 892 Primary incomplete 10.4 7.0 0.1 0.1 0.4 11.3 65.6 0.1 4.1 0.0 0.7 0.1 100.0 17.6 904 Primary complete1 14.8 8.8 0.0 0.1 0.3 11.0 60.8 0.1 3.8 0.0 0.3 0.0 100.0 23.7 581 Secondary incomplete 24.8 11.1 0.4 0.3 0.6 11.5 47.2 0.3 3.5 0.0 0.4 0.0 100.0 36.6 1,956 Secondary complete or higher2 60.4 9.9 0.8 0.1 0.0 10.6 17.6 0.0 0.6 0.0 0.0 0.0 100.0 71.2 623 Wealth quintile Lowest 5.3 5.7 0.0 0.4 0.8 11.2 69.0 0.2 6.7 0.0 0.7 0.0 100.0 11.5 1,135 Second 11.7 6.3 0.3 0.3 0.5 11.7 63.9 0.2 4.1 0.0 0.9 0.0 100.0 18.6 1,003 Middle 18.0 9.6 0.3 0.3 0.2 12.5 54.9 0.5 3.3 0.0 0.4 0.0 100.0 28.2 974 Fourth 30.5 11.8 0.6 0.3 0.4 11.5 41.5 0.1 3.0 0.2 0.1 0.1 100.0 43.2 963 Highest 51.5 11.9 0.3 0.0 0.2 7.4 27.6 0.1 1.0 0.0 0.0 0.0 100.0 63.8 881 Total 22.2 8.9 0.3 0.3 0.4 10.9 52.5 0.2 3.8 0.0 0.4 0.0 100.0 31.7 4,956 Note: Total includes 9 women who gave birth in other type of facility. If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. 1 Medically trained provider includes doctor, nurse, midwife, paramedic, FWV, CSBA, and MA/SACMO. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. The type of assistance during childbirth varies with certain background characteristics. Medically assisted births are more common among women having their first birth (43 percent), women in urban areas (54 percent), women who have completed secondary or higher education (71 percent), and women from the highest wealth quintile (64 percent). Among divisions, Khulna has the highest proportion of births assisted by medically-trained providers (49 percent), while Sylhet has the lowest (24 percent). 132 • Maternal and Newborn Health The HPNSDP 2011-2016 target for delivery by a medically-trained provider is set at 50 percent of deliveries, to be achieved by 2016 (MOHFW, 2011). Over the past seven years, the proportion of deliveries by medically-trained providers has doubled, from 16 percent in 2004 to 21 percent in 2007, and to 32 percent in 2011 (Figure 9.4). This is almost solely due to an increase in institutional delivery, given that the majority of births delivered at home are mostly performed by unskilled individuals (95 percent in 2011) (Table 9.6). Figure 9.4 Trend in skilled attendance at deliveries 16 21 32 2004 BDHS 2007 BDHS 2011 BDHS Percent 9.3 POSTNATAL CARE FOR MOTHERS AND CHILDREN Postnatal care is a crucial component of safe motherhood. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their babies. A large proportion of maternal and neonatal deaths occur during the 24 hours following delivery. In addition, the first two days following delivery are critical for monitoring complications arising from the delivery. To assess the extent of postnatal care utilization, the 2011 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 five years preceding the survey. 9.3.1 Postnatal Checkup for Mother Table 9.7 shows the percent distribution of last births in the three years preceding the survey for which the mothers and their newborn babies received postnatal care. The 2011 BDHS data show that 27 percent of mothers and 30 percent of children received postnatal care from a medically-trained provider within the crucial first two days of delivery. On the other hand, 71 percent of mothers and 66 percent of children did not receive a postnatal checkup from a medically-trained provider. The percentage of mothers receiving postnatal checkup from medically-trained providers within 2 days of delivery has increased from 16 percent in 2004 to 20 percent in 2007, and 27 percent in 2011 (see Figure 9.5). However, it is still much lower than the HPNSDP 2011-2016 target of 50 percent that needs to Maternal and Newborn Health • 133 be achieved by 2016 (MOHFW, 2011). Similarly, the percentage of children receiving postnatal care from a medically-trained provider within two days of delivery has increased from 13 percent in 2004, to 20 percent in 2007, and to 30 percent in 2011 (Figure 9.5). Table 9.7 Postnatal care for mothers and children Percent distribution of last births in the three years preceding the survey for which the mothers and children received postnatal care from any provider and a medically trained provider, by timing of postnatal care, Bangladesh 2011 Timing Women Children Any provider Medically trained provider1 Any provider Medically trained provider1 Within 2 days of delivery 27.6 27.1 40.5 29.6 3-6 days after delivery 0.9 0.6 2.4 1.0 7-41 days after delivery 1.6 1.2 7.0 3.5 Did not receive postnatal check up 69.5 70.6 49.9 65.8 Don’t know/missing 0.4 0.4 0.2 0.2 Total 100.0 100.0 100.0 100.0 Number 4,652 4,652 4,652 4,652 Note: Women and children who received a checkup after 41 days are assumed to have not received postnatal care. 1 Medically trained provider includes doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendants (CSBA) and MA/SACMO. Figure 9.5 Trend in utilization of postnatal care for women and children from a medically trained provider within two days of delivery, 2004-2011 16 13 20 20 27 30 Mothers Newborn infants 2004 BDHS 2007 BDHS 2011 BDHS Percent Table 9.8 shows that 29 percent of mothers who give birth in the three years preceding the survey received a postnatal checkup from a medically-trained provider within 41 days of delivery. About one in four women received a postnatal checkup within the first four hours after delivery (23 percent), 2 percent received a checkup within 4 to 23 hours, and 2 percent were seen 1 to 2 days following delivery. 134 • Maternal and Newborn Health Differences in receiving postnatal care from a medically-trained provider within two days of delivery by mother’s age, birth order, place of delivery, residence, education, and wealth quintile are pronounced. Women who are younger than age 35 at the time of birth (27 to 28 percent), women having their first child (38 percent), urban women (46 percent), women who have completed a secondary education or higher (63 percent), and women in the highest wealth quintile (58 percent) are much more likely to receive the first postnatal checkup from a medically-trained provider in the first two days after delivery than other women. The first postnatal checkup from a trained provider within two days of delivery is most common in Khulna (42 percent) and least common in Sylhet (19 percent). Table 9.8 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, according to background characteristics, Bangladesh 2011 Background characteristic Time after delivery of mother’s first postnatal checkup No postnatal checkup1 Total Number of women 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 22.0 2.7 2.3 1.0 0.9 0.3 70.8 100.0 1,414 20-34 24.0 1.9 1.7 0.4 1.3 0.4 70.2 100.0 3,060 35-49 16.1 2.1 2.0 1.0 1.9 0.3 76.6 100.0 178 Birth order 1 31.8 3.3 2.5 0.9 0.8 0.5 60.2 100.0 1,681 2-3 21.7 1.6 1.7 0.5 1.6 0.5 72.4 100.0 2,174 4-5 9.3 1.2 1.3 0.5 1.0 0.1 86.5 100.0 601 6+ 5.5 1.6 0.1 0.3 1.5 0.0 90.9 100.0 196 Place of delivery Health facility 78.4 7.2 5.9 0.6 0.8 1.1 6.1 100.0 1,352 Elsewhere 0.4 0.1 0.3 0.6 1.4 0.1 97.0 100.0 3,300 Residence Urban 40.1 2.9 3.2 0.7 1.4 0.6 51.2 100.0 1,068 Rural 18.0 2.0 1.5 0.6 1.2 0.4 76.4 100.0 3,584 Division Barisal 18.5 1.6 1.0 0.5 1.7 0.2 76.5 100.0 260 Chittagong 18.6 2.4 2.8 0.8 2.0 0.4 72.9 100.0 1,083 Dhaka 24.4 2.5 2.1 0.7 0.8 0.3 69.3 100.0 1,418 Khulna 37.7 2.9 1.3 0.5 0.6 0.5 56.5 100.0 441 Rajshahi 25.0 1.2 1.1 0.6 0.5 0.4 71.2 100.0 618 Rangpur 21.7 1.7 1.1 0.1 1.7 0.6 73.1 100.0 491 Sylhet 14.9 2.0 2.0 0.9 1.8 0.8 77.7 100.0 342 Education No education 9.0 1.0 0.4 0.0 0.4 0.1 89.1 100.0 819 Primary incomplete 12.0 1.2 1.3 0.5 0.6 0.0 84.4 100.0 853 Primary complete2 15.8 2.0 1.7 0.8 0.8 0.6 78.3 100.0 545 Secondary incomplete 26.4 2.2 2.5 0.8 1.5 0.6 65.9 100.0 1,844 Secondary complete or higher3 54.9 5.2 3.0 0.9 2.8 0.8 32.4 100.0 591 Wealth quintile Lowest 7.9 0.6 0.4 0.2 0.5 0.0 90.4 100.0 1,062 Second 11.9 1.7 1.1 0.6 1.1 0.5 83.0 100.0 920 Middle 20.1 2.5 0.6 0.8 1.6 0.1 74.3 100.0 919 Fourth 30.3 2.7 3.7 1.0 1.3 0.7 60.3 100.0 911 Highest 49.8 3.7 4.1 0.6 1.8 0.8 39.1 100.0 841 Total 23.1 2.2 1.9 0.6 1.2 0.4 70.6 100.0 4,652 Note: Medically trained provider includes 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 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 9.9 shows that among women who gave birth in the last three years, 21 percent of women received care from a qualified doctor, and 6 percent received care from a nurse, midwife, paramedic or family welfare visitor (FWV) within two days after birth. Seventy-two percent of women who gave birth received no postnatal checkup within two days of birth. Maternal and Newborn Health • 135 Table 9.9 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 2011 Background characteristic Medically-trained Non- medically trained provider No postnatal checkup in the first two days after birth1 Total Percentage receiving checkup within 2 days of delivery from a medically- trained provider Number of women Qualified doctor Nurse/ midwife/ paramedic/ FWV Mother’s age at birth <20 18.3 8.7 0.4 72.6 100.0 27.0 1,414 20-34 22.7 4.9 0.6 71.8 100.0 27.6 3,060 35-49 14.6 5.5 0.0 79.8 100.0 20.2 178 Birth order 1 28.4 9.2 0.5 61.8 100.0 37.6 1,681 2-3 20.2 4.9 0.4 74.6 100.0 25.1 2,174 4-5 8.8 3.0 1.0 87.2 100.0 11.8 601 6+ 5.5 1.8 0.0 92.7 100.0 7.3 196 Place of delivery Health facility 70.6 20.8 0.8 7.8 100.0 91.4 1,352 Elsewhere 0.8 0.1 0.4 98.8 100.0 0.8 3,300 Residence Urban 35.8 10.3 0.9 52.9 100.0 46.2 1,068 Rural 16.6 4.8 0.4 78.1 100.0 21.5 3,584 Division Barisal 16.1 4.8 0.5 78.4 100.0 21.0 260 Chittagong 20.1 3.7 0.2 75.9 100.0 23.9 1,083 Dhaka 22.7 6.3 0.6 70.4 100.0 29.0 1,418 Khulna 30.6 11.4 0.4 57.6 100.0 42.0 441 Rajshahi 20.1 7.3 0.6 72.1 100.0 27.3 618 Rangpur 17.5 7.1 0.4 75.0 100.0 24.6 491 Sylhet 15.5 3.3 0.8 80.3 100.0 18.8 342 Education No education 6.7 3.7 0.7 88.9 100.0 10.4 819 Primary incomplete 9.0 5.5 0.7 84.9 100.0 14.4 853 Primary complete2 13.0 6.5 0.8 79.7 100.0 19.5 545 Secondary incomplete 24.2 6.9 0.2 68.6 100.0 31.2 1,844 Secondary complete or higher3 55.9 7.2 0.4 36.5 100.0 63.1 591 Wealth quintile Lowest 4.7 4.2 0.3 90.8 100.0 8.9 1,062 Second 9.9 4.8 1.0 84.3 100.0 14.8 920 Middle 18.0 5.2 0.1 76.7 100.0 23.2 919 Fourth 28.0 8.7 1.0 62.3 100.0 36.7 911 Highest 49.7 7.9 0.2 42.2 100.0 57.6 841 Total 21.0 6.1 0.5 72.4 100.0 27.1 4,652 Note: Medically trained provider includes 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. 9.3.2 Postnatal Checkup for the Newborn Table 9.10 shows that 30 percent of last births in the three years preceding the survey received a postnatal checkup after birth from medically-trained providers within the first two days. One in four newborns (25 percent) had a postnatal checkup within four hours after birth, and 27 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 discussed for mothers’ timing of postnatal checkups. 136 • Maternal and Newborn Health Table 9.10 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 2011 Background characteristic Time after birth of newborn’s first postnatal checkup No postnatal checkup1 Total Number of births 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 14.9 9.5 2.4 3.3 1.0 3.6 0.0 65.3 100.0 1,414 20-34 15.3 10.6 1.9 2.0 0.9 3.5 0.3 65.4 100.0 3,060 35-49 12.8 4.9 2.1 1.4 1.2 2.1 0.0 75.5 100.0 178 Birth order 1 19.9 14.6 3.0 3.3 1.3 4.0 0.1 53.7 100.0 1,681 2-3 14.8 8.6 1.7 2.1 0.9 3.3 0.3 68.3 100.0 2,174 4-5 6.2 4.9 1.7 1.7 0.4 2.6 0.0 82.5 100.0 601 6+ 3.4 3.8 0.0 0.1 0.0 3.3 0.1 89.2 100.0 196 Place of delivery Health facility 47.5 30.4 5.8 4.9 1.1 1.7 0.6 8.0 100.0 1,352 Elsewhere 1.8 1.8 0.6 1.3 0.9 4.2 0.0 89.4 100.0 3,300 Residence Urban 26.4 16.9 3.5 3.6 1.0 4.5 0.3 44.0 100.0 1,068 Rural 11.7 8.1 1.7 2.0 1.0 3.2 0.2 72.2 100.0 3,584 Division Barisal 15.3 6.1 2.5 2.4 1.0 5.3 0.2 67.2 100.0 260 Chittagong 11.7 8.8 1.9 3.5 1.1 3.7 0.2 69.0 100.0 1,083 Dhaka 15.8 11.7 2.1 2.0 0.9 3.3 0.3 64.0 100.0 1,418 Khulna 22.4 19.0 3.1 2.1 0.3 1.9 0.0 51.2 100.0 441 Rajshahi 17.2 6.7 1.3 1.8 1.5 4.2 0.0 67.3 100.0 618 Rangpur 14.6 8.3 1.9 2.1 0.6 2.1 0.2 70.2 100.0 491 Sylhet 9.8 7.8 2.7 2.3 1.0 4.9 0.5 71.0 100.0 342 Mother’s education No education 5.0 5.1 1.1 0.5 0.2 2.1 0.0 86.0 100.0 819 Primary incomplete 8.0 6.3 1.2 2.0 0.7 3.1 0.0 78.7 100.0 853 Primary complete2 11.1 7.9 1.6 1.4 1.2 2.9 0.6 73.3 100.0 545 Secondary incomplete 17.3 10.9 2.3 3.3 1.2 4.1 0.3 60.6 100.0 1,844 Secondary complete or higher3 35.8 22.0 4.6 3.5 1.3 4.3 0.2 28.2 100.0 591 Wealth quintile Lowest 5.9 4.3 0.6 0.6 0.2 3.1 0.0 85.3 100.0 1,062 Second 7.3 5.1 2.0 1.6 1.3 2.3 0.3 80.1 100.0 920 Middle 12.4 9.0 1.9 1.7 1.0 3.6 0.1 70.3 100.0 919 Fourth 20.0 13.2 2.3 4.4 1.6 4.1 0.3 54.0 100.0 911 Highest 32.7 20.7 4.0 4.0 0.9 4.2 0.4 33.1 100.0 841 Total 15.1 10.1 2.1 2.4 1.0 3.5 0.2 65.8 100.0 4,652 Note: Medically trained provider includes doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendants (CSBA) and MA/SACMO. 1 Includes newborns who received a checkup after 41 days and newborn 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 9.11 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 7 percent received a checkup from a nurse, midwife, paramedic, or FWV within the first two days after birth. Eleven percent of newborns received their first postnatal checkup from a non-medically- trained provider within the first two days after birth. Sixty percent of newborns received no postnatal checkup in the first two days after birth. Maternal and Newborn Health • 137 Table 9.11 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 a postnatal checkup in the first two days after birth from a medically-trained provider, according to background characteristics, Bangladesh 2011 Background characteristic Qualified doctor Nurse/ midwife/ paramedic/ FWV CSBA/ MA/ SACMO Non- medically trained provider No postnatal checkup in the first two days after birth Total Percentage receiving checkup within 2 days of delivery from a medically- trained provider Number of births Mother’s age at birth <20 20.6 9.3 0.2 10.8 59.1 100.0 30.1 1,414 20-34 23.7 6.0 0.2 10.9 59.2 100.0 29.9 3,060 35-49 15.5 5.0 0.7 11.1 67.7 100.0 21.2 178 Birth order 1 30.9 9.9 0.1 8.9 50.3 100.0 40.9 1,681 2-3 21.0 5.9 0.2 11.8 61.1 100.0 27.1 2,174 4-5 10.1 4.2 0.3 12.8 72.7 100.0 14.5 601 6+ 4.8 1.9 0.6 12.0 80.7 100.0 7.4 196 Place of delivery Health facility 70.0 18.5 0.0 0.9 10.5 100.0 88.6 1,352 Elsewhere 3.0 2.2 0.3 14.9 79.6 100.0 5.5 3,300 Residence Urban 38.2 12.1 0.0 7.9 41.7 100.0 50.3 1,068 Rural 17.8 5.4 0.2 11.8 64.8 100.0 23.4 3,584 Division Barisal 18.9 7.0 0.3 6.4 67.3 100.0 26.3 260 Chittagong 21.5 4.2 0.3 8.9 65.1 100.0 26.0 1,083 Dhaka 24.2 7.1 0.1 10.9 57.7 100.0 31.5 1,418 Khulna 32.2 14.0 0.4 12.0 41.3 100.0 46.6 441 Rajshahi 20.2 6.8 0.0 11.2 61.8 100.0 27.0 618 Rangpur 19.0 7.7 0.2 17.2 55.9 100.0 26.9 491 Sylhet 17.2 5.2 0.2 9.5 68.0 100.0 22.6 342 Mother’s education No education 7.4 3.9 0.3 11.9 76.4 100.0 11.7 819 Primary incomplete 11.2 6.1 0.1 12.7 69.9 100.0 17.5 853 Primary complete1 14.3 7.5 0.2 11.1 66.9 100.0 22.0 545 Secondary incomplete 26.0 7.6 0.2 11.0 55.2 100.0 33.8 1,844 Secondary complete or higher2 56.0 9.9 0.0 6.4 27.7 100.0 65.9 591 Wealth quintile Lowest 5.8 5.2 0.4 13.0 75.7 100.0 11.4 1,062 Second 11.3 4.6 0.2 13.1 70.8 100.0 16.1 920 Middle 18.6 6.1 0.2 9.9 65.1 100.0 24.9 919 Fourth 30.3 9.6 0.1 11.5 48.6 100.0 39.9 911 Highest 51.5 9.9 0.0 6.2 32.4 100.0 61.4 841 Total 22.5 7.0 0.2 10.9 59.5 100.0 29.6 4,652 Note: Medically trained provider includes doctor, nurse, midwife, paramedic, family welfare visitor (FWV), community skilled birth attendants (CSBA) and MA/SACMO. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 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 2011 BDHS is the second 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 wrapping, and bathing of the newborn following birth. 138 • Maternal and Newborn Health 9.4.1 Care of the Umbilical Cord According to the 2011 BDHS, a blade is the most common instrument used to cut the umbilical cord (97 percent). Table 9.12 shows that a blade from the delivery kit was used for only 14 percent of the births, while the rest of the blades came from other sources (83 percent). The instrument used to cut the cord was boiled before use in 84 percent of noninstitutional births. The use of a boiled instrument to cut the umbilical cord varies by background characteristics. For example, a boiled instrument was used in 88 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 quintile to a high of 89 percent in the highest quintile. Table 9.12 Type of instrument used to cut the umbilical cord Percent distribution of noninstitutional births that 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 2011 Background characteristic Instrument used to cut the umbilical cord Percentage of births using sterile/boiled instruments for cutting the cord Number of births Blade from delivery kit Blade from other source Bamboo strips Scissors Other Cord was not cut Don’t know Total Mother’s age at birth <20 14.1 81.4 1.7 1.3 0.0 0.5 1.1 100.0 79.5 995 20-34 13.9 83.4 1.1 0.8 0.1 0.1 0.6 100.0 85.4 2,153 35-49 17.1 80.0 2.1 0.8 0.0 0.0 0.0 100.0 86.1 143 Birth order 1 15.3 80.3 1.2 1.6 0.0 0.7 1.0 100.0 79.8 1,001 2-3 14.1 83.2 1.3 0.5 0.0 0.0 0.8 100.0 85.5 1,583 4-5 12.5 85.1 1.2 0.9 0.1 0.0 0.1 100.0 85.4 526 6+ 11.9 84.1 2.7 1.4 0.0 0.0 0.0 100.0 83.1 181 Residence Urban 13.9 83.1 1.2 1.4 0.0 0.1 0.2 100.0 87.8 538 Rural 14.1 82.6 1.3 0.9 0.0 0.2 0.8 100.0 82.8 2,753 Division Barisal 10.8 85.4 1.1 1.1 0.0 0.6 1.0 100.0 80.0 203 Chittagong 9.2 86.3 2.6 1.2 0.0 0.2 0.6 100.0 84.9 806 Dhaka 11.5 86.4 0.4 0.8 0.0 0.2 0.8 100.0 82.1 988 Khulna 13.6 84.3 0.0 1.2 0.0 0.0 0.9 100.0 84.2 240 Rajshahi 15.3 80.2 1.2 2.0 0.0 0.3 1.0 100.0 78.7 431 Rangpur 29.4 69.2 0.9 0.0 0.0 0.3 0.1 100.0 88.0 356 Sylhet 18.9 76.6 3.1 0.3 0.4 0.0 0.7 100.0 89.8 268 Mother’s education No education 10.7 86.6 1.4 0.7 0.1 0.1 0.4 100.0 82.2 723 Primary incomplete 12.4 84.0 2.0 0.3 0.0 0.2 1.1 100.0 78.9 715 Primary complete1 10.3 86.8 0.9 1.1 0.0 0.4 0.5 100.0 87.1 429 Secondary incomplete 15.6 80.9 1.2 1.2 0.0 0.2 0.8 100.0 85.3 1,225 Secondary complete or higher2 30.8 65.5 0.0 2.1 0.0 0.6 0.9 100.0 88.0 199 Wealth quintile Lowest 11.7 85.2 1.5 0.7 0.0 0.1 0.8 100.0 81.4 955 Second 13.1 83.4 1.8 0.6 0.1 0.5 0.7 100.0 81.8 765 Middle 15.9 80.8 1.3 1.1 0.0 0.1 0.9 100.0 83.9 690 Fourth 16.6 80.7 0.7 1.2 0.0 0.1 0.6 100.0 86.7 547 Highest 15.1 81.2 0.9 1.8 0.2 0.4 0.5 100.0 88.6 336 Total 14.1 82.7 1.3 0.9 0.0 0.2 0.7 100.0 83.6 3,291 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. The use of a blade from a delivery kit has increased from 6 percent in 2007 to 14 percent in 2011, while the use of boiled instruments has increased slightly, from 82 percent in 2007 to 84 percent in 2011 (Figure 9.6). Maternal and Newborn Health • 139 Figure 9.6 Trend in use of appropriate cord care, 2007-2011 6 82 56 14 84 59 Blade from kit Boiled instrument to cut cord Nothing applied to cord 2007 BDHS 2011 BDHS Percent Table 9.13 shows what material was applied to the cord immediately after cutting it, according to the mother’s background characteristics. In most cases (59 percent), nothing was applied to the cord after it was cut, which is the recommended practice. When something was applied to the cord, mustard oil with garlic and antibiotics were the most common materials (11 percent each), followed by antiseptics (8 percent), and boric powder (4 percent). 140 • Maternal and Newborn Health Table 9.13 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 after cutting and tying the umbilical cord, according to background characteristics, Bangladesh 2011 Background characteristic Anti- biotics Anti- septic Mustard oil with garlic Boric powder Other1 Don’t know Nothing Number of births Mother’s age at birth <20 11.1 7.5 11.6 3.7 9.1 0.8 59.7 995 20-34 10.3 8.6 11.1 3.8 9.9 0.9 58.0 2,153 35-49 11.6 10.7 10.3 2.5 7.0 0.4 60.2 143 Birth order 1 12.5 7.3 11.4 2.4 9.9 0.8 58.7 1,001 2-3 10.8 8.6 11.7 4.6 9.2 1.1 57.1 1,583 4-5 7.8 9.8 9.1 3.6 9.4 0.2 62.1 526 6+ 6.9 7.8 12.2 4.1 11.3 0.5 61.0 181 Residence Urban 12.8 7.2 13.5 4.0 9.3 0.9 55.4 538 Rural 10.2 8.6 10.8 3.7 9.6 0.8 59.2 2,753 Division Barisal 9.3 8.1 29.2 2.3 14.7 1.8 40.4 203 Chittagong 6.7 6.4 19.2 1.8 10.8 0.8 57.7 806 Dhaka 11.5 7.8 7.9 6.9 9.6 0.8 58.4 988 Khulna 21.8 11.1 7.2 3.5 9.3 0.8 50.2 240 Rajshahi 7.9 9.2 5.8 3.6 9.9 1.1 64.7 431 Rangpur 13.5 9.0 5.8 1.7 1.2 0.0 70.0 356 Sylhet 10.5 11.8 4.8 2.2 12.7 1.4 58.0 268 Mother’s education No education 7.6 8.6 13.1 2.8 10.0 0.1 60.5 723 Primary incomplete 9.9 6.8 11.1 6.2 11.7 1.5 56.8 715 Primary complete1 10.5 9.1 8.7 3.5 12.0 0.7 58.5 429 Secondary incomplete 12.0 8.2 11.6 3.2 7.3 1.0 59.0 1,225 Secondary complete or higher2 15.7 12.2 7.5 2.2 8.7 0.3 55.9 199 Wealth quintile Lowest 7.7 7.0 13.2 2.9 10.5 0.5 61.8 955 Second 7.3 9.0 11.0 4.9 8.5 1.0 60.2 765 Middle 12.2 10.6 11.4 4.4 10.2 0.5 54.7 690 Fourth 13.9 7.5 7.8 3.4 9.7 1.8 58.2 547 Highest 17.9 7.6 11.2 2.8 8.0 0.6 54.4 336 Total 10.6 8.4 11.2 3.7 9.6 0.8 58.6 3,291 1 Includes spirits/alcohol, chewed rice, turmeric juice/powder, ginger juice, shidur, gentian violet (blue ink), and talcum powder, each of which were under 2 percent 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. The recommended practice of applying nothing to the umbilical cord increased slightly, from 56 percent in 2007 to 59 percent in 2011 (Figure 9.6). 9.4.2 Drying, Wrapping, and Bathing the Newborn Newborns should be dried and wrapped within minutes after birth and should not be bathed in the first 24 hours in order to reduce the risk of hypothermia. The 2011 BDHS asked mothers with noninstitutional deliveries in the past five years about when the newborn was first dried and wrapped and when the newborn was first bathed. The tables are based on births in the past three years. Table 9.14 shows that half of the newborns were dried within the recommended 5 minutes of birth, 77 percent of the newborns were dried within 10 minutes, and 15 percent after 10 minutes. Six percent of newborns were not dried. There is little variation in early drying of newborns by background characteristics. Newborns in Rajshahi are more likely to be dried within five minutes of birth (58 percent) than newborns in other divisions (52 percent and lower). Early drying is most common among mothers who have completed secondary education (56 percent) and is lowest among mothers with no education or incomplete primary Maternal and Newborn Health • 141 education (49 percent). Early drying of newborns is also highest among newborns in the highest quintile (57 percent). Results show that 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. On the other hand, only 6 percent of newborns were not dried or wiped in 2011 compared with 41 percent in 2007. The practice of keeping the newborn warm is not common in Bangladesh. The general practice is to look for clothes after the baby is born, and in most cases families do not have warm clothes ready at the time of delivery. The newborn is kept naked or covered by a thin piece of cloth until the placenta is delivered or the umbilical cord is cut. Table 9.14 also shows that one-third of the newborns are wrapped immediately after birth, i.e., within 5 minutes. Sixty-nine percent of newborns are wrapped within 10 minutes, and 25 percent are wrapped 10 minutes or more after birth. Table 9.14 Newborn care practices: Timing of drying and wrapping Percent distribution of noninstitutional births that were women’s most recent live birth in the three years preceding the survey by timing of drying and wrapping the newborn, according to background characteristics, Bangladesh 2011 Background characteristic Timing of drying after delivery Timing of wrapping after delivery Number of births 0-4 minutes 5-9 minutes 10+ minutes Not dried Don’t know/ missing Total 0-4 minutes 5-9 minutes 10+ minutes Not wrapped Don’t know/ missing Total Mother’s age at birth <20 51.1 26.3 13.6 7.2 1.9 100.0 32.0 37.0 24.2 5.0 1.8 100.0 995 20-34 52.2 26.0 15.2 5.5 1.1 100.0 33.8 36.2 24.9 4.2 0.9 100.0 2,153 35-49 41.6 22.7 22.3 9.7 3.7 100.0 25.6 31.0 34.1 4.3 5.1 100.0 143 Birth order 1 51.9 26.3 14.0 5.7 2.0 100.0 32.3 35.9 25.9 4.0 1.9 100.0 1,001 2-3 51.8 26.7 14.7 5.5 1.1 100.0 34.3 37.1 23.7 3.8 1.0 100.0 1,583 4-5 52.0 22.9 16.0 7.7 1.4 100.0 31.8 34.7 25.5 6.6 1.4 100.0 526 6+ 43.8 25.6 20.0 10.2 0.5 100.0 26.6 35.1 30.9 5.9 1.5 100.0 181 Residence Urban 50.6 26.9 15.2 6.7 0.6 100.0 36.0 31.8 26.9 4.7 0.6 100.0 538 Rural 51.6 25.7 15.0 6.1 1.6 100.0 32.3 37.1 24.7 4.4 1.5 100.0 2,753 Division Barisal 47.7 26.6 17.6 5.4 2.7 100.0 28.1 40.1 24.3 4.8 2.7 100.0 203 Chittagong 51.9 23.7 17.5 6.1 0.8 100.0 32.7 35.7 26.8 3.9 1.0 100.0 806 Dhaka 52.0 26.2 13.7 6.7 1.4 100.0 34.1 34.8 25.0 4.8 1.4 100.0 988 Khulna 50.3 34.0 11.6 1.7 2.3 100.0 27.5 43.7 25.8 0.9 2.0 100.0 240 Rajshahi 57.8 23.0 15.2 2.2 1.8 100.0 44.5 33.3 19.4 1.6 1.2 100.0 431 Rangpur 49.4 31.3 14.8 3.5 1.0 100.0 31.9 40.7 23.7 2.4 1.3 100.0 356 Sylhet 44.1 21.8 13.6 19.1 1.4 100.0 20.1 32.4 31.3 14.9 1.3 100.0 268 Mother’s education No education 48.6 26.8 14.5 9.2 0.8 100.0 31.9 35.7 24.9 5.9 1.6 100.0 723 Primary incomplete 48.5 26.9 16.8 6.0 1.8 100.0 32.3 35.0 26.6 5.1 1.1 100.0 715 Primary complete1 53.2 25.8 12.4 7.9 0.7 100.0 34.9 37.3 21.8 5.4 0.6 100.0 429 Secondary incomplete 53.5 24.9 15.1 4.8 1.7 100.0 33.0 36.0 25.9 3.4 1.7 100.0 1,225 Secondary complete or higher2 55.7 26.0 15.7 0.6 2.0 100.0 33.4 42.2 22.3 0.7 1.5 100.0 199 Wealth quintile Lowest 48.4 28.3 15.6 6.7 1.0 100.0 30.5 37.0 26.6 4.8 1.2 100.0 955 Second 51.8 23.5 16.5 6.7 1.5 100.0 31.8 37.7 24.5 4.5 1.5 100.0 765 Middle 54.1 24.0 13.9 6.0 2.0 100.0 34.7 35.7 23.6 4.2 1.8 100.0 690 Fourth 49.4 27.7 15.4 5.8 1.7 100.0 33.3 35.2 25.8 4.2 1.5 100.0 547 Highest 56.9 26.0 11.6 4.9 0.6 100.0 37.8 33.6 24.1 4.0 0.5 100.0 336 Total 51.4 25.9 15.0 6.2 1.4 100.0 32.9 36.2 25.1 4.4 1.4 100.0 3,291 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. The practice of immediate wrapping has also improved considerably since 2007 when only 2 percent of newborns were wrapped; that percentage is low compared with the 33 percent wrapped within five minutes in 2011. On the other hand, in 2011 only 4 percent of newborns were not wrapped compared with 38 percent in 2007. 142 • Maternal and Newborn Health The 2011 BDHS assessed the timing of a newborn’s first bath. Table 9.15 shows that 28 percent of newborns are first bathed 72 hours or more following birth, which is the recommended practice in Bangladesh. Thirty-eight percent of the newborns are bathed within the first 6 hours of birth, while 45 percent are 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 first-order births. Among divisions, Rangpur (48 percent) has the highest proportion of newborns bathed after 72 hours of delivery, while Chittagong, Dhaka, and Khulna (23 to 24 percent) have the lowest. Waiting to give a newborn the first bath is also associated with the mother’s education. Twenty-one percent of newborns of women with no education are bathed at least 72 hours after birth, compared with 35 percent of newborns whose mothers have completed secondary or higher education. A comparison of the 2007 and 2011 BDHS findings shows considerable improvement in newborn bathing practices in Bangladesh. The recommended practice of first bathing babies at least 72 hours after birth has increased by 67 percent—from 17 percent in 2007 to 28 percent in 2011 (Figure 9.7). Table 9.15 Newborn care practices: Timing of first bath Percent distribution of noninstitutional 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 2011 Background characteristic Timing of first bath after delivery Number of births 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 35.8 4.5 1.9 23.9 30.8 1.9 1.1 100.0 995 20-34 38.6 4.7 2.7 25.2 27.3 1.0 0.5 100.0 2,153 35-49 34.2 6.2 1.6 27.4 27.7 2.9 0.0 100.0 143 Birth order 1 34.0 4.6 2.3 23.8 33.0 1.7 0.6 100.0 1,001 2-3 36.8 5.0 2.4 27.0 26.5 1.4 0.9 100.0 1,583 4-5 45.8 4.1 2.9 20.5 25.6 0.7 0.5 100.0 526 6+ 40.4 4.7 2.0 24.6 27.2 1.0 0.0 100.0 181 Residence Urban 34.0 4.8 2.0 29.2 28.5 1.1 0.5 100.0 538 Rural 38.3 4.7 2.5 24.0 28.4 1.4 0.7 100.0 2,753 Division Barisal 24.3 3.4 0.7 30.2 37.3 3.4 0.7 100.0 203 Chittagong 43.3 6.3 2.5 23.4 23.3 1.0 0.2 100.0 806 Dhaka 43.4 4.4 2.6 24.8 23.6 0.6 0.7 100.0 988 Khulna 25.1 7.6 3.3 37.9 24.0 1.2 1.0 100.0 240 Rajshahi 34.3 4.5 3.5 23.1 31.2 1.9 1.6 100.0 431 Rangpur 19.3 3.5 1.6 26.2 47.6 1.5 0.4 100.0 356 Sylhet 49.9 1.4 1.8 15.0 28.3 3.0 0.5 100.0 268 Mother’s education No education 49.4 4.3 3.0 20.5 21.3 1.4 0.2 100.0 723 Primary incomplete 41.3 4.3 3.2 23.3 25.8 1.1 1.0 100.0 715 Primary complete2 37.0 5.8 1.2 21.6 33.4 0.9 0.0 100.0 429 Secondary incomplete 30.0 4.7 2.2 29.4 31.3 1.5 1.1 100.0 1,225 Secondary complete or higher3 29.9 5.7 2.0 25.6 34.6 2.2 0.0 100.0 199 Wealth quintile Lowest 44.0 4.7 2.7 20.6 26.3 1.1 0.6 100.0 955 Second 36.4 4.3 2.9 25.5 28.6 1.5 0.8 100.0 765 Middle 35.0 5.7 2.0 28.8 26.3 1.8 0.5 100.0 690 Fourth 32.6 4.1 2.7 24.9 33.2 1.2 1.3 100.0 547 Highest 35.4 4.7 1.1 27.5 30.0 1.3 0.0 100.0 336 Total 37.6 4.7 2.4 24.9 28.4 1.4 0.7 100.0 3,291 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. Maternal and Newborn Health • 143 9.4.3 Essential Newborn Care The National Neonatal Health Strategy and Guidelines for Bangladesh recommend a set of essential newborn care practices: the use of a boiled instrument to cut the cord, applying nothing to the cord, immediate (within 5 minutes) drying and wrapping of the infant, delaying bathing to 72 hours after birth, and initiating breastfeeding within 1 hour of delivery (MOHFW, 2009). To assess the extent to which newborn care practices have been followed, Table 9.16 is presented to show the percentage of nonnstitutional last live births in the three years preceding the survey by each of the essential newborn care practices and the percentage that receives all of the essential newborn care practices. All of the components of essential newborn practices have been presented in the preceding tables. The key indicator in Table 9.16 is that only 2 percent of newborns receive all the essential newborn care practices. Whereas Figure 9.6 shows the trend in appropriate cord care (use blade from the kit, boil the instrument, and apply nothing to the cord), Figure 9.7 summarizes the trend in the four other practices since 2007; immediate (within 5 minutes) drying and wrapping, delay in bathing to 72 hours after birth, and initiating breastfeeding within 1 hour of delivery. For all of these indicators, the practices in 2011 have improved over those in 2007. Table 9.16 Essential newborn care Percentage of non-institutional births which were their mother’s most recent live birth in the three years preceding the survey by essential newborn care practices, Bangladesh 2011 Essential newborn care practices Percentage of noninstitutional births with newborn care practices Instrument boiled before the cord was cut 83.6 Nothing applied to the umbilical cord after it was cut and tied 58.6 Dried within 0-4 minutes of birth 51.4 Wrapped within 0-4 minutes of birth 32.9 Delayed bathing (bathed 72+ hours after delivery) 28.4 Immediate breastfeeding (breastfed within 1 hour after birth) 49.8 All the essential newborn care practices 2.2 Number of noninstitutional births 3,291 144 • Maternal and Newborn Health Figure 9.7 Trend in essential newborn care 6 2 17 43 51 33 28 50 Dried within 5 minutes of birth Wrapped within 5 minutes of birth Bathed 72+ hours after delivery Breastfed within 1 hour of birth 2007 BDHS 2011 BDHS Percent Child Health • 145 CHILD HEALTH 10 his chapter presents findings in several areas of importance to child health, including the mother’s estimate of baby’s size at birth, the vaccination status of children, and the prevalence and treatment of important childhood illnesses. Information on perceived size at birth is important for the design and implementation of programs aimed at reducing neonatal and infant mortality. Information on vaccination coverage focuses on children age 12-23 months. Overall coverage levels at the time of the survey, and at age 12 months, are shown for this group. In addition, the source of the information—a written vaccination card or the mother’s recall—is shown. Knowing how vaccination coverage varies among subgroups of the population can aid in program planning. Information on vaccination coverage is also important for the monitoring and evaluation component of the Expanded Program on Immunization (EPI). Examining treatment practices and contact with health services for children with the three most important childhood illnesses—diarrhea, acute respiratory infection (ARI), and fever—can help assess national programs aimed at reducing mortality from these illnesses. Information is provided on the prevalence of ARI and fever and the extent to which treatment is sought from medically trained providers, pharmacies, and traditional (unqualified) doctors. Measuring the coverage of oral rehydration therapy (ORT) and increased fluids to treat diarrheal disease can help assess the effectiveness of programs that recommend these treatments. 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 important indicator of the child’s vulnerability to the risk of childhood illness 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 not likely to be known for many babies, particularly for those born at home, the mother’s estimate of the baby’s size was obtained in the BDHS. A mother’s report of a child being “very small” or “smaller than average”, even though subjective, is considered a useful proxy for LBW. T Key Findings • The proportion of children age 12-23 months who are fully vaccinated has increased from 83 percent in 2007 to 86 percent in 2011. • Five percent of children under age 5 had diarrhea in the two weeks preceding the survey. Of these children, 25 percent received treatment from a health facility or health provider, an increase from 20 percent in 2007, and 81 percent received oral rehydration therapy (ORT). • Six percent of children under age 5 had symptoms of acute respiratory infection (ARI) in the two weeks preceding the survey. Thirty-five percent of these children received treatment from a health facility or health provider, a decrease from 37 percent in 2007. • Nearly four in ten children under age 5 had a fever in the two weeks preceding the survey. Of these children, 27 percent received treatment from a health facility or health provider. • Over six in ten children with fever who sought treatment received care from the private medical sector. 146 • Child Health Table 10.1 shows that according to their mother’s estimate, 5 percent of children were very small at birth, 12 percent were smaller than average, and 82 percent were average or larger in size. The likelihood of reporting very small children increases with a child’s birth order, from 5 percent for first births to at least 7 percent for births of order four and higher. Among the divisions, the highest percentage of very small children is seen in Chittagong and Sylhet (7 percent) and the lowest is in Rangpur (3 percent). The highest percentages of very small children are also seen among children whose mothers have no education (6 percent) and the lowest are among children whose mothers have completed secondary or higher education (4 percent). Table 10.1 Child’s size at birth Percent distribution of all live births in the five years preceding the survey by mother’s estimate of baby’s size at birth, according to background characteristics, Bangladesh 2011 Background characteristic Percent distribution of all live births by size of child at birth Total Number of births Very small Smaller than average Average or larger Don’t know/ missing Mother’s age at birth <20 4.6 14.6 80.6 0.1 100.0 2,815 20-34 5.7 11.1 83.2 0.0 100.0 5,586 35-49 5.1 14.0 80.9 0.0 100.0 388 Birth order 1 4.9 13.8 81.2 0.1 100.0 3,111 2-3 4.7 11.3 84.0 0.0 100.0 4,069 4-5 7.7 12.2 80.1 0.0 100.0 1,184 6+ 7.2 12.3 80.6 0.0 100.0 425 Residence Urban 4.2 11.3 84.3 0.2 100.0 1,955 Rural 5.6 12.7 81.7 0.0 100.0 6,833 Division Barisal 4.4 9.5 86.1 0.0 100.0 491 Chittagong 7.4 13.8 78.7 0.0 100.0 2,017 Dhaka 4.5 12.0 83.4 0.1 100.0 2,727 Khulna 4.0 12.1 83.8 0.1 100.0 796 Rajshahi 5.7 11.0 83.1 0.1 100.0 1,150 Rangpur 2.6 11.3 86.1 0.0 100.0 926 Sylhet 7.0 15.4 77.5 0.0 100.0 682 Mother’s education No education 6.2 13.3 80.5 0.0 100.0 1,785 Primary incomplete 5.7 11.7 82.6 0.0 100.0 1,613 Primary complete1 4.4 13.9 81.6 0.1 100.0 1,094 Secondary incomplete 5.5 12.7 81.8 0.1 100.0 3,244 Secondary complete or higher2 3.8 8.9 87.3 0.0 100.0 1,053 Wealth quintile Lowest 5.7 13.6 80.6 0.0 100.0 2,068 Second 6.0 13.3 80.7 0.0 100.0 1,799 Middle 5.5 12.5 82.0 0.0 100.0 1,703 Fourth 4.4 11.2 84.2 0.1 100.0 1,685 Highest 4.7 10.5 84.7 0.1 100.0 1,533 Total 5.3 12.4 82.3 0.0 100.0 8,789 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 10.2 VACCINATION OF CHILDREN Universal immunization of children under age 1 against major vaccine-preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, hemophilus influenza type B disease, poliomyelitis, and measles) is one of the most cost-effective programs to reduce infant and child morbidity and mortality. The government of Bangladesh established the routine EPI program against six vaccine- preventable diseases in 1979: tuberculosis, DPT (diphtheria, pertussis, and tetanus), polio, and measles. Efforts intensified after 1985 when Bangladesh committed itself to reaching universal immunization by Child Health • 147 1990 (Jamil et al., 1999). In 2003 the national EPI program incorporated the hepatitis B vaccine with support from the Global Alliance for Vaccination and Immunization (GAVI) (EPI 2004; MOHFW, 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. In January 2009, the Bangladesh EPI program introduced the hemophilus influenza type B (Hib) vaccine. This was done in the form of the pentavalent vaccine that included the DPT and hepatitis B vaccines and the new Hib vaccine. By June 2009, the pentavalent vaccine had replaced the DPT and hepatitis B vaccines in the EPI program in Bangladesh. For this reason, the DPT statistics reported here include either DPT or the pentavalent vaccine. 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 immunized when they have received one dose of the vaccine against tuberculosis (BCG), three doses of the vaccine against diphtheria, pertussis, and tetanus (DPT) or of the pentavalent vaccine, three doses of polio vaccine (excluding polio vaccine given at birth), and one dose of measles vaccine. One dose of BCG is given at birth or at first contact with health workers; the pentavalent or DPT and polio vaccines require three doses at approximately 6, 10, and 14 weeks; and measles 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 2011 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 questionnaire. If the vaccination card was not available (or a vaccination was not recorded), 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. Data are presented for children age 12-23 months, thereby including only those children who have reached the age by which they should be fully vaccinated. The first three rows show the proportions of these children vaccinated at any time before the survey. These results are presented according to the source of the information used to determine coverage, that is, a vaccination card, a mother’s report, or either source. The last row shows the proportion of children who had been vaccinated by age 12 months, the age by which WHO recommends vaccination coverage should be complete. According to information from both vaccination cards and mothers’ reports, 86 percent of Bangladeshi children age 12-23 months are fully vaccinated. The level of coverage for BCG, three doses of pentavalent vaccine (tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, and hemophilus influenza type B), and three doses of polio vaccine is 93 percent or higher. Coverage for measles vaccine is slightly lower (88 percent). The Health, Population, and Nutrition Sector Development Program (HPNSDP) 2011-2016 has set a target of 90 percent coverage for measles vaccine by age 12 months by 2016 (MOHFW, 2011). The 2011 BDHS shows that the coverage is 84 percent by age 12 months. The coverage for the pentavalent and polio vaccine declines with the dosage, from 98 percent for the first dose to 93 percent for the third dose. Only 2 percent of children age 12-23 months have not received any vaccinations. Vaccinations are most effective when given at the proper age. Therefore, it is recommended that children complete the schedule of immunizations during their first year of life (i.e., by 12 months of age). Overall, 83 percent of children age 12-23 months had received all the recommended vaccinations before their first birthday. 148 • Child Health 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 12 months of age, Bangladesh 2011 Source of information BCG Pentavalent Polio Measles All basic vaccinations1 No vaccinations Number of children 1 2 3 1 2 3 Vaccinated any time before survey Vaccination card 66.7 66.7 65.6 64.2 66.7 65.7 64.2 59.6 59.4 0.0 1,032 Mother’s report 31.1 31.1 30.0 29.2 31.1 30.1 29.2 27.9 26.6 2.1 515 Either source 97.8 97.8 95.6 93.4 97.8 95.8 93.4 87.5 86.0 2.1 1,547 Vaccinated by 12 months2 97.8 97.8 95.6 93.2 97.8 95.8 93.2 84.0 82.5 2.1 1,547 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). 2 For children whose information is based on the mother’s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. 10.2.2 Differentials in Vaccination Coverage Table 10.3 shows that vaccination cards were seen for 67 percent of children age 12-23 months. Results indicate that vaccination coverage varies little by the sex of the child, with boys being slightly more likely than girls to have received all vaccines (87 percent compared with 85 percent). Birth order is negatively related to the likelihood of fully vaccinated; as birth order increases, vaccination coverage declines. Among administrative divisions, the highest level of coverage is seen in Khulna (94 percent) and the lowest in Sylhet (80 percent). As expected, mother’s education is positively associated with children’s likelihood of being fully vaccinated: 97 percent of children whose mothers completed secondary or higher education are fully vaccinated, compared with 76 percent of children whose mothers have no education. Similarly, children from households in the highest wealth quintile are more likely to be fully vaccinated (94 percent) than children in the lowest quintile (77 percent). Child Health • 149 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 the interviewer, by background characteristics, Bangladesh 2011 Background characteristic BCG DPT/Penta Polio Measles All basic vaccinations1 No vaccinations Percentage with a vaccination card seen Number of children 1 2 3 1 2 3 Sex Male 98.1 97.9 96.5 94.6 98.1 96.7 94.3 88.3 87.3 1.8 68.8 762 Female 97.6 97.7 94.7 92.3 97.5 95.0 92.5 86.8 84.7 2.3 64.6 785 Birth order 1 98.7 98.7 96.9 94.1 98.5 97.1 93.7 89.4 87.9 1.3 63.2 553 2-3 98.1 98.1 95.7 94.4 98.2 95.9 94.4 87.9 86.4 1.7 71.0 732 4-5 97.3 97.3 94.9 92.8 97.3 95.6 93.2 86.9 85.3 2.7 65.7 191 6+ 89.4 89.4 85.9 79.2 89.4 85.9 80.6 70.8 68.7 10.6 52.5 71 Residence Urban 98.8 98.8 96.7 93.9 98.8 96.6 93.8 87.5 86.5 1.2 64.3 375 Rural 97.5 97.5 95.3 93.2 97.5 95.6 93.3 87.6 85.8 2.3 67.5 1,172 Division Barisal 98.5 98.5 96.1 91.4 99.2 96.8 92.0 86.1 83.3 0.8 64.8 84 Chittagong 96.9 96.5 94.3 90.9 96.9 95.4 92.0 83.9 81.8 3.1 61.8 366 Dhaka 98.4 98.4 95.4 93.9 98.4 95.4 93.5 86.6 85.0 1.6 63.9 478 Khulna 99.1 99.1 98.5 97.2 99.1 98.5 97.2 94.2 93.5 0.9 71.9 144 Rajshahi 97.4 97.9 95.8 95.3 97.4 95.5 94.5 90.7 89.8 2.1 68.9 218 Rangpur 98.4 98.4 98.1 96.1 98.4 98.1 96.0 92.9 92.2 1.6 76.4 148 Sylhet 96.0 96.0 93.2 88.9 95.0 92.7 87.9 82.9 80.1 4.0 72.1 109 Mother’s education No education 93.0 93.0 88.9 85.2 92.8 88.9 84.9 78.3 76.4 7.0 59.7 255 Primary incomplete 95.3 95.2 93.0 90.6 95.5 93.6 91.1 78.0 77.3 4.1 69.7 290 Primary complete2 99.7 99.7 97.4 93.6 99.7 97.4 93.6 85.8 84.2 0.3 69.6 182 Secondary incomplete 99.7 99.7 97.7 95.8 99.6 97.9 95.7 93.2 90.7 0.3 68.2 605 Secondary complete or higher3 100.0 100.0 99.9 99.9 100.0 99.9 99.9 97.2 97.2 0.0 64.2 215 Wealth quintile Lowest 95.7 96.0 93.1 90.3 95.8 93.7 90.3 79.2 76.8 4.0 66.6 330 Second 96.4 96.4 92.8 90.1 96.1 93.0 89.8 87.5 84.9 3.4 65.4 318 Middle 99.2 98.8 96.0 93.2 99.2 96.2 93.7 88.1 86.9 0.8 68.8 306 Fourth 98.2 98.2 97.5 96.3 98.2 97.5 96.1 90.4 89.0 1.8 65.6 312 Highest 100.0 100.0 99.3 97.8 100.0 99.3 97.8 93.6 93.5 0.0 67.2 280 Total 97.8 97.8 95.6 93.4 97.8 95.8 93.4 87.5 86.0 2.1 66.7 1,547 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 DPT/Penta 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 DPT/Penta 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 DPT/Penta and polio 0, polio 1, and polio 2 only, it was assumed that polio 0 was in fact polio1, polio 1 was in fact polio 2, and polio 2 was in fact polio 3. 1 BCG, measles and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth). 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 10.2.3 Trends in Vaccination Coverage Comparing the 2011 BDHS with previous BDHS surveys shows continued improvement in vaccination coverage (Figure 10.1). The proportion of children age 12-23 months who are fully vaccinated has increased by 13 percentage points since 2004 (from 73 percent to 86 percent). This trend is the result of increases in all of the basic vaccinations, in addition to a continued decline in dropout rates from the first to the third doses for polio and DPT (now replaced by the Pentavalent) vaccines. Improvements in vaccination coverage have occurred in all divisions except in Barisal, where the coverage has declined from 90 percent in 2007 to 83 percent in 2011(data not shown). 150 • Child Health Figure 10.1 Trends in vaccination coverage among children age 12-23 months 85 66 67 69 59 86 69 62 70 54 91 72 71 71 60 93 81 82 76 73 97 91 91 83 82 98 93 93 88 86 BCG DPT3 Polio3 Measles All Percent 1993-1994 1996-1997 1999-2000 2004 2007 2011 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 as well as data concerning types of treatment and feeding practices during diarrhea are presented. 10.3.1 Childhood Diarrhea Diarrhea remains a leading cause of childhood morbidity and mortality in developing countries. Dehydration caused by severe diarrhea is a major cause of illness among young children, although the condition can be easily treated with oral rehydration therapy (ORT). During diarrhea, the child is given a solution that can be prepared by mixing water with a commercially prepared packet of oral rehydration salts (ORS)—called khabar, or packet saline, in Bangladesh—or by making a homemade mixture of sugar, salt, and water—called labon gur. Oral rehydration packets are available through health facilities and at shops and pharmacies, many of which are supplied by the Social Marketing Company (SMC). 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 International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B) have helped to build an evidence base for integrating zinc treatment into current child health practice and policies (ICDDR,B, 2008). The 2011 BDHS asked mothers if each child under age 5 had experienced an episode of diarrhea in the two weeks before the survey. If the child had diarrhea during this period, 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 July through December when the fieldwork took place. Table 10.4 presents information on recent episodes of diarrhea among young children in the two weeks before the interview. Overall, 5 percent of children under age 5 were reported to have had diarrhea in the two-week period before the survey. The prevalence of diarrhea is highest at age 6-23 months, a Child Health • 151 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 boys, children whose source of drinking water is not improved, children living in households with non-improved toilet facilities, children living in rural areas, and children in Chittagong and Sylhet divisions than among other children. The relationship between diarrhea prevalence with mother’s education and wealth is not linear, but it is lowest among children of mothers who had completed secondary or higher education. Table 10.4 Prevalence of diarrhea Percentage of children under age five who had diarrhea in the two weeks preceding the survey, by background characteristics, Bangladesh 2011 Background characteristic Diarrhea in the two weeks preceding the survey Number of children All diarrhea Diarrhea with blood Age in months <6 3.1 0.1 816 6-11 8.4 0.7 864 12-23 7.1 1.3 1,547 24-35 4.1 0.3 1,545 36-47 3.5 0.4 1,866 48-59 2.9 0.6 1,757 Sex Male 5.0 0.7 4,271 Female 4.2 0.5 4,124 Source of drinking water1 Improved 4.6 0.6 8,275 Not improved 6.7 0.5 119 Toilet facility2 Improved, not shared 4.3 0.3 2,761 Shared3 4.1 0.6 1,451 Non-improved 5.0 0.8 4,183 Residence Urban 3.7 0.5 1,871 Rural 4.9 0.6 6,524 Division Barisal 4.9 1.1 464 Chittagong 5.9 0.9 1,946 Dhaka 4.0 0.3 2,601 Khulna 2.6 0.2 767 Rajshahi 4.7 0.8 1,087 Rangpur 4.1 0.7 891 Sylhet 6.0 0.6 639 Mother’s education No education 4.3 0.7 1,689 Primary incomplete 6.4 0.7 1,526 Primary complete4 6.5 0.5 1,050 Secondary incomplete 3.7 0.6 3,112 Secondary complete or higher5 3.5 0.5 1,017 Wealth quintile Lowest 5.5 0.9 1,965 Second 4.4 0.7 1,700 Middle 6.0 0.5 1,631 Fourth 3.0 0.5 1,617 Highest 4.0 0.3 1,481 Total 4.6 0.6 8,395 1 See Table 2.1 for definition of categories. 2 See Table 2.2 for definition of categories. 3 Shared facility of an otherwise improved type. 4 Primary complete is defined as completing grade 5. 5 Secondary complete is defined as completing grade 10. 152 • Child Health 10.3.2 Treatment of Diarrhea Table 10.5 shows data on the treatment of recent episodes of diarrhea among children under age 5, as reported by their mothers. Overall, one in four children with diarrhea was taken to a medically trained health provider for advice or treatment. Children age 6-11 months, children with bloody diarrhea, urban children, children living in Sylhet, children whose mothers have attended secondary education, and children from households in the highest wealth quintile are more likely than other children to visit a health professional or a health facility to treat the diarrhea. 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 given other treatments, by background characteristics, Bangladesh 2011 Background characteristic 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 ORS packets Recom- mended home fluids (RHF) Either ORS or RHF Zinc syrup Zinc tablets Age in months <6 (43.6) (46.1) (0.0) (46.1) (1.7) (46.1) (13.9) (7.2) (41.6) 25 6-11 30.1 73.4 9.3 76.2 23.0 79.7 39.4 21.9 8.5 73 12-23 27.0 75.7 7.1 77.7 25.5 79.4 32.0 23.2 12.9 109 24-35 22.6 88.5 9.3 91.3 24.7 93.1 29.4 19.4 5.7 63 36-47 9.7 81.6 19.0 89.0 39.8 92.8 20.7 16.6 6.4 65 48-59 25.3 84.5 8.8 86.3 21.4 86.3 27.3 20.3 8.3 52 Sex Male 24.8 82.2 11.1 84.1 26.1 86.1 31.3 21.5 7.7 215 Female 24.9 71.9 7.8 76.3 24.1 78.5 26.7 17.6 15.2 173 Type of diarrhea Non-bloody 24.7 76.6 9.7 80.0 24.1 82.0 30.7 18.7 10.9 324 Bloody 29.1 83.0 11.0 84.1 31.7 85.1 21.9 29.8 12.4 50 Residence Urban 45.4 84.4 3.3 86.5 22.7 87.3 37.5 26.0 5.2 70 Rural 20.3 76.1 11.0 79.3 25.8 81.7 27.5 18.4 12.4 318 Division Barisal (34.0) (72.6) (11.7) (75.3) (36.3) (78.0) (30.8) (19.1) (15.2) 23 Chittagong 19.8 77.4 8.0 78.2 23.9 80.5 26.6 27.7 13.6 115 Dhaka 26.2 87.6 9.4 91.4 24.5 93.9 30.8 14.4 6.1 104 Khulna (19.3) (67.0) (0.0) (67.0) (27.1) (69.7) (19.1) (21.1) (18.7) 20 Rajshahi (19.0) (56.0) (8.1) (61.8) (20.9) (64.1) (29.5) (16.8) (16.8) 51 Rangpur (30.9) (80.8) (19.6) (86.8) (27.8) (86.8) (31.7) (16.4) (6.3) 37 Sylhet 35.3 84.7 11.4 87.6 26.9 89.0 34.9 17.8 7.5 38 Mother’s education No education 19.0 78.7 10.5 83.0 22.9 86.3 28.4 19.1 11.2 73 Primary incomplete 22.3 77.4 11.8 80.1 32.2 84.7 25.6 22.2 12.7 97 Primary complete2 19.0 78.9 8.1 83.9 18.0 83.9 29.2 15.1 5.0 68 Secondary incomplete 29.0 73.0 7.6 75.3 21.0 76.2 35.4 19.1 14.9 114 Secondary complete or higher3 (41.4) (87.8) (11.4) (87.8) (38.5) (87.8) (21.4) (25.8) (5.5) 35 Wealth quintile Lowest 19.5 81.2 9.9 84.2 16.6 85.4 27.1 10.0 10.6 108 Second 17.2 83.4 3.6 84.3 27.8 88.4 37.2 20.2 6.0 75 Middle 21.5 71.2 10.5 74.0 24.6 77.1 24.3 28.9 15.0 97 Fourth 25.3 67.6 23.8 77.1 42.3 77.1 24.8 24.3 16.5 49 Highest 49.4 82.3 3.6 83.3 24.5 84.2 34.9 18.4 7.3 59 Total 24.8 77.6 9.6 80.6 25.2 82.7 29.3 19.8 11.1 388 Note: ORT includes solution prepared from oral rehydration salt (ORS), pre-packaged ORS packet, and recommended home fluids (RHF), such as soup, rice water, and yogurt drink. Total includes 14 children with missing information on type of diarrhea. Figures in parentheses are based on 25-49 unweighted cases. 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. Child Health • 153 Eighty-three percent of children with diarrhea were given oral rehydration therapy (ORT) or increased fluids. More than three- fourths of children with diarrhea received oral rehydration salt (ORS) packets, while one-tenth received a recommended homemade fluid. Overall, 81 percent were given either OS or a recommended homemade fluid. One in four children was given increased liquids. One in nine children was given nothing to treat the diarrhea. The use of commercially available ORS packets has remained at the same level since 2007; it was 77 percent in 2007 and is 78 percent in 2011. The percentage of children receiving homemade fluid has decreased by half, from 20 percent in 2007 to 10 percent in 2011. At the same time, the percentage of children receiving increased fluids has also decreased from 48 percent in 2007 to 25 percent in 2011. 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, 47 percent of children under age 5 with diarrhea received ORT only, 7 percent received zinc only, and 34 percent received both ORT and zinc. The combined treatment, ORT and zinc, varies little across the child’s age after age 6 months. Male children are more likely than female children to receive ORT and zinc (37 and 31 percent, respectively). Having bloody diarrhea increases the likelihood of receiving ORT and zinc treatment. Children living in urban areas are more likely to receive both ORT and zinc (44 percent) compared with children living in rural areas (32 percent). Children in the highest wealth quintile were more likely to receive both ORT and zinc than children in the lowest wealth quintile. In the 2011 BDHS, mothers who treated their children’s diarrhea with oral rehydration salt (ORS) were asked the source of the ORS. Table 10.7 shows that the majority (78 percent) obtained the ORS from the private medical sector. Only 7 percent of mothers say that they obtained the ORS from the public sector, and 12 percent went to another source. There are small differences across subgroups of children. 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 2011 Background characteristic ORT but not zinc Zinc syrup/ tablets but not ORT ORT and zinc Number of children Age in months <6 (37.3) (12.3) (8.8) 25 6-11 40.4 11.8 35.8 73 12-23 38.0 7.7 39.7 109 24-35 55.3 3.0 36.0 63 36-47 58.9 1.6 30.0 65 48-59 51.0 5.4 35.3 52 Sex Male 47.6 6.8 36.5 215 Female 45.1 6.6 31.2 173 Type of diarrhea Nonbloody 45.9 7.1 34.1 323 Bloody 45.3 3.5 39.0 51 Residence Urban 42.6 7.5 43.9 70 Rural 47.3 6.5 32.0 318 Division Barisal (40.1) (6.8) (35.2) 23 Chittagong 39.3 5.9 39.0 115 Dhaka 53.2 0.0 38.2 104 Khulna (44.8) (11.6) (22.2) 20 Rajshahi (46.8) (21.4) (14.9) 51 Rangpur (51.0) (6.9) (35.8) 37 Sylhet 49.7 4.8 37.9 38 Mother’s education No education 49.4 4.0 33.7 73 Primary incomplete 45.7 2.5 34.4 97 Primary complete1 54.2 11.1 29.7 68 Secondary incomplete 40.4 9.3 34.9 114 Secondary complete or higher2 (47.3) (6.7) (40.5) 35 Wealth quintile Lowest 55.5 4.0 28.7 108 Second 45.7 5.5 38.6 75 Middle 41.4 9.7 32.6 97 Fourth 40.2 6.4 36.9 49 Highest 44.5 8.5 38.8 59 Total 46.5 6.7 34.1 388 Note: ORT includes solution prepared from oral rehydration salt (ORS), pre-packaged ORS packet, and recommended home fluids (RHF). Figures in parentheses are based on 25-49 unweighted cases. Total includes 14 children with missing information about type of diarrhea. 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 154 • Child Health Table 10.7 Source of ORS packets Percent distribution of children under age 5 who had diarrhea in the two weeks preceding the survey who were given ORS packets by the source of the packets, according to background characteristics, Bangladesh 2011 Background characteristic Public sector NGO sector Private medical sector Other source Don’t know/ missing Total Number of children given ORS packets Age in months <6 * * * * * * 12 6-11 6.7 0.0 79.3 7.8 6.2 100.0 53 12-23 7.3 0.2 78.3 9.5 4.6 100.0 83 24-35 5.4 0.5 77.2 15.2 1.7 100.0 56 36-47 5.6 0.0 75.9 16.7 1.8 100.0 53 48-59 (4.7) (0.0) (81.5) (10.7) (3.0) (100.0) 44 Sex Male 7.8 0.1 77.5 11.5 3.1 100.0 176 Female 5.7 0.1 78.4 11.8 4.0 100.0 124 Type of diarrhea Non-bloody 7.2 0.1 78.8 10.7 3.1 100.0 248 Bloody (5.4) (0.4) (71.9) (19.0) (3.2) (100.0) 42 Residence Urban 9.3 0.8 77.4 11.1 1.5 100.0 59 Rural 6.3 0.0 78.0 11.8 3.9 100.0 242 Division Barisal (12.5) (0.0) (72.5) (15.0) (0.0) (100.0) 17 Chittagong 3.3 0.0 81.0 9.0 6.7 100.0 89 Dhaka (4.1) (0.0) (87.3) (5.9) (2.8) (100.0) 91 Khulna * * * * * * 13 Rajshahi * * * * * * 28 Rangpur (10.7) (0.0) (70.8) (15.3) (3.3) (100.0) 30 Sylhet 7.4 1.4 80.0 11.1 0.0 100.0 33 Mother’s education No education 5.0 0.0 78.7 16.3 0.0 100.0 58 Primary incomplete 6.3 0.0 78.0 5.9 9.8 100.0 75 Primary complete1 4.6 0.3 84.1 11.0 0.0 100.0 54 Secondary incomplete 9.4 0.0 74.9 14.5 1.1 100.0 83 Secondary complete or higher2 (9.3) (0.8) (72.7) (10.5) (6.7) (100.0) 31 Wealth quintile Lowest 7.5 0.0 77.9 13.1 1.5 100.0 88 Second 5.6 0.0 71.5 14.6 8.3 100.0 63 Middle 6.9 0.0 85.1 6.7 1.2 100.0 69 Fourth (10.7) (0.0) (71.9) (14.5) (2.9) (100.0) 33 Highest 4.9 0.9 79.6 10.3 4.3 100.0 48 Total 6.9 0.1 77.8 11.7 3.5 100.0 301 Note: Total includes 12 children with missing information on type of diarrhea. Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that 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 with diarrhea normally and to increase the amount of fluids they offer. The 2011 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 usual practice. Table 10.8 shows that only 25 percent of children with diarrhea received more fluids than usual, while 51 percent were given the same amount of fluids as usual. About one in four mothers still engages in the dangerous practice of curtailing fluid intake when her child has diarrhea. The percentage of children with diarrhea receiving more liquids than usual has declined from 48 percent in 2007 to 25 percent in 2011. Child Health • 155 Table 10.8 Feeding practices during diarrhea Percent distribution of children under age 5 who had diarrhea in the two weeks preceding the survey by amount of liquids and food offered compared with normal practice, the percentage of children given increased fluids and continued feeding during the diarrheal episode, and the percentage of children who continued feeding and were given ORT and/or increased fluids during the diarrheal episode, by background characteristics, Bangladesh 2011 Background characteristic Amount of liquids given Amount of food given Percentage given increased fluids and continued feeding1 Percentage who continued feeding and were given ORT and/or increased fluids1 Number of children with diarrhea More Same as usual Some- what less Much less None Total More Same as usual Some- what less Much less None Never gave food Total Age in months <6 (1.7) (71.9) (16.5) (5.3) (4.6) 100.0 (0.0) (50.1) (16.5) (5.3) (7.7) (20.4) 100.0 (1.7) (29.7) 25 6-11 23.0 44.5 25.1 7.0 0.4 100.0 14.9 40.0 29.4 9.3 1.1 5.3 100.0 21.1 68.1 73 12-23 25.5 50.3 21.8 2.4 0.0 100.0 12.5 54.7 23.8 4.4 4.5 0.2 100.0 23.6 72.9 109 24-35 24.7 49.1 26.2 0.0 0.0 100.0 12.4 59.8 21.9 5.9 0.0 0.0 100.0 23.1 88.3 63 36-47 39.8 42.3 17.8 0.0 0.0 100.0 11.8 55.5 30.7 2.0 0.0 0.0 100.0 39.8 90.7 65 48-59 21.4 63.3 11.6 3.7 0.0 100.0 5.4 66.4 20.9 2.7 2.7 1.9 100.0 19.6 79.1 52 Sex Male 26.1 46.1 23.7 3.9 0.3 100.0 7.4 55.3 26.9 6.3 1.2 2.9 100.0 24.6 78.1 215 Female 24.1 56.7 17.2 1.6 0.5 100.0 15.6 52.7 22.2 3.3 3.8 2.3 100.0 22.9 72.4 173 Type of diarrhea Non-bloody 24.1 50.9 22.3 2.2 0.4 100.0 10.1 54.1 25.7 4.6 2.5 3.1 100.0 22.5 74.7 324 Bloody 31.7 55.0 10.1 3.2 0.0 100.0 16.5 54.5 18.7 7.8 2.1 0.4 100.0 31.7 78.0 50 Residence Urban 22.7 65.1 10.7 1.2 0.4 100.0 10.8 65.4 15.7 5.4 1.7 1.0 100.0 21.4 81.4 70 Rural 25.8 47.7 23.0 3.2 0.4 100.0 11.1 51.7 26.8 4.9 2.5 3.0 100.0 24.4 74.2 318 Division Barisal (36.3) (46.4) (13.4) (0.0) (3.9) (100.0) (17.9) (47.4) (20.3) (7.9) (3.9) (2.7) (100.0) (36.3) (70.1) 23 Chittagong 23.9 55.3 18.5 2.3 0.0 100.0 13.9 51.7 21.4 8.7 4.3 0.0 100.0 21.9 70.5 115 Dhaka 24.5 51.4 18.8 5.3 0.0 100.0 10.9 59.9 23.6 3.5 0.0 2.2 100.0 24.5 88.2 104 Khulna (27.1) (60.5) (12.4) (0.0) (0.0) (100.0) (0.0) (72.2) (25.2) (0.0) (0.0) (2.6) (100.0) (27.1) (67.0) 20 Rajshahi (20.9) (42.8) (32.3) (4.0) (0.0) (100.0) (5.1) (57.4) (26.6) (1.0) (2.3) (7.6) (100.0) (18.7) (61.8) 51 Rangpur (27.8) (49.2) (23.0) (0.0) (0.0) (100.0) (12.0) (39.5) (37.6) (5.4) (2.9) (2.7) (100.0) (22.5) (78.8) 37 Sylhet 26.9 45.5 24.1 2.1 1.4 100.0 11.8 50.3 26.5 3.7 2.8 4.9 100.0 26.9 79.0 38 Mother’s education No education 22.9 52.0 21.8 3.2 0.0 100.0 5.8 38.1 42.0 5.6 7.5 1.0 100.0 21.7 72.2 73 Primary incomplete 32.2 41.3 21.8 4.7 0.0 100.0 12.2 58.2 19.0 6.8 0.6 3.2 100.0 29.8 77.2 97 Primary complete2 18.0 52.4 25.6 4.1 0.0 100.0 15.2 50.1 27.3 4.0 0.0 3.4 100.0 18.0 79.9 68 Secondary incomplete 21.0 55.1 21.5 1.2 1.3 100.0 9.1 59.3 21.6 4.3 2.7 3.0 100.0 20.0 71.2 114 Secondary complete or higher3 (38.5) (57.5) (4.1) (0.0) (0.0) (100.0) (17.2) (67.8) (10.8) (2.7) (0.0) (1.5) (100.0) (35.7) (83.5) 35 Wealth quintile Lowest 16.6 53.5 26.6 2.2 1.1 100.0 11.2 44.4 34.3 4.1 3.9 2.1 100.0 15.8 77.4 108 Second 27.8 49.2 18.4 4.3 0.4 100.0 14.1 48.1 22.6 4.3 4.3 6.6 100.0 26.5 76.6 75 Middle 24.6 44.8 25.2 5.4 0.0 100.0 7.6 63.7 20.4 6.1 0.6 1.6 100.0 24.6 71.8 97 Fourth 42.3 40.6 16.6 0.5 0.0 100.0 14.2 53.0 24.6 7.0 0.0 1.3 100.0 39.5 72.7 49 Highest 24.5 66.4 9.1 0.0 0.0 100.0 10.0 65.0 17.9 3.9 2.0 1.2 100.0 20.9 79.3 59 Total 25.2 50.8 20.8 2.8 0.4 100.0 11.1 54.1 24.8 5.0 2.4 2.6 100.0 23.8 75.5 388 Note: It is recommended that children should be given more liquids to drink during diarrhea and food should not be reduced. Total includes 14 children with missing information on type of diarrhea. Figures in parentheses are based on 25-49 unweighted cases. 1 Continued feeding includes children who were given more, same as usual, or somewhat less food during the diarrhea episode. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 10.3.4 Acute Respiratory Infections (ARI) Acute respiratory infections (ARI), primarily pneumonia, are a leading cause of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can reduce the number of deaths caused by ARIs, particularly deaths resulting from pneumonia. The 2011 BDHS estimated the prevalence of ARIs by asking mothers whether their children under age 5 had been ill in the two weeks preceding the survey with a cough accompanied by short, rapid breathing or by difficulty in breathing that the mother considered to be chest-related. These symptoms are considered to be a proxy for pneumonia. 156 • Child Health Table 10.9 shows that 6 percent of children under age 5 had symptoms of an ARI, that is, cough accompanied by short, rapid breathing and/or by difficult breathing which was chest-related, at some time in the two weeks preceding the survey. The prevalence of ARIs decreases slightly with the increasing age of the child. Children living in rural areas are more likely to suffer from ARIs than children living in urban areas. A higher proportion of children living in Chittagong and Barisal divisions have symptoms of ARIs than those in other divisions. Table 10.9 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 2011 Background characteristic Among children under age 5: Among children under age 5 with symptoms of ARI: 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 6.2 816 (39.8) (16.7) (47.1) (0.0) (4.1) (69.1) 51 6-11 7.4 864 42.8 22.6 32.3 3.0 11.8 81.8 64 12-23 6.9 1,547 41.4 25.5 24.8 0.6 8.7 78.0 106 24-35 6.1 1,545 36.1 15.4 25.3 0.0 26.6 62.4 95 36-47 4.9 1,866 29.8 27.6 29.1 2.4 18.8 76.1 91 48-59 4.5 1,757 22.7 22.6 27.2 0.0 27.6 61.0 78 Sex Male 6.6 4,271 39.5 19.2 30.6 0.7 14.6 75.7 281 Female 5.0 4,124 29.3 26.3 27.8 1.4 20.4 65.6 205 Residence Urban 4.8 1,871 54.3 21.0 17.9 0.7 8.6 77.5 89 Rural 6.1 6,524 30.9 22.4 32.0 1.0 19.0 70.1 397 Division Barisal 7.0 464 40.1 36.6 23.2 0.0 19.7 69.8 33 Chittagong 7.4 1,946 24.3 25.5 31.6 2.0 18.8 69.5 144 Dhaka 4.6 2,601 38.0 23.0 25.9 1.6 17.8 72.2 121 Khulna 6.4 767 45.4 7.0 40.7 0.0 11.6 73.5 49 Rajshahi 5.5 1,087 31.1 23.5 28.1 0.0 21.3 73.6 59 Rangpur 5.4 891 46.6 14.0 30.5 0.0 11.0 71.0 48 Sylhet 4.9 639 43.2 22.0 22.8 0.0 13.7 72.3 32 Mother’s education No education 6.9 1,689 25.4 17.2 38.1 0.0 21.2 63.4 116 Primary incomplete 6.4 1,526 28.6 32.1 27.6 2.0 17.1 76.3 98 Primary complete3 5.4 1,050 31.5 34.4 21.4 0.0 19.3 78.7 57 Secondary incomplete 5.2 3,112 39.7 17.0 31.2 1.4 16.4 70.6 161 Secondary complete or higher4 5.4 1,017 58.4 17.3 17.6 1.1 8.0 74.7 55 Wealth quintile Lowest 7.3 1,965 24.7 24.3 33.1 0.0 21.9 69.4 143 Second 5.4 1,700 30.3 27.0 36.5 0.0 12.5 73.9 92 Middle 5.9 1,631 28.8 16.7 32.0 4.3 23.9 66.0 97 Fourth 4.8 1,617 46.2 18.2 27.2 0.0 15.1 67.4 77 Highest 5.1 1,481 57.9 23.3 12.9 0.8 7.0 83.3 76 Total 5.8 8,395 35.2 22.2 29.4 1.0 17.1 71.4 486 Note: Numbers in parentheses are based on 25-49 unweighted cases. 1 Symptoms of ARI (cough accompanied by short, rapid breathing which was chest-related and/or by difficult breathing which was chest-related) is considered a proxy for pneumonia. 2 Excludes pharmacy, shop, and traditional practitioner 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. Thirty-five percent of children with symptoms of ARI were taken to a health facility or a medically trained provider for treatment. This is slightly lower than that recorded in the 2007 BDHS (37 percent). Boys are more likely than girls to be taken to a health facility or trained provider when ill with ARI (40 percent versus 29 percent). Urban children are more likely than rural children to receive treatment at a health facility or from a medically trained provider (54 percent versus 31 percent). Child Health • 157 Table 10.9 also shows that 71 percent of children with symptoms of ARI received antibiotics. This already far exceeds the HPNSDP 2011-2016 target of 50 percent of children under age 5 with pneumonia receiving antibiotics (MOHFW, 2011). Children age 6-11 months, male children, children living in urban areas, and children living in households in the highest wealth quintile are more likely to receive antibiotics for symptoms of ARI. The BDHS results indicate that most children with ARI symptoms for whom treatment was sought from a health provider received antibiotics. Overall, 79 percent of the children seeing a provider were prescribed antibiotics, 90 percent in urban areas and 77 percent in rural areas (data not shown). Figure 10.2 shows the percentage of children with ARI symptoms receiving a prescribed antibiotic according to the type of provider prescribing the antibiotic. Overall, around one in three children with ARI symptoms saw a provider and were prescribed an antibiotic; children receiving a prescribed antibiotic from a provider were twice as likely to have been treated by a provider in the public sector as a public sector provider. Urban children were more likely to have received a prescribed antibiotic than rural children; more than half of urban children received a prescribed antibiotic compared to around three in ten rural children. Among the urban children receiving a prescribed antibiotic, around three-quarters were prescribed the antibiotic by a private sector provider. Rural children were somewhat less likely to have had the antibiotic prescribed by a private provider; around three in five children prescribed an antibiotic by a health provider were prescribed the antibiotic by a private provider. Figure 10.2 Source of antibiotics 56 31 36 Urban Rural Total Private medical NGO Public sector BDHS 2011 Percent 43 19 23 12 12 12 1 0 1 10.4 FEVER Table 10.10 shows the percentage of children under age 5 who had a fever during the two weeks preceding the survey and their treatments. Nearly two in five children under age 5 had a fever in the two weeks before the survey. The prevalence of fever varies by age, with children age 6-23 months being more likely to have a fever than either younger or older children. The prevalence of fever is highest among children residing in Chittagong division (44 percent) and lowest in Dhaka (32 percent). 158 • Child Health children in other divisions to receive this kind of treatment. The likelihood of being taken to a health facility or provider for treatment increases with a mother’s education and wealth. For example, 23 percent of children in the lowest wealth quintile were taken to a health facility or a medically-trained provider for treatment of their fever, compared with 43 percent of children in the highest quintile. Table 10.10 also shows that 66 percent of children with fever received antibiotics. Children age 12-23 months, male children, and children living in Khulna division are more likely than other children to receive antibiotic treatment. Furthermore, children of mothers who have completed secondary or higher education and those living in households in the highest wealth quintile are more likely to receive antibiotics for fever than their counterparts. Less than 1 percent of children received antimalarial drugs. The percentage of children with fever for whom medical care is sought from a health facility or provider has increased slightly over the past four years, from 24 percent in 2007 to 27 percent in 2011. Table 10.10 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 2011 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 35.1 816 36.0 1.8 54.3 286 50.9 155 6-11 49.2 864 32.8 0.1 66.9 425 40.1 284 12-23 42.6 1,547 29.0 0.9 70.7 659 35.8 466 24-35 37.7 1,545 25.7 0.1 64.2 582 30.2 373 36-47 33.3 1,866 21.7 0.8 67.7 622 28.0 421 48-59 27.9 1,757 22.2 0.1 62.9 491 29.1 309 Sex Male 36.5 4,271 29.7 0.6 66.5 1,559 35.9 1,036 Female 36.5 4,124 24.2 0.6 64.5 1,506 31.7 972 Residence Urban 31.8 1,871 38.6 0.8 66.3 595 48.5 394 Rural 37.9 6,524 24.2 0.5 65.4 2,469 30.3 1,614 Division Barisal 40.0 464 27.1 0.6 59.7 185 36.5 111 Chittagong 43.5 1,946 25.4 1.1 67.6 846 29.8 572 Dhaka 31.6 2,601 27.3 0.2 66.1 821 34.1 543 Khulna 34.0 767 31.6 0.0 69.3 261 43.1 181 Rajshahi 36.3 1,087 23.6 1.3 59.8 394 27.4 236 Rangpur 35.5 891 29.9 0.0 64.0 317 40.3 203 Sylhet 37.6 639 28.2 0.2 68.2 240 36.6 164 Mother’s education No education 36.1 1,689 22.1 0.1 60.9 610 28.5 372 Primary incomplete 39.4 1,526 21.3 0.4 64.9 601 25.7 390 Primary complete2 39.3 1,050 26.6 0.3 66.8 412 31.6 276 Secondary incomplete 36.8 3,112 30.1 0.8 66.1 1,145 39.4 757 Secondary complete or higher3 29.0 1,017 37.2 1.7 72.4 295 41.5 214 Wealth quintile Lowest 40.7 1,965 22.3 0.0 58.9 800 29.4 472 Second 36.4 1,700 21.0 0.9 67.0 618 25.0 415 Middle 37.8 1,631 25.6 0.2 66.3 617 30.5 409 Fourth 37.1 1,617 29.5 1.3 68.0 600 38.8 408 Highest 29.0 1,481 42.8 0.8 71.2 429 50.8 306 Total 36.5 8,395 27.0 0.6 65.5 3,064 33.9 2,008 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. Child Health • 159 One in three children with fever who were given antibiotic drugs had the drug prescribed by a health professional. Children of younger mothers, boys, and those living in urban areas and in Khulna are more likely than other children to receive prescribed medication. Children whose mothers have secondary or higher education and those with mothers in the highest wealth quintile are most likely to take a prescribed antibiotic compared with children whose mothers had less education and were in the lowest quintile. In the 2011 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 10.11 shows the first source of treatment. The private medical sector is the predominant first source of treatment of fever (65 percent). Only 8 percent received their first treatment from the public sector, and for 24 percent of children with fever, no treatment was sought. Table 10.11 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 2011 Background characteristic Public sector NGO sector Private medical sector Other source Missing No treatment sought Total Number of children with fever Age in months <6 9.4 0.1 69.9 1.3 0.2 19.1 100.0 286 6-11 10.6 0.9 67.6 1.6 0.0 19.3 100.0 425 12-23 7.3 1.0 68.2 0.8 0.2 22.5 100.0 659 24-35 9.3 0.3 61.6 1.0 0.4 27.4 100.0 582 36-47 6.0 0.5 64.6 1.2 0.0 27.8 100.0 622 48-59 8.3 0.8 62.8 1.1 0.4 26.6 100.0 491 Sex Male 8.9 0.8 66.0 1.1 0.1 23.1 100.0 1,559 Female 7.5 0.4 64.8 1.1 0.4 25.8 100.0 1,506 Residence Urban 10.3 0.9 64.7 0.5 0.1 23.5 100.0 595 Rural 7.8 0.6 65.6 1.2 0.2 24.6 100.0 2,469 Division Barisal 10.1 0.0 63.2 0.3 0.0 26.4 100.0 185 Chittagong 6.0 0.2 70.7 1.4 0.3 21.5 100.0 846 Dhaka 7.1 0.7 63.1 0.5 0.0 28.6 100.0 821 Khulna 12.1 0.7 66.7 1.8 0.0 18.7 100.0 261 Rajshahi 8.2 0.5 59.9 1.0 0.7 29.7 100.0 394 Rangpur 11.9 2.1 64.9 1.7 0.0 19.4 100.0 317 Sylhet 9.5 0.4 64.7 1.6 0.7 23.0 100.0 240 Mother’s education No education 7.1 0.6 64.4 0.2 0.0 27.7 100.0 610 Primary incomplete 8.1 0.0 66.5 0.7 0.0 24.7 100.0 601 Primary complete1 10.1 1.4 61.6 0.1 0.0 26.8 100.0 412 Secondary incomplete 8.1 0.6 66.2 1.8 0.6 22.7 100.0 1,145 Secondary complete or higher2 8.9 0.7 67.9 2.4 0.0 20.1 100.0 295 Wealth quintile Lowest 8.1 0.4 61.5 0.5 0.3 29.2 100.0 800 Second 7.5 1.0 67.9 0.4 0.0 23.2 100.0 618 Middle 10.0 0.5 65.1 1.5 0.3 22.6 100.0 617 Fourth 7.4 0.4 66.4 2.1 0.2 23.5 100.0 600 Highest 8.2 1.1 68.2 1.2 0.1 21.2 100.0 429 Total 8.2 0.6 65.4 1.1 0.2 24.4 100.0 3,064 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Nutrition of Children and Adults • 161 NUTRITION OF CHILDREN AND ADULTS 11 ood nutrition is a prerequisite for the national development of countries and for the well-being of individuals. 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 especially important 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. Common illnesses such as diarrhea and acute respiratory infections are also common in young children (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 (Cesar et al., 2008). A woman of poor nutritional status (indicated by a low body mass index, 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 high for both the woman and her baby. Poor nutritional status is a key health problem 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. G Key Findings • Forty-one percent of children under age 5 are stunted, 16 percent are wasted, and 36 percent are underweight. • Breastfeeding is nearly universal in Bangladesh: 90 percent of children are breastfed until age 2, as recommended. • Sixty-four percent of children less than age 6 months are exclusively breastfed, and the median duration of exclusive breastfeeding is 3.5 months. • Complementary foods are not introduced in a timely fashion for all children. Only 67 percent of breastfed children age 6-9 months receive complementary foods. • Overall, only 21 percent of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices. • Fifty-one percent of children age 6-59 months are anemic, 29 percent are mildly anemic, 21 percent are moderately anemic, and less than 1 percent are severely anemic. • Twenty-four percent of ever-married women age 15-49 are undernourished (BMI <18.5), and 17 percent are overweight or obese (BMI ≥25.0). Women’s nutritional status has improved only slightly over the years. • Forty-two percent of ever-married women age 15-49 are anemic, 36 percent are mildly anemic, 7 percent are moderately anemic, and less than 1 percent are severely anemic. • Overall, 65 percent of ever-married women age 15-49 live in a food- secure environment. However, only 35 percent of women in the lowest wealth quintile are food secure compared with 90 percent of women in the highest wealth quintile. 162 • Nutrition of Children and Adults As in past DHS surveys in Bangladesh, the 2011 survey measured height and weight of children under age 5 and of ever-married women of reproductive age. The 2011 BDHS also collected data on feeding practices for infants and young children, including breastfeeding, the feeding of solid and semisolid 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. For the first time in DHS history in Bangladesh, the 2011 survey measured the hemoglobin level of children and ever-married women and the height and weight of men. The 2011 BDHS also asked eligible women questions intended to gauge food security. 11.1 NUTRITIONAL STATUS OF CHILDREN The 2011 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 contributes 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 achieving 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 of 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. 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 he or she is considered to be 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. Nutrition of Children and Adults • 163 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 age because he or she is stunted, because he or she 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 All children listed in the household questionnaire who were born in January 2006 or later were eligible for height and weight measurement. Thus, height and weight measurements were collected from children whose mothers may not have been interviewed in the survey. Each interviewing team carried two 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. 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 2011 Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children 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 4.6 18.0 -0.7 6.3 16.0 4.6 -0.6 4.4 16.5 0.7 -1.0 695 6-8 5.4 17.4 -0.9 4.3 14.8 2.5 -0.7 5.7 23.2 0.0 -1.2 403 9-11 11.6 27.8 -1.3 3.9 13.9 3.4 -0.6 7.6 24.4 0.4 -1.2 412 12-17 15.6 46.4 -1.8 3.8 15.0 1.8 -0.8 9.2 33.6 0.5 -1.5 786 18-23 21.9 52.1 -2.0 4.9 16.9 1.0 -0.9 12.8 38.6 0.6 -1.7 671 24-35 18.8 47.6 -1.9 3.4 14.9 0.9 -1.0 11.5 39.8 0.3 -1.7 1,450 36-47 18.1 47.0 -1.9 4.1 15.9 0.8 -1.1 13.4 42.9 0.3 -1.8 1,763 48-59 14.3 41.9 -1.8 3.0 16.2 0.9 -1.1 10.3 41.4 0.2 -1.8 1,679 Sex Male 14.7 40.6 -1.7 4.1 16.0 1.4 -0.9 9.4 34.3 0.4 -1.6 3,974 Female 15.9 42.0 -1.7 3.8 15.2 1.7 -0.9 11.4 38.5 0.3 -1.7 3,887 Birth interval in months3 First birth4 12.6 37.6 -1.6 3.7 14.8 1.5 -0.9 8.3 32.7 0.4 -1.5 2,665 <24 23.7 50.6 -2.0 4.1 15.6 2.0 -0.9 13.0 44.1 0.6 -1.8 563 24-47 19.3 47.5 -1.9 4.1 17.2 1.3 -1.0 13.9 41.6 0.2 -1.8 1,945 48+ 12.6 38.0 -1.6 3.9 15.1 1.7 -0.9 8.9 34.1 0.4 -1.5 2,459 Size at birth3 Very small 25.1 53.6 -2.1 7.6 26.9 2.7 -1.2 25.4 57.5 0.6 -2.1 371 Small 21.2 52.1 -2.0 5.3 23.2 0.4 -1.2 16.9 52.2 0.0 -2.0 928 Average or larger 13.7 38.9 -1.6 3.4 13.8 1.7 -0.9 8.4 32.7 0.4 -1.5 6,321 Mother’s interview status Interviewed 15.1 41.2 -1.7 3.9 15.6 1.6 -0.9 10.3 36.3 0.4 -1.6 7,632 Not interviewed5 20.2 44.0 -1.8 6.9 17.2 1.0 -1.2 14.8 40.4 0.0 -1.8 229 Residence Urban 13.0 36.2 -1.4 3.5 14.0 2.2 -0.7 7.4 28.0 0.8 -1.3 1,709 Rural 15.9 42.7 -1.7 4.1 16.0 1.4 -1.0 11.2 38.7 0.2 -1.7 6,152 Continued… 164 • Nutrition of Children and Adults Table 11.1—Continued Background characteristic Height-for-age1 Weight-for-height Weight-for-age Number of children 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) Division Barisal 20.3 45.1 -1.8 2.7 15.2 1.6 -0.9 11.0 40.0 0.2 -1.7 433 Chittagong 16.0 41.3 -1.7 3.8 15.9 1.3 -1.0 10.2 37.4 0.5 -1.6 1,773 Dhaka 15.9 43.3 -1.7 4.3 15.7 1.9 -0.9 11.2 36.6 0.5 -1.6 2,469 Khulna 11.2 34.1 -1.5 3.5 14.6 1.3 -0.8 6.8 29.1 0.2 -1.4 744 Rajshahi 8.8 33.7 -1.5 5.2 16.4 1.0 -1.1 10.1 34.2 0.2 -1.6 986 Rangpur 16.0 42.9 -1.8 2.9 13.2 1.5 -0.9 9.2 34.5 0.2 -1.6 859 Sylhet 22.0 49.3 -1.9 4.1 18.4 1.8 -1.1 14.4 44.9 0.2 -1.9 596 Mother’s education6 No education 22.1 51.1 -2.0 4.7 17.7 0.8 -1.1 14.5 48.8 0.1 -1.9 1,532 Primary incomplete 20.0 48.6 -1.9 3.9 17.3 1.1 -1.1 14.2 43.7 0.0 -1.8 1,400 Primary complete7 15.1 44.5 -1.8 4.6 19.4 0.9 -1.1 12.4 40.2 0.1 -1.8 944 Secondary incomplete 12.1 37.1 -1.6 3.4 13.7 1.8 -0.8 7.5 30.4 0.4 -1.5 2,841 Secondary complete or higher8 5.6 22.9 -1.0 3.2 11.1 3.4 -0.6 3.5 17.8 1.5 -1.0 916 Wealth quintile Lowest 24.5 53.7 -2.1 4.5 17.5 0.9 -1.1 16.6 50.3 0.1 -2.0 1,883 Second 16.9 45.4 -1.8 4.1 16.2 1.0 -1.1 11.3 41.6 0.1 -1.8 1,616 Middle 14.1 40.7 -1.7 3.9 17.7 1.6 -1.0 11.5 36.0 0.3 -1.6 1,531 Fourth 11.2 35.9 -1.5 3.4 13.6 1.7 -0.8 6.3 27.5 0.1 -1.4 1,478 Highest 6.4 25.7 -1.1 3.7 12.1 2.9 -0.6 3.9 20.9 1.2 -1.1 1,352 Total 15.3 41.3 -1.7 4.0 15.6 1.5 -0.9 10.4 36.4 0.3 -1.6 7,861 Note: Table is based on children who spent the night before the interview in the household. Each of the indices is expressed in standard deviation (SD) units 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 1977 NCHS/CDC/WHO reference. Total includes three children with missing information on size at birth. 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 Adults • 165 Figure 11.1 Nutritional status of children by age 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 (months) Stunted Wasted Underweight Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five-month moving average. BDHS 2011 11.1.3 Levels of Child Malnutrition Table 11.1 shows the percentage of children under age 5 classified as malnourished according to the three anthropometric indices of nutritional status (height-for-age, weight-for-height, and weight-for- age) by various background characteristics. A total of 8,550 children under age 5 (unweighted) in the BDHS sample households were eligible for anthropometric measurements. The following analysis focuses on the 7,826 children (92 percent) for whom complete and credible anthropometric and age data are available. Height-for-age (stunting) At the national level, 41 percent of children under age 5 are stunted, and 15 percent are severely stunted. Analysis by age group shows that stunting is highest (52 percent) in children age 18-23 months and lowest (17 percent) in children age 6-8 months (Figure 11.1). Severe stunting shows a similar pattern, with the highest proportion of severe stunting in children age 18-23 months (22 percent). Stunting is slightly higher among female children (42 percent) than among male children (41 percent). Stunting is highest among children with a preceding birth interval of less than 24 months (51 percent), followed by children with a preceding birth interval of 24-47 months (48 percent). The 2011 BDHS asked mothers their perception of their child’s birth size: average or larger, small, or very small. The 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 more than half of the children perceived by their mothers to be very small or small are stunted. A previous study in Bangladesh has shown similar results: that children’s birth weight is an important determinant of their nutritional status (Rahman and Chowdhury, 2007). Children in rural areas are more likely to be stunted (43 percent) compared with those in urban areas (36 percent). Stunting is lowest in Khulna and Rajshahi divisions (34 percent). In other divisions, stunting varies from 41 percent in Chittagong to 49 percent in Sylhet. Mother’s level of education has an inverse relationship with stunting levels. Children of mothers with no education are more than twice as 166 • Nutrition of Children and Adults likely to be stunted (51 percent) when compared with children of mothers who have completed secondary and higher education (23 percent). A similarly large differential exists by wealth quintiles; as wealth increases, the extent of stunting among children decreases. Children from the lowest wealth quintile are two times more likely to be stunted than children from the highest wealth quintile (54 percent in the lowest compared with 26 percent in the highest quintile). Weight-for-height (wasting) Overall, 16 percent of children in Bangladesh are wasted. Analysis by age group shows that wasting is highest (17 percent) in children age 18-23 months and lowest (14 percent) in children age 9-11 months. Male children are slightly more likely to be wasted (16 percent) than female children (15 percent). 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. Children residing in urban areas are less likely to be wasted (14 percent) than children living in rural areas (16 percent). By division, wasting in children ranges from 13 percent in Rangpur to 18 percent in Sylhet. Wasting prevalence 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 (19 percent) and among children of women from the lowest and middle wealth quintiles (18 percent). Weight-for-age (underweight) Table 11.1 shows that 36 percent of children under age 5 are underweight and 10 percent are severely underweight. The proportion of underweight children is highest (43 percent) among children age 36-47 months and lowest (17 percent) among children under 6 months. Female children are more likely to be underweight (39 percent) than male children (34 percent). The data show a strong correlation between underweight children and their perceived birth size. Babies perceived by mothers as very small and small at birth are much more likely to be underweight (58 percent for very small and 52 percent for small) than those perceived as average or larger at birth (33 percent). Rural children are more likely to be underweight (39 percent) than urban children (28 percent). Sylhet has the highest proportion (45 percent) of underweight children, while among the other divisions the proportion ranges from 29 percent in Khulna to 40 percent in Barisal. As with wasting and stunting, mother’s education is associated with underweight, with the percentage of children who are underweight being lowest among children of mothers with a secondary and higher education (18 percent) and highest among children of mothers with no education (49 percent). A similar negative relationship is observed between household wealth and the percentage of underweight children; children in the poorest households are more than two times more likely to be underweight (50 percent) compared with children in the wealthiest households (21percent). 11.1.4 Trends in Children’s Nutritional Status Figure 11.2 shows that children’s nutritional status has improved somewhat since 2004. The level of stunting has declined from 51 percent in 2004 to 41 percent in 2011. The proportion of underweight children has declined from 43 percent in 2004 to 36 percent in 2011. The pattern and change in wasting has been small and inconsistent. Wasting increased from 15 percent in 2004 to 17 percent in 2007, and declined to 16 percent in 2011. The MDG target for nutrition in Bangladesh is to reduce underweight among children under age 5 to 33 percent (General Economic Division/Bangladesh Planning Commission, 2012). If the current pace of decline is sustained, the target can be achieved. Nutrition of Children and Adults • 167 Figure 11.2 Trends in nutritional status of children under age 5, 2004, 2007, and 2011 51 15 4343 17 4141 16 36 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age) Percent 2004 BDHS 2007 BDHS 2011 BDHS Note: The data for all three surveys are based on the WHO Child Growth standards adopted in 2006. 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 of life and that children be given solid or semisolid 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, semisolid, or soft foods. WHO recommends that breastfeeding 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 breast milk production 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. Table 11.2 presents by background characteristics the breastfeeding status of all last-born children born in the two years preceding the survey. 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 prior to the commencement of breastfeeding. Breastfeeding is almost universal in 168 • Nutrition of Children and Adults Bangladesh; 99 percent of last-born children who were born in the two years preceding the survey were breastfed at some point in their life, almost the same proportion as in the 2007 BDHS. There are no marked differences by background characteristics in the proportion of children ever breastfed. Overall, 47 percent of children are breastfed within one hour after birth, and 90 percent are breastfed within one day after delivery. These results are not directly comparable to those of the 2007 BDHS because the results for the 2011 BDHS are for last-born children born in the two years preceding the survey whereas the 2007 BDHS results were based on last-born children born in the five years preceding the survey. For comparison purposes, the 2007 BDHS data have been reanalyzed for the same time period of two years (data not shown). Compared with data for 2007, the percentage of children who were breastfed within one hour of birth has increased by three percentage points (from 44 to 47 percent). The percentage of children who started breastfeeding within one day of birth was similar in 2007 and 2011 (89 percent to 90 percent). Table 11.2 indicates no marked differences in the timing of initial breastfeeding within one hour of birth, either by the sex of the child or by urban-rural residence. Notable variations, however, can be seen by geographic division. The proportion of children breastfed within one hour of birth is highest in Sylhet division (54 percent) and lowest in Dhaka (43 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, children attended by a health professional at delivery, children of mothers who completed secondary or higher education, and children from households in the highest wealth quintile. Similar patterns were also reported in the 2007 BDHS. This finding merits further investigation and appropriate program response. 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. Thirty-nine percent of Bangladeshi children receive a prelacteal feed. The likelihood of receiving a prelacteal feed is higher for births assisted by traditional birth attendants and for births delivered at home. Prelacteal feeding is more common in Dhaka (50 percent), Khulna (45 percent), and Rajshahi (42 percent) than in other divisions. Children of mothers with limited education and less wealth are more likely to receive prelacteal feeds. The 2011 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). Nutrition of Children and Adults • 169 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 2011 Background characteristic Among last-born children born in the past two years: Among last-born children born in the past two years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last-born children Percentage who received a prelacteal feed2 Number of last-born children ever breastfed Sex Male 98.4 48.0 90.0 1,673 39.4 1,646 Female 98.8 46.1 90.8 1,592 37.7 1,573 Assistance at delivery Health professional3 97.9 39.3 86.1 1,078 35.9 1,056 Traditional birth attendant 99.0 50.5 92.5 2,025 40.3 2,006 Other 98.1 55.5 91.6 151 34.9 148 Place of delivery Health facility 97.9 38.9 85.6 997 36.1 976 At home 98.9 50.7 92.5 2,259 39.7 2,235 Residence Urban 98.3 44.3 90.6 738 37.9 726 Rural 98.7 47.9 90.3 2,526 38.8 2,493 Division Barisal 97.4 43.6 89.5 177 36.8 172 Chittagong 98.9 46.2 91.3 783 28.8 775 Dhaka 98.5 43.0 89.1 988 49.5 972 Khulna 98.9 45.7 88.1 305 44.5 302 Rajshahi 98.5 53.5 88.3 439 42.2 432 Rangpur 99.2 50.8 93.7 334 27.0 331 Sylhet 98.2 54.0 95.6 238 29.0 234 Mother’s education No education 98.8 46.9 89.7 551 41.1 545 Primary incomplete 98.3 50.3 92.0 587 41.6 577 Primary complete4 98.0 46.9 88.7 384 40.0 376 Secondary incomplete 99.2 47.9 90.6 1,328 36.5 1,317 Secondary complete or higher5 97.7 40.2 89.6 414 36.5 405 Wealth quintile Lowest 98.9 49.9 91.3 718 43.0 710 Second 98.6 46.6 91.7 652 39.6 643 Middle 99.2 49.1 91.5 646 37.6 641 Fourth 98.2 48.0 88.9 673 34.6 661 Highest 98.1 40.6 88.1 576 37.6 565 Total 98.6 47.1 90.4 3,264 38.6 3,219 Note: Table is based on 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 11 last-born children with no assistance at delivery and 8 children with other place of delivery. 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, auxiliary midwife, skilled birth attendant, or family welfare visitor 4 Primary complete is defined as completing grade 5. 5 Secondary complete is defined as completing grade 10. 11.3 BREASTFEEDING STATUS BY AGE Breast milk contains all the nutrients needed by children in the first six months of life. It is recommended that during the first six months of life a child should not be given any complementary liquid or solid food or plain water. Giving complementary foods to children is discouraged because it increases the likelihood of contamination and may increase the risk of diarrhea. When the child reaches age 6 months, solid or semisolid complementary foods should be added to the diet with continued breastfeeding. 170 • Nutrition of Children and Adults The 2011 BDHS collected data on infant and young child feeding for all last-born children under age 2 living with their mothers, using a 24-hour recall method. As shown in Table 11.3 and Figure 11.3, almost all Bangladeshi children are breastfed during the first year of life, and breastfeeding continues through the second year for 90 percent of the children. However, supplementing breast milk with other liquids or foods starts at an early age in Bangladesh. Contrary to the recommendation that children under age 6 months should be exclusively breastfed, 10 percent of the children consume plain water, 3 percent consume non-milk liquids, 16 percent consume other milk, and 6 percent consume complementary foods 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 2011 Age in months 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 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 0.0 84.5 5.9 0.0 8.6 1.1 100.0 100.0 265 5.6 266 2-3 0.6 71.0 9.5 3.0 13.7 2.1 100.0 99.4 281 12.9 282 4-5 1.9 36.3 14.3 5.3 27.1 15.1 100.0 98.1 264 29.8 267 6-8 3.6 7.3 15.3 3.9 9.6 60.4 100.0 96.4 416 21.5 423 9-11 3.7 0.6 6.8 1.1 1.1 86.7 100.0 96.3 436 16.4 441 12-17 5.5 0.9 4.7 1.0 1.5 86.4 100.0 94.5 820 16.0 833 18-23 8.5 0.5 2.6 0.4 0.1 87.9 100.0 91.5 686 11.6 714 0-3 0.3 77.5 7.7 1.5 11.2 1.6 100.0 99.7 546 9.4 549 0-5 0.8 64.1 9.9 2.8 16.4 6.0 100.0 99.2 810 16.1 816 6-9 3.4 5.4 13.4 3.6 7.2 67.1 100.0 96.6 561 20.4 568 12-15 5.0 1.0 4.4 1.3 1.9 86.5 100.0 95.0 552 15.9 559 12-23 6.9 0.7 3.7 0.7 0.9 87.1 100.0 93.1 1,506 14.0 1,547 20-23 10.4 0.2 2.0 0.6 0.1 86.7 100.0 89.6 451 10.7 471 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, and breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semisolids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and 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 also presents the percentage of children using a bottle with a nipple. Use of bottle feeding is highest among children age 4-5 months (30 percent). At age 6-8 months, 22 percent of children are bottle fed, and 11 percent of children age 20-23 months use bottles with nipples. For the purpose of comparison, the 2007 BDHS data were reanalyzed for the same reference period as in the 2011 BDHS (data not shown). After remaining stagnant at around 40 percent for almost a decade, the rate of exclusive breastfeeding during the first 6 months of life increased by 21 percentage points, from 43 percent in the 2007 BDHS to 64 percent in the 2011 BDHS. Nutrition of Children and Adults • 171 Figure 11.3 Infant feeding practices by age 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 The dramatic increase in the level of exclusive breastfeeding between 2007 and 2011 can be explained in part by an increase in the proportion of infants age 0-3 months in the 2011 sample (67 percent) compared with that in the 2007 sample (56 percent). Another explanation is the intensive mass media campaigns that focused on maternal health, newborn care, and child health one or two years prior to the survey. However, an evaluation of a community-based program to improve infant and young child feeding in Bangladesh has reported that only 50 percent of children under age 2 are being exclusively breastfed (Saha et al., 2011). Nevertheless, to confirm this large increase in exclusive breastfeeding, further rigorous investigation should be undertaken. If the current level of exclusive breastfeeding of 36 percent at 4-5 months is true and sustainable, the HPNSDP 2011–2016 target of 50 percent of infants up to six months of age being exclusively breastfed can be achieved (MOHFW, 2011). Figure 11.4 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 mothers. Although 64 percent of all children under age 6 months are exclusively breastfed, only 36 percent of those age 4-5 months are exclusively breastfed. Almost all children (95 percent) continue breastfeeding at age 1, and 90 percent continue to breastfeed until age 2. Sixty-two percent of children are introduced to complementary foods at an appropriate age. Seventy-eight percent of children 0-23 months are breastfed appropriately for their age, i.e., exclusive breastfeeding for children 0-5 months and continued breastfeeding along with complementary foods for children age 6-23 months. Predominant breastfeeding (receiving breastmilk and only plain water or non-milk liquids such as juice, clear broth, and other liquids) is prevalent in 77 percent of the children; 16 percent of children under age 2 are bottle fed. 172 • Nutrition of Children and Adults Figure 11.4 IYCF indicators on breastfeeding status 64 36 95 62 90 78 77 16 Exclusive breastfeeding under 6 months of age Exclusive breastfeeding at 4-5 months of age Continued breastfeeding at 1 year Introduction of solid, semi-solid, or soft foods (6-8 months) Continued breastfeeding at 2 years Age-appropriate breastfeeding (0-23 months) Predominant breastfeeding (0-5 months) Bottle feeding (0-23 months) Percentage of children BDHS 2011 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 2011 is 31.2 months. The median duration of exclusive breastfeeding is estimated at 3.5 months, while the median duration of predominant breastfeeding is 4.9 months. The mean duration of any breastfeeding is 28.6 months, while the mean duration of exclusive breastfeeding is 4.4 months and of predominant breastfeeding 6.4 months. The median duration of exclusive breastfeeding and predominant breastfeeding has increased since 2007 (data for the same reference period, not shown). The median duration of exclusive breastfeeding increased from 1.8 months to 3.5 months, and the median duration of predominant breastfeeding increased from 3.2 months to 4.9 months. The median durations of any, exclusive, and predominant breastfeeding do not vary much across the background characteristics. The median duration of any breastfeeding is 3 months shorter in urban areas than in rural areas. Duration of exclusive breastfeeding increases slightly with mother’s education. Similarly, the median duration of exclusive breastfeeding generally increases as the household wealth increases. Differentials in exclusive breastfeeding and predominant breastfeeding across subgroups of children are smaller than for any breastfeeding. Nutrition of Children and Adults • 173 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 2011 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breastfeeding Exclusive breastfeeding Predominant breastfeeding2 Sex Male 30.9 3.4 4.6 Female 31.4 3.5 5.3 Residence Urban 29.1 3.5 4.9 Rural 32.3 3.5 4.9 Division Barisal 31.5 2.3 5.2 Chittagong 25.3 4.0 6.1 Dhaka 32.1 3.0 4.1 Khulna na 4.0 5.2 Rajshahi na 2.9 3.8 Rangpur na 4.1 4.8 Sylhet 29.9 3.9 6.2 Mother’s education No education na 2.9 4.7 Primary incomplete 34.1 2.9 5.2 Primary complete3 31.1 3.6 4.2 Secondary incomplete 30.7 3.7 5.0 Secondary complete or higher4 28.1 4.4 5.0 Wealth quintile Lowest na 3.0 5.3 Second 34.0 3.2 4.4 Middle 29.8 3.6 5.1 Fourth 31.5 4.2 5.0 Highest 27.1 3.5 4.7 Total 31.2 3.5 4.9 Mean for all children 28.6 4.4 6.4 Note: Median and mean durations are calculated from the distributions of the proportion of children fitting the criteria at the time of the survey by months since birth. Includes children living and deceased at the time of the survey. na = Median durations of more than 36 months 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. 11.5 TYPES OF COMPLEMENTARY FOODS As mentioned above, it is recommended that complementary feeding (giving solid or semi-solid foods to infants in addition to breast milk) start at age 6 months, 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 semisolid 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. In the 2011 BDHS, women who had at least one child living with them who was born in 2009 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 2009 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 174 • Nutrition of Children and Adults and liquids if the child was fed by other individuals during the period. Unlike previous BDHS surveys, the information in Table 11.5 is restricted to the youngest children under age 21 living with the mother at the time of the survey. Despite these limitations, the information collected in the 2011 BDHS on the types of foods and liquids consumed by young children is useful in assessing timely and appropriate complementary feeding. For many breastfeeding children, liquids other than breast milk are introduced earlier than the recommended age of 6 months. Seven percent of breastfeeding children under age 2 months are given infant formula and 2 percent receive other milk in addition to breast milk. One percent of breastfeeding children under 2 months is given solid or semisolid 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 2011 Age in months Liquids Solid or semi-solid foods Any solid or semi- solid food Number of children 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 6.6 2.4 0.0 0.0 0.6 0.0 0.0 0.0 0.0 0.6 0.0 0.2 1.1 265 2-3 10.8 4.8 5.2 0.0 0.6 0.6 0.8 0.6 0.0 0.6 0.0 0.7 2.2 279 4-5 15.1 18.5 11.9 2.4 2.3 2.9 0.0 2.2 0.0 2.1 1.3 3.2 15.4 259 6-8 9.3 16.5 21.9 6.2 40.9 13.9 5.3 18.5 4.0 12.0 12.8 4.2 62.6 401 9-11 6.0 21.9 21.8 8.0 72.7 30.6 14.7 37.3 3.2 36.0 22.2 5.8 90.0 420 12-17 4.6 23.8 22.4 3.8 81.3 41.2 18.8 45.1 6.9 48.3 30.4 5.6 91.4 775 18-23 3.7 29.3 22.6 2.4 90.4 49.2 27.5 52.6 6.8 60.7 27.9 8.1 96.1 628 6-23 5.4 23.7 22.2 4.6 75.0 36.5 18.0 40.9 5.7 42.9 25.0 6.1 87.3 2,223 Total 6.9 19.6 17.8 3.6 55.4 27.2 13.3 30.3 4.2 31.8 18.5 4.8 65.7 3,026 NONBREASTFEEDING CHILDREN 12-17 (33.8) (32.5) (50.0) (12.9) (78.3) (26.7) (17.3) (45.7) (6.6) (59.6) (16.7) (16.5) 88.5 45 18-23 5.2 46.8 31.1 15.2 88.4 56.7 24.1 53.0 10.9 66.8 42.8 15.1 96.4 59 6-23 20.5 42.6 37.2 16.8 76.8 41.1 18.8 43.8 9.8 54.2 28.2 15.0 87.9 135 Total 23.5 41.0 35.4 16.0 73.1 39.1 17.9 41.7 9.3 51.6 27.6 14.6 84.9 141 Note: Breastfeeding status and food consumed refer to a “24-hour” period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Other milk includes fresh, tinned, and powdered cow or other animal milk. 2 Other liquids doesn’t include plain water but does include juice, juice drinks, clear broth, or other non-milk liquids. 3 Includes fortified baby food 4 Includes ripe jackfruit, orange, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables (such as poi sag, methi, kolmi, kochu, spinach), ripe mangoes, ripe papayas, and any 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. However, Table 11.5 indicates that 10 percent of breastfeeding children ages 9-11 months did not receive any solid or semi-solid food on the day before the interview. Overall, three in four breastfeeding children age 6-23 months consume foods made from grains (including fortified baby foods), 37 percent consume vitamin A-rich fruits and vegetables, 43 percent have meat, fish, or poultry, and 25 percent consume eggs. In addition to being breastfed, 5 percent of these children also receive infant formula, 24 percent receive other milk, and 6 percent receive cheese, yogurt, or other milk products. As expected, nonbreastfed children age 6-23 months are more likely than breastfed children to receive the different types of liquids and solid and semisolid foods. The difference in the consumption of solid and semisolid food between breastfed and nonbreastfed children is especially marked in the consumption of fortified baby foods, meat, fish or poultry, and cheese, yogurt, or other milk products. 1 To allow comparison with data in the 2011 BDHS, the 2007 data were retabulated for children under age 2 instead of age 3. Nutrition of Children and Adults • 175 However, caution should be exercised while interpreting these results because the number of nonbreastfed children is small compared with the number of breastfed children. Figure 11.5 presents the trends in the consumption of solid and semisolid 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 semisolid foods, with a slight decrease occurring since 2007. Figure 11.5 Trends in complementary feeding for breastfeeding children 6-9 months 29 28 59 62 74 67 1993-94 BDHS 1996-97 BDHS 1999-2000 BDHS 2004 BDHS 2007 BDHS 2011 BDHS Percent BDHS Surveys 11.6 INFANT AND YOUNG CHILD FEEDING PRACTICES Infant and young child feeding (IYCF) practices include initiating timely feeding of solid or semisolid 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, there are infants who 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 nonbreastfed children. Studies have shown that plant-based complementary foods by themselves are insufficient to meet the needs for certain micronutrients (WHO and UNICEF, 1998). 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 176 • Nutrition of Children and Adults (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 nonbreastfed children. However, diversity scores for breastfed and nonbreastfed 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: • Breastfed infants 6-8 months should be fed meals of complementary foods two to three times per day, with one to two snacks as desired; breastfed children 9-23 months should be fed meals three to four times per day, with one to two snacks. • Nonbreastfed children 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 nonbreastfed young children. Nonbreastfed children should be fed meals four to five times per day, with one to 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 nonbreastfed 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 breast milk intake 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 the IYCF practices for the youngest children age 6-23 months living with the mother. The recommendations take into account children for whom feeding practices meet minimum standards with respect to: • Food diversity (the number of food groups consumed) • Feeding frequency (the number of times the child is fed) • Consumption of breast milk or other types of milk or milk products It is important to note that data from the 2011 BDHS are not comparable with data from previous BDHS reports because of changes in the definition of IYCF indicators and the data collection tool in 2011. The results presented in Table 11.6 show that 24 percent of breastfed children age 6-23 months are fed foods from four or more food groups, and 64 percent are fed the minimum number of times. Because 95 percent of children age 6-23 months are still breastfed, the number of nonbreastfed children is too small to come to any meaningful conclusions. Table 11.6 shows that nearly all breastfed and nonbreastfed children age 6-23 months are given breast milk or other milk products (97 percent). Overall, only one of four children receives the appropriately diverse diet, and 65 percent of children are fed the recommended number of times with solid or semisolid foods. One in five children (21 percent) complies with the IYCF recommendations of consuming breastmilk or other milk products, having the minimum dietary diversity, and having the minimum meal frequency. The proportion of all children 6-23 months who are fed according to all 3 IYCF recommendations increases with the child’s age, from 6 percent for children 6-8 months to 31 percent for children 18-23 months. Feeding practices do not vary between boys and girls, but there are differences across other background characteristics. Children living in urban areas (28 percent) are more likely to be fed according to the recommendation than their rural counterparts (19 percent). Children living in Sylhet Division are the least likely to be fed according to all IYCF practices (11 percent), while in other divisions the proportion ranges from 17 percent in Chittagong to 28 percent in Khulna. There is a positive relationship between infant and child feeding practices and mother’s education and household wealth status. Nutrition of Children and Adults • 177 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 2011 Background characteristic Among breastfed children 6-23 months, percentage fed: Among nonbreastfed children 6-23 months, percentage fed: Among all children 6-23 months, percentage fed: 4+ food groups1 Minimum times or more2 Both 4+ food groups and minimum times or more Number of breast- fed children 6-23 months Milk or milk products3 4+ food groups 4+ times or more With 3 IYCF practices4 Number of non- breast- fed children 6-23 months Breast milk, milk, or milk products3 4+ food groups Minimum times or more5 With 3 IYCF practices4 Number of all children 6-23 months Age in months 6-8 5.9 51.4 5.8 401 * * * * 15 99.2 5.9 52.0 5.6 416 9-11 17.9 58.0 14.5 420 * * * * 16 98.9 19.2 58.3 14.7 436 12-17 27.7 64.8 24.1 775 (56.6) (31.7) (64.8) (16.9) 45 97.6 27.9 64.8 23.7 820 18-23 35.8 75.9 32.0 628 44.9 54.1 72.3 15.2 59 95.3 37.3 75.6 30.6 686 Sex Male 23.8 65.1 20.9 1,135 52.0 41.7 64.3 20.8 55 97.8 24.6 65.1 20.9 1,190 Female 24.6 63.3 21.6 1,088 57.6 41.0 71.4 10.6 80 97.1 25.7 63.9 20.8 1,167 Residence Urban 33.1 66.9 28.3 476 63.8 49.6 75.7 24.5 57 96.1 34.9 67.8 27.9 533 Rural 21.8 63.5 19.3 1,747 49.1 35.2 63.2 7.7 78 97.8 22.3 63.5 18.8 1,825 Division Barisal 22.1 61.2 17.5 125 * * * * 6 97.5 24.1 62.0 17.5 132 Chittagong 20.0 55.2 16.9 516 50.2 43.2 66.1 15.1 52 95.4 22.1 56.2 16.8 568 Dhaka 25.3 65.2 23.6 662 * * * * 43 97.9 26.2 65.7 23.3 705 Khulna 30.7 82.2 28.4 206 * * * * 7 99.1 31.4 82.7 28.2 213 Rajshahi 29.7 63.5 24.8 310 * * * * 9 99.1 30.4 63.8 24.6 319 Rangpur 25.3 73.2 21.7 240 * * * * 8 98.2 25.2 72.4 20.9 248 Sylhet 14.3 57.1 11.5 164 * * * * 9 96.0 14.7 55.9 10.9 173 Mother’s education No education 11.8 52.9 10.3 376 * * * * 18 96.1 12.3 51.9 9.8 394 Primary incomplete 19.4 60.5 17.9 421 * * * * 19 96.8 19.0 59.7 17.2 440 Primary complete6 20.8 58.2 17.7 261 * * * * 11 97.8 21.9 58.2 18.0 273 Secondary incomplete 27.6 68.4 23.5 902 (61.0) (43.6) (73.8) (15.2) 42 98.3 28.3 68.6 23.1 944 Secondary complete or higher7 41.4 78.3 37.8 262 (80.7) (58.9) (92.9) (24.3) 44 97.2 43.9 80.4 35.9 306 Wealth quintile Lowest 13.0 54.0 11.5 513 * * * * 15 97.8 12.9 53.5 11.2 528 Second 17.9 64.3 15.3 450 * * * * 25 96.4 18.2 64.1 14.7 475 Middle 26.3 69.7 23.7 448 * * * * 15 98.4 26.8 69.5 23.3 463 Fourth 32.0 65.1 28.1 444 (56.3) (50.0) (67.9) (16.2) 34 96.9 33.3 65.3 27.2 477 Highest 35.6 70.7 30.7 368 80.7 53.8 86.4 26.6 46 97.9 37.6 72.5 30.3 414 Total 24.2 64.2 21.2 2,223 55.3 41.3 68.5 14.8 135 97.4 25.2 64.5 20.9 2,358 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that 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 Non-breastfed children ages 6-23 months are considered to be fed with a minimum standard of three Infant and young child feeding practices if they receive other milk or milk products and are fed at least the minimum number of times per day with at least the minimum number of food groups. 5 Fed solid or semi-solid food at least twice a day for infants 6-8 months, 3+ times for other breastfed children, and 4+ times for non-breastfed children 6 Primary complete is defined as completing grade 5. 7 Secondary complete is defined as completing grade 10. Figure 11.6 shows IYCF practices according to breastfeeding status. In terms of dietary diversity, a higher proportion of nonbreastfed children meet the minimum requirements (41 percent) than breastfed children (24 percent). There are smaller differences between breastfed and nonbreastfed children in meeting the minimum meal frequency criteria. 178 • Nutrition of Children and Adults Figure 11.6 Percentage fed according to minimum standard of acceptable feeding practices 24 64 21 41 69 15 25 65 21 Minimum dietary diversity Minimum meal frequency Minimum acceptable diet Percent Among breastfed children Among non-breastfed children Among all children 6-23 months BDHS 2011 11.7 PREVALENCE OF ANEMIA IN CHILDREN Anemia, characterized by a low level of hemoglobin in the blood, is a major health problem in Bangladesh, especially among young children and pregnant women. Anemia may be an underlying cause of maternal mortality, spontaneous abortions, premature births, and low birth weight. The most common cause of anemia is inadequate dietary intake of nutrients necessary for synthesis of hemoglobin, such as iron, folic acid, and vitamin B12. Anemia also results from sickle cell disease, malaria, and parasitic infections (Benoist et al., 2008). A number of interventions have been put in place to address anemia in children in Bangladesh. These include expanded distribution of iron supplements and deworming medication to children age 1-5 every six months. The measurement of hemoglobin (Hb) is the standardized method of screening for anemia. The 2011 BDHS used HemoCue rapid testing methodology to measure Hb. The HemoCue system consists of a battery-operated photometer and a disposable microcuvette, a small transparent laboratory vessel coated with a dried reagent that serves as the blood collection device. For the test, a drop of capillary blood is taken from a child’s fingertip or heel and is drawn into the microcuvette. The blood in the microcuvette is analyzed using the photometer, which displays the hemoglobin concentration. Given that hemoglobin requirements differ substantially depending on altitude, an adjustment to sea-level equivalents was made using CDC formulas before classifying children according to level of anemia (CDC, 1998). Hemoglobin testing was carried out among children age 6-59 months in every third household in the BDHS sample, i.e., those households that were selected for interviews with ever-married men. Hemoglobin levels were successfully measured for 92 percent of the children eligible for the testing. Nutrition of Children and Adults • 179 Table 11.7 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, by background characteristics, Bangladesh 2011 Background characteristic Anemia status by hemoglobin level Any anemia (<11.0 g/dl) Mild anemia (10.0-10.9 g/dl) Moderate anemia (7.0-9.9 g/dl) Severe anemia (<7.0 g/dl) Number of children Age in months 6-8 67.6 27.4 38.3 1.9 136 9-11 78.7 29.1 48.1 1.5 132 12-17 76.4 32.4 42.6 1.4 259 18-23 62.5 35.4 25.8 1.3 238 24-35 46.9 32.0 14.4 0.5 458 36-47 41.8 27.2 14.0 0.6 562 48-59 38.0 25.2 12.7 0.1 568 Sex Male 52.8 28.8 23.3 0.7 1,197 Female 49.8 29.5 19.5 0.8 1,155 Mother’s interview status Interviewed 51.9 29.7 21.5 0.7 2,263 Not interviewed 36.2 16.2 18.3 1.7 90 Residence Urban 46.3 26.7 18.5 1.1 498 Rural 52.7 29.9 22.2 0.6 1,855 Division Barisal 59.6 32.1 26.3 1.1 136 Chittagong 51.6 27.6 23.4 0.7 509 Dhaka 47.7 27.4 19.5 0.9 738 Khulna 54.2 33.9 19.4 0.9 225 Rajshahi 49.3 29.3 19.6 0.4 293 Rangpur 57.7 33.0 24.7 0.0 268 Sylhet 49.5 27.2 20.7 1.6 185 Mother’s education1 No education 51.9 27.3 23.6 1.1 444 Primary incomplete 53.8 33.3 19.5 1.1 464 Primary complete2 54.6 28.8 25.5 0.3 284 Secondary incomplete 53.6 31.1 21.8 0.7 809 Secondary complete or higher3 40.7 24.0 16.6 0.0 262 Wealth quintile Lowest 56.1 31.2 24.2 0.7 591 Second 58.7 30.6 26.9 1.2 487 Middle 51.1 31.4 19.2 0.5 431 Fourth 44.2 26.7 17.4 0.2 444 Highest 43.5 25.0 17.4 1.2 400 Total 51.3 29.2 21.4 0.7 2,353 Note: Table is based on children who spent the night before the interview in the household. Prevalence of anemia, based on hemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Hemoglobin is measured in grams per deciliter (g/dl). 1 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Table 11.7 shows the anemia status of children 6-59 months according to selected background characteristics. Half (51 percent) of children age 6-59 months suffer from some level of anemia (Hb <11.0 g/dl), 29 percent of children have mild anemia (Hb 10.0-10.9 g/dl), and 21 percent have moderate anemia (Hb 7.0-9.9 g/dl). Less than 1 percent of children age 6-59 months has severe anemia (Hb <7.0 g/dl). The prevalence of anemia peaks at 9-17 months (76-79 percent). Female children and children residing in urban areas are less likely to be anemic. The prevalence of any anemia in children varies across divisions, ranging from 48 percent in Dhaka to 60 percent in Barisal. There seems to be no marked linear association between anemia prevalence and mother’s education status or wealth status. However, children with the lowest percentage anemic are those whose mothers have completed secondary education (41 percent) and those from the highest wealth quintiles (44 percent). 180 • Nutrition of Children and Adults Moderate anemia is most prevalent among children 9-11 months (48 percent). Across divisions, the level of moderate anemia ranges from 19 percent in Khulna to 26 percent in Barisal. 11.8 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 2011 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. Household salt samples were also tested for iodine levels. Table 11.8 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 had received vitamin A supplements or deworming medication in the six months preceding the survey and iron supplements in the week before the survey. The table also presents information on children age 6-59 months who live in households with iodized salt. 11.8.1 Consumption of Micronutrient-rich Foods Table 11.8 shows that 64 percent of the youngest children, age 6-23 months, who were living with their mothers 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 28 percent among children age 6-8 months to 81 percent among children age 18-23 months. Consumption of vitamin A-rich foods is similar among male and female children. Urban children are more likely to consume vitamin A-rich foods (67 percent) compared with children in rural areas (63 percent). The proportion of children consuming vitamin A-rich foods is highest in Khulna Division (75 percent) and lowest in Sylhet Division (51 percent). Mother’s educational status and household wealth correlate positively with the consumption of vitamin A- rich foods. Seventy-eight percent of children of mothers with secondary or higher education consumed vitamin A-rich foods compared with 54 percent of children whose mothers are not educated or have incomplete primary education. Similarly, 70 percent of children in the highest wealth quintile consumed vitamin A-rich foods compared with 53 percent of children in the lowest wealth quintile. Overall, the consumption of vitamin A-rich foods in children age 6-23 months has declined from 70 percent in 2007 to 64 percent in 2011. However, these results should be interpreted with caution because the instruments used to collect the dietary data were not similar in the two surveys. Also, the 2007 and 2011 surveys were fielded at different times of the year, which can influence the consumption of locally-available foods rich in vitamin A. At the national level, 54 percent of children age 6-23 months consumed foods rich in iron (Table 11.8). Differences in the intake of iron-rich foods by background characteristics are largely similar to the consumption of vitamin A-rich foods. The consumption of iron-rich foods increases with mother’s education. The consumption of iron-rich foods among children age 6-23 months has increased from 48 percent in 2007 (data reanalyzed for this age group) to 54 percent in 2011. As mentioned above, these data should be interpreted with caution because of the differences in data collection instruments and seasonality issues. Nutrition of Children and Adults • 181 Table 11.8 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, and among all children age 6-59 months who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Bangladesh 2011 Background characteristic Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Among children age 6-59 months living in households tested for iodized salt: 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 Percentage living in households with iodized salt4 Number of children Age in months 6-8 27.8 20.4 416 23.2 1.6 1.8 423 81.5 415 9-11 60.1 46.6 436 46.2 3.0 6.0 441 79.8 430 12-17 69.8 59.6 820 59.6 2.7 23.8 833 82.9 821 18-23 81.0 71.0 686 61.8 1.6 37.5 714 80.1 700 24-35 na na 0 61.8 2.6 58.2 1,545 80.6 1,527 36-47 na na 0 64.5 2.8 66.4 1,866 82.0 1,834 48-59 na na 0 63.2 1.6 66.2 1,757 83.2 1,734 Sex Male 64.0 54.3 1,190 59.0 2.3 50.0 3,846 82.7 3,792 Female 63.6 52.9 1,167 60.0 2.3 50.4 3,732 80.8 3,669 Breastfeeding status Breastfeeding 63.5 52.9 2,223 54.9 2.3 36.0 3,705 81.0 3,647 Not breastfeeding 70.6 66.5 130 63.9 2.3 63.8 3,840 82.6 3,782 Mother’s age at birth 15-19 69.8 59.3 498 49.4 2.8 35.4 911 82.6 893 20-29 63.2 53.7 1,454 60.8 2.5 51.0 4,871 81.5 4,793 30-39 59.1 46.8 373 61.6 1.8 55.5 1,576 82.3 1,557 40-49 (55.2) (42.8) 33 57.9 0.3 55.3 221 79.7 219 Residence Urban 67.3 59.9 533 57.5 2.6 50.3 1,683 92.4 1,653 Rural 62.8 51.8 1,825 60.1 2.2 50.2 5,896 78.7 5,808 Division Barisal 65.8 51.9 132 71.5 3.3 51.7 427 87.5 420 Chittagong 60.5 50.1 568 66.3 2.4 54.2 1,741 76.2 1,715 Dhaka 60.9 50.0 705 49.3 2.2 51.0 2,353 85.9 2,318 Khulna 75.4 68.1 213 56.4 1.2 40.2 681 93.8 675 Rajshahi 68.8 61.7 319 66.1 2.9 47.3 978 72.6 960 Rangpur 71.0 60.4 248 56.0 2.2 48.3 814 75.6 805 Sylhet 51.3 38.7 173 69.1 2.5 52.9 585 87.2 569 Mother’s education No education 53.7 41.8 394 52.6 1.5 48.6 1,548 71.6 1,519 Primary incomplete 53.5 44.2 440 55.4 2.0 47.0 1,394 78.3 1,364 Primary complete5 59.3 49.0 273 63.8 2.3 51.8 954 81.8 938 Secondary incomplete 69.6 59.2 944 62.4 2.5 50.4 2,760 85.6 2,729 Secondary complete or higher6 78.1 69.1 306 63.9 3.6 55.1 923 92.5 911 Wealth quintile Lowest 53.2 41.2 528 55.2 1.8 47.3 1,796 69.8 1,766 Second 60.6 50.7 475 56.5 2.2 49.7 1,545 77.7 1,518 Middle 69.6 55.5 463 60.8 2.6 52.6 1,465 81.9 1,436 Fourth 68.3 62.3 477 64.1 2.1 51.3 1,443 88.7 1,424 Highest 69.6 60.7 414 62.3 3.1 50.7 1,330 94.9 1,318 Total 63.8 53.6 2,358 59.5 2.3 50.2 7,579 81.8 7,462 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. Total includes children with missing information on breastfeeding status. 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 2 Includes meat (including organ meat), fish, poultry, and eggs 3 Deworming for intestinal parasites is commonly done for helminthes and for schistosomiasis. 4 Excludes children in households in which salt was not tested. 5 Primary complete is defined as completing grade 5. 6 Secondary complete is defined as completing grade 10. 182 • Nutrition of Children and Adults 11.8.2 Micronutrient Supplementation Sixty percent of children age 6-59 months received a vitamin A supplement in the six months preceding the survey. Children age 36-47 months are the most likely to have received vitamin A supplements (65 percent). Across divisions, the proportion of children who received vitamin A supplements ranges from 49 percent in Dhaka to 72 percent in Barisal. In general, the likelihood of a child being given vitamin A supplements increases with mother’s education and with wealth quintile. In 2007, the coverage of vitamin A supplementation among children age 6-59 months was 84 percent (the 2007 BDHS data were retabulated for this age group). The substantial decline in coverage of vitamin A supplementation raises concern because the HPNSDP 2011-2016 target of 90 percent by 2016 had seemed very achievable based on the 2007 BDHS results. In the 2011 BDHS, mothers were asked if their children under age 5 had taken an iron tablet in the seven days prior to the survey. Table 11.8 shows that only two percent of children age 6-59 months received iron supplements in this period. The iron supplementation varies little by the child’s background characteristics. Fortified salt that contains 15 parts of iodine per million of salt (15 ppm) is considered adequate for the prevention of iodine deficiency (ICCIDD, UNICEF, and WHO, 2001). To assess the use of iodized salt in Bangladesh, the 2011 BDHS included salt testing at the household level using the MBI rapid test kit. The MBI rapid test kit provides a good qualitative indication of the presence or absence of iodine. Interviewers asked households to provide a teaspoon of salt used for cooking. A recheck solution was used when the salt showed no change in color. Table 11.8 presents information about all children age 6-59 months who live in households that use iodized salt. At the national level, 82 percent of children live in households that use iodized salt: 92 percent in urban and 79 percent in rural areas. The percentage of children living in households that use iodized salt ranges from 73 percent in Rajshahi division to 94 percent in Khulna division. Mother’s education and household wealth are positively associated with the likelihood of children living in households that use iodized salt. 11.8.3 Deworming Certain types of intestinal parasites can cause anemia. Periodic deworming for organisms such as helminthes can improve children’s micronutrient status. The 2011 BDHS asked mothers if their children under age 5 had taken deworming medication in the six months prior to the survey. At the national level, 50 percent of children age 6-59 months received deworming medication in this period (Table 11.8). The percentage of children who received deworming medication increases with age, ranging from 2 percent of children age 6-8 months to 66 percent of children age 36-59 months. Breastfed children are less likely than nonbreastfed children to receive deworming medication (36 percent and 64 percent, respectively). There is no difference between urban and rural areas, but the coverage of deworming medication varies across divisions, ranging from 40 percent in Khulna to 54 percent in Chittagong. Mother’s education and household wealth have positive associations with children’s likelihood of receiving deworming medication. 11.9 HOUSEHOLD IODIZED SALT CONSUMPTION Salt used in the household is the most common vehicle for iodine fortification to prevent the public health concerns of iodine deficiency disorders. In Bangladesh, the compound used for fortification of salt is potassium iodate (KIO3). According to the World Health Organization, a country’s salt iodization program is considered to be on a good track to eliminate iodine deficiency when 90 percent of households use iodized salt. Nutrition of Children and Adults • 183 Table 11.9 Presence of iodized salt in household Among all households, the percentage with salt tested for iodine content and the percentage with no salt in the household; and among households with salt tested, the percentage, with iodized salt, according to background characteristics, Bangladesh 2011 Background characteristic Among all households, the percentage: Among households with tested salt: With salt tested With no salt in the household Number of households Percentage with iodized salt Number of households Residence Urban 98.8 1.2 4,305 92.9 4,254 Rural 98.3 1.7 12,836 78.7 12,620 Division Barisal 98.3 1.7 1,014 89.1 997 Chittagong 98.6 1.4 2,939 77.4 2,899 Dhaka 98.4 1.6 5,599 85.9 5,507 Khulna 99.1 0.9 2,024 92.7 2,005 Rajshahi 98.1 1.9 2,572 73.7 2,524 Rangpur 98.4 1.6 2,079 73.5 2,045 Sylhet 98.0 2.0 914 89.8 896 Wealth quintile Lowest 98.0 2.0 3,756 70.9 3,681 Second 98.4 1.6 3,481 76.0 3,424 Middle 97.9 2.1 3,325 82.6 3,256 Fourth 98.5 1.5 3,283 87.8 3,234 Highest 99.5 0.5 3,296 96.1 3,279 Total 98.4 1.6 17,141 82.3 16,874 Table 11.9 shows the proportion of households with iodized salt according to background characteristics. Overall, salt was tested in 98 percent of households and 82 percent of the tested households were found to use salt with iodine. This result is similar to the results of a national survey in 2004-05 on iodine deficiency disorders and universal salt iodization, which reported 81 percent of households as using iodized salt (INFS et al., 2007). Urban households are more likely to consume iodized salt compared with their rural counterparts (93 percent and 79 percent, respectively). Khulna has the highest proportion of households consuming iodized salt (93 percent), while Rangpur and Rajshahi have the lowest (74 percent each). The percentage of households with iodized salt increases with wealth. 11.10 ADULT NUTRITIONAL STATUS 11.10.1 Nutritional Status of Women Low pre-pregnancy body mass index (BMI) and short stature of women are known risk factors for poor maternal and birth outcomes. In developing countries, maternal underweight is a leading risk factor for preventable death and diseases. The prevalence of overweight women and men is also a growing concern in developing countries. 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. In many countries, though, chronic energy deficiency, characterized by a BMI of less than 18.5 among adults remains the predominant problem, leading to low work productivity and reduced resistance to illness. The 2011 BDHS measured the height and weight of ever-married women age 12-49. Because there were only 90 ever-married women age 12-14 (less than one percent), these women were removed from the data set and the weights were recalculated for the 15-49 age group. Therefore, the subsequent nutritional status table includes data from 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 150 184 • Nutrition of Children and Adults centimeters. The 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 undernutrition. A BMI of 25 or above usually indicates overweight, and a BMI of 30 or above indicates obesity. Table 11.10.1 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 2011 Height Body Mass Index 1 Background characteristic 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 (Moder- ately and severely thin) ≥25.0 (Total over- weight or obese) 25.0-29.9 (Over- weight) ≥30.0 (Obese) Number of women Age 15-19 13.0 108 20.9 63.7 25.4 17.0 8.3 10.9 9.2 1.8 102 20-29 13.7 3,760 21.4 60.6 23.4 14.1 9.4 16.0 13.0 3.0 3,477 30-39 13.2 5,659 21.4 59.1 24.2 14.8 9.4 16.7 13.8 2.9 5,236 40-49 13.4 5,280 21.4 58.3 24.9 14.2 10.7 16.8 13.9 2.8 4,878 Residence Urban 12.7 4,482 23.0 57.6 13.5 8.7 4.8 28.9 22.5 6.4 4,194 Rural 13.6 12,830 20.8 59.9 28.0 16.4 11.6 12.1 10.5 1.7 11,831 Division Barisal 13.4 945 20.9 60.4 27.0 15.9 11.1 12.6 10.8 1.8 873 Chittagong 11.5 3,134 21.6 59.6 22.4 14.3 8.1 17.9 14.7 3.2 2,868 Dhaka 14.9 5,585 21.6 58.2 23.6 13.3 10.3 18.3 14.6 3.6 5,166 Khulna 9.8 2,109 21.9 61.2 19.0 12.1 6.9 19.8 16.6 3.2 1,989 Rajshahi 13.1 2,576 21.3 59.7 24.8 14.4 10.4 15.5 13.1 2.5 2,408 Rangpur 15.5 2,019 20.7 62.4 27.1 16.5 10.6 10.5 9.1 1.4 1,884 Sylhet 14.1 944 20.6 51.6 35.2 19.7 15.5 13.1 10.9 2.2 837 Educational attainment No education 16.8 4,808 20.7 59.1 29.8 17.2 12.5 11.1 9.3 1.8 4,611 Primary incomplete 16.0 3,194 20.9 60.3 26.9 15.6 11.3 12.8 11.0 1.7 2,995 Primary complete2 15.5 2,012 21.2 58.8 26.1 14.8 11.3 15.1 12.4 2.7 1,823 Secondary incomplete 10.2 5,267 21.6 59.9 22.1 13.5 8.6 18.0 14.6 3.4 4,729 Secondary complete or higher3 7.0 2,031 23.5 57.2 9.5 6.8 2.6 33.3 27.0 6.4 1,867 Wealth quintile Lowest 17.2 3,185 19.6 54.9 40.1 22.0 18.1 5.0 4.6 0.3 2,929 Second 15.6 3,407 20.2 63.2 30.2 17.9 12.3 6.7 6.1 0.6 3,122 Middle 13.7 3,486 20.9 63.1 25.6 15.4 10.2 11.2 10.0 1.3 3,205 Fourth 10.8 3,572 21.9 60.2 19.5 12.3 7.2 20.3 17.4 2.9 3,335 Highest 10.0 3,661 23.9 55.1 8.4 5.5 2.9 36.5 27.8 8.7 3,434 Food security status Food secure 11.6 11,196 21.9 59.6 20.3 12.4 7.9 20.1 16.3 3.8 10,315 Mild food insecurity 15.9 4,338 20.7 59.7 29.3 17.0 12.3 11.0 9.5 1.5 4,012 Moderate food insecurity 17.3 1,463 19.9 56.7 35.9 19.2 16.6 7.4 7.0 0.4 1,394 Severe food insecurity 20.5 280 20.0 53.5 38.9 24.1 14.9 7.6 7.5 0.1 269 Total 13.3 17,312 21.4 59.3 24.2 14.3 9.8 16.5 13.6 2.9 16,024 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. In the 2011 BDHS, height and weight measurements were obtained for 17,640 ever-married women age 15-49 who were present in the sample households at the time of the survey2. Table 11.10.1 presents the height analysis based on 17,312 ever-married women age 15-49 years, while the analysis of BMI is based on 16,024 women. The table 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. 2 In the 2011 BDHS height and weight information was also collected for never-married women age 35 and older. However, to keep the data comparable with the previous surveys, never-married women age 35 and older are not included in Table 11.10.1. These women are included in Chapter 15 on Adult Health Issues. Nutrition of Children and Adults • 185 Overall, 13 percent of ever-married women fall 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 from Khulna division tend to be taller than other women. Woman’s educational status and household wealth are positively associated with height. For example, 17 percent of uneducated women and women in the lowest wealth quintile are below 145 centimeters, compared with 7 percent of women who have completed secondary education and 10 percent of women in the highest wealth quintile. A woman’s height and food security3 status show a positive linear correlation. Twenty-one percent of ever-married women living in an environment of severe food insecurity are less than 145 centimeters tall, which is 7 percentage points higher than the national average of 13 percent. The mean BMI for ever-married women age 15-49 years is 21.4 (Table 11.10.1), which falls in the normal BMI classification. About six in ten ever-married women (59 percent) have a normal BMI, 24 percent are undernourished or thin (BMI less than 18.5), and 17 percent are overweight or obese (BMI 25 or higher). Variations are apparent by background characteristics. Ever-married women age 15-19 and age 40-49 are slightly more likely to be thin or undernourished than women in other age cohorts (25 percent in both age groups). The proportion of overweight women increases with age. Rural women are two times more likely to be undernourished than urban women (28 percent and 14 percent, respectively), whereas urban women are more than twice as likely to be overweight or obese when compared with rural women (29 percent and 12 percent, respectively). Among the divisions, the proportion of undernourished women ranges from 19 percent in Khulna to 35 percent in Sylhet. As educational attainment and household wealth rise, the proportion of women who are undernourished declines sharply, while the proportion of overweight or obese women increases. Bangladeshi women from the highest wealth quintile are seven times more likely to be overweight or obese compared with women from the lowest wealth quintile. Ever- married women from households with food insecurity are much more likely to be thin than those from households in which food is more secure. Anthropometric measurements of ever-married women age 15-49 were collected in the 2004, 2007, and 2011 BDHS surveys. Comparisons of data from the three surveys 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 2011. At the same time, the mean BMI has increased from 20.2 in 2004 to 21.4 in 2011 (NIPORT et al., 2009). Consequently, the proportion of women with a BMI below 18.5 has decreased from 34 percent in 2004 to 24 percent in 2011 (Figure 11.7). Moreover, the proportion of women who are overweight or obese has almost doubled, increasing from 9 percent in 2004 to 17 percent in 2011 (data not shown). 3 Refer to Section 11.4 for the detailed information about the food security indicators. 186 • Nutrition of Children and Adults Figure 11.7 Trends in nutritional status of ever-married women 16 34 15 30 13 24 Height less than 145 cm BMI less than 18.5 2004 BDHS 2007 BDHS 2011 BDHS Percent 11.10.2 Nutritional Status of Men For the first time in a BDHS, height and weight measurements were collected from men in a third of the BDHS sample households. The anthropometric data were collected for all men age 15 and older except for never-married men age 15-34. Table 11.10.2 presents the nutritional status of ever-married men age 15-34, and Table 11.10.3 presents the same data for men age 35 and older. Ever-married men age 15-34 Although height and weight measurements were obtained for 1,452 ever-married men age 15-34, Table 11.10.2 presents data for only 1,393 men (96 percent) for whom complete and credible data were available. The mean BMI for ever-married men age 15-34 is 20.5 (Table 11.10.2). About seven in ten men (67 percent) have a normal BMI, 27 percent are undernourished or thin (BMI less than 18.5), and 6 percent are overweight or obese (BMI 25 or higher). There are large variations in BMI by background characteristics. Younger ever-married men age 20-29 are more likely to be thin or undernourished than men age 30-34 (29 percent compared with 22 percent). Rural men are more likely to be undernourished than urban men (29 percent and 20 percent, respectively), while urban men are almost three times more likely to be overweight or obese than rural men (11 percent and 4 percent, respectively). Among the divisions, Barisal and Sylhet have the highest proportion of men who are undernourished (35 percent), while Rangpur has the lowest proportion (22 percent). There is a distinct contrast in BMI by educational attainment and household wealth; the proportion of undernourished men declines sharply whereas the proportion of overweight or obese men increases dramatically as education and wealth increase. For example, although less than 1 percent of men in the lowest wealth quintile are overweight or obese, the corresponding proportion for men in the highest quintile is 17 percent. Nutrition of Children and Adults • 187 Table 11.10.2 Nutritional status of ever-married men age 15-34 Among ever-married men age 15-34, mean Body Mass Index (BMI), and the percentage with specific BMI levels, by background characteristics, Bangladesh 2011 Background characteristic Body Mass Index Mean Body Mass Index (BMI) 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Moder- ately and severely thin) ≥25.0 (Total over- weight or obese) 25.0-29.9 (Over- weight) ≥30.0 (Obese) Number of men Age 15-19 * * * * * * * * 21 20-29 20.3 65.2 29.4 21.5 8.0 5.3 4.6 0.7 798 30-34 20.8 70.1 22.3 15.5 6.8 7.6 6.9 0.7 574 Residence Urban 21.2 68.8 20.2 14.0 6.2 11.0 10.0 1.0 401 Rural 20.2 66.4 29.3 21.1 8.2 4.3 3.7 0.6 991 Division Barisal 19.7 60.9 35.3 22.3 13.0 3.8 3.8 0.0 65 Chittagong 20.7 65.5 24.5 17.7 6.8 10.0 8.5 1.5 225 Dhaka 20.5 68.5 26.7 17.8 8.8 4.8 4.3 0.4 461 Khulna 20.7 69.0 24.6 20.9 3.7 6.3 6.3 0.0 174 Rajshahi 20.3 63.0 30.2 20.4 9.7 6.9 5.7 1.1 212 Rangpur 20.8 72.4 21.7 17.8 3.9 5.9 4.9 1.0 195 Sylhet 19.8 60.0 35.2 24.0 11.2 4.8 4.8 0.0 61 Educational attainment No education 19.5 59.1 38.7 26.2 12.5 2.2 1.7 0.5 284 Primary incomplete 20.0 65.1 31.0 21.3 9.7 3.9 3.1 0.9 364 Primary complete1 19.9 68.2 27.7 14.9 12.8 4.1 4.1 0.0 165 Secondary incomplete 20.8 72.1 21.9 18.7 3.2 5.9 5.2 0.7 366 Secondary complete or higher2 22.4 71.6 10.6 9.5 1.1 17.8 16.6 1.2 214 Wealth quintile Lowest 19.5 64.6 34.6 24.8 9.8 0.7 0.4 0.4 263 Second 19.7 64.2 33.8 26.0 7.8 2.0 1.3 0.8 294 Middle 20.2 68.2 28.3 17.2 11.1 3.5 3.5 0.0 269 Fourth 20.8 69.0 22.7 15.7 7.0 8.3 7.5 0.8 302 Highest 22.3 69.5 13.7 11.4 2.3 16.8 15.3 1.5 265 Total 15-34 20.5 67.1 26.7 19.1 7.6 6.2 5.5 0.7 1,392 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 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Men 35 and older Table 11.10.3 presents data on the nutritional status of 3,781 men age 35 and older. The mean BMI of men 35 and older is 20.5. Overall, 62 percent of men age 35 and older have a normal BMI, 29 percent are thin, and 9 percent are overweight or obese. Men age 70 and older are two times more likely to be thin than men ages 35–39 and 40-44. As expected, men from rural areas are more likely to be undernourished (32 percent) compared with men from urban areas (18 percent). Barisal and Sylhet have the highest proportion of undernourished men (33 percent each) compared with men in other divisions. Differentials in BMI by education and wealth quintile among men age 35 and older are similar to those among ever-married men age 15-34. 188 • Nutrition of Children and Adults Table 11.10.3 Nutritional status of men age 35 and older Among all men age 35 and older, mean Body Mass Index (BMI), and the percentage with specific BMI levels, by background characteristics, Bangladesh 2011 Background characteristic Body Mass Index Mean Body Mass Index (BMI) 18.5-24.9 (Total normal) <18.5 (Total thin) 17.0-18.4 (Mildly thin) <17 (Moder- ately and severely thin) ≥25.0 (Total over- weight or obese) 25.0-29.9 (Over- weight) ≥30.0 (Obese) Number of men Age 35-39 21.2 67.4 20.1 14.6 5.5 12.5 12.0 0.5 655 40-44 20.9 68.5 21.3 14.7 6.6 10.2 9.9 0.3 617 45-49 20.8 63.1 25.2 17.1 8.1 11.7 10.7 1.0 581 50-54 20.2 57.7 33.9 19.1 14.8 8.4 7.4 1.0 605 55-59 20.9 65.3 24.2 13.8 10.4 10.5 9.7 0.8 294 60-69 20.0 60.5 33.1 18.2 14.9 6.4 5.7 0.8 550 70+ 19.1 49.7 47.1 20.6 26.5 3.2 2.7 0.5 478 Residence Urban 21.9 62.9 17.7 11.0 6.7 19.3 17.7 1.7 900 Rural 20.0 61.7 32.4 18.8 13.6 6.0 5.6 0.4 2,881 Division Barisal 20.1 62.2 32.7 23.5 9.2 5.1 4.5 0.5 221 Chittagong 20.6 59.1 29.8 16.9 12.9 11.0 10.4 0.7 589 Dhaka 20.5 63.8 27.6 15.0 12.6 8.6 7.9 0.7 1,222 Khulna 20.8 64.6 24.7 14.0 10.7 10.6 9.9 0.7 509 Rajshahi 20.5 60.4 29.3 18.4 10.9 10.3 9.4 0.9 544 Rangpur 20.2 61.1 31.8 20.8 11.0 7.1 6.7 0.5 480 Sylhet 20.3 58.4 32.5 15.8 16.8 9.1 8.0 1.0 216 Education No education 19.4 58.5 39.0 22.2 16.7 2.5 2.4 0.2 1,369 Primary incomplete 20.0 62.6 31.5 17.7 13.8 6.0 5.6 0.4 946 Primary complete1 20.8 62.6 26.1 16.3 9.8 11.4 10.9 0.4 446 Secondary incomplete 21.6 64.6 19.2 12.6 6.6 16.2 14.8 1.4 569 Secondary complete or higher2 23.0 67.2 8.0 5.5 2.5 24.7 22.4 2.3 451 Wealth quintile Lowest 18.9 55.3 43.9 22.9 21.0 0.9 0.9 0.0 746 Second 19.5 60.7 36.7 22.6 14.2 2.6 2.6 0.0 741 Middle 20.0 62.6 31.6 17.8 13.8 5.8 5.6 0.1 742 Fourth 21.2 66.6 21.9 13.9 8.0 11.6 10.4 1.2 768 Highest 22.7 64.4 11.6 8.1 3.4 24.0 21.9 2.1 785 Total 20.5 62.0 28.9 16.9 12.0 9.1 8.4 0.7 3,781 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 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 11.11 PREVALENCE OF ANEMIA IN WOMEN Anemia is a key health status indicator for maternal nutrition. It is estimated that one-fifth of perinatal mortality and one–tenth of maternal mortality are attributable to iron deficiency anemia. Anemia also results in an increased risk of premature delivery and low birth weight. Iron deficiency, a major cause of anemia, is one of the top 10 risk factors in developing countries for “lost years of healthy life” (Benoist et al., 2008). Information on the prevalence of anemia can be useful for the development of health intervention programs designed to prevent and control anemia, such as iron supplementation and fortification programs. Iron supplementation of women during pregnancy protects mother and infant. In Bangladesh, a number of interventions have been put in place to address anemia in women. These include supplementation of iron with folic acid tablets for pregnant women from the second trimester to 45 days following delivery and deworming of pregnant women after completion of the first trimester. Anemia among ever-married Bangladeshi women age 15-49 was measured in a third of the eligible households (households selected for male interviews) using a procedure similar to that used for children, except that capillary blood was collected exclusively from a finger prick. Anemia measurements were obtained from 5,902 ever-married women age 15-49, of which 95 percent of the measurements were complete and credible. Table 11.11 shows the anemia prevalence based on hemoglobin levels (adjusted for pregnancy status and altitude), by selected background characteristics. The adjustment of hemoglobin levels by altitude and smoking status used the formulas recommended by the CDC (CDC, 1998). Nutrition of Children and Adults • 189 Table 11.11 Prevalence of anemia in women Percentage of ever-married women age 15-49 with anemia, by background characteristics, Bangladesh 2011 Background characteristic Anemia status by hemoglobin level Any (NP <12.0 g/dl / P <11.0 g/dl) Mild (NP 10.0-11.9 g/dl / P 10.0-10.9 g/dl) Moderate (NP 7.0-9.9 g/dl / P 7.0-9.9 g/dl) Severe (NP <7.0 g/dl / P <7.0 g/dl) Number of women Age 15-19 48.6 39.2 9.4 0.0 39 20-29 40.2 32.4 7.8 0.0 1,223 30-39 44.3 37.1 7.0 0.2 1,847 40-49 39.4 34.2 5.2 0.1 1,754 Number of children ever born 0 39.6 32.2 7.4 0.1 548 1 38.8 33.2 5.6 0.0 1,143 2-3 41.4 35.5 5.9 0.1 2,433 4-5 45.4 38.6 6.7 0.2 1,087 6+ 52.8 41.0 10.5 1.3 465 Maternity status Pregnant 49.6 27.2 22.4 0.0 347 Breastfeeding 47.8 41.6 6.1 0.0 1,356 Neither 40.0 34.5 5.2 0.2 3,973 Using IUD Yes 58.7 49.1 9.6 0.0 44 No 42.3 35.7 6.5 0.2 5,632 Residence Urban 36.1 30.4 5.6 0.1 1,468 Rural 44.7 37.6 6.8 0.2 4,207 Division Barisal 45.6 37.6 8.0 0.0 306 Chittagong 38.4 31.5 6.7 0.2 991 Dhaka 43.1 36.9 5.9 0.3 1,850 Khulna 37.4 33.1 4.3 0.0 708 Rajshahi 44.1 36.8 7.2 0.0 847 Rangpur 49.5 41.7 7.8 0.0 664 Sylhet 39.7 30.9 8.5 0.4 310 Educational attainment No education 47.1 38.0 8.7 0.4 1,549 Primary incomplete 44.0 37.6 6.2 0.2 1,076 Primary complete1 45.7 37.7 7.8 0.2 665 Secondary incomplete 40.1 35.2 4.9 0.0 1,746 Secondary complete or higher2 31.4 26.9 4.6 0.0 641 Wealth quintile Lowest 49.8 42.0 7.3 0.5 1,078 Second 48.1 39.5 8.5 0.1 1,103 Middle 42.6 36.3 6.3 0.0 1,100 Fourth 40.6 35.1 5.3 0.2 1,196 Highest 32.2 26.9 5.3 0.1 1,199 Total 42.4 35.8 6.5 0.2 5,676 Note: Prevalence is adjusted for altitude and for smoking status, if known, using formulas in CDC, 1998. NP = Not pregnant P = Pregnant 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. Table 11.11 shows that 42 percent of women age 15-49 are anemic; 36 percent are mildly anemic, 7 percent are moderately anemic and less than 1 percent are severely anemic. There is no clear pattern for anemia levels by age. Anemia prevalence increases as the number of children ever born increases. More than half of the women who have had six or more children are anemic (53 percent) compared with 39 percent of women who have had only one child. The prevalence of anemia is associated with maternity status; pregnant (50 percent) and lactating (48 percent) women are more likely to be anemic than women who are neither pregnant nor lactating (40 percent). This could be due to the high demand for iron and folic acid during pregnancy. Women using an intra-uterine device (IUD) are more likely to be anemic than non- IUD users. 190 • Nutrition of Children and Adults Anemia is more prevalent in rural areas (45 percent) than in urban areas (36 percent). Anemia levels are highest in Rangpur (50 percent). In other divisions, anemia prevalence ranges from 37 percent in Khulna to 46 percent in Barisal. Anemia is least prevalent among women with the highest education and women in the highest wealth quintile. 11.12 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Finally, iodine deficiency is related to a number of adverse pregnancy outcomes including abortion and stillbirth, as well as fetal brain damage and congenital malformation. In Bangladesh, micronutrient deficiency among pregnant and lactating mothers is a common public health problem. Vitamin A deficiency (VAD) can be prevented through the 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 2011 BDHS collected data on use of vitamin A supplements among women age 15-49 years with a child born in the past five years. Table 11.12 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, 27 percent of women age 15- 49 with a child born in the past five 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 the age of the women. Women in urban areas (30 percent) are more likely to receive vitamin A supplements than those in rural areas (26 percent). The percentage of women who received a postpartum vitamin A dose is highest in Rangpur (36 percent) and lowest in Dhaka (24 percent). Postpartum vitamin A supplementation increases steadily with women’s educational level, ranging from 18 percent of women with no education to 41 percent of women who have completed secondary or higher education. Vitamin A supplementation is also associated with household wealth, increasing from 19 percent among mothers in the lowest wealth quintile to 35 percent among mothers in the highest quintile. Postpartum vitamin A coverage has increased by 7 percentage points between 2007 and 2011 (20 percent in 2007 to 27 percent in 2011). Postpartum Vitamin A coverage has increased more in rural areas (18 percent in 2007 to 26 percent in 2011) than in urban areas (24 percent in 2007 to 30 percent in 2011). Table 11.12 also shows that 82 percent of ever-married women age 15-49 with a child born in the past five years lives in a household with iodized salt. Urban women are more likely to live in households that use iodized salt than their rural counterparts (93 percent and 79 percent, respectively). Khulna has the highest proportion of women using iodized salt (94 percent, while Rajshahi has the lowest percentage (73 percent). The proportion of women living in households with iodized salt is positively related to educational level and household wealth status. Nutrition of Children and Adults • 191 Table 11.12 Micronutrient intake among mothers Among women age 15-49 with a child born in the past five years, the percentage who received a vitamin A dose in the first two months after the birth of the last child, and among women age 15-49 with a child born in the past five years who live in households that were tested for iodized salt, the percentage who live in households with iodized salt, by background characteristics, Bangladesh 2011 Background characteristic Percentage who received vitamin A dose postpartum1 Number of women Among women with a child born in the last five years, who live in households that were tested for iodized salt Percentage living in households with iodized salt2 Number of women Age 15-19 (28.5) 44 (64.6) 43 20-29 26.2 1,626 81.7 1,599 30-39 27.7 2,377 82.9 2,347 40-49 27.5 2,235 82.2 2,194 Residence Urban 29.6 1,718 92.7 1,692 Rural 26.1 5,632 79.1 5,548 Division Barisal 24.7 429 88.6 421 Chittagong 26.8 1,589 77.0 1,565 Dhaka 24.0 2,312 86.6 2,280 Khulna 26.2 712 94.1 706 Rajshahi 28.6 998 72.6 981 Rangpur 35.9 803 74.6 794 Sylhet 25.8 505 88.6 493 Educational attainment No education 18.3 1,414 72.3 1,393 Primary incomplete 21.8 1,316 78.5 1,289 Primary complete3 22.0 901 82.2 886 Secondary incomplete 30.6 2,779 85.6 2,743 Secondary complete or higher4 41.0 940 93.0 930 Wealth quintile Lowest 19.2 1,614 70.9 1,587 Second 23.4 1,472 76.0 1,446 Middle 27.2 1,452 82.7 1,425 Fourth 30.9 1,450 89.0 1,431 Highest 35.3 1,362 95.0 1,351 Total 26.9 7,350 82.3 7,241 1 In the first two months after delivery 2 Excludes women in households where salt was not tested 3 Primary complete is defined as completing grade 5. 4 Secondary complete is defined as completing grade 10. 11.13 HOUSEHOLD FOOD SECURITY Food security refers to the availability of food and a person’s access to it. It is a complex sustainable development issue, which is closely related to undernutrition. A household is considered food- secure when its occupants do not live in hunger or fear or starvation (Hunt, 2009). In 1996, the World Food Summit defined food security as “the situation when all people at all times have access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” (FAO, 2002). Common to most definitions of food security are the elements of availability, access (physical and economic), utilization, and stability or sustainability. Food insecurity is rooted in poverty and leads to poor health, low productivity, low income, food shortage, and hunger. A food insecurity module was included in the BDHS 2011. The questions on food insecurity were developed using the 2011 Nepal DHS food insecurity module and Household Food Insecurity Access Scale (HFIAS) indicators developed by USAID’s Food and Nutrition Technical Assistance (FANTA) project. The Technical Working Group of the 2011 BDHS systematically reviewed the standard food insecurity questions and modified them to be specific to Bangladesh. The reference period for the food insecurity 192 • Nutrition of Children and Adults assessment was kept as 12 months preceding the interview to allow for the seasonal variation. Although the questions on food security were included in the Woman’s Questionnaire, they are expected to reflect the status of food security for the woman herself and her family. Table 11.13 presents the percent distribution of ever-married women by the frequency of having three square (“full-stomach”) meals a day in the previous 12 months. Eight in ten women say that they mostly have had three full-stomach meals in the last 12 months, 15 percent sometimes have had full- stomach meals, and about 4 percent rarely or never had a full-stomach meal. Ever-married women residing in urban areas (88 percent) are more likely to have mostly had three square meals a day, compared with rural women (79 percent). Women in Rangpur (76 percent) are the least likely to have three square meals most of the time. As one would expect, wealth is a strong predictor of being able to have full-stomach meals among ever-married Bangladeshi women. Table 11.13 Availability of meals every day Percent distribution of ever-married women age 15-49 by frequency of having three square meals a day in the past 12 months, according to selected background characteristics, Bangladesh 2011 Background characteristic Mostly Sometimes Rarely (1-6 times this year) Never Total Number of women Residence Urban 87.8 10.0 1.8 0.4 100.0 4,619 Rural 79.0 16.0 4.2 0.8 100.0 13,130 Division Barisal 79.5 14.8 4.9 0.8 100.0 1,002 Chittagong 81.8 14.4 3.5 0.3 100.0 3,222 Dhaka 85.6 11.0 2.6 0.8 100.0 5,736 Khulna 77.8 17.4 4.3 0.5 100.0 2,139 Rajshahi 80.6 15.1 3.6 0.6 100.0 2,646 Rangpur 75.6 18.7 5.1 0.7 100.0 2,039 Sylhet 76.8 17.8 3.9 1.5 100.0 967 Wealth quintile Lowest 55.7 32.9 9.4 2.0 100.0 3,250 Second 73.3 20.7 5.3 0.7 100.0 3,487 Middle 85.9 11.1 2.7 0.3 100.0 3,567 Fourth 91.6 7.2 0.9 0.3 100.0 3,664 Highest 96.2 3.1 0.5 0.2 100.0 3,781 Total 81.3 14.5 3.6 0.7 100.0 17,749 Note: A square meal is defined as a “full stomach” meal. The percent distribution of ever-married women by frequency of having to skip entire meals because there was not enough food in the past 12 months is presented in Table 11.14. The majority of women (82 percent) say that they never had to skip meals in the last 12 months, 12 percent rarely had to skip meals, 4 percent had to skip meals 7 to 12 times in the last year, and 2 percent skipped meals a few times every month in the past 12 months. Urban women, those living in Dhaka division, and women in the highest wealth quintile are the least likely to skip entire meals. Nutrition of Children and Adults • 193 Table 11.14 Frequency of skipping meals Percent distribution of ever-married women age 15-49 by frequency of having to skip entire meals because there was not enough food in the past 12 months, according to selected background characteristics, Bangladesh 2011 Background characteristic Never Rarely (1-6 times this year) Sometimes (7-12 times this year) Often (few times each month) Missing Total Number of women Residence Urban 88.0 8.9 2.0 1.0 0.1 100.0 4,619 Rural 79.7 13.5 4.8 1.9 0.1 100.0 13,130 Division Barisal 79.5 12.2 5.9 2.3 0.1 100.0 1,002 Chittagong 81.0 12.4 5.0 1.6 0.0 100.0 3,222 Dhaka 86.5 9.3 2.7 1.5 0.1 100.0 5,736 Khulna 80.8 14.1 3.8 1.2 0.0 100.0 2,139 Rajshahi 81.6 11.9 4.8 1.6 0.1 100.0 2,646 Rangpur 75.2 18.0 4.8 2.0 0.0 100.0 2,039 Sylhet 76.5 15.6 4.3 3.5 0.1 100.0 967 Wealth quintile Lowest 56.2 27.3 11.3 5.2 0.1 100.0 3,250 Second 74.3 17.5 5.9 2.3 0.0 100.0 3,487 Middle 86.6 10.2 2.6 0.6 0.0 100.0 3,567 Fourth 92.0 6.0 1.2 0.6 0.2 100.0 3,664 Highest 96.5 2.8 0.3 0.3 0.1 100.0 3,781 Total 81.9 12.3 4.1 1.7 0.1 100.0 17,749 Table 11.15 addresses the frequency of having less food in a meal because there was not enough food available to consume in the past 12 months. Overall, 78 percent of women reported that they never ate less food, 14 percent rarely ate less food, 6 percent ate less food 7 to 12 times in the last 12 months, and 2 percent ate less food a few times every month. Urban women, women in Dhaka, and women in the highest wealth quintile were more likely to say that they never had insufficient food in the 12 months before the survey. Twenty-eight percent of women in the lowest wealth quintile had to have less food in a meal 1 to 6 times in the past year because there was not enough food available for them to eat. Table 11.15 Frequency of having less food in a meal Percent distribution of ever-married women age 15-49 by frequency of having less food in a meal because there was not enough food in the past 12 months, according to selected background characteristics, Bangladesh 2011 Background characteristic Never Rarely (1-6 times this year) Sometimes (7-12 times this year) Often (few times each month) Missing Total Number of women Residence Urban 85.9 9.8 2.9 1.4 0.0 100.0 4,619 Rural 75.6 15.1 6.6 2.6 0.1 100.0 13,130 Division Barisal 77.3 12.6 6.6 3.4 0.1 100.0 1,002 Chittagong 77.3 14.2 5.9 2.5 0.0 100.0 3,222 Dhaka 84.2 9.6 4.2 1.9 0.0 100.0 5,736 Khulna 76.4 15.7 6.3 1.6 0.0 100.0 2,139 Rajshahi 76.7 15.3 6.0 1.9 0.1 100.0 2,646 Rangpur 71.0 19.2 7.2 2.6 0.0 100.0 2,039 Sylhet 71.8 17.2 6.3 4.7 0.0 100.0 967 Wealth quintile Lowest 50.3 27.5 15.5 6.6 0.1 100.0 3,250 Second 69.0 20.1 7.9 3.0 0.1 100.0 3,487 Middle 82.4 12.9 3.6 1.0 0.1 100.0 3,567 Fourth 90.1 7.3 1.7 0.9 0.0 100.0 3,664 Highest 95.8 3.0 0.8 0.4 0.0 100.0 3,781 Total 78.3 13.7 5.6 2.3 0.0 100.0 17,749 Rice is a staple food in Bangladesh. Table 11.16 presents the percent distribution of ever-married women by the frequency of having her or any other member of her family eat a rice substitute (wheat or any other grain) due to its unavailability. Although the question explicitly indicates that the intake of other grains should not be reported if the woman or any other family member was sick and the rice replacement was given due to individual choice, there is a possibility the results are not exclusively reflective of the 194 • Nutrition of Children and Adults replacement of rice due to food insecurity. More than eight in 10 women report never having to replace rice with other grains, 12 percent rarely substituted for rice with other grains, 4 percent sometimes did, and 1 percent did a few times every month in the 12 months before the survey. Rural women, women in Sylhet and Rangpur divisions, and women in the lowest wealth quintile are most likely to replace rice with other grains. Table 11.16 Frequency of having rice replacement Percent distribution of ever-married women age 15-49 by frequency of having her or any of her family members eat wheat or another grain in place of rice in the past 12 months, according to selected background characteristics, Bangladesh 2011 Background characteristic Never Rarely (1-6 times this year) Sometimes (7-12 times this year) Often (few times each month) Missing Total Number of women Residence Urban 88.6 8.3 2.1 0.9 0.0 100.0 4,619 Rural 80.7 13.0 4.7 1.4 0.1 100.0 13,130 Division Barisal 82.0 10.5 5.8 1.7 0.1 100.0 1,002 Chittagong 82.1 11.9 4.5 1.4 0.0 100.0 3,222 Dhaka 87.2 8.6 3.3 0.9 0.0 100.0 5,736 Khulna 81.8 13.5 3.6 1.0 0.1 100.0 2,139 Rajshahi 82.4 11.9 4.4 1.1 0.2 100.0 2,646 Rangpur 75.2 18.6 4.2 2.0 0.0 100.0 2,039 Sylhet 78.5 13.7 5.0 2.7 0.1 100.0 967 Wealth quintile Lowest 61.2 25.1 10.1 3.4 0.1 100.0 3,250 Second 75.0 17.4 5.9 1.7 0.0 100.0 3,487 Middle 86.4 9.9 3.0 0.6 0.1 100.0 3,567 Fourth 91.6 6.1 1.6 0.6 0.0 100.0 3,664 Highest 96.4 2.6 0.5 0.4 0.0 100.0 3,781 Total 82.8 11.8 4.1 1.3 0.1 100.0 17,749 Table 11.17 shows the percent distribution of ever-married women by frequency of having to ask for food from relatives or neighbors to make a meal in the past 12 months. The results indicate that a third of the women had to ask their relatives or neighbors for food at some point in the 12 months preceding the survey. Twenty-two percent of women reported asking for food rarely, 8 percent asked for food sometimes, and 3 percent asked for food often. The pattern of results by background characteristics for this food security indicator is similar to those described earlier. The only notable difference for this indicator compared with other food security indicators addressed so far is that women from Rajshahi Division are most likely to ask for food from relatives or neighbors compared with other divisions. Nutrition of Children and Adults • 195 Table 11.17 Frequency of having to ask food Percent distribution of ever-married women age 15-49 by frequency of having to ask for food from relatives or neighbors to make a meal in the past 12 months, according to selected background characteristics, Bangladesh 2011 Background characteristic Never Rarely (1-6 times this year) Sometimes (7-12 times this year) Often (few times each month) Missing Total Number of women Residence Urban 77.8 16.7 4.1 1.4 0.1 100.0 4,619 Rural 63.5 24.1 9.0 3.4 0.0 100.0 13,130 Division Barisal 67.2 18.8 10.5 3.4 0.1 100.0 1,002 Chittagong 70.5 18.5 7.5 3.6 0.0 100.0 3,222 Dhaka 70.8 19.8 7.7 1.7 0.0 100.0 5,736 Khulna 66.1 25.6 5.9 2.5 0.0 100.0 2,139 Rajshahi 61.0 27.5 8.5 3.0 0.0 100.0 2,646 Rangpur 62.3 25.7 8.0 3.9 0.1 100.0 2,039 Sylhet 65.2 21.4 7.5 5.9 0.1 100.0 967 Wealth quintile Lowest 38.2 34.9 18.6 8.1 0.1 100.0 3,250 Second 54.6 30.3 11.1 4.0 0.0 100.0 3,487 Middle 69.6 23.3 5.5 1.6 0.0 100.0 3,567 Fourth 78.9 16.6 3.7 0.8 0.0 100.0 3,664 Highest 90.2 7.8 1.2 0.6 0.1 100.0 3,781 Total 67.2 22.1 7.7 2.9 0.0 100.0 17,749 Based on the responses to the questions on the women’s perception and experience of food vulnerability, four categories of food insecurity were created to form a composite indicator. A quantitative score ranging from 0 to 3 was assigned to each food security indicator question category, with zero being the most food-secure response. After assigning the individual food frequency scores, all the frequency responses were summed in a single food security score for each ever-married woman. The range of the composite score varied from a minimum of “0” to a maximum of “15” which was then classified into the following four categories, as suggested in Household Food Insecurity Access Scale indicator calculations (Coates et al., 2007). Composite food security score Label 0 Food secure—Ever-married women who report that they did not experience any food insecurity (access) conditions or had to worry about it. This category represents women who live in food- secure households. 1 to 5 Mild food insecurity—Ever-married women who worry about not having enough food rarely or sometimes and/or are unable to eat preferred food (rice). These women do not have to cut back on quantity of food and rarely have to ask someone for food. 6 to 10 Moderate food insecurity—Ever-married women who sacrifice on eating rice and/or rarely or sometimes have to cut back on the quantity by reducing the size of the meal or number of meals. However, these women do not experience any of the conditions in the most severe form. 11 to 15 Severe food insecurity—Ever-married women who report that they never have square meals, and often have to skip the meals, and/or cut-back on food, and/or have to some other grain than rice, and/or ask for food from a relative or neighbor. 196 • Nutrition of Children and Adults Table 11.18 Food security by background characteristics Percent distribution of ever-married women 15-49 by food security, according to background characteristics, Bangladesh 2011 Background characteristic Secure Mildly food insecure Moderately food insecure Severely food insecure Total Number of women Residence Urban 75.8 19.1 4.2 0.9 100.0 4,611 Rural 61.1 27.1 10.0 1.9 100.0 13,100 Division Barisal 64.9 21.5 11.6 2.1 100.0 999 Chittagong 67.5 22.3 8.2 2.0 100.0 3,220 Dhaka 69.3 23.0 6.4 1.3 100.0 5,724 Khulna 64.7 25.1 9.1 1.1 100.0 2,135 Rajshahi 56.4 33.8 8.6 1.3 100.0 2,633 Rangpur 60.7 25.5 11.9 1.9 100.0 2,036 Sylhet 62.7 24.2 9.7 3.4 100.0 965 Wealth quintile Lowest 35.0 37.4 22.6 5.0 100.0 3,240 Second 51.4 34.3 12.3 2.0 100.0 3,482 Middle 66.6 27.1 5.7 0.6 100.0 3,562 Fourth 77.1 19.8 2.6 0.6 100.0 3,655 Highest 89.7 8.8 1.2 0.3 100.0 3,773 Total 64.9 25.0 8.5 1.6 100.0 17,712 Table 11.18 indicates that only 65 percent of the ever-married women fall in the category of being food secure based on the interview responses. One in four ever-married women is mildly food insecure, 9 percent are moderately food insecure, and 2 percent are severely food insecure. Urban women are 15 percentage points more likely to be in a food-secure environment than their rural counterparts. Among divisions, women residing in Dhaka are the most food secure (69 percent), while women in Rajshahi are least likely to be food secure (56 percent). One in three women (35 percent) in the lowest wealth quintile is food secure compared with 90 percent of women in the highest wealth quintile. Overall, it is apparent that wealth is a key predictor of food security. The variation of food security by division can be used to guide future programs and policies aimed at improving the nutritional status of women and the general population in Bangladesh. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 197 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 2011, a total of 445 new cases of HIV infection, 251 new AIDS cases, and 84 deaths due to AIDS were reported. The reported number of HIV-positive people in Bangladesh increased from 363 in 2003 to 1,207 in 2007. By the end of 2011, the number of HIV-positive people had increased to 2,533, an increase of more than double in four years. However, the estimated number of HIV/AIDS cases remains at 7,500, indicating both the likelihood of incomplete reporting and the potential for growth of the epidemic in Bangladesh (NASP, 2012). Bangladesh’s HIV/AIDS prevention program 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 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 comprised of national experts from various disciplines relevant to the prevention and control of HIV and sexually transmitted disease (STDs). With political support from the National AIDS Council 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 98 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, 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 Programme (NASP) was formed under the DGHS, and has functioned since 1998. The major role of the NASP is to A Key Findings • Sixty-nine percent of ever-married women and 88 percent of ever- married men age 15-49 have heard of AIDS. • Comprehensive knowledge of AIDS is not widespread among either women (11 percent) or men (17 percent) age 15-49. • More men than women know how HIV is transmitted. Older women and men (age 40-49) are less knowledgeable than younger respondents about how HIV infection is prevented. • Sixty-one percent of ever-married women and 79 percent of ever-married men know that the HIV virus can be transmitted both by using an unsterilized needle or syringe and by blood transfusion. • The majority of ever-married women and men (92 percent and 82 percent, respectively) think that if a woman knows her husband has a sexually transmitted infection (STI), she is justified in refusing to have sex with him. 198 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior formulate policies, coordinate information, and regulate the implementation of the HIV/AIDS prevention efforts in the country. 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 low HIV prevalence country. HIV intervention programs targeting the vulnerable population in Bangladesh evolved over a period of more than 10 years, stretching 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 targeted at the most vulnerable groups in the population. 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. 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, the 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. 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. In past 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 NGO organizations, particularly with groups considered to be at high risk for transmission of HIV/AIDS. 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 men and women of reproductive age. This chapter also discusses self-reported prevalence of sexually transmitted infections (STIs) and symptoms. 12.1 KNOWLEDGE OF HIV/AIDS AND TRANSMISSION AND PREVENTION METHODS 12.1.1 Knowledge of AIDS The 2011 BDHS included a series of questions to gauge respondents’ knowledge and attitudes about HIV and AIDS. All ever-married women age 15-49 and ever-married men 15-54 were first asked if they had ever heard of AIDS. Those who had heard of AIDS were then asked about their knowledge of HIV transmission and prevention. Table 12.1 shows that 77 percent of ever-married women and 88 percent of ever-married men have heard of HIV/AIDS. Awareness of HIV/AIDS among ever-married women varies by age and marital status, with older women and women who are divorced, separated, or widowed less likely to know about HIV. Knowledge of HIV/AIDS is higher among urban (86 percent) than rural (63 percent) women. Awareness of HIV/AIDS ranges from 79 percent among women in Khulna to 55 percent among women in HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 199 Rangpur. Nearly all women who have completed secondary education have heard of 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 wealth increases. Ever-married men show similar patterns of awareness of AIDS by background characteristics. Table 12.1 Knowledge of AIDS Percentage of ever-married women and ever-married men age 15-49 who have heard of AIDS by background characteristics, Bangladesh 2011 Background characteristic Women Men Have heard of AIDS Number of women Have heard of AIDS Number of men Age 15-24 77.3 5,484 90.2 270 15-19 75.1 1,970 * 21 20-24 78.5 3,514 91.2 249 25-29 74.7 3,394 92.0 621 30-39 67.2 4,900 90.0 1,285 40-49 55.3 3,971 82.3 1,215 Marital status Married 69.9 16,635 87.7 3,360 Divorced/separated/ widowed 57.0 1,114 (81.5) 31 Residence Urban 85.6 4,619 95.6 949 Rural 63.3 13,130 84.5 2,442 Division Barisal 70.7 1,002 87.1 174 Chittagong 68.6 3,222 86.4 519 Dhaka 75.1 5,736 92.0 1,095 Khulna 79.1 2,139 94.8 430 Rajshahi 62.9 2,646 84.9 556 Rangpur 54.9 2,039 77.0 442 Sylhet 58.1 967 82.3 175 Education No education 40.3 4,912 70.4 890 Primary incomplete 59.3 3,264 86.4 823 Primary complete1 71.8 2,062 94.1 305 Secondary incomplete 88.4 5,383 96.8 758 Secondary complete or higher2 99.1 2,127 99.5 615 Wealth quintile Lowest 43.1 3,250 71.3 654 Second 53.6 3,487 81.0 666 Middle 69.9 3,567 90.9 647 Fourth 81.2 3,664 94.3 726 Highest 93.2 3,781 99.2 699 Total 15-49 69.1 17,749 87.6 3,392 50-54 na na 72.3 605 Total 15-54 na na 85.3 3,997 Note: Numbers in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 12.1.2 Knowledge of HIV Prevention Methods HIV prevention programs focus their messages and efforts on two important aspects of behavior: (1) limiting the number of sexual partners and staying faithful to one uninfected partner and (2) using condoms. To ascertain whether programs have effectively communicated these messages, respondents were asked specific questions about whether it is possible to reduce the chance of getting the AIDS virus by using a condom at every sexual encounter and by limiting sexual intercourse to one uninfected partner. 200 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.2 shows that 51 percent of ever-married women are aware that the chance of getting the AIDS virus can be reduced by limiting sex to one uninfected partner who has no other partners; 44 percent know about using condoms at every sexual encounter, and 37 percent are aware of both of these means of reducing the risk of HIV transmission. Table 12.2 Knowledge of HIV prevention methods Percentage of ever-married women and ever-married men 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 2011 Background characteristic Women Men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner2 Number of men Age 15-24 49.0 57.6 42.0 5,484 72.0 69.6 56.5 270 15-19 47.7 56.3 41.3 1,970 * * * 21 20-24 49.6 58.3 42.3 3,514 73.4 70.2 57.4 249 25-29 48.5 54.7 41.6 3,394 75.8 74.6 63.6 621 30-39 43.3 49.2 36.7 4,900 72.4 70.9 59.5 1,285 40-49 33.0 39.8 28.1 3,971 62.3 64.4 52.3 1,215 Marital status Married 44.5 51.5 38.0 16,635 69.4 69.2 57.5 3,360 Divorced/separated/ widowed 32.7 39.4 27.6 1,114 (70.6) (59.8) (54.7) 31 Residence Urban 57.0 64.5 50.1 4,619 79.3 75.1 64.8 949 Rural 39.1 45.9 32.9 13,130 65.5 66.8 54.6 2,442 Division Barisal 48.6 55.9 42.0 1,002 64.1 67.0 52.2 174 Chittagong 43.6 50.4 37.1 3,222 65.5 64.9 53.9 519 Dhaka 47.4 55.2 41.4 5,736 72.0 72.1 58.2 1,095 Khulna 47.7 56.8 39.9 2,139 81.0 86.2 74.9 430 Rajshahi 40.8 45.3 34.0 2,646 68.3 69.5 57.4 556 Rangpur 36.8 42.0 31.4 2,039 65.0 56.7 51.6 442 Sylhet 31.3 40.1 25.9 967 56.1 53.7 40.3 175 Education No education 21.8 26.7 17.9 4,912 50.9 51.8 40.0 890 Primary incomplete 32.5 40.6 26.7 3,264 64.0 68.2 53.8 823 Primary complete3 43.1 52.1 36.4 2,062 73.7 70.6 59.0 305 Secondary incomplete 57.5 66.2 49.4 5,383 81.3 79.8 69.3 758 Secondary complete or higher4 77.2 81.4 69.3 2,127 86.6 81.7 72.1 615 Wealth quintile Lowest 25.1 30.6 20.8 3,250 55.1 54.1 44.9 654 Second 31.7 37.4 26.5 3,487 59.4 62.5 48.6 666 Middle 42.0 50.1 35.2 3,567 71.4 69.8 57.8 647 Fourth 50.8 59.5 43.4 3,664 75.8 75.5 63.2 726 Highest 65.6 72.5 57.8 3,781 83.8 82.3 71.3 699 Total 15-49 43.7 50.7 37.4 17,749 69.4 69.1 57.4 3,392 50-54 na na na na 54.5 58.3 46.3 605 Total 15-54 na na na na 67.1 67.5 55.8 3,997 Note: Numbers in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 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. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 201 Many more men than women know how HIV is transmitted. Ever-married men age 15-49 are equally likely to know that the risk of transmitting HIV can be reduced by using condoms or by limiting sexual intercourse to one uninfected partner (69 percent for each). Over half of men age 15-49 are aware of both means of reducing transmission (57 percent). Older women and men (age 40-49) are less knowledgeable about the various modes of HIV prevention than other respondents. Knowledge of prevention methods among both women and men is higher in urban than in rural areas, higher among those with more education than among those with less, and higher among those in the higher wealth quintiles than among those in lower quintiles. 12.1.3 Comprehensive Knowledge about AIDS As part of the effort to assess HIV and AIDS knowledge, the 2011 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 is defined as follows: (1) knowing that consistent condom use and having just one faithful partner can reduce the chance of getting the AIDS virus, (2) knowing that a healthy-looking person can have the AIDS virus, and (3) 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 Tables 12.3.1 and 12.3.2 indicate that many Bangladeshi adults lack accurate knowledge about the ways in which the AIDS virus can and cannot be transmitted. Table 12.3.1 shows that only 49 percent of ever-married women know that a healthy-looking person can have HIV and 32 percent know that HIV cannot be transmitted by mosquito bites. Thirty-eight percent of women correctly believe that a person cannot become infected by sharing food with a person who has AIDS. The table also shows that only 11 percent of ever-married women have comprehensive knowledge about AIDS. Comprehensive knowledge about AIDS is higher among married respondents and urban residents than among other women. Among administrative divisions, comprehensive AIDS knowledge is lowest in Rajshahi (7 percent). Comprehensive knowledge about AIDS increases with education, rising from 4 percent among women with no education to 33 percent among women who have completed secondary or higher education. Comprehensive knowledge about AIDS also increases with household wealth. Table 12.3.2 shows that 72 percent of ever-married men age 15-49 know that that a healthy- looking person can have HIV, and 43 percent know that the AIDS virus cannot be transmitted by mosquito bites. Forty-five percent of men correctly believe that a person cannot become infected by sharing food with a person who has AIDS. Men are more likely to have comprehensive knowledge of AIDS than women for all background characteristics shown. The same patterns are observed among men as are seen in the data for women with regard to comprehensive knowledge by education and wealth quintile. Figure 12.1 summarizes the information in Tables 12.3.1 and 12.3.2. 202 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Table 12.3.1 Comprehensive knowledge about AIDS: Women 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 2011 Background characteristic 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 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 Age 15-24 53.1 35.4 44.0 17.4 11.9 5,484 15-19 50.1 33.5 41.2 15.9 11.4 1,970 20-24 54.8 36.4 45.5 18.2 12.1 3,514 25-29 52.0 37.4 44.2 19.8 12.6 3,394 30-39 48.7 31.8 36.3 16.8 11.5 4,900 40-49 40.5 24.4 27.2 12.6 8.6 3,971 Marital status Married 49.3 32.9 38.8 16.9 11.4 16,635 Divorced/separated/ widowed 41.7 24.3 27.8 12.1 7.7 1,114 Residence Urban 61.3 47.5 55.6 28.1 20.1 4,619 Rural 44.5 27.0 32.0 12.6 8.0 13,130 Division Barisal 54.8 30.8 33.5 14.7 9.5 1,002 Chittagong 40.9 33.6 39.8 13.9 8.9 3,222 Dhaka 54.7 37.9 44.4 21.2 15.5 5,736 Khulna 59.0 34.3 42.8 18.4 11.6 2,139 Rajshahi 45.2 24.3 31.9 12.7 7.4 2,646 Rangpur 39.4 26.8 27.1 14.0 9.7 2,039 Sylhet 41.7 25.7 30.2 12.9 7.5 967 Education No education 27.9 14.9 16.3 5.9 3.7 4,912 Primary incomplete 41.6 21.8 26.9 8.7 4.9 3,264 Primary complete3 49.3 31.2 35.9 15.9 10.7 2,062 Secondary incomplete 62.4 41.7 50.0 20.9 13.5 5,383 Secondary complete or higher4 73.7 65.8 77.9 43.3 32.7 2,127 Wealth quintile Lowest 30.5 15.5 17.4 6.2 3.4 3,250 Second 37.7 19.9 23.4 8.2 5.3 3,487 Middle 49.2 29.7 34.7 13.5 8.2 3,567 Fourth 56.6 38.8 46.4 20.4 13.4 3,664 Highest 67.0 54.5 64.8 32.6 24.0 3,781 Total 15-49 48.9 32.3 38.1 16.6 11.2 17,749 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. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 203 Table 12.3.2 Comprehensive knowledge about AIDS: Men Percentage of men 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 AIDS transmission or prevention, and the percentage with a comprehensive knowledge about AIDS by background characteristics, Bangladesh 2011 Background characteristic 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 men 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 Age 15-24 70.6 42.4 41.4 19.5 14.4 270 15-19 * * * * * 21 20-24 71.4 43.2 43.1 21.0 15.4 249 25-29 72.5 43.0 50.8 22.3 16.2 621 30-39 74.1 44.6 48.7 24.6 18.2 1,285 40-49 68.9 40.6 40.1 22.2 16.1 1,215 Marital status Married 71.6 42.7 45.5 23.0 16.8 3,360 Divorced/separated/ widowed (73.8) (39.8) (34.1) (21.6) (14.2) 31 Residence Urban 79.2 54.0 58.1 33.5 24.4 949 Rural 68.7 38.3 40.5 18.9 13.8 2,442 Division Barisal 79.8 36.0 39.2 23.1 15.0 174 Chittagong 72.0 38.0 45.4 21.3 15.0 519 Dhaka 74.2 47.4 48.8 27.2 19.7 1,095 Khulna 79.9 52.7 52.4 26.2 22.6 430 Rajshahi 68.4 38.9 43.1 20.0 15.0 556 Rangpur 58.9 36.6 39.0 16.9 12.0 442 Sylhet 69.5 36.8 37.4 18.1 9.5 175 Education No education 54.7 25.7 26.3 8.6 6.5 890 Primary incomplete 68.3 37.6 35.7 15.9 10.5 823 Primary complete3 75.6 44.6 45.6 22.2 15.5 305 Secondary incomplete 80.9 48.5 53.7 26.5 19.3 758 Secondary complete or higher4 87.3 65.9 76.0 49.2 37.7 615 Wealth quintile Lowest 55.3 26.9 24.4 9.5 7.2 654 Second 65.4 33.9 36.0 13.8 8.7 666 Middle 73.9 38.6 42.4 20.7 15.1 647 Fourth 78.3 50.4 51.7 27.0 19.7 726 Highest 83.9 61.5 70.3 42.1 32.1 699 Total 15-49 71.7 42.7 45.4 23.0 16.8 3,392 50-54 58.4 33.2 33.0 18.3 13.3 605 Total 15-54 69.6 41.2 43.5 22.3 16.3 3,997 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. 204 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Figure 12.1 Comprehensive knowledge about AIDS among ever-married women and men 15-49 49 32 38 17 11 72 43 45 23 17 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 Women Men Percent BDHS 2011 12.2 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Knowledge about how to prevent mother-to-child transmission (MTCT) of HIV and how to use antiretroviral medication before delivery to reduce transmission is critical. To assess MTCT knowledge, ever-married women age 15-49 were asked whether HIV can be transmitted from a mother to a child through breastfeeding and whether a mother can reduce the chance of transmitting HIV to her child during pregnancy and delivery by taking antiretroviral drugs. Table 12.4 shows that 59 percent of ever-married women know that HIV can be transmitted during pregnancy, while 48 percent of women know that HIV can be transmitted during delivery, and 56 percent of women know that HIV can be transmitted through breastfeeding. Knowledge of MTCT is highest among young women, married women, urban women, women living in Khulna, women who have completed secondary or higher education, and women who belong to the highest wealth quintile. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 205 Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV: Women 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 the mother taking special drugs during pregnancy, by background characteristics, Bangladesh 2011 Background characteristic Percentage who know that HIV can be transmitted: Number of women During pregnancy During delivery By breastfeeding Age 15-24 63.8 50.8 61.1 5,484 15-19 61.1 48.8 59.2 1,970 20-24 65.4 51.9 62.2 3,514 25-29 63.9 52.1 60.7 3,394 30-39 58.4 48.5 55.8 4,900 40-49 47.5 38.8 45.4 3,971 Marital status Married 59.4 48.3 56.8 16,635 Divorced/separated/ widowed 48.5 39.7 45.4 1,114 Currently pregnant Pregnant 61.4 48.0 58.2 1,069 Not pregnant or not sure 58.5 47.7 55.9 16,680 Residence Urban 72.3 58.4 67.3 4,619 Rural 53.9 44.0 52.1 13,130 Division Barisal 62.2 53.9 58.9 1,002 Chittagong 58.6 47.4 54.0 3,222 Dhaka 63.0 48.9 60.4 5,736 Khulna 68.2 57.6 66.3 2,139 Rajshahi 53.6 44.9 51.9 2,646 Rangpur 46.1 38.2 44.7 2,039 Sylhet 49.2 41.5 47.1 967 Education No education 33.1 27.4 32.2 4,912 Primary incomplete 49.8 41.2 49.5 3,264 Primary complete1 61.1 49.5 58.2 2,062 Secondary incomplete 75.5 61.1 71.7 5,383 Secondary complete or higher2 86.7 69.1 79.8 2,127 Wealth quintile Lowest 35.9 30.1 36.1 3,250 Second 45.1 36.2 43.2 3,487 Middle 59.6 48.9 57.5 3,567 Fourth 68.7 56.0 65.9 3,664 Highest 80.2 64.4 74.2 3,781 Total 15-49 58.7 47.7 56.1 17,749 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 whether respondents know about nonsexual means of transmission of HIV, the 2011 BDHS 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 64 percent of ever-married women and 81 percent of ever-married men know that the AIDS virus can be transmitted by using an unsterilized needle or syringe, while 63 percent of women and 83 percent of men know that the AIDS virus can be transmitted through blood transfusion. Sixty-one percent of women and 79 percent of men know both of these means of HIV transmission. Table 12.5 also reveals considerable variation in respondents’ knowledge of HIV transmission by 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 who belong to the highest wealth quintile. Similar patterns are observed for men. 206 • 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 and men 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 2011 Background characteristic Women Men Using an unsterilized needle or syringe Via blood transfusion Both Number of women Using an unsterilized needle or syringe Via blood transfusion Both Number of men Age 15-24 71.5 71.2 68.8 5,484 78.3 81.0 75.1 270 15-19 69.0 67.9 65.6 1,970 * * * 21 20-24 73.0 73.0 70.6 3,514 78.3 82.0 75.5 249 25-29 69.8 68.6 66.8 3,394 85.4 87.0 82.8 621 30-39 62.1 61.7 59.7 4,900 84.4 85.1 82.8 1,285 40-49 50.0 50.1 47.7 3,971 76.6 77.8 74.8 1,215 Marital status Married 64.6 64.1 62.0 16,635 81.3 82.6 79.4 3,360 Divorced/separated/ widowed 51.6 51.6 49.0 1,114 (75.7) (69.7) (69.7) 31 Residence Urban 80.2 80.4 78.2 4,619 90.0 92.9 89.4 949 Rural 58.0 57.4 55.2 13,130 77.9 78.4 75.4 2,442 Division Barisal 65.3 65.1 62.6 1,002 79.8 80.8 77.6 174 Chittagong 62.9 62.1 60.0 3,222 78.4 77.3 75.1 519 Dhaka 69.8 69.8 67.6 5,736 86.2 87.8 84.7 1,095 Khulna 74.4 72.8 71.1 2,139 89.9 90.9 88.6 430 Rajshahi 57.5 57.8 55.2 2,646 78.3 80.0 76.2 556 Rangpur 49.9 49.2 47.2 2,039 71.7 73.8 69.7 442 Sylhet 52.6 51.7 49.5 967 73.1 75.5 71.1 175 Education No education 34.9 35.0 32.9 4,912 62.2 62.8 59.9 890 Primary incomplete 53.2 52.4 50.4 3,264 79.7 80.7 77.2 823 Primary complete1 66.1 64.7 62.8 2,062 84.9 87.6 82.8 305 Secondary incomplete 82.9 82.4 80.0 5,383 91.3 92.8 89.1 758 Secondary complete or higher2 96.0 96.1 94.2 2,127 97.0 98.1 96.5 615 Wealth quintile Lowest 38.7 38.1 36.5 3,250 62.8 63.4 59.8 654 Second 48.4 48.1 46.0 3,487 74.6 76.3 72.6 666 Middle 63.0 62.7 60.0 3,567 83.6 85.6 81.7 647 Fourth 75.3 74.4 72.1 3,664 88.6 88.6 85.9 726 Highest 89.2 89.0 87.1 3,781 95.3 97.0 95.0 699 Total 15-49 63.8 63.4 61.2 17,749 81.3 82.5 79.3 3,392 50-54 na na na na 65.7 66.3 63.8 605 Total 15-54 na na na na 78.9 80.0 77.0 3,997 Note: Numbers in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 12.4 ATTITUDES TOWARD NEGOTIATING SAFE SEXUAL RELATIONS WITH HUSBANDS Comprehensive knowledge about HIV transmission and ways to prevent it are basic prerequisites for HIV prevention. Translating knowledge into behavior, however, depends on a number of individual, social, and contextual factors. One of the important determinants of practicing safer sex is control over one’s own sexuality. 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. In an effort to assess a woman’s ability to negotiate safer sex, the 2011 BDHS asked women and men 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. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 207 Table 12.6 shows that the majority of ever-married women and men (92 percent and 82 percent, respectively) think that if a woman knows her husband has a sexually transmitted infection (STI), she is justified in refusing to have sex with him. There are minimal variations in women’s attitudes toward negotiating safer sex with husbands by background characteristics. The exception is for administrative division: the proportion of women who support a woman’s right to refuse sex ranges from 86 percent in Chittagong to 97 percent in Dhaka. Seventy-three percent of men in Bangladesh believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows he has sex with other women. Table 12.6 Attitudes toward negotiating safer sexual relations with husband Percentage of ever-married women and ever-married men-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), and percentage of ever-married men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows he has sex with other women, by background characteristics, Bangladesh 2011 Background characteristic Women Men Woman is justified in: Woman is justified in: Refusing to have sexual intercourse with her husband if she knows that her husband has an STI Number of women Refusing to have sexual intercourse with her husband if she knows he has sex with other women Refusing to have sexual intercourse with her husband if she knows that her husband has an STI Number of men Age 15-24 92.5 5,484 70.9 80.3 270 15-19 92.6 1,970 * * 21 20-24 92.4 3,514 70.6 79.8 249 25-29 92.8 3,394 71.1 77.8 621 30-39 92.5 4,900 74.5 83.0 1,285 40-49 91.4 3,971 73.7 82.5 1,215 Marital status Married 92.3 16,635 73.3 81.8 3,360 Divorced/separated/ widowed 91.8 1,114 (67.1) (71.6) 31 Residence Urban 94.0 4,619 80.0 85.9 949 Rural 91.7 13,130 70.7 80.0 2,442 Division Barisal 90.7 1,002 75.1 82.6 174 Chittagong 85.5 3,222 71.9 76.4 519 Dhaka 96.8 5,736 83.6 87.7 1,095 Khulna 95.9 2,139 68.2 82.3 430 Rajshahi 88.2 2,646 65.7 78.8 556 Rangpur 95.0 2,039 63.1 80.0 442 Sylhet 87.2 967 73.2 70.5 175 Education No education 91.8 4,912 69.9 80.3 890 Primary incomplete 92.3 3,264 73.9 80.8 823 Primary complete1 92.1 2,062 71.5 79.5 305 Secondary incomplete 92.3 5,383 75.6 82.3 758 Secondary complete or higher2 93.7 2,127 75.3 85.1 615 Wealth quintile Lowest 91.9 3,250 69.6 80.5 654 Second 92.1 3,487 70.0 80.4 666 Middle 92.2 3,567 72.3 81.5 647 Fourth 90.8 3,664 74.7 80.6 726 Highest 94.4 3,781 79.4 85.2 699 Total 15-49 92.3 17,749 73.3 81.7 3,392 50-54 na na 70.8 82.7 605 Total 15-54 na na 72.9 81.8 3,997 Note: Numbers in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 208 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior 12.5 SELF-REPORTED PREVALENCE OF SEXUALLY TRANSMITTED INFECTIONS (STIS) AND STI SYMPTOMS Information about the prevalence of sexually transmitted infections (STIs) is useful not only as a marker of unprotected sexual intercourse but also as a cofactor for HIV transmission. STIs are closely associated with HIV because they increase the likelihood of contracting HIV and share similar risk factors. The 2011 BDHS asked respondents who ever had sex whether, in the past 12 months, they had contracted a disease through sexual contact. They were also asked whether they had experienced a genital sore or ulcer or had any abnormal genital discharge in the past year. These symptoms are useful in identifying STIs among men. However, they are less easily interpreted in women because women are likely to experience more conditions of the reproductive tract other than STIs that produce a genital discharge. Table 12.7 shows that self-reported STI prevalence among ever-married women and men age 15- 49 in Bangladesh is small. About 1 percent of women and 3 percent of men report having had an STI in the 12 months prior to the survey. It is likely that these figures underestimate the actual prevalence of STIs among the sexually active population in Bangladesh, as many STI symptoms are not easily recognized, and many STIs do not have visible symptoms. Self-reported prevalence of STIs and/or STI symptoms, including genital sore or ulcer and bad smelling or abnormal genital discharge, is higher among women than men. Fifteen percent of ever-married women report having had an STI and/or symptoms of an STI in the 12 months prior to the survey, compared with only 6 percent of men. 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 (7 percent). The percentage of women and men reporting an STI and/or STI symptoms is highest in Barisal and lowest in Rangpur. When women or men reported having an STI, STI symptoms, or both in the past 12 months, the 2011 BDHS interviewer asked them whether they sought any advice or treatment for it. Figure 12.2 shows that 45 percent of women and 42 percent of men sought no advice or treatment, while 31 percent of women and 17 percent of men sought advice or treatment from a clinic, hospital, private doctor, or other health professional. More men (26 percent) than women (8 percent) sought advice or medicine from a shop/pharmacy. HIV/AIDS-Related Knowledge, Attitudes, and Behavior • 209 Table 12.7 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms Among ever-married women and men 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 2011 Background characteristic Women Men STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/ genital discharge/ sore or ulcer Number of women who ever had sexual inter- course STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/ genital discharge/ sore or ulcer Number of men who ever had sexual inter- course Age 15-24 0.5 10.1 6.5 14.2 5,461 2.5 1.7 4.7 6.7 270 15-19 0.4 8.7 5.3 12.0 1,953 * * * * 21 20-24 0.6 10.9 7.1 15.4 3,508 2.7 1.5 5.0 7.0 249 25-29 1.0 12.3 7.6 16.5 3,393 2.7 1.8 4.8 7.6 619 30-39 1.0 11.0 7.8 15.4 4,895 2.5 1.2 3.2 5.8 1,284 40-49 0.8 8.8 6.0 12.5 3,968 3.3 1.3 2.7 5.6 1,214 Marital status Married 0.8 10.5 7.0 14.7 16,613 2.8 1.4 3.4 6.1 3,357 Divorced/separated/ widowed 0.7 10.5 5.6 13.5 1,105 (2.1) (0.0) (8.6) (8.6) 30 Residence Urban 0.8 9.4 6.2 13.1 4,611 2.3 0.9 2.4 4.5 949 Rural 0.8 10.8 7.2 15.1 13,106 3.0 1.6 3.9 6.8 2,438 Division Barisal 2.7 11.3 9.1 16.4 1,001 5.4 2.5 5.7 10.9 174 Chittagong 0.7 10.3 8.8 15.4 3,213 2.1 1.8 6.2 8.0 516 Dhaka 0.6 9.8 6.0 13.5 5,728 3.7 0.7 1.8 5.1 1,095 Khulna 0.9 12.0 7.7 16.3 2,132 1.7 1.9 4.6 6.2 429 Rajshahi 0.8 11.8 7.3 16.2 2,646 3.1 2.2 3.6 6.7 556 Rangpur 0.5 9.2 5.0 12.5 2,031 1.5 0.6 1.7 3.3 441 Sylhet 1.2 9.6 6.1 12.7 966 2.2 1.5 4.8 7.3 175 Education No education 0.5 11.2 6.8 14.7 4,909 3.5 1.9 3.5 6.5 889 Primary incomplete 1.0 11.7 8.0 16.5 3,261 2.7 1.3 3.8 7.0 821 Primary complete1 0.8 11.4 7.5 15.2 2,061 3.9 2.2 4.8 8.1 305 Secondary incomplete 1.0 10.2 6.9 14.6 5,369 2.3 1.2 3.6 6.0 756 Secondary complete or higher2 1.0 6.6 5.4 10.8 2,117 2.2 0.6 2.0 3.6 615 Wealth quintile Lowest 0.5 12.6 8.2 17.1 3,243 3.8 1.4 4.3 7.9 653 Second 0.7 11.7 7.4 15.8 3,480 2.0 2.1 3.9 6.8 664 Middle 0.9 11.0 6.5 14.8 3,563 3.7 1.6 4.7 7.6 647 Fourth 1.1 9.9 7.0 14.3 3,655 3.0 1.3 3.0 5.7 724 Highest 0.9 7.5 5.8 11.4 3,776 1.6 0.6 1.5 2.9 699 Total 15-49 0.8 10.5 7.0 14.6 17,717 2.8 1.4 3.5 6.1 3,387 50-54 na na na na na 2.2 0.7 1.6 4.3 604 Total 15-54 na na na na na 2.7 1.3 3.2 5.9 3,991 Note: Numbers in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 210 • HIV/AIDS-Related Knowledge, Attitudes, and Behavior Figure 12.2 Women and men seeking treatment for STIs 31 8 18 45 17 26 20 42 Clinic/hospital/private doctor/other health professional Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment Percentage Women Men BDHS 2011 Women’s Empowerment and Demographic and Health Outcomes • 211 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 13 he 1994 International Conference on Population and Development declared that “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 programmes” (United Nations, 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 Programme’s (UNDP) Human Development Report for 2011, Bangladesh ranks 112 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 labour market.” The 2011 Global Gender Gap Index, developed by the World Economic Forum, ranks Bangladesh 69 out of 135 countries in terms of gender equality (Hausmann et al., 2011). Thus, based on both gender-related indices, Bangladesh ranks among the bottom half of countries included in each index. Empowerment and autonomy 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 the sharing of responsibilities for the care and nurture of children as well as for the maintenance of the household. In Bangladesh, women’s empowerment is high on the list of priority improvements sought in the social and economic conditions of its people. Data from the 2011 BDHS, previously discussed, show that women lag behind men in educational attainment, literacy, employment, and exposure to mass media. Achievements in these areas are critical 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 personality and can help strengthen her position in the household and in society. In this chapter, 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 T Key Findings • Over one-third of currently married employed women who earn cash make decisions mainly by themselves on how to use their own earnings. • More than half of currently married women go alone to the health center or hospital. • Less than half (42 percent) of currently married women participate in all four decisions regarding their own health care, major household purchases, child health care, and visits to their family or relatives. • One in three women agree with one or more reasons justifying wife beating. • Contraceptive use increases as women’s score on the decision making increases. • Access to antenatal care, delivery assistance, and postnatal care within the first two days of delivery from health personnel increases the higher is women's score on the empowerment indices. 212 • Women’s Empowerment and Demographic and Health Outcomes women’s acceptance of wife beating are discussed. 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 contraception, and receipt of health care services during pregnancy, at delivery, and in the postnatal period. In addition, survivorship of children is tabulated by these indices. 13.1 EMPLOYMENT AND FORM OF EARNINGS Employment, particularly employment for cash, and control over how earnings are used are important indicators of empowerment for women. 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, both, or neither). Thirteen percent of currently married women age 15-49 reported being employed in the past 12 months. By age, employment increases from 8 percent among women age 15-19 to 16 percent among women age 30-34, before declining to 12 percent in the oldest age group (45-49 years). Although employment is assumed to go hand in hand with payment for work, not all women receive earnings for the work they do. Even among women who receive earnings, not all are paid in cash. Ninety-two percent of employed women are paid in cash only, 4 percent receive both cash and in-kind earnings, 2 percent are paid in kind, and 1 percent does not receive any form of payment for their work. Women age 15-19 are more likely to be paid in cash (97 percent) than their older counterparts. 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 2011 Age 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 Percentage employed Number of women Cash only Cash and in-kind In-kind only Not paid Missing/ don’t know 15-19 7.9 1,925 97.3 1.3 0.8 0.6 0.0 100.0 153 20-24 12.5 3,396 94.6 2.9 0.8 1.1 0.6 100.0 425 25-29 15.4 3,262 94.7 2.8 1.6 0.9 0.0 100.0 501 30-34 15.9 2,532 91.6 4.2 1.8 1.3 1.2 100.0 404 35-39 14.1 2,081 91.2 4.7 2.0 2.1 0.0 100.0 294 40-44 13.2 1,937 87.5 6.5 3.7 0.8 1.6 100.0 255 45-49 11.9 1,501 85.3 8.1 3.9 0.9 1.8 100.0 179 Total 13.3 16,635 92.2 4.1 1.9 1.1 0.7 100.0 2,210 13.2 WOMEN’S CONTROL OVER THEIR OWN EARNINGS Besides having access to income, women need to have control over their earnings to be empowered. To assess control over earnings, the survey asked currently married women with cash earnings in the past 12 months who the main decision maker is with regard to the use of their earnings. It is expected that women who control their own cash earnings will have a greater say in the use of 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. Over one-third of currently married women who earn cash report that they themselves mainly decide how their cash earnings are used; another 55 percent report that they decide jointly with their husbands, and 8 percent Women’s Empowerment and Demographic and Health Outcomes • 213 report that their husbands alone decide how their earnings are used. Women age 30-34 are less likely than older and younger women to mainly decide by themselves how their earnings are used (30 percent). Women with no children are more likely to make decisions regarding the use of their earnings than women with children. For example, 37 percent of currently married women with no children mainly decide by themselves how their earnings are used compared with 30 percent of women with five or more children. Urban women are more likely than rural women to mainly make decisions themselves about spending their earnings (36 percent and 32 percent, respectively). Rural women are more likely than urban women to report that their husbands alone make decisions about the use of their earnings (11 percent versus 5 percent, respectively). 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 2011 Background characteristic Person who decides how the wife’s cash earnings are used: Total Number of employed women with cash earnings Mainly wife Wife and husband jointly Mainly husband Other Missing Age 15-19 34.4 47.7 6.9 8.1 2.9 100.0 150 20-24 34.2 49.4 12.3 1.2 2.9 100.0 414 25-29 33.8 56.1 7.5 0.7 1.8 100.0 488 30-34 30.4 59.6 8.1 0.2 1.7 100.0 386 35-39 32.2 57.2 6.2 0.0 4.3 100.0 282 40-44 39.7 52.6 5.1 0.5 2.2 100.0 240 45-49 31.6 56.5 8.1 0.4 3.4 100.0 167 Number of living children 0 37.0 46.0 8.9 3.6 4.5 100.0 254 1-2 34.5 55.1 7.0 1.0 2.3 100.0 1,220 3-4 30.7 56.8 10.1 0.3 2.1 100.0 534 5+ 29.8 58.1 8.6 0.0 3.5 100.0 121 Residence Urban 35.9 56.4 4.6 0.9 2.3 100.0 868 Rural 32.0 53.4 10.5 1.2 2.8 100.0 1,260 Division Barisal 41.8 50.9 7.0 0.0 0.3 100.0 99 Chittagong 37.0 51.0 7.1 2.5 2.4 100.0 321 Dhaka 33.5 57.1 6.5 0.7 2.2 100.0 800 Khulna 40.7 46.1 9.0 0.8 3.3 100.0 241 Rajshahi 33.4 51.1 10.7 1.7 3.1 100.0 343 Rangpur 18.7 69.5 7.8 0.4 3.6 100.0 245 Sylhet 35.5 43.4 17.4 0.7 3.0 100.0 79 Education No education 25.4 62.6 8.5 0.4 3.1 100.0 581 Primary incomplete 30.3 57.6 8.8 0.6 2.7 100.0 405 Primary complete1 36.3 48.8 11.8 1.0 2.1 100.0 216 Secondary incomplete 39.5 47.1 7.9 2.8 2.7 100.0 502 Secondary complete or higher2 39.6 52.8 5.2 0.5 2.0 100.0 425 Wealth quintile Lowest 29.7 56.0 10.4 0.7 3.3 100.0 400 Second 24.1 60.1 10.8 1.2 3.8 100.0 358 Middle 34.7 51.5 10.8 1.4 1.5 100.0 367 Fourth 37.3 52.2 7.2 1.4 1.9 100.0 484 Highest 38.9 54.3 3.4 0.9 2.5 100.0 519 Total 33.6 54.6 8.1 1.1 2.6 100.0 2,128 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. There is substantial variation among the divisions in who makes decisions on how women’s earnings are used. The proportion of employed women who mainly decide by themselves about the use of their earnings ranges from a high of 42 percent in Barisal to a low of 19 percent in Rangpur. Joint decision making on how the wife’s earnings are used also varies among the divisions, ranging from 43 percent in 214 • Women’s Empowerment and Demographic and Health Outcomes Sylhet to 70 percent in Rangpur. The women in Sylhet are more likely to have their husbands decide how their earnings are used (17 percent) than women in any other division. Women’s decision-making power regarding their earnings increases with their level of education and household wealth. Two in five women who have at least some secondary education mainly make the decision by themselves on how to use the money they earn compared with one in four women with no education (25 percent). Women with no education are more likely to decide jointly with their husbands (63 percent) about the use of their earnings. Thirty-nine percent of women in the highest wealth quintile mainly decide by themselves about the use of their earnings compared with 30 percent of women in the lowest wealth quintile. 13.3 FREEDOM OF MOVEMENT Freedom of movement outside the home is an important aspect of women’s autonomy and empowerment. This is particularly true in a largely patriarchal country such as Bangladesh with a long tradition, especially in rural areas, of purdah, which is the practice of secluding women from the view of men. The 2011 BDHS asked currently married women whether they go to a health center or hospital or, if they don’t go, whether they can go alone or with their young children to a health center or hospital. Table 13.3 shows that 56 percent of women say that they go alone or with their young children to a health center or hospital and 22 percent do not go to a health center or hospital but say that they can go to these health facilities alone or with their children. The proportion of women who cannot go to the hospital or health center alone or accompanied by their children decreases from 42 percent among women age 15-19 to 16- 18 percent among older women. Women with 1 to 4 children, urban women, 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. On the other hand, young women, rural women, women in Sylhet, and women in the lower wealth quintiles are more likely to be among those who cannot go to a health facility alone or accompanied by their young children. Women’s Empowerment and Demographic and Health Outcomes • 215 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 2011 Background characteristic Go alone or with children to health center or hospital Do not go to health center or hospital Other Total Number of women Can go alone or with children Cannot go alone or with children Age 15-19 44.6 12.3 41.5 1.6 100.0 1,925 20-24 53.5 20.8 24.5 1.2 100.0 3,396 25-29 57.8 24.3 17.5 0.3 100.0 3,262 30-34 59.1 24.8 15.9 0.2 100.0 2,532 35-39 59.7 23.9 16.1 0.3 100.0 2,081 40-44 58.7 24.1 16.7 0.5 100.0 1,937 45-49 57.3 24.4 18.0 0.3 100.0 1,501 Number of living children 0 50.7 2.1 44.5 2.7 100.0 1,688 1-2 57.3 22.4 19.7 0.5 100.0 8,389 3-4 57.6 26.1 16.0 0.2 100.0 5,037 5+ 47.9 30.3 21.5 0.3 100.0 1,521 Residence Urban 63.3 20.1 16.3 0.3 100.0 4,292 Rural 53.3 22.9 23.0 0.8 100.0 12,343 Division Barisal 59.2 21.6 18.0 1.2 100.0 952 Chittagong 51.4 23.5 24.3 0.8 100.0 3,015 Dhaka 57.0 21.9 20.6 0.5 100.0 5,334 Khulna 60.6 20.7 18.7 0.0 100.0 1,996 Rajshahi 53.5 23.9 21.8 0.8 100.0 2,526 Rangpur 59.7 21.0 18.4 1.0 100.0 1,927 Sylhet 49.2 21.4 28.4 0.9 100.0 884 Education No education 52.2 24.0 23.2 0.7 100.0 4,379 Primary incomplete 53.4 25.4 20.6 0.6 100.0 3,056 Primary complete1 53.1 24.1 22.4 0.5 100.0 1,963 Secondary incomplete 57.1 20.4 21.7 0.8 100.0 5,176 Secondary complete or higher2 67.1 16.4 15.9 0.5 100.0 2,061 Wealth quintile Lowest 50.7 24.4 24.1 0.8 100.0 2,975 Second 53.2 22.5 23.5 0.8 100.0 3,267 Middle 53.2 22.7 23.3 0.7 100.0 3,372 Fourth 56.6 23.0 19.7 0.7 100.0 3,457 Highest 64.6 18.8 16.4 0.2 100.0 3,564 Total 55.9 22.2 21.2 0.6 100.0 16,635 1 Primary complete is defined as completing grade 5. 2 Secondary complete is defined as completing grade 10. 13.4 WOMEN’S EMPOWERMENT The 2011 BDHS survey collected information from women on other measures of women’s autonomy and status. In particular, questions were asked about women’s participation in household decisions and their attitudes regarding 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 their overall welfare. To assess currently married women’s decision-making autonomy, the 2011 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 216 • Women’s Empowerment and Demographic and Health Outcomes currently married women age 15-49, according to the person in the household who usually makes decisions concerning these matters. 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 2011 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number of women Own health care 12.9 50.1 30.6 6.0 0.2 0.1 100.0 16,635 Major household purchases 7.0 52.5 29.8 10.2 0.3 0.1 100.0 16,635 Child health care 14.5 52.1 19.6 4.6 9.0 0.2 100.0 16,635 Visits to her family or relatives 9.7 52.9 28.7 8.2 0.3 0.2 100.0 16,635 Half of women make each of the four types of decisions jointly with their husbands. About thirty percent of currently married women report that their husbands are the main decision makers for decisions 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; 15 percent say that they mainly make these decisions, and 20 percent report that their husbands mainly make these decisions. Table 13.5 shows how currently married women’s participation (alone or jointly) in decision making varies by background characteristics. The table presents the results for the four specific types of decisions asked about, 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 individual decision either alone or jointly with their husbands. Forty-two percent of currently married women participate in all four decisions, and 19 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, with women age 15-24 being the least likely to participate in all four decisions. Urban women participate more in all four decisions than their rural counterparts (48 percent versus 39 percent, respectively). As expected, employed women who have cash earnings are more likely to participate in all four decisions than women who are not employed (52 percent versus 40 percent, respectively). Women with no children are less likely to participate in all four household decisions (8 percent) than women with children (42 percent or higher). Among administrative divisions, women’s participation in decision making is lowest in Sylhet (35 percent) and Rajshahi (36 percent). Women in Sylhet also have the highest percentage of women who do not participate in any of the four types of decisions (25 percent). Women’s participation in decision making does not vary greatly by education or wealth, although women who have completed secondary or higher education (48 percent) and women in the highest wealth quintile (48 percent) are most likely to participate in all four decisions, and least likely to not participate in all four decisions. Women’s Empowerment and Demographic and Health Outcomes • 217 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 husbands, by background characteristics, Bangladesh 2011 Background characteristic Specific decisions Percentage who participate in all four decisions Percentage who participate in none of the four decisions Number of women Woman’s own health care Making major household purchases Child’s health care Visits to her family or relatives Age 15-19 48.1 40.1 36.7 44.4 20.0 34.3 1,925 20-24 55.9 52.7 58.7 55.9 33.0 23.2 3,396 25-29 67.0 61.4 73.2 63.9 45.1 15.7 3,262 30-34 69.1 67.2 76.2 68.3 50.3 13.0 2,532 35-39 71.6 67.8 77.0 71.2 52.4 13.2 2,081 40-44 67.4 66.7 73.4 70.3 48.4 13.6 1,937 45-49 61.9 62.2 69.1 66.6 42.1 16.4 1,501 Employment (last 12 months) Not employed 61.3 57.3 65.7 61.1 39.9 19.6 14,425 Employed for cash 75.2 74.0 72.8 72.8 52.4 11.0 2,128 Employed not for cash 65.5 62.8 73.7 66.8 47.2 18.5 67 Number of living children 0 50.1 43.3 11.9 48.5 7.9 34.7 1,688 1-2 64.2 60.0 72.5 63.3 44.7 17.1 8,389 3-4 66.2 64.3 73.9 66.5 47.2 15.2 5,037 5+ 60.7 59.2 70.3 61.4 42.3 18.8 1,521 Residence Urban 68.6 68.1 71.3 71.2 48.4 13.4 4,292 Rural 61.1 56.5 65.0 59.6 39.2 20.3 12,343 Division Barisal 65.8 60.2 71.2 64.7 46.2 18.3 952 Chittagong 61.1 53.3 63.4 55.7 38.5 22.9 3,015 Dhaka 62.9 62.0 65.9 67.3 41.9 16.9 5,334 Khulna 65.5 62.5 72.1 64.3 42.9 15.1 1,996 Rajshahi 60.3 57.1 62.1 57.0 36.1 20.5 2,526 Rangpur 69.0 66.7 73.2 69.2 51.9 14.1 1,927 Sylhet 56.5 49.4 62.9 53.2 35.0 24.6 884 Education No education 62.4 60.4 67.2 63.7 42.4 18.7 4,379 Primary incomplete 62.1 60.6 69.0 61.8 41.8 18.1 3,056 Primary complete1 60.3 56.2 64.4 60.9 40.6 21.8 1,963 Secondary incomplete 61.9 56.8 63.7 59.2 38.3 19.8 5,176 Secondary complete or higher2 71.3 65.9 71.2 71.7 48.3 12.2 2,061 Wealth quintile Lowest 62.0 59.9 65.5 61.8 41.0 18.9 2,975 Second 61.0 58.1 65.1 59.5 39.6 20.3 3,267 Middle 59.9 56.5 63.2 59.2 38.4 21.4 3,372 Fourth 63.2 57.3 66.6 62.1 40.1 18.8 3,457 Highest 68.5 65.5 72.1 69.8 48.1 13.4 3,564 Total 63.0 59.5 66.6 62.6 41.5 18.5 16,635 Note: Total includes 15 women with missing information on employment in the last 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. Two in five currently married women participate in all four household decisions, yet about one in five participates in none. 218 • Women’s Empowerment and Demographic and Health Outcomes Figure 13.1 Number of decisions in which currently married women participate 19 11 12 17 42 1 2 3 4 5 Percentage Number of household decisions BDHS 2011 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. One of the most common forms of violence against women worldwide is abuse by the husband or partner (Heise et al., 1999). The 2011 BDHS obtained information on women’s attitudes toward wife beating. Women were asked 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 currently married women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics. One-third 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 (22 percent), followed by neglecting the children (19 percent). Less than one-fifth of women (17 percent) agree that going out without telling her husband is a justifiable reason for wife beating. Eight percent of women agree that refusing to have sexual intercourse is an acceptable reason for a man 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 with age or marital status. Women who are employed and get paid in cash (30 percent), reside in urban areas (24 percent), reside in Khulna (27 percent), have completed secondary or higher education (18 percent), and are in households within the highest wealth quintile (19 percent) are less likely than most other women to agree with at least one reason for wife beating. Women’s Empowerment and Demographic and Health Outcomes • 219 Table 13.6 Women’s attitude toward wife beating Percentage of women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, by background characteristics, Bangladesh 2011 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of women Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 4.1 22.4 14.3 18.7 6.5 32.7 1,970 20-24 3.8 22.4 16.5 19.2 7.9 32.2 3,514 25-29 2.8 21.0 16.2 18.4 7.7 31.3 3,394 30-34 3.9 21.2 18.3 18.4 8.3 32.1 2,654 35-39 4.6 23.4 18.5 19.3 8.7 32.6 2,246 40-44 5.3 24.4 19.3 19.4 9.2 34.2 2,152 45-49 5.2 23.6 19.1 18.4 8.6 33.9 1,820 Employment (last 12 months) Not employed 4.2 22.7 17.5 19.2 8.3 33.0 15,090 Employed for cash 3.2 20.6 16.1 16.3 7.0 29.7 2,553 Employed not for cash 4.0 31.0 23.4 28.2 7.5 42.7 88 Number of living children 0 3.4 20.2 13.9 17.6 5.3 29.9 1,867 1-2 3.4 21.1 15.9 18.1 7.6 30.8 8,889 3-4 4.9 24.3 19.6 19.8 9.3 34.9 5,359 5+ 6.0 26.1 21.8 21.0 10.4 37.4 1,635 Marital status Married or living together 3.9 22.4 17.2 18.8 8.0 32.5 16,635 Divorced/separated/ widowed 6.1 23.3 18.6 19.6 9.8 32.6 1,114 Residence Urban 2.5 15.6 11.9 14.2 5.4 23.8 4,619 Rural 4.6 24.9 19.3 20.5 9.1 35.6 13,130 Division Barisal 3.8 22.7 16.7 19.1 7.3 30.5 1,002 Chittagong 6.4 23.4 20.5 21.6 10.5 34.1 3,222 Dhaka 2.6 17.3 14.7 17.4 5.8 27.9 5,736 Khulna 2.1 19.6 13.0 13.4 5.3 26.6 2,139 Rajshahi 4.9 34.9 23.1 24.4 11.2 46.2 2,646 Rangpur 4.5 19.8 16.3 16.9 7.9 30.3 2,039 Sylhet 6.9 27.6 19.1 18.9 13.1 37.5 967 Education No education 5.9 27.4 22.1 21.4 10.4 38.4 4,912 Primary incomplete 5.3 26.4 20.0 21.2 10.0 36.2 3,264 Primary complete1 4.1 23.8 20.1 20.3 9.2 35.0 2,062 Secondary incomplete 2.9 19.8 14.1 17.7 6.6 29.9 5,383 Secondary complete or higher2 1.0 10.5 7.5 10.8 2.7 17.9 2,127 Wealth quintile Lowest 6.5 30.7 22.2 24.4 11.6 41.3 3,250 Second 5.8 27.3 21.7 23.1 10.7 38.4 3,487 Middle 4.4 23.9 19.7 20.2 8.8 34.5 3,567 Fourth 2.9 20.5 15.8 16.6 6.8 31.0 3,664 Highest 1.2 11.4 8.3 10.9 3.4 19.3 3,781 Total 4.1 22.4 17.3 18.8 8.1 32.5 17,749 Note: Total includes 18 women with missing information on employment in the last 12 months. 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 220 • Women’s Empowerment and Demographic and Health Outcomes in household decision making and their attitudes toward wife beating are summarized in two separate indices. 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) with which women agree justifying 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, 65-66 percent of women who participate in 0-3 decisions reject all the reasons for wife beating compared with 70 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. Although, the percentage of women who participate in all four decisions is highest, at 43 percent, for women who do not agree with any reason for wife beating and falls to 34 percent for women who agree with 3-4 reasons for wife beating, it rises again to 42 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 2011 Empowerment indicator Percentage who participate in all four decisions Percentage who disagree with all the reasons justifying wife beating Number of women Number of decisions in which women participate1 0 na 65.2 3,075 1-2 na 65.2 3,882 3 na 66.1 2,768 4 na 70.3 6,910 Number of reasons for which wife beating is justified2 0 43.3 na 11,223 1-2 39.1 na 3,632 3-4 33.7 na 1,390 5 42.1 na 391 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 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 Women’s Empowerment and Demographic and Health Outcomes • 221 distribution of currently married women age 15-49 by current contraceptive method, according to the two women’s empowerment indices. Contraceptive use is positively associated with women’s participation in household decision making, but varies little by women’s agreement with wife beating. In particular, use of any method and any modern method is higher among women who participate in all four decisions (66 percent and 56 percent, respectively) than among women who participate in none (51 percent and 44 percent, respectively). 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 2011 Empowerment indicator Any method Modern methods Any traditional method Not currently using Total Number of women Any modern method Female sterili- zation Male sterili- zation Temporary modern female methods1 Male condom Number of decisions in which women participate2 0 51.4 44.3 4.1 1.0 35.0 4.3 7.1 48.6 100.0 3,075 1-2 60.6 51.3 4.9 1.3 39.6 5.6 9.3 39.4 100.0 3,882 3 60.8 51.3 4.1 1.3 40.0 6.0 9.5 39.2 100.0 2,768 4 66.1 56.2 5.8 1.3 43.2 5.9 9.9 33.9 100.0 6,910 Number of reasons for which wife beating is justified3 0 61.9 52.8 4.9 1.2 40.3 6.4 9.1 38.1 100.0 11,223 1-2 60.3 50.7 4.9 1.2 40.5 4.2 9.5 39.7 100.0 3,632 3-4 58.5 50.0 5.6 1.4 39.7 3.3 8.5 41.5 100.0 1,390 5 59.5 50.5 6.8 1.9 39.9 1.9 9.0 40.5 100.0 391 Total 61.2 52.1 5.0 1.2 40.3 5.5 9.2 38.8 100.0 16,635 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 amenorrhoea 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 ability of women to make decisions effectively has important implications for their fertility preferences and for meeting their family-size goals. In particular, it is expected that more empowered women will want smaller families and be better able to negotiate decisions regarding 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 for which wife beating is justified by them. Women who agree that wife beating is not justified at all desire 2.2 children compared with 2.4 children for women who agree that wife beating is justified for all five reasons. There is an association between participation in decision making and unmet need for family planning. Women who participate in no household decisions have higher unmet need for family planning (16 percent) than women who participate in one or more decisions (12-14 percent). Unmet need is however higher among women who do not agree with any reason for wife beating and declines somewhat with the number of reasons justifying wife beating from 14 percent for women who agree with no reason for wife beating to 12 percent for women who agree with all five reasons. 222 • Women’s Empowerment and Demographic and Health Outcomes Table 13.9 Women’s empowerment and ideal number of children and unmet need for family planning Mean ideal number of children for women 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 2011 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of women For spacing For limiting Total Number of decisions in which women participate3 0 2.2 3,026 9.0 7.1 16.1 3,075 1-2 2.2 3,837 5.7 6.7 12.4 3,882 3 2.2 2,752 4.5 7.0 11.6 2,768 4 2.2 6,878 4.0 9.7 13.7 6,910 Number of reasons for which wife beating is justified4 0 2.2 11,900 5.5 8.0 13.5 11,223 1-2 2.2 3,805 5.3 8.2 13.4 3,632 3-4 2.3 1,469 5.7 8.1 13.8 1,390 5 2.4 415 3.7 8.5 12.3 391 Total 2.2 17,590 5.4 8.1 13.5 16,635 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 to better meet their own reproductive health goals, including the goal of 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 health personnel increases from 51 percent among women who participate in no decisions to 56-57 percent among women who participate in 3-4 decisions; the corresponding increase in the proportion of women receiving delivery assistance from health personnel increases from 28 percent among women who participate in no decisions to 34 percent among women who participate in all four decisions. A similar increase of about seven percentage points is observed in the proportion of women who received postnatal care within two days of delivery from health personnel between women with the lowest and the highest value on the decision making index. Women’s Empowerment and Demographic and Health Outcomes • 223 Women’s attitude toward wife beating is also related to their use of all three health services. Compared with women who believe that wife beating is not justified for any reason, women who accept all five reasons for wife beating are less likely to receive antenatal care (38 percent compared with 58 percent for women who agree with no reason) and delivery assistance (20 percent compared with 35 percent for women who agree with no reason) from health personnel. Women who agree with 3-5 reasons justifying wife beating are also less likely to have received postnatal care (16 percent) within the first two days of delivery from health personnel than women who reject all the reasons for wife beating (30 percent). 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 health personnel for the most recent birth, by indicators of women’s empowerment, Bangladesh 2011 Empowerment indicator Received antenatal care from health personnel Received delivery assistance from health personnel Received postnatal care from health personnel within the first two days after delivery1 Number of women with a child born in the past three years Number of decisions in which women participate2 0 51.0 28.4 22.7 983 1-2 54.2 31.9 26.4 1,152 3 57.2 32.1 28.5 668 4 56.3 34.1 29.6 1,803 Number of reasons for which wife beating is justified3 0 58.2 35.0 30.2 3,128 1-2 50.7 28.1 23.5 1,023 3-4 40.6 20.6 15.5 391 5 37.7 20.0 15.9 110 Note: For delivery assistance, “health personnel” includes doctor, nurse, midwife, auxiliary nurse, family welfare visitor (FWV), and community skilled-birth attendant (CSBA). For antenatal care and postnatal care, “health personnel” includes these cadres plus medical assistant (MA) and sub-assistant community medical officer (MA/SACMO) 1 Includes both women who gave birth in a health facility and 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 are essential aspects of empowerment. It follows that if women, who are the primary caretakers of children, are empowered, the health and survival of their children would be enhanced. 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 that infant and under-five mortality rates decline as women’s participation in decision making increases. For example, in the case of women who make no decisions, infant mortality is 49 deaths per 1,000 live births and under-five mortality is 59 deaths per 1,000 live births, compared with an infant mortality of 38 deaths per 1,000 live births and an under-five mortality of 47 deaths per 1,000 live births for women who participate in all four decisions. Similarly, infant mortality and under-five mortality rise sharply with women’s agreement with wife beating. Among women who do not agree with any reason for wife beating, infant mortality and under-five mortality are 39 and 49 per 1,000 live births, respectively, compared with 56 and 71 for women who agree with 3-4 reasons for wife beating. 224 • Women’s Empowerment and Demographic and Health Outcomes Table 13.11 Early childhood mortality rates by women’s empowerment Infant, child, and under-five mortality rates for the 5-year period preceding the survey, by indicators of women’s empowerment, Bangladesh 2011 Empowerment indicator Infant mortality (1q0) Child mortality (4q1) Under-five mortality (5q0) Number of decisions in which women participate1 0 49 10 59 1-2 43 14 56 3 44 14 57 4 38 10 47 Number of reasons for which wife beating is justified2 0 39 10 49 1-2 49 13 62 3-4 56 16 71 5 * * * * An asterisk indicates that the indicator is based on fewer than 250 children exposed, and has been suppressed. 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. Causes of Death in Children Under Age 5 • 225 CAUSES OF DEATH IN CHILDREN UNDER AGE 5 14 nderstanding the causes of death among children under age 5 is important for health sector planning, including assessment of program needs, monitoring of progress of interventions, and reassessment of health priorities. Data on causes of death is often limited in developing countries, however. This is true for Bangladesh, as the country’s vital registration system has poor coverage, and most deaths occur outside of the health system where the cause of death is not reported. Verbal autopsy has been used to assign the cause of death in such settings. Verbal autopsy is a method of assessing the cause of death based on an interview with the next of kin or caregivers who were present at the time of death or who are knowledgeable about the events leading up to the death. To meet the demand for population-level disease-burden estimates to be used in policy development, planning, priority-setting, and benchmarking, verbal autopsy has become a source of cause-of-death statistics (Murray et al., 1996). Verbal autopsies have been used previously in Bangladesh to provide important data on the causes of child death (Chen et al., 1980; Zimicki et al., 1985; D’Souza, 1985; Bhatia, 1989; Fauveau et al., 1994; Snow et al., 1992; Kalter et al., 1990; Kamal et al., 1994; Salway et al., 1994; Baqui et al., 1998; Baqui et al. 2001, Arifeen et al., 2005). According to the verbal autopsy study in the 2004 BDHS (Arifeen et al., 2005), possible serious infections (31 percent) and acute respiratory infections (ARIs) (21 percent) were the two leading causes of all under-5 deaths. These were followed by birth asphyxia (12 percent), diarrhea (5 percent), and prematurity or low birth weight (7 percent). Drowning was responsible for about 19 percent of deaths at 12-59 months. The 2011 BDHS shows that the under-5 mortality rate has declined by 18 percent since the 2007 BDHS survey (65 and 53 deaths per 1,000 live births, respectively) and by 40 percent since the 2004 BDHS (88 and 65 deaths per 1,000 live births, respectively). The decline in neonatal mortality in the two periods is 14 percent and 21 percent respectively. This impressive decline in child mortality warrants further investigation. An assessment of the cause structure 1of child deaths may help explain these declines while guiding attention towards causes of death that remain persistently high. This chapter presents information on the relative and proportional distribution of causes of neonatal, postneonatal, infant, and child deaths. The cause of death distribution is disaggregated by the sex of the child, urban-rural residence, division, and mother’s education. 14.1 DATA COLLECTION In the 2011 BDHS, information on deaths of children under age 5 in the sampled households was obtained from the birth history section of the Woman’s Questionnaire that was administered to all ever- U Key Findings • Pneumonia remains the largest single cause of under-5 deaths in Bangladesh, accounting for one-fifth of all deaths. • Possible serious infection or sepsis is responsible for almost a quarter of neonatal deaths and for 15 percent of all under-5 deaths. • Birth asphyxia is responsible for 21 percent of neonatal deaths and for 12 percent of all under-5 deaths. • Drowning is responsible for two-fifths of deaths of children between ages 12 months and 59 months. 226 • Causes of Death in Children Under Age 5 married women age 12-49 years.1 If a child under age 5 had died in a household in the five years preceding the survey (which corresponds roughly to calendar years 2006-2011), a Verbal Autopsy Questionnaire (VAQ) was administered by the data collection team supervisor within a day of identification of the death. Two types of VAQs were used in the 2011 BDHS: one was administered for deaths under age 4 weeks, and the other was used for deaths between age four weeks and age 5. The verbal autopsy questionnaires used in the 2011 BDHS are basically similar to those used in the 2004 BDHS. The 2004 BDHS verbal autopsy instrument was developed from several other instruments, including the questionnaire used in the verbal autopsy surveys based on the 1993-94 and 1996-97 BDHS samples (Baqui et al., 1998; Baqui et al., 2001), the WHO verbal autopsy questionnaire, and the instrument being used since 2003 in the Matlab Health and Demographic Surveillance System (HDSS). This instrument was developed on the basis of work done by the In-Depth Verbal Autopsy Working Group, which used the verbal autopsy questionnaire from the Adult Morbidity and Mortality Project in Tanzania, which, in turn, had evolved out of the WHO questionnaire. The differences between the 2011 BDHS instruments and the 2004 BDHS instruments are primarily in the structure and in the coding categories, which were made to be consistent with those used in the Woman’s Questionnaire. A few questions, particularly on timing of symptoms/signs, were excluded from the 2011 BDHS questionnaires to make them simpler and easier to administer. The 2011 BDHS VAQs included some questions with pre-coded responses and other questions that allowed open-ended responses, including narrative stories. The instruments included the following sections: 1) Identification, including the detailed address of the respondent and informed consent 2) Information about the caretaker, or the respondent, for the deceased child 3) Information on the age and place of death of the deceased child 4) An open-ended narrative history of events leading to the death 5) Information on prenatal care, labor, delivery, and obstetrical complications 6) Information about accidental death or a delivery history 7) Detailed description of the signs and symptoms preceding death; information about treatment preceding death; and information about any direct, underlying, or contributing causes of death to be gained from the death certificate, if available. 14.2 ASSIGNMENT OF CAUSE OF DEATH The assignment of the causes of death in this survey was done by physicians who were specially hired and trained for this task. This is the most common method of interpreting verbal autopsy data without the use of computer algorithms (Soleman et al., 2006; Fottrell and Byass, 2010). The physician’s interpretation of data recorded in the questionnaires involves subjectivity and judgment. Therefore, the questionnaires were independently analyzed by two physicians from a group of three physicians. The physicians were blinded regarding the order of the review by allocating different codes to the verbal autopsy forms. The codes were generated and maintained by a statistician who reallocated the forms with different codes to the next reviewer after the completion of each review. The physicians coded the causes of deaths based on the 2010 version of the International Classification of Deaths (ICD-10), allocating a single, direct cause, two underlying causes, and a single contributory cause. When the two physicians agreed on the direct cause and at least one of the underlying causes, then the agreed-upon causes were considered to be the final causes. In the absence of agreement, an additional review was conducted by a third physician. If the direct cause and at least one underlying cause were agreed upon by any two physicians, these were considered the final direct and underlying cause of death. If no agreement was 1 Because information on deaths was collected only from ever-married respondents, the verbal autopsy results presented in the report exclude deaths of children born to women in the reference period whose mothers died prior to the survey. Causes of Death in Children Under Age 5 • 227 reached after the third physician review, the death was recorded as “undetermined.” In a few cases where two physicians had assigned identical causes of deaths but disagreed on whether these were the direct or underlying causes, a discussion was arranged to reconcile the differences. The cause of death results from the 2011 BDHS are compared in this report with the 2004 findings. In interpreting those findings several factors should be considered. First, in the 2011 BDHS questionnaires, some key questions included in the 2004 BDHS instrument were excluded. These questions asked whether the child had stopped crying before death; appeared lethargic; was able to grasp objects; and had noisy breathing, stridor, wheezing, dry mouth, or loose skin that persisted until death. The 2004 BDHS also handled the assignment of causes of death differently than the 2011 survey. In the 2004 BDHS, the causes of death were assigned using computer algorithms involving a hierarchical process that followed several mutually exclusive tiers of algorithms applied in sequence (Arifeen et al., 2005). If no causes of deaths were ascertained by the computer algorithms, the cause of death was assigned based on a physician’s review. To enable comparison of the 2011 BDHS data with data in the 2004 BDHS in these sections, the 2004 BDHS data was reanalyzed based only on physicians’ reviews. However, pre- term births were underestimated as a cause of death in the physician review of the 2004 BDHS, because some of these deaths were reported under direct causes of death (for example birth asphyxia or infections) or had been classified as undetermined or unspecified. To correct for this, when the physicians assigned premature birth as the underlying cause or the physician assigned an undetermined or unspecified cause, and the VAQ reported that the child was born smaller than normal or before term, then the child's cause of death was changed to premature birth. Because the verbal autopsy information was collected only for deaths of children born in the 5 years preceding the survey rather than for all deaths under age 5 in the five years prior to the survey, there is an under-representation of deaths with increasing age. In fact, there are no deaths reported between age 48 and age 59 months. In the 2011 analysis and the 2004 reanalysis of the cause of deaths, the under- representation was addressed by inflating the number of deaths with verbal autopsy data to get the estimated number of deaths that would have been included if all under-5 deaths in the past five years had been included. The mortality rates for each age group were calculated for the five years before the survey based on the full birth history, and the expected number of deaths by age and background characteristics was estimated. The ratio of the expected deaths and actual deaths with VA data was used to inflate the number of deaths by cause and characteristic, which was used to calculate the percent distribution of deaths. The inflation and rounding by different causes and characteristics resulted in small differences in the total number of deaths in the tables presented in the next section. 14.3 CAUSES OF DEATH AMONG CHILDREN UNDER AGE 5 The percent distribution by cause of deaths among children under age 5 is presented in Table 14.1 by age group. For all children under age 5, pneumonia is the most important cause of deaths (22 percent), followed by possible serious infections or sepsis (15 percent), birth asphyxia (12 percent), drowning (9 percent), and pre-term birth (7 percent). For 17 percent of the cases, the causes of death were not ascertained because of a lack of information. These causes were classified as unspecified. For 3 percent of deaths, the causes of death could not be determined because of a lack of agreement between the reviewing physicians. 228 • Causes of Death in Children Under Age 5 Table 14.1 Causes of death among children under five by age group Percent distribution of deaths among children under age 5 (weighted), by cause of death according to age group, Bangladesh 2011 Cause of death Age group Neonatal (0-28 days) Postneonatal (29 days- 11 months) Age 12-59 months Under 5 years Neonatal tetanus 3.0 0.0 0.0 1.8 Congenital abnormality 1.2 1.4 0.0 1.0 Drowning 0.0 0.7 42.6 9.2 Birth asphyxia 20.5 0.0 0.0 12.4 Birth injury 4.0 0.0 0.0 2.4 Measles 0.0 3.3 0.0 0.6 Diarrhoea 0.0 7.5 2.8 2.0 Pneumonia 12.6 52.9 21.7 22.0 Meningitis 0.2 6.7 0.0 1.4 Neonatal jaundice 2.3 0.0 0.0 1.4 Pre-term birth 11.3 0.0 0.0 6.8 Possible serious infection 24.3 1.4 1.0 15.1 Malnutrition 0.0 2.3 0.0 0.4 Other causes1 0.1 10.5 10.4 4.2 Unspecified 17.5 11.7 18.1 16.6 Undetermined 3.0 1.6 3.5 2.9 Total 100.0 100.0 100.0 100.0 Number of deaths 286 88 101 475 1 Other causes include acute paralytic poliomyelitis, acute viral hepatitis, leukaemia, nephrotic syndrome, intestinal obstruction, malaria, and food in respiratory tract. Among neonates, possible serious infections are the most important cause of death (24 percent), followed by birth asphyxia (21 percent), pneumonia (13 percent), and pre-term birth (11 percent). More than half of deaths among post-neonates (age 29 days to 11 months) are associated with pneumonia, while meningitis contributed an additional 7 percent and diarrhea 8 percent. Eleven percent of deaths are attributed to other causes, including acute paralytic poliomyelitis, intestinal obstruction, leukemia, nephritic syndrome, and food in respiratory track. Forty-three percent of deaths among children 12-59 months were attributed to drowning, followed by pneumonia (22 percent). There is a large increase in deaths due to drowning among the infants age 12- 59 months, from 19 percent in 2004 to 43 percent in 2011. At the same time, there is a considerable reduction of “confirmed” diarrhea as a cause of death, from 8 percent in 2004 to 3 percent in 2011. There are several differences between the 2011 BDHS and the 2004 BDHS in the cause-of-death patterns, particularly in the greater prominence of neonatal causes of deaths, which can be related to a greater proportion of neonatal deaths in 2011 (60 percent) compared with 2004 (47 percent). 14.4 DIFFERENTIALS IN CAUSE OF UNDER-5 DEATHS Differentials in cause of death by sex of child, urban-rural residence, mother’s education, and administrative division are presented in Tables 14.2 to 14.4. There is a small difference in the total number of deaths reported in the different tables. This difference is due to a rounding error that occurred in the process when verbal autopsy data were inflated by causes and characteristics on the basis of birth history data. There are some differences in causes of death between boys and girls (Table 14.2). Whereas pneumonia is the most important cause of death for boys and girls, it is more common among girls (25 percent) than boys (19 percent). Boys are much more likely to die from birth asphyxia than girls (17 percent versus 8 percent, respectively). Causes of Death in Children Under Age 5 • 229 Table 14.2 Causes of death among children under 5 by sex of child and residence Percent distribution of deaths among children under 5 by cause of death (weighted), according to sex of child and residence, Bangladesh 2011 Cause of death Sex of child Residence Male Female Rural Urban Neonatal tetanus 2.3 1.3 2.3 0.0 Congenital abnormality 0.2 1.9 1.1 0.6 Drowning 8.7 9.7 9.9 6.2 Birth asphyxia 16.5 7.6 10.7 19.0 Birth injury 2.6 2.2 2.1 3.6 Measles 1.1 0.0 0.7 0.3 Diarrhoea 1.1 3.0 1.6 3.3 Pneumonia 19.3 25.2 22.3 20.7 Meningitis 0.6 2.2 1.3 1.4 Neonatal jaundice 2.1 0.6 1.5 0.8 Premature birth 7.1 6.4 6.8 6.8 Possible serious infection 14.1 16.2 16.3 10.4 Malnutrition 0.8 0.0 0.5 0.0 Other causes1 4.2 4.1 4.5 3.1 Unspecified 15.6 17.9 16.2 18.1 Undetermined 3.7 1.9 2.1 5.7 Total 100.0 100.0 100.0 100.0 Number of deaths 256 219 378 98 1 Other causes include acute paralytic poliomyelitis, acute viral hepatitis, leukaemia, nephrotic syndrome, intestinal obstruction, malaria, and food in the respiratory tract. Possible serious infection is more common in rural areas than in urban areas (16 percent versus 10 percent), while birth asphyxia is more important in urban than rural areas (19 percent versus 11 percent), which is partly due to the larger contribution of neonatal deaths in urban areas. Deaths by drowning are more often found in rural areas than in urban areas (10 percent versus 6 percent). Birth asphyxia (20 percent), pneumonia (18 percent), and possible serious infections (18 percent), are the most often-reported causes of death for children whose mothers had at least a secondary education (Table 14.3). Pneumonia causes 27 percent of deaths for children whose mothers had no education. Possible serious infections are the second most important cause of deaths (12 percent) for children whose mothers had no education. For a very large number of cases (15-27 percent), the cause of death for children whose mothers had less than secondary education are unspecified due to lack of information. 230 • Causes of Death in Children Under Age 5 Table 14.3 Causes of death among children under 5 by mother’s education Percent distribution of deaths among children under 5 by cause of death (weighted), according to mother’s level of education, Bangladesh 2011 Cause of death Mother’s education No education Primary incomplete and completed primary Incomplete secondary, completed secondary, and higher than secondary Neonatal tetanus 2.1 1.0 2.2 Congenital abnormality 0.9 0.4 1.5 Drowning 4.4 14.0 8.6 Birth asphyxia 3.6 11.1 19.8 Birth injury 1.4 0.9 4.4 Measles 1.9 0.2 0.0 Diarrhoea 1.4 2.5 1.9 Pneumonia 27.4 22.5 17.7 Meningitis 1.4 1.6 1.1 Neonatal jaundice 0.1 1.1 2.5 Premature birth 5.0 7.8 7.2 Possible serious infection 12.2 14.4 17.6 Malnutrition 0.0 1.3 0.0 Other causes1 5.0 3.2 4.0 Unspecified 26.8 15.4 10.8 Undetermined 6.1 2.6 0.9 Total 100.0 100.0 100.0 Number of deaths 137 155 186 1 Other causes include acute paralytic poliomyelitis, acute viral hepatitis, leukaemia, nephrotic syndrome, intestinal obstruction, malaria, and food in the respiratory tract. The small number of cases in most of the divisions makes it difficult to be conclusive about the divisional variations in cause of death (Table 14.4). To have a larger number of deaths to assess, Barisal and Khulna, and Rajshahi and Rangpur, divisions are presented together. The groupings are also based on the fact that Barisal was carved out of Khulna division and Rangpur from Rajshahi division. Pneumonia is the most important cause of childhood deaths in all divisions except Dhaka, where possible serious infections are the most common cause of deaths (20 percent). The second most common cause of death in Barisal and Khulna is birth asphyxia (18 percent); in Chittagong, it is drowning and birth asphyxia (11 percent each); in Dhaka, it is pneumonia (13 percent); in Rajshahi, and Rangpur, it is possible serious infection (17 percent); and in Sylhet, it is possible serious infection and premature birth (13 percent each). Deaths caused by prematurity are relatively more often reported in Barisal and Khulna divisions and in Sylhet division than in other divisions. There is a small difference in the total number of deaths computed in different tables. This difference is due to a rounding error that occurred in the process when verbal autopsy data were inflated by causes and characteristics on the basis of birth history data. Causes of Death in Children Under Age 5 • 231 Table 14.4 Causes of death among children under 5 by division Percent distribution deaths among children under 5 by cause of death (weighted), according to division, Bangladesh 2011 Cause of death Division Barisal and Khulna Chittagong Dhaka Rajshahi and Rangpur Sylhet Neonatal tetanus 0.0 1.3 2.7 2.0 2.0 Congenital abnormality 1.0 2.6 0.0 1.3 0.0 Drowning 5.5 11.4 8.2 11.1 7.8 Birth asphyxia 18.1 10.6 9.7 15.0 11.3 Birth injury 0.0 1.4 4.9 2.2 0.0 Measles 1.6 0.0 1.3 0.0 0.0 Diarrhoea 2.0 3.0 2.4 0.0 2.9 Pneumonia 19.7 31.6 13.1 25.7 25.1 Meningitis 2.5 0.9 1.3 1.9 0.0 Neonatal jaundice 3.7 3.1 0.0 0.0 2.6 Premature birth 13.1 3.5 4.8 6.3 13.1 Possible serious infection 14.3 6.9 19.6 17.3 13.0 Malnutrition 1.0 1.4 0.0 0.0 0.0 Other causes1 1.1 7.4 5.1 1.9 4.1 Unspecified 13.7 10.6 24.5 12.0 17.5 Undetermined 2.7 4.3 2.5 3.3 0.4 Total 100.0 100.0 100.0 100.0 100.0 Number of deaths 60 98 155 113 49 1 Other causes include acute paralytic poliomyelitis, acute viral hepatitis, leukaemia, nephrotic syndrome, intestinal obstruction, malaria, and food in respiratory tract. 14.5 COMPARISON OF CAUSE-SPECIFIC MORTALITY RATES BETWEEN 2004 AND 2011 A comparison of the distribution of cause-specific mortality from the 2004 BDHS and 2011 BDHS is presented in Figure 14.1. The cause-specific mortality is calculated by applying the cause-of- death distribution in each survey to the estimated number of under-5 deaths. For both surveys, the distribution is based on physician-assigned causes of death. The 2011 BDHS shows large reductions in under-5 mortality due to pneumonia (by 33 percent), birth asphyxia (by 46 percent), diarrhea (by 85 percent), premature birth (by 20 percent), and possible serious infection (by 60 percent). Some of the differences may be due to methodological differences between the 2004 BDHS and 2011 BDHS. It is noted that death rates due to drowning increased from 3 per 1,000 live births in 2004 to 5 per 1,000 live births in 2011. 232 • Causes of Death in Children Under Age 5 Figure 14.1 Specific causes of death among children under age 5, 2004 BDHS and 2011 BDHS 18 13 7 3 1 6 5 20 14 12 7 1 5 3 3 4 8 10 Pneumonia Birth asphyxia Diarrhea Drowning Other neonatal Other causes (including injury) Premature Possible serious infection Unspecific/Undetermined 2004 BDHS 2011 BDHS Deaths per 1,000 live births 14.6 CONCLUSION The absolute risk of death (per 1,000 live births) has declined substantially between 2004 and 2011 for most of causes, except for deaths due to drowning. The pattern of causes of death among children under age 5 in Bangladesh is changing and has important implications for the intervention package being delivered by the public health system. Respiratory (mostly pneumonia) and other serious infections are associated with almost two-fifths of all under-5 deaths. A majority of these deaths occur in the neonatal period. Interventions will need to focus on both prevention and treatment. Birth asphyxia is responsible for a fifth of neonatal deaths and 12 percent of all under-5 deaths. Interventions to reduce birth asphyxia deaths, particularly those providing resuscitation, have to be linked to efforts to increase skilled attendance at delivery. Premature birth results in a large proportion of neonatal deaths (11 percent) and is an important cause of under-5 deaths (7 percent). Although interventions that address premature births as a cause of neonatal deaths exist, they have not yet been scaled up in Bangladesh. Diarrhea, which has always been considered a major cause of child morbidity and mortality in Bangladesh, is now responsible for only 2 percent of under-5 deaths. Although deaths from infectious disease have declined, drowning has emerged as a key cause of death, especially among children age 12 to 59 months (43 percent). Other Adult Health Issues • 233 OTHER ADULT HEALTH ISSUES 15 round the world, whether in developed or developing countries, the rapid increase of noncommunicable diseases (NCDs) is becoming a challenge in achievement of global progress. This group of chronic diseases, that is, diabetes, cardiovascular disease, cancer, and chronic respiratory disease, contribute to almost 60 percent of the death toll around the world, and 80 percent of these deaths occur in developing countries like Bangladesh (WHO, 2010a). With each passing day, this death toll will rise unless proper measures are taken. Based on current trends, by 2020 NCDs will account for 73 percent of deaths and 60 percent of the disease burden in developing countries (WHO, 2010b). The causal factor for the NCD epidemic is the increase in lifestyle-related risk factors, such as unhealthy food habits, physical inactivity, high body mass index, and substance abuse. They operate through intermediate risk factors such as high blood pressure and elevated blood glucose and plasma lipid levels. These are the most prevalent NCD risk factors around the world (WHO, 2003). These risk factors are fuelled by a shift in population age structure, a decrease in maternal and child deaths, and rapid urbanization (WHO 2010b). In most cases, the NCD-associated risk factors are modifiable and preventable. Hence, early identification and preventive behavior for high blood pressure and elevated plasma lipid and blood glucose levels can reduce the risk of developing coronary heart disease and stroke by 80 percent and the risk of type II diabetes by 90 percent (CDC, 2009). A Key Findings • Blood pressure and fasting blood glucose measurements in this chapter refer to women and men age 35 and older. • One in three (32 percent) women and 19 percent of men have elevated blood pressure or are currently taking medicine to lower their blood pressure. An additional 28 percent of women and men are pre-hypertensive. • Forty-five percent of women and 57 percent of men are not aware that they have elevated blood pressure. • Forty-five percent of women and 36 percent of men with hypertension are taking medication for their condition, but over half of them have not controlled their blood pressure to normal levels. • Only 20 percent of women and 16 percent of men with hypertension are taking medication and have their blood pressure under control. • Eleven percent of women and men are diabetic; that is they have elevated fasting plasma glucose values or report that they are taking diabetes medication. An additional 25 percent of women and men are pre-diabetic. • Fifty-nine percent of women and 65 percent of men are not aware that their plasma glucose levels are elevated. • Thirty-seven percent of women and 31 percent of men with diabetes are taking medication for their condition, but the majority of them do not have their blood glucose under control within normal levels. • Only 15 percent of women and 10 percent of men with diabetes are taking medication and have their fasting plasma glucose under control at normal levels. • Women and men with a higher-than-normal BMI (25.0 or higher) are more likely to have elevated blood pressure and elevated fasting blood glucose. 234 • Other Adult Health Issues Similar to other developing countries, Bangladesh is experiencing a shift in disease and death patterns from communicable diseases to NCDs (Karar et al., 2009). Until very recently, nationally representative data on NCDs were not available for Bangladesh. Small-scale population-based studies showed a significantly increasing trend in NCD prevalence (Zaman et al., 2007). However, a recent national study on NCD risk factors revealed a devastating scenario in which 98 percent of the adult population had at least one risk factor. Seventy-seven percent of adults have two or more risk factors that can develop into one of these NCDs (WHO, 2011). To meet this health challenge, the government of Bangladesh has identified NCDs as a new and continuing challenge and has taken steps to prioritize the expansion of services related to NCD control activities. The current sector-wide program, Health Population and Nutrition Sector Development Program (HPNSDP 2011-16), also has a strategy for streamlining referral systems and strengthening hospital accreditation and management systems (MOHFW, 2011). The key to prevention and control of NCDs depends on having information about these diseases as well as the biological intermediate risk factors. The 2011 BDHS is the first national survey to include biomarker measurements for blood pressure and fasting blood glucose. These biomarkers were collected in an effort to provide information on the prevalence of blood pressure and fasting blood glucose among a subsample of women and men age 35 and older in one-third of the households selected in the survey. Blood pressure and blood glucose levels were measured in consenting respondents. 15.1 COVERAGE RATES FOR BLOOD PRESSURE AND BLOOD GLUCOSE MEASUREMENT In one in three households selected in the 2011 BDHS survey, all ever-married men age 15-54 were selected and interviewed for the male survey. In this subsample, all woman and men age 35 and older were eligible to participate in the biomarker component, which included blood pressure measurements, testing for anemia, blood glucose testing, and height and weight measurements. Table 15.1 shows that 4,311 women and 4,524 men age 35 and older were eligible for blood pressure and blood glucose measurement. Among these individuals, 92 percent of women and 86 percent of men participated in the blood pressure measurement, and 89 percent of women and 83 percent of men participated in the blood glucose measurement. Other Adult Health Issues • 235 Table 15.1 Coverage of testing for blood pressure and fasting blood glucose measurement among women and men age 35 and older Percentage of women and men age 35 and older eligible for blood pressure and blood glucose measurements, by testing status, according to selected background characteristics (unweighted), Bangladesh 2011 Background characteristic Women Men Percentage measured for blood pressure Percentage measured for fasting blood glucose Number of women Percentage measured for blood pressure Percentage measured for fasting blood glucose Number of men Age 35-39 93.9 90.6 864 83.4 78.8 820 40-44 94.1 90.6 766 84.4 80.6 762 45-49 94.2 91.0 692 84.8 80.5 702 50-54 94.7 91.0 457 90.2 86.5 694 55-59 90.9 88.4 449 85.9 83.1 354 60-69 88.5 84.4 583 87.4 84.8 650 70+ 88.0 83.8 500 89.7 85.6 542 Residence Urban 89.6 86.4 1,447 83.7 80.2 1,545 Rural 93.8 90.1 2,864 87.7 83.8 2,979 Division Barisal 90.9 84.7 530 81.3 74.5 560 Chittagong 91.9 87.0 682 83.9 79.2 664 Dhaka 90.4 88.3 753 85.3 83.1 783 Khulna 94.6 92.3 648 90.2 87.6 693 Rajshahi 92.5 88.9 602 84.2 80.2 665 Rangpur 94.4 92.3 558 93.1 90.5 611 Sylhet 91.8 88.5 538 86.1 81.6 548 Education No education 92.8 89.0 2,378 86.8 82.8 1,532 Primary incomplete 91.4 87.7 922 87.5 83.5 1,116 Primary complete1 90.4 86.8 395 78.0 75.1 614 Secondary incomplete 93.7 91.6 394 84.7 81.2 718 Secondary complete or higher2 92.3 90.5 222 94.1 89.9 544 Wealth quintile Lowest 93.7 90.5 746 85.4 81.7 824 Second 93.3 88.8 757 88.0 83.0 820 Middle 94.3 91.3 826 88.2 83.6 850 Fourth 93.3 90.2 908 88.2 84.9 901 Highest 88.5 84.8 1,074 82.8 80.1 1,129 Total 92.3 88.9 4,311 86.3 82.5 4,524 15.2 HYPERTENSION Blood pressure rises and falls throughout the day. When blood pressure stays elevated over time, it is called high blood pressure. The medical term for high blood pressure is hypertension. Raised or high blood pressure acts as one of the contributing and intermediate risk factors for developing coronary heart disease, stroke, and kidney disease. The measurements taken for blood pressure in 2011 BDHS were not intended to provide a medical diagnosis of the disease but rather to provide a cross-sectional assessment of the prevalence of high blood pressure in the population at the time of the survey. Although the results of the blood pressure measurements are regarded only as a statistical description of the survey population, they provide insight into the size and characteristics of the population at risk for hypertension. The 2011 BDHS used the LIFE SOURCE® UA-767 Plus Blood Pressure Monitor model; the automatic device included separate cuffs for measuring blood pressure in respondents with small, medium, and large arm circumferences. This model is one of the blood pressure monitors recommended for use by World Health Organization (WHO). Interviewers were trained to use this device according to the manufacturer’s recommended protocol, and the 2011 BDHS Anthropometry, Anemia Testing, Blood Glucose Testing and Blood Pressure Measurement Field Manual. One health technician in each data collection team was trained to measure and record the blood pressure of consenting adults age 35 and older. Three measurements of both systolic and diastolic blood pressure were taken during the survey at approximately 10-minute intervals between measurements. The average of the second and third measurements was used to report respondent’s blood pressure values. 236 • Other Adult Health Issues Arterial blood pressure is the force exerted by the blood on the wall of a blood vessel as the heart pumps (contracts) and relaxes. Systolic blood pressure (SBP) is the measures the force when the heart pumps (contracts), and the diastolic blood pressure (DBP) measures the degree of force when the heart is relaxes. The 2011 BDHS uses the American Heart Association guidelines for cut-off points for blood pressure measurements (AHA, 2003). The chart below summarizes the systolic and diastolic blood pressure values as they relate to hypertension classification. The cut-off points correspond to the clinical classification for hypertension as they relate to the systolic and diastolic blood pressure measurements. Classification Systolic blood pressure (SB) in mmHg Diastolic blood pressure (DBP) in mmHg Not elevated Normal less than 120 and less than 80 Prehypertension 120–139 or 80–89 Elevated (Hypertensive) Stage 1 140–159 or 90–99 Stage 2 160 or higher or 100 or higher Source: American Heart Association, 2003. Blood pressure values considered normal are less than 120 mmHg for SBP and less than 80 mmHg for DBP. An SBP value of 120-139 mmHg or a DBP value of 80-89 mmHg is classified as prehypertension. For high blood pressure, two stages are used to classify hypertension. Stage 1 hypertension is an early form of high blood pressure and may require treatment with medicine, together with frequent monitoring in order to avoid progression to Stage 2 hypertension. Stage 2 hypertension is a serious form of high blood pressure, which requires immediate treatment. Stage 1 hypertension is defined as SBP values in the range of 140-159 mmHg or DBP measurements in the range of 90-99 mmHg. For stage 2, SBP values are 160 mmHg or higher, or DBP values are 100 mmHg or higher. For this report, blood pressure measurements are classified into four broad groups using the AHA classification scheme. However, it must be recognized that the results do not reflect a clinical diagnosis of hypertension. In a clinical setting, an individual’s blood pressure would be taken and monitored over a prolonged period of time, with a clinical history for that individual, prior to diagnosing whether the individual has hypertension. In the survey setting, an individual’s blood pressure is taken in the survey for one day only and is recorded to provide information on the national status of this important NCD- associated risk factor. 15.2.1 History of Hypertension In addition to the blood pressure measurement, women and men age 35 and older were asked questions related to their experiences with blood pressure measurement and treatment to lower their blood pressure. Specifically, respondents were asked the following questions: “Before this survey, had your blood pressure ever been checked?” “Have you ever been told by a doctor or nurse that you have high blood pressure?” “To lower your blood pressure, are you now taking a prescribed medicine?” Table 15.2 presents the results. Overall, 73 percent of men and women age 35 and older had their blood pressure measured prior to the survey, and 27 percent had never had their blood pressure measured. Women are more likely than men to have had their blood pressure measured (75 percent and 70 percent, respectively). Sixteen percent of women and men say that a doctor or a nurse told them that they have high blood pressure (21 percent of women and 11 percent of men). Among the 1,260 women and men who report that they have high blood pressure, 66 percent say that they are currently taking medicine to lower their blood pressure (67 percent of women and 65 percent of men). Other Adult Health Issues • 237 Table 15.2 History of hypertension and actions taken to lower blood pressure Percent distribution of women age 35 and older and men age 35 and older by history of hypertension (high blood pressure), and among those told they had high blood pressure, percentage taking various actions to treat the illness, Bangladesh 2011 History of hypertension and actions taken to treat hypertension Women Men Total History of hypertension Percentage who never had blood pressure measured 24.2 29.1 26.6 Percentage who have ever had blood pressure measured 75.1 70.1 72.6 Missing 0.7 0.8 0.8 Total 100.0 100.0 100.0 Told high blood pressure by a doctor or nurse Percentage who were told they had high blood pressure by a doctor or nurse 21.0 10.7 15.9 Percentage never told they had blood pressure 78.3 88.4 83.3 Missing 0.7 1.0 0.8 Total 100.0 100.0 100.0 Number of respondents 4,007 3,925 7,932 Taken medicine to lower high pressure Percentage currently taking medicine to lower high blood pressure 66.8 64.5 66.0 Percentage who have never taken medicine to lower blood pressure 33.2 35.5 34.0 Total 100.0 100.0 100.0 Number of respondents told they have high blood pressure by a doctor or nurse 841 418 1,260 15.2.2 Prevalence and Treatment of Hypertension Tables 15.3.1 and 15.3.2 present data on blood pressure values for women and men age 35 and older, by background characteristics. In the table, elevated blood pressure is defined as blood pressure values of systolic blood pressure (SBP) greater than or equal to 140 mmHg or diastolic blood pressure (DBP) greater than or equal to 90 mmHg. A person who reports that they are currently taking antihypertensive medication to lower their blood pressure is also classified as having hypertension. Table 15.3.1 and Figure 15.1 show that 32 percent of women age 35 and older are hypertensive; they have elevated blood pressure values or are currently taking medicine to lower their blood pressure. In addition, 28 percent of women are pre-hypertensive; that is, they have blood pressure values of 120-139 mmHg SBP or 80-89 mmHg DBP and are not taking medication. Eighteen percent have elevated blood pressure and are not taking medications; 12 percent are hypertensive at Stage 1 (BP 140-159 mmHg SBP or 90-99 mmHg DBP) and 6 percent are hypertensive at stage 2 level (BP 160+ mmHg SBP or 100+ mmHg DBP). Fourteen percent of women classified as hypertensive are taking blood pressure medication. Among those who are taking medication, 56 percent do not have their BP at a normal level. Age is positively associated with blood pressure values; 18 percent of women age 35-39 are hypertensive compared with 50 percent of women age 70 and older. Urban women are more likely than rural women to have hypertension (40 percent compared with 29 percent). Across divisions, the percentage of women with hypertension ranges from 37 percent in Khulna to 25 percent in Sylhet. Although there is no clear pattern in the relationship between hypertension and the woman’s education, women who have completed secondary or higher education have a lower prevalence of hypertension (27 percent). The percentage of women with hypertension increases with increasing wealth; women in the highest wealth quintile are almost twice as likely as women in the lowest wealth quintile to have hypertension (44 percent compared with 25 percent). 238 • Other Adult Health Issues Being overweight or obese increases the risk of developing high blood pressure. In fact, blood pressure rises as body weight increases. Being overweight or obese are also risk factors for heart disease and other non-communicable diseases, as excess weight increases a person’s chance of developing high blood cholesterol and diabetes—two more risk factors for heart disease. One measure used to determine if someone is overweight or obese is body mass index (BMI). The BMI is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). It gives an approximation of total body fat, which increases the risk of diseases that are related to being overweight. In the 2011 BDHS, anthropometric measurements were also recorded for the men and women for whom blood pressure measurements were taken to obtain data on nutritional status. Table 15.3.1 shows that as BMI increases, the percentage of women with elevated blood pressure increases. For example, whereas 23 percent of thin women (BMI<18.5) are hypertensive, the proportion for overweight women (BMI 25.0-29.9) is 46 percent and for obese women (BMI ≥ 30.0) is 57 percent. On the other hand, whereas more than half of thin women (54 percent) have normal blood pressure, the corresponding proportion for overweight and obese women is 31 percent and 21 percent, respectively. Table 15.3.1 Blood pressure levels and treatment status by background characteristics: Women Among women age 35 and older, prevalence of hypertension, percent distribution by blood pressure values and treatment status, and percentage having normal blood pressure and taking medication, according to background characteristics, Bangladesh 2011 Background characteristic Prevalence of hyper- tension1 Blood pressure values1 Total Normal BP and taking medication Number of women BP <120 mmHg SBP and <80 mmHg DBP BP 120-139 mmHg SBP or 80-89 mmHg DBP BP 140-159 mmHg SBP or 90-99 mmHg DBP BP 160+ mmHg SBP or 100+ mmHg DBP Taking medicine Not taking medicine Taking medicine Not taking medicine Taking medicine Not taking medicine Taking medicine Not taking medicine Age 35-39 17.9 1.5 53.1 2.5 29.0 1.9 8.3 1.8 1.8 100.0 4.1 813 40-44 25.0 1.9 46.4 4.6 28.6 3.7 9.1 2.1 3.6 100.0 6.5 737 45-49 31.2 1.8 41.6 4.8 27.2 3.0 13.9 3.5 4.2 100.0 6.6 625 50-54 33.5 4.1 39.4 4.8 27.1 5.1 11.7 4.5 3.3 100.0 8.9 437 55-59 38.1 2.7 36.4 4.4 25.6 5.8 15.7 4.1 5.3 100.0 7.1 380 60-69 42.7 2.0 29.2 3.5 28.1 3.9 16.0 6.0 11.2 100.0 5.6 526 70+ 50.1 2.3 24.7 5.3 25.2 4.9 13.5 11.1 13.1 100.0 7.5 444 Residence Urban 40.2 3.4 32.5 6.2 27.3 5.7 14.4 5.2 5.3 100.0 9.6 907 Rural 29.4 1.8 43.0 3.5 27.6 3.2 11.3 4.0 5.6 100.0 5.3 3,056 Division Barisal 31.0 2.3 43.4 2.2 25.6 4.6 9.6 6.6 5.7 100.0 4.5 237 Chittagong 26.3 3.2 47.7 5.5 25.9 3.3 9.1 2.8 2.4 100.0 8.6 719 Dhaka 34.0 2.0 36.2 4.3 29.8 4.7 13.0 3.9 6.2 100.0 6.3 1,274 Khulna 37.0 0.7 34.8 3.6 28.2 3.5 13.7 5.0 10.4 100.0 4.4 505 Rajshahi 30.5 3.4 44.8 4.7 24.7 3.3 10.1 5.3 3.8 100.0 8.1 562 Rangpur 34.5 0.9 37.2 1.8 28.3 1.8 18.7 4.9 6.5 100.0 2.7 434 Sylhet 25.2 2.9 48.2 5.0 26.7 4.5 6.4 3.0 3.3 100.0 7.9 232 Education No education 32.7 2.0 39.8 3.4 27.5 2.8 13.0 4.4 7.1 100.0 5.4 2,312 Primary incomplete 29.0 2.3 41.8 3.3 29.2 4.0 10.6 4.2 4.6 100.0 5.6 809 Primary complete1 32.9 2.5 45.6 7.2 21.5 5.7 10.3 5.1 2.1 100.0 9.8 320 Secondary incomplete 35.0 2.4 37.5 7.6 27.5 6.7 12.7 3.4 2.2 100.0 10.0 336 Secondary complete or higher2 26.5 3.0 41.8 5.7 31.7 5.4 7.0 2.8 2.7 100.0 8.7 187 Wealth quintile Lowest 24.8 0.7 46.4 2.2 28.8 1.0 10.6 3.2 7.1 100.0 2.9 757 Second 27.6 1.6 46.3 3.1 26.1 1.3 13.3 3.4 4.9 100.0 4.7 747 Middle 27.7 1.8 44.1 3.7 28.2 2.7 9.7 4.1 5.7 100.0 5.4 794 Fourth 34.0 2.6 38.1 3.9 27.9 5.1 12.4 4.2 5.7 100.0 6.6 829 Highest 43.9 4.0 29.3 7.4 26.8 8.1 13.9 6.2 4.3 100.0 11.4 836 Nutritional status Thin (BMI <18.5) 22.7 0.9 52.7 0.9 24.6 1.9 10.7 3.3 4.9 100.0 1.8 1,154 Normal (BMI 18.5-24.9) 31.6 2.2 39.0 4.7 29.4 3.2 12.3 3.7 5.6 100.0 6.9 2,101 Overweight (BMI 25.0- 29.9) 45.8 5.0 26.1 7.6 28.0 7.7 12.1 7.1 6.5 100.0 12.5 556 Obese (BMI ≥30.0) 56.7 2.3 18.8 8.7 24.5 11.3 17.6 9.7 7.2 100.0 11.0 142 Total 31.9 2.2 40.6 4.1 27.6 3.7 12.0 4.2 5.5 100.0 6.3 3,963 Note: Total includes 7 pregnant or postpartum women and 3 women whose nutritional status is out of range. BP = blood pressure. SBP = Systolic blood pressure, the degree of force when the heart is pumping (contracting). DBP = Diastolic blood pressure, the degree of force when the heart is relaxed. 1 An individual is classified as having hypertension if s/he has blood pressure levels >=140 mmHg SBP or >=90 mmHg DBP, or s/he is currently taking antihypertensive medication to lower their blood pressure. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Other Adult Health Issues • 239 Table 15.3.2 and Figure 15.1 show that 19 percent of men age 35 and older have elevated blood pressure values or report that they are currently taking medicine to lower their blood pressure. Twenty- seven percent of men are pre-hypertensive. Men are less likely to be hypertensive than women (19 percent and 32 percent, respectively), but men are as likely as women to be pre-hypertensive (28 and 27 percent, respectively). Seven percent of men are taking medication for blood pressure, yet 56 percent of those who take medication do not have their blood pressure controlled at normal levels. Twelve percent have elevated blood pressure (9 percent are hypertensive at Stage 1 and 3 percent are hypertensive at stage 2 level) and are not taking medication. Table 15.3.2 Blood pressure levels and treatment status by background characteristics: Men Among men age 35 and older, prevalence of hypertension, percent distribution by blood pressure values and treatment status, and percentage having normal blood pressure and taking medication, according to background characteristics, Bangladesh 2011 Background characteristic Prevalence of hyper- tension1 Blood pressure values Total Normal BP and taking medication Number of men BP <120 mmHg SBP and <80 mmHg DBP BP 120-139 mmHg SBP or 80-89 mmHg DBP BP 140-159 mmHg SBP or 90-99 mmHg DBP BP 160+ mmHg SBP or 100+ mmHg DBP Taking medicine Not taking medicine Taking medicine Not taking medicine Taking medicine Not taking medicine Taking medicine Not taking medicine Age 35-39 9.8 0.1 61.2 0.4 29.1 0.7 7.3 0.2 1.0 100.0 0.5 664 40-44 14.5 1.1 57.8 1.0 27.7 0.9 9.0 0.8 1.7 100.0 2.0 635 45-49 16.2 1.0 52.8 2.1 31.0 0.8 9.0 1.3 2.0 100.0 3.1 588 50-54 21.1 1.0 55.5 1.5 23.4 3.3 9.7 2.1 3.6 100.0 2.5 617 55-59 20.1 0.1 49.9 2.1 30.0 4.6 6.9 1.8 4.5 100.0 2.2 308 60-69 28.2 3.2 49.0 5.2 22.8 3.5 8.4 2.7 5.2 100.0 8.4 569 70+ 30.0 1.4 42.7 2.6 27.3 2.8 12.1 3.9 7.1 100.0 4.0 496 Residence Urban 25.2 1.4 41.7 2.8 33.2 3.3 10.1 3.5 4.0 100.0 4.2 923 Rural 17.6 1.1 57.1 1.8 25.3 1.8 8.6 1.2 3.2 100.0 2.9 2,953 Division Barisal 18.1 2.2 57.0 2.8 24.9 1.2 6.5 2.2 3.2 100.0 5.0 227 Chittagong 16.9 2.3 57.5 1.9 25.6 2.1 6.0 1.9 2.7 100.0 4.2 615 Dhaka 19.9 1.0 52.3 2.4 27.8 2.8 9.5 1.4 2.9 100.0 3.4 1,241 Khulna 23.5 0.6 46.0 1.7 30.6 1.5 11.5 2.4 5.8 100.0 2.3 514 Rajshahi 16.9 1.2 58.4 2.0 24.7 2.1 7.5 1.2 2.9 100.0 3.2 574 Rangpur 22.5 0.5 47.4 1.5 30.1 1.6 13.1 1.6 4.1 100.0 2.0 488 Sylhet 15.4 0.9 62.1 1.8 22.5 2.8 5.3 2.7 1.8 100.0 2.7 217 Education No education 16.8 1.0 59.9 1.7 23.3 1.0 7.4 1.1 4.5 100.0 2.7 1,412 Primary incomplete 15.6 0.5 56.8 1.3 27.7 1.8 7.8 1.9 2.2 100.0 1.9 974 Primary complete1 24.9 1.5 45.4 2.4 29.6 4.4 10.8 2.3 3.5 100.0 4.0 459 Secondary incomplete 22.0 2.1 50.1 3.2 27.9 3.1 9.3 1.4 2.8 100.0 5.3 577 Secondary complete or higher2 27.2 1.3 38.1 3.0 34.7 2.9 14.0 3.1 2.8 100.0 4.4 455 Wealth quintile Lowest 12.9 0.4 65.6 1.5 21.5 0.2 7.6 0.4 2.8 100.0 1.9 767 Second 15.8 1.5 61.4 0.9 22.9 1.2 7.7 0.9 3.5 100.0 2.4 760 Middle 16.7 1.3 56.1 1.1 27.3 1.1 8.7 1.3 3.1 100.0 2.4 757 Fourth 20.9 1.1 49.2 2.8 29.9 3.2 8.8 2.1 2.8 100.0 4.0 790 Highest 30.4 1.5 35.7 3.9 33.9 4.7 11.8 3.8 4.5 100.0 5.4 801 Nutritional status Thin (BMI <18.5) 12.6 0.9 65.2 0.9 22.2 0.8 6.6 0.7 2.7 100.0 1.8 1,130 Normal (BMI 18.5-24.9) 20.5 1.2 51.4 1.7 28.1 2.5 9.5 1.9 3.5 100.0 3.0 2,381 Overweight (BMI 25.0- 29.9) 32.7 1.6 29.7 6.9 37.6 4.0 12.1 3.6 4.4 100.0 8.6 332 Obese (BMI ≥30.0) (43.6) (0.0) (28.9) (15.7) (27.5) (5.1) (15.) (5.4) (1.6) 100.0 (15.7) 34 Total 19.4 1.2 53.4 2.1 27.2 2.2 8.9 1.7 3.4 100.0 3.2 3,876 Note: Figures in parentheses are based on 25-49 unweighted cases. BP = blood pressure. SBP = Systolic blood pressure, the degree of force when the heart is pumping (contracting). DBP = Diastolic blood pressure, the degree of force when the heart is relaxed. 1 An individual is classified as having hypertension if s/he has blood pressure levels >=140 mmHg SBP or >=90 mmHg DBP, or s/he is currently taking antihypertensive medication to lower their blood pressure. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 240 • Other Adult Health Issues Men show the same pattern in hypertension by age as women; prevalence is lower among younger men and increases with age. Also similar to women, urban men are more likely than rural men to be hypertensive (25 percent compared with 18 percent). Among the divisions, the prevalence of hypertension ranges from 15 percent in Sylhet to 24 percent in Khulna. There is no clear relationship between a man’s education and his blood pressure value. However, men who have completed secondary or higher education are most likely to have hypertension compared with men with no education (27 percent versus 17 percent). This is the reverse of the pattern shown by women; women who have completed secondary or higher education level are the least likely to be hypertensive (27 percent). Similar to the pattern observed for women, men in the highest wealth quintile are more than twice as likely as men in the lowest wealth quintile to have hypertension (30 percent compared with 13 percent). As in the case of women, overweight and obese men are more likely to be hypertensive than thin men or men with normal BMI. For example, 13 percent of thin men are hypertensive compared with 33 percent of overweight men. Figure 15.1 Prevalence of hypertension and pre-hypertension among women and men age 35 and older 32 19 28 27 Women Men Hypertensive Pre-hypertensive Percent BDHS 2011 The first step for individuals to bring their blood pressure under control is to be aware of their condition. Having identified NCDs as a new challenge, the government of Bangladesh has taken steps to prioritize the expansion of services related to NCD disease control activities. The level of awareness of hypertension and treatment status is presented in Figure 15.2. It shows that 45 percent of women and 57 percent of men who are hypertensive are unaware that they have an elevated blood pressure. Eleven percent of women and 8 percent of men are aware of their hypertension, but are not treating it. One in four women and one in five men are aware of their condition, are taking medication to lower the blood pressure, but are unsuccessful in controlling the elevated blood pressure. Only one in five women and one in six men are aware of their hypertension, are treating it, and have the hypertension under control. Other Adult Health Issues • 241 Figure 15.2 Awareness of hypertension and treatment status among hypertensive women and men age 35 and over 45 11 25 20 Women 57 8 20 16 Men Not aware, elevated Aware, not treated, elevated Aware, treated, and not controlled Aware, treated and controlled 15.3 DIABETES Diabetes has serious consequences for individuals and poses a large burden on health services, especially in developing countries. According to the International Diabetes Federation (IDF), diabetes poses a daunting challenge to the sustainable development of the nation, as more than 12 percent of the adult population in Bangladesh is estimated to be affected by either diabetes or prediabetes (IDF 2011). Nearly half of the population with diabetes is undiagnosed; and among those diagnosed with diabetes, only 1 in 3 people is treated and roughly 1 in 13 achieves treatment targets (Latif et al., 2011). The prevalence of diabetes in the adult population has increased very rapidly in most South Asian populations, and Bangladesh is no exception to this trend. Almost all population-based assessments in Bangladesh indicate an increasing trend of diabetes prevalence; with recent levels as high as 7 percent (Rahim et al., 2007). In another survey among slum populations in Bangladesh, the prevalence of diabetes was 9 percent for women and 8 percent for men (Hussein et al., 2005). The only national urban health survey states that the prevalence of diabetes was higher among both women and men age 35 and older in the non-slum areas (17 percent and 14 percent, respectively) than among their counterparts in the slums (6 percent of women and 8 percent of men) (NIPORT et al., 2008). A recent WHO study in Bangladesh estimated the diabetes prevalence (reported, not diagnosed) at 4 percent (WHO, 2011). Women and men age 35 and older in one third of the households selected for the 2011 BDHS were eligible to have their blood glucose levels tested. The respondent was asked if she or he had eaten or drunk anything at all (except water) from the time she or he had awakened in the morning until the time of the glucose testing. If the subject was fasting at the time of interview, a capillary blood sample was obtained from the middle or ring finger of the respondent. If the respondent had not been fasting at the time of interview, an appointment was made for the next morning to collect and test a fasting capillary blood sample as described above. Response to the request for testing and fasting was encouraging; more than 90 percent of eligible women and men actually fasted 8 hours or more prior to the measurement (data not shown). Blood glucose was measured using the HemoCue 201+ blood glucose analyzer in capillary whole blood obtained from the middle or ring finger from adults after an overnight fast. The finger was cleaned with a swab containing 70 percent isopropyl alcohol, allowed to dry, and pricked with a retractable, non- reusable lancet. The first two drops of blood were wiped away, and the third drop was drawn into the glucose microcuvette by capillary action after placing the tip of the microcuvette in the middle of the blood drop. The outside of the microcuvette was wiped clean with gauze and placed in the analyzer to obtain a glucose measurement. The HemoCue 201+ analyzer displayed the blood glucose measurements in milligrams per deciliter (mg/dL). This unit of measurement was converted into millimoles per liter (mmol/L) to maintain consistency with the units used in the 2006 Bangladesh Urban Health Survey. To 242 • Other Adult Health Issues convert the blood glucose measurements from mg/dL to mmol/L, the values were multiplied by 0.0551 (Lehman and Henry, 2001). The WHO recommends that venous plasma be used for measuring the glucose concentration in blood (WHO, 2006). However, capillary sampling (whole blood obtained from a finger prick) is widely used, particularly in resource-limited countries. If whole blood is used, it is necessary to adjust the blood glucose measurements in whole blood to the plasma glucose equivalent values. To achieve this, the whole blood glucose measurements in the BDHS 2011 were adjusted by multiplying each value by 1.11 (D’Orazio et al., 2005). For the purpose of comparing fasting glucose values with other national data, the data for fasting whole blood glucose values corresponding to the fasting plasma glucose values are also presented. The 2011 BDHS uses WHO cut-off points for measuring fasting plasma glucose (WHO, 2006). The cut-off points correspond to the clinical classification for normal fasting plasma glucose levels, prediabetes, and diabetes. Fasting plasma glucose values considered to be normal are 3.9-6.0 mmol/L. A fasting plasma glucose value of 6.1-6.9 mmol/L is classified as prediabetes, and values greater than or equal to 7.0 mmol/L are considered to be diabetes. The chart below summarizes the fasting plasma glucose values as they relate to diabetes classification. Classification Level in mmol/L Normal 3.9-6.0 Prediabetes 6.1-6.9 Diabetes ≥7.0 Source: WHO, 2006. The data are presented according to the fasting plasma glucose values obtained from the respondents. The fasting plasma glucose measurements taken in the survey provide a cross-sectional assessment of the prevalence of diabetes in the surveyed population at the time of the BDHS interviews and do not represent a medical diagnosis of diabetes. Although the results of the fasting plasma glucose measurements are regarded only as a statistical description of the survey population, they are useful in providing insight into the size and characteristics of the population at risk for diabetes. For the purposes of the survey, fasting plasma glucose values are not presented using the diagnostic terms prediabetes or diabetes. In a clinical setting, an individual’s fasting plasma glucose levels would be taken and monitored over a prolonged period of time, with a clinical history for that individual prior to diagnosing whether the individual has diabetes. In the survey setting, an individual’s fasting plasma glucose is taken in the survey for one day only, and the value is recorded to provide information on the national status of this important NCD. 15.3.1 History of Diabetes Women and men age 35 and older were asked questions related to any previous diagnosis of diabetes and whether they were taking medication to treat their diabetes. Specifically, respondents were asked the following questions: “Have you ever heard of an illness called diabetes?” “Have you ever been told by a doctor or nurse that you have diabetes?” “Are you now taking medication for diabetes prescribed by a doctor or nurse?” “How do you take the medication?” Other Adult Health Issues • 243 Table 15.4 presents the findings. Overall, 5 percent of women and men age 35 and older say that a doctor or a nurse told them that they had diabetes prior to the survey. Among those diagnosed with diabetes, two-thirds report they are receiving treatment for their diabetes. The majority of those receiving treatment take medication orally (73 percent), 17 percent take injections, and 8 percent take medication both orally and by injection. Table 15.4 History of diabetes Percent distribution of women and men age 35 and older by history of diabetes, and among those previously diagnosed with diabetes, the percentage taking medicine and the method taking medicine, Bangladesh 2011 History of diabetes Women Men Total History of diabetes Told had diabetes by a doctor or a nurse 5.8 4.9 5.3 Receiving treatment 3.9 3.2 3.6 Not receiving treatment 1.8 1.6 1.7 Missing 0.1 0.1 0.1 Never told had diabetes 83.4 89.8 86.6 Never heard of diabetes 10.8 5.4 8.1 Total 100.0 100.0 100.0 Number of respondents 4,007 3,925 7,932 Method of taking medicine Injected 16.5 17.6 17.0 Orally 71.8 74.7 73.1 Injected and orally 10.0 5.0 7.8 Missing 1.6 2.7 2.1 Total 100.0 100.0 100.0 Number of respondents diagnosed with diabetes and receiving treatment 157 127 284 15.3.2 Prevalence and Treatment of Diabetes The fasting whole blood glucose measurements taken in the survey provide a cross-sectional assessment of the elevated fasting plasma values in the surveyed population at the time of the BDHS interviews and do not represent a medical diagnosis of diabetes. Whole blood values, which are physiologically different from plasma values, have been converted to plasma equivalent values by multiplying by a constant factor of 1.11. This factor is based on the relationship between plasma and whole blood glucose at normal hematocrit (0.43). Tables 15.5.1 and 15.5.2 present the fasting plasma glucose levels. The corresponding tables with fasting whole blood glucose values by background characteristics are presented in Appendix Tables D-5.5.1 and D-5.5.2. Tables 15.5.1 and 15.5.2 and Figure 15.3 present data on fasting blood glucose values and treatment status for women and men age 35 and older. Data show that 11 percent each of women and men have diabetes; either because they have fasting plasma glucose (FPG) values of 7 mmol/L or higher or because they report that they are currently taking diabetes medication. An additional 25 percent of women and 26 percent of men are pre-diabetic. Four percent of women and 3 percent of men are taking medication for diabetes. Among those who are taking medication for diabetes, only 40 percent of women and 32 percent of men have their blood glucose controlled at normal levels. Table 15.5.1 shows that diabetes has a positive relationship with age; 9 percent of women age 35- 39 have elevated FPG values or are currently taking diabetes medicine compared with 15 percent of women age 55-59. Urban women are almost twice as likely as rural women to be classified as having diabetes (17 percent compared with 10 percent). Among the divisions, women in Chittagong have the highest percentage of women with diabetes (14 percent), while women in Khulna have the lowest percentage (7 percent). The likelihood of having diabetes increases with the women’s education. Women who have completed secondary or higher education are twice as likely to have diabetes as women with no education (19 percent compared with 9 percent). Similar to the pattern observed for education, the percentage of women with diabetes increases with an increase in wealth. Women in the highest wealth 244 • Other Adult Health Issues quintile are three times as likely as women in the lowest wealth quintile to have diabetes (21 percent compared with 7 percent). Table 15.5.1 also shows that relationship between diabetes and nutrition status. The percentage of women classified as having diabetes increases from 6 percent among thin women to 11 percent among women with normal BMI. One in five overweight women and 27 percent of obese women are diabetic. Table 15.5.1 Fasting plasma glucose values and treatment status: Women Among women age 35 and older, prevalence of diabetes, percent distribution by fasting plasma glucose (FPG) values and treatment status, and percentage with normal fasting plasma glucose level and taking medication, by background characteristics, Bangladesh 2011 Background characteristic Prevalence of diabetes1 Fasting plasma glucose values Total Normal FPG and taking medication Number of women <3.9 mmol/L (Below normal) 3.9-6.0 mmol/L (Normal) 6.1-6.9 mmol/L (Prediabetic) ≥7 mmol/L (Elevated FPG) Taking medication Not taking medication Taking medication Not taking medication Taking medication Not taking medication Taking medication Not taking medication Age 35-39 9.4 0.1 2.9 0.2 65.1 0.6 22.7 1.7 6.7 100.0 0.9 789 40-44 10.5 0.0 2.2 1.3 62.2 0.2 25.1 2.9 6.1 100.0 1.5 712 45-49 10.8 0.2 2.8 0.2 60.6 0.3 25.7 1.9 8.2 100.0 0.7 603 50-54 12.4 0.0 3.3 0.6 56.5 1.2 27.7 2.6 8.0 100.0 1.8 421 55-59 15.3 0.0 1.4 0.7 58.8 1.1 24.5 4.8 8.6 100.0 1.8 370 60-69 11.2 0.0 3.4 1.9 62.4 1.1 23.0 2.8 5.4 100.0 3.0 501 70+ 12.0 0.0 1.6 1.3 60.1 1.1 26.4 1.5 8.1 100.0 2.4 425 Residence Urban 17.3 0.0 1.9 1.6 59.3 1.5 21.5 5.2 8.9 100.0 3.1 872 Rural 9.5 0.1 2.8 0.6 62.0 0.5 25.8 1.6 6.6 100.0 1.2 2,950 Division Barisal 13.0 0.0 2.0 0.5 50.9 0.2 34.1 1.5 10.7 100.0 0.7 220 Chittagong 13.8 0.0 2.1 0.5 51.4 0.5 32.7 3.5 9.3 100.0 1.0 677 Dhaka 11.8 0.0 2.4 1.4 65.3 1.3 20.5 3.0 6.2 100.0 2.7 1,245 Khulna 7.1 0.0 1.1 0.3 71.8 0.4 20.0 1.5 5.0 100.0 0.6 493 Rajshahi 11.7 0.2 3.0 1.2 59.8 0.8 25.5 2.3 7.1 100.0 2.2 539 Rangpur 8.7 0.2 5.7 0.1 63.3 0.1 22.3 1.0 7.2 100.0 0.4 424 Sylhet 11.2 0.0 2.4 0.7 57.3 0.7 29.1 2.9 6.9 100.0 1.5 224 Education No education 8.8 0.1 2.5 0.6 64.1 0.4 24.6 0.9 6.8 100.0 1.0 2,224 Primary incomplete 12.6 0.1 3.2 1.2 58.8 0.6 25.4 3.4 7.2 100.0 2.0 780 Primary complete1 16.2 0.0 1.5 1.5 59.9 3.3 22.3 5.3 6.2 100.0 4.8 303 Secondary incomplete 15.9 0.0 3.5 0.2 55.4 1.1 25.2 6.1 8.7 100.0 1.2 331 Secondary complete or higher2 18.8 0.0 1.3 2.5 52.6 0.7 27.3 5.8 9.7 100.0 3.3 185 Wealth quintile Lowest 6.7 0.0 2.7 0.2 60.7 0.4 29.9 0.5 5.6 100.0 0.6 732 Second 7.1 0.0 3.9 0.4 65.2 0.4 23.8 0.0 6.2 100.0 0.9 717 Middle 7.9 0.3 2.0 0.5 65.1 0.2 25.0 0.5 6.3 100.0 1.0 770 Fourth 12.1 0.0 2.6 1.5 61.4 0.6 23.9 3.2 6.7 100.0 2.2 800 Highest 21.4 0.0 1.9 1.4 55.0 1.8 21.7 7.6 10.5 100.0 3.2 802 Nutritional status Thin (BMI <18.5) 6.2 0.0 2.7 0.4 64.3 0.7 26.8 0.4 4.8 100.0 1.1 1,119 Normal (BMI 18.5-24.9) 10.6 0.1 2.8 0.7 62.0 0.3 24.5 2.5 7.1 100.0 1.1 2,022 Overweight (BMI 25.0- 29.9) 19.6 0.0 1.2 2.6 57.9 2.0 21.3 5.8 9.2 100.0 4.7 533 Obese (BMI ≥30.0) 27.1 0.0 4.1 0.0 42.7 2.0 26.0 5.1 20.1 100.0 2.0 138 Total 11.2 0.1 2.6 0.8 61.4 0.7 24.8 2.5 7.1 100.0 1.6 3,822 Note: Total includes 6 pregnant and postpartum women and 3 women with out of range nutritional status. FPG = Fasting Plasma Glucose. 1 An individual is classified as having diabetes if s/he reports taking medication for diabetes or has fasting blood glucose ≥7.0 mmol/L. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. Table 15.5.2 shows the variation in fasting plasma glucose values and treatment of diabetes among men by age; the prevalence of diabetes among men peaks at 19 percent among men age 55-59. Similar to women, urban men and those living in Chittagong division have higher prevalence of diabetes than men in other areas. Diabetes prevalence increases with the man’s education, ranging from 8 percent for men with no education to 14 to15 percent for men with secondary education. Diabetes prevalence is lower among men in the lower three wealth quintiles (7-8 percent) than among those in the upper two quintiles (11 and 19 percent). Other Adult Health Issues • 245 The relationship between blood glucose and nutrition status in men is also shown in Table 15.5.2. As in the case of women, the percentage of men who are classified as having diabetes increases with BMI, ranging from 7 percent among thin men to 11 percent among men with normal BMI, and up to 20 percent for overweight men. Table 15.5.2 Fasting plasma glucose values and treatment status by background characteristics: Men Among men age 35 and older, prevalence of diabetes, percent distribution by fasting plasma glucose (FPG) values and treatment status, and percentage with normal FPG and taking medication by background characteristics, Bangladesh 2011 Background characteristic Prevalence of diabetes1 Fasting plasma glucose values Total Normal FPG and taking medication Number of men <3.9 mmol/L (Below normal) 3.9-6.0 mmol/L (Normal) 6.1-6.9 mmol/L (Prediabetic) ≥7 mmol/L (Elevated FPG) Taking medication Not taking medication Taking medication Not taking medication Taking medication Not taking medication Taking medication Not taking medication Age 35-39 7.3 0.0 3.1 0.1 67.1 0.3 22.5 1.2 5.8 100.0 0.4 626 40-44 8.1 0.0 1.5 0.1 67.3 0.2 23.0 1.2 6.7 100.0 0.3 607 45-49 11.4 0.0 2.2 0.7 62.5 1.1 23.9 2.8 6.9 100.0 1.8 563 50-54 9.1 0.0 2.3 0.0 63.2 0.3 25.5 2.7 6.0 100.0 0.3 592 55-59 19.2 0.0 3.5 0.5 53.9 0.8 23.4 4.4 13.5 100.0 1.3 298 60-69 13.0 0.3 2.6 0.9 53.7 1.4 30.7 2.8 7.7 100.0 2.6 555 70+ 11.3 0.0 1.8 1.2 56.3 0.4 30.6 2.1 7.6 100.0 1.6 479 Residence Urban 14.9 0.2 2.2 1.0 63.4 1.2 19.5 4.2 8.4 100.0 2.3 888 Rural 9.3 0.0 2.4 0.3 60.7 0.4 27.5 1.7 6.9 100.0 0.7 2,832 Division Barisal 12.1 0.0 2.6 0.9 52.5 0.5 32.9 1.3 9.4 100.0 1.4 208 Chittagong 14.8 0.0 1.9 0.2 52.8 0.5 30.5 4.3 9.9 100.0 0.7 579 Dhaka 10.7 0.1 2.0 0.6 62.2 0.7 25.2 2.8 6.4 100.0 1.5 1,212 Khulna 7.5 0.0 1.3 0.4 71.6 0.0 19.6 1.8 5.3 100.0 0.4 499 Rajshahi 9.7 0.0 3.1 0.5 61.1 0.6 26.1 1.4 7.2 100.0 1.1 543 Rangpur 8.7 0.0 4.4 0.3 65.0 0.6 21.9 0.8 7.0 100.0 0.9 475 Sylhet 12.5 0.0 1.8 0.8 57.2 1.6 28.5 2.0 8.1 100.0 2.4 205 Education No education 7.7 0.0 2.9 0.3 62.2 0.3 27.2 0.7 6.5 100.0 0.5 1,358 Primary incomplete 9.8 0.0 2.6 0.1 60.3 0.5 27.3 1.3 7.8 100.0 0.7 933 Primary complete1 12.6 0.3 1.6 0.7 58.4 0.1 27.4 2.9 8.5 100.0 1.1 443 Secondary incomplete 15.0 0.0 2.0 1.2 62.7 1.5 20.3 4.9 7.3 100.0 2.7 552 Secondary complete or higher2 14.3 0.0 1.6 0.7 62.2 1.1 21.9 5.3 7.2 100.0 1.9 435 Wealth quintile Lowest 7.9 0.0 2.3 0.0 63.7 0.3 26.1 0.7 6.9 100.0 0.3 740 Second 7.6 0.0 2.9 0.3 60.6 0.1 28.9 0.0 7.2 100.0 0.4 721 Middle 7.3 0.0 2.5 0.3 61.1 0.0 29.1 1.3 5.6 100.0 0.3 722 Fourth 10.5 0.0 2.7 0.3 63.5 1.0 23.3 1.5 7.7 100.0 1.3 761 Highest 19.5 0.2 1.4 1.4 58.0 1.5 21.0 7.6 8.8 100.0 3.1 777 Nutritional status Thin (BMI <18.5) 7.4 0.0 3.0 0.3 59.0 0.3 30.6 0.5 6.3 100.0 0.6 1,093 Normal (BMI 18.5-24.9) 10.6 0.1 2.2 0.4 64.4 0.7 22.8 2.4 7.1 100.0 1.2 2,279 Overweight (BMI 25.0- 29.9) 19.8 0.0 1.8 1.0 50.6 0.8 27.9 7.1 10.8 100.0 1.8 317 Obese (BMI ≥30.0) (34.9) (0.0) (0.0) (6.0) (33.5) (1.7) (31.6) (9.5) (17.6) 100.0 7.7 32 Total 10.7 0.0 2.4 0.5 61.4 0.6 25.6 2.3 7.3 100.0 1.1 3,721 Note: Figures in parentheses are based on 25-49 unweighted cases. FPG = Fasting Plasma Glucose. Total includes men with missing information on nutritional status. Total includes men with missing information on history of history of diabetes. 1 An individual is classified as having diabetes if s/he reports taking medication for diabetes or has fasting blood glucose ≥7.0 mmol/L. 2 Primary complete is defined as completing grade 5. 3 Secondary complete is defined as completing grade 10. 246 • Other Adult Health Issues Figure 15.3 Prevalence of diabetes and pre-diabetes among women and men age 35 and older 11 11 25 26 Women Men Diabetic Pre-diabetic Percent BDHS 2011 Figure 15.4 shows awareness of diabetes and treatment status among women and men with diabetes. Almost 60 percent of women and 65 percent of men are not aware that their plasma glucose levels are elevated. Five percent of women and men are aware that they are diabetic, have elevated blood glucose at the time of the survey, and are not treating it. More than one in five women and men are aware of their condition and are taking medication to lower the plasma glucose to normal values, but they are not successful in having it under control. Finally, 15 percent of women and 10 percent of men are aware that they have diabetes, are treating it, and have the plasma glucose level controlled within normal levels. Figure 15.4 Awareness of diabetes and treatment status among diabetic women and men age 35 and over 59 5 22 15 Women 654 21 10 Men Not aware, elevated Aware, not treated, elevated Aware, treated, and not controlled Aware, treated and controlled Community Characteristics • 247 COMMUNITY CHARACTERISTICS 16 n the 2011 BDHS, the Community Questionnaire was administered in each of the selected clusters during the household listing operation. Questions asked about the existence of development organizations in the community and the availability and accessibility of health services and other facilities. The Community Questionnaire was administered to a group of informants in each cluster, including the chairman or members of the union council, the ward commissioner, village/mohalla heads, teachers, imams, and female opinion leaders. Distance to facilities was measured from the center of each sample point. All interviewed women in the cluster were assumed to be the same distance from the facility. Table 16.1 presents the percent distribution of ever-married women age 15-49 by distance to various general services. Access to weekly markets was not asked about in urban areas because they are not the norm; the median distance to markets in rural areas, however, is 2.1 km. Urban women live slightly closer to a post office than rural women, with median distances of 1.5 km and 2.2 km, respectively. Cinema halls are mostly an urban phenomenon; the median distance to a cinema hall is 2.5 km compared with 9.9 km in rural areas. Overall, 28 percent of all ever-married women (all in rural areas) have a weekly market less than 1 km away, 26 percent (29 percent in urban areas and 25 percent in rural areas) have a post office less than 1 km away, and 4 percent (15 percent in urban areas and less than 1 percent in rural areas) have a cinema hall less than 1 km away. In conclusion, the data show that urban and rural women have similar access to a post office; urban women are much more likely to be close to a cinema hall than rural women; and rural women have exclusive access to weekly markets. Table 16.1 Distance to the nearest general services Percent distribution of ever-married women age 15-49 by distance to the nearest specified service location, according to distance, Bangladesh 2011 Distance to the nearest service location Urban Rural Total Post office Cinema hall Weekly market Post office Cinema hall Weekly market Post office Cinema hall <1 km 28.7 14.7 27.6 24.9 0.8 27.6 25.9 4.4 1-4 km 66.2 63.5 63.7 68.0 15.8 63.7 67.6 28.2 5-9 km 5.0 13.0 5.8 6.4 34.1 5.8 6.0 28.6 ≥10 km 0.0 8.8 2.8 0.7 49.4 2.8 0.5 38.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 4,619 4,619 13,130 13,130 13,130 13,130 17,749 17,749 Median distance 1.5 2.5 2.1 2.2 9.9 2.1 1.9 7.9 Table 16.2 shows the percent distribution of ever-married women age 15-49 by distance to the nearest education facility, according to type of facility. Religious schools are widespread in Bangladesh; half of the women live in a village/mohalla that has a madrasha, and an additional 46 percent of women have a madrasha within 5 kilometers. Overall, 83 percent of women live in a village/mohalla where there is a primary school, and virtually all have access to a primary school within a distance of 5 km. Access to a boys’ high school is more limited than access to a girls’ high school; 8 percent of women live in a village/mohalla where there is a boys’ high school compared with 12 percent with a girls’ high school. A total of 37 percent of women have access to a coeducational high school within their village/mohalla, and an additional 60 percent have access within 5 km. Urban women are more likely than rural women to have a school nearby for all the specified educational facilities. I 24 8 • C om m un ity C ha ra ct er is tic s Ta bl e 16 .2 D is ta nc e to th e ne ar es t e du ca tio n fa ci lit y Pe rc en t d is tri bu tio n of e ve r- m ar rie d w om en a ge 1 5- 49 b y di st an ce to th e ne ar es t e du ca tio n fa ci lit y, a cc or di ng to d is ta nc e, B an gl ad es h 20 11 D is ta nc e to th e ne ar es t fa ci lit y U rb an R ur al To ta l M ad ra sh a1 P rim ar y sc ho ol Bo ys ’ h ig h sc ho ol G irl s’ h ig h sc ho ol C o- ed u- ca tio na l hi gh sc ho ol M ad ra sh a1 P rim ar y sc ho ol Bo ys ’ h ig h sc ho ol G irl s’ h ig h sc ho ol C o- ed u- ca tio na l hi gh sc ho ol M ad ra sh a1 P rim ar y sc ho ol B oy s’ h ig h sc ho ol G irl s’ h ig h sc ho ol C o- ed u- ca tio na l hi gh sc ho ol W ith in v ill ag e/ m oh al la 60 .4 85 .8 24 .6 29 .3 47 .1 46 .8 82 .1 2. 3 6. 2 33 .3 50 .3 83 .0 8. 1 12 .2 36 .9 1- 4 km 39 .3 14 .2 48 .4 61 .6 51 .8 48 .5 17 .7 18 .9 41 .8 62 .3 46 .1 16 .8 26 .6 46 .9 59 .6 5- 9 km 0. 4 0. 0 11 .1 7. 1 0. 7 3. 8 0. 0 23 .4 26 .0 3. 5 2. 9 0. 0 20 .2 21 .1 2. 8 ≥ 1 0 km 0. 0 0. 0 15 .9 2. 1 0. 4 1. 0 0. 2 55 .3 26 .0 0. 9 0. 7 0. 2 45 .0 19 .8 0. 8 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f w om en 4, 61 9 4, 61 9 4, 61 9 4, 61 9 4, 61 9 13 ,1 30 13 ,1 30 13 ,1 30 13 ,1 30 13 ,1 30 17 ,7 49 17 ,7 49 17 ,7 49 17 ,7 49 17 ,7 49 M ed ia n di st an ce a a 2. 1 1. 7 1. 1 1. 2 a 10 .9 5. 3 1. 8 a a 8. 4 3. 9 1. 5 N ot e: T ot al s m ay n ot a dd to 1 00 .0 d ue to m is si ng v al ue s. 1 R el ig io us s ch oo l a = U nk no w n; m ed ia n di st an ce c an no t b e ca lc ul at ed b ec au se m or e th an 5 0 pe rc en t o f t he c as es a re in th e ca te go rie s “w ith in v ill ag e” a nd “w ith in m oh al la ” 248 • Community Characteristics Community Characteristics • 249 During the administration of the Community Questionnaire, informants were asked whether specific 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. Table 16.3 shows that 89 percent of ever-married women age 15-49 live in villages/mohallas that have a Grameen Bank, followed by BRAC (87 percent), ASA (86 percent), other NGO income-generating activities (64 percent), and cooperative society (61 percent). One in ten women lives in areas with cottage industries. Women in rural areas are more likely than those in urban areas to have access to Grameen Bank (95 percent versus 72 percent), BRAC (89 percent versus 78 percent), and ASA (89 percent versus 76 percent). On the other hand, urban women have more access than rural women to voluntary organizations (43 percent versus 22 percent), mothers’ clubs or ladies’ associations (12 percent versus 6 percent), cooperative societies (68 percent versus 58 percent), cottage industries of the Bangladesh Small Industries Corporation (BSIC) (21 percent versus 6 percent), and the NGO, PROSHIKA (46 percent versus 34 percent). Table 16.3 Availability of income-generating organizations Percentage of ever-married women age 15-49 who have access to specific organizations, by residence, Bangladesh 2011 Income-generating organization Residence Total Urban Rural Mothers’ club or ladies’ association 11.5 5.9 7.4 Grameen Bank member 71.5 94.8 88.7 Voluntary organization 43.2 22.1 27.6 BRAC income-generating activities 78.2 89.4 86.5 PROSHIKA 45.8 34.3 37.3 ASA 75.8 89.3 85.8 Cottage industries of BSIC 21.0 6.4 10.2 Cooperative society 67.9 58.3 60.8 Other NGO income-generating activities 76.8 59.6 64.1 Number of women 4,619 13,130 17,749 BRAC = Bangladesh Rural Advancement Committee PROSHIKA = name of NGO ASA = Association of Social Advancement BSIC = Bangladesh Small Industries Corporation Informants to the Community Questionnaire were asked to list the names of “depot holders,” or health and family planning workers who work in the village/mohalla, as well as pharmacies or shops and satellite clinics that provide services to individuals in the village/mohalla. Table 16.4 shows the results. Nine percent of women live in a village/mohalla with a depot holder; 5 percent in urban compared with 10 percent in rural areas. Seven in 10 women live in a village where there are pharmacies or shops that sell family planning methods. Urban women are much more likely to have a pharmacy or shop nearby compared with rural women (82 and 67 percent, respectively). Almost all women (99 percent) live in villages/mohallas where satellite clinics are held. Satellite clinics are almost equally available in urban and rural areas (97 and 99 percent, respectively). Table 16.4 Availability of family planning and health services Percentage of ever-married women age 15-49 who have access to specific family planning and health services, by residence, Bangladesh 2011 Family planning or health service Residence Total Urban Rural Depot holder who sells family planning methods 4.8 9.8 8.5 Pharmacy/shop that sells family planning methods 81.5 66.9 70.7 Satellite clinic 96.8 99.2 98.5 Number of women 4,619 13,130 17,749 250 • Community Characteristics Table 16.5 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 of each division. Overall, 42 percent of the people go to their upazila headquarters by car, bus, or tempo and 20 percent, each, use rickshaw (or rickshaw van) and a baby taxi. Car, bus, or tempo use is highest in Khulna (55 percent) and Barisal (53 percent). Car, bus, or tempo use is also widespread in Rangpur and Rajshahi (42 and 48 percent, respectively).Rickshaws or rickshaw vans are the second most common means of travel to upazila headquarters in Rangpur (40 percent) and Rajshahi (32 percent). Almost half of people in Chittagong (47 percent) and one in three in Sylhet (33 percent) use a baby taxi to travel to upazila headquarters. Boat use overall is only 4 percent, and it is highest in Sylhet (15 percent). Table 16.5 Means of transport to upazila headquarters Percent distribution of sample clusters by most common means of transport to upazila headquarters, according to division, Bangladesh 2011 Division Most common transport Total Number of clusters Car/ bus/ tempo Motor- cycle Motor launch Bicycle Boat Path Rickshaw/ rickshaw van Train Baby taxi Other Missing Barisal 53.4 4.1 8.8 0.0 7.4 1.8 13.5 0.0 11.0 0.0 0.0 100.0 30 Chittagong 29.2 0.0 5.8 0.0 0.0 10.7 2.9 0.0 46.6 4.7 0.0 100.0 81 Dhaka 40.1 3.2 0.0 0.0 6.0 3.2 19.0 1.4 24.1 2.9 0.0 100.0 128 Khulna 54.8 1.4 0.0 0.0 3.5 1.9 20.9 0.0 1.7 14.3 1.5 100.0 55 Rajshahi 47.9 0.0 0.0 0.0 1.4 2.1 31.9 0.0 5.9 10.8 0.0 100.0 72 Rangpur 42.3 0.0 0.0 1.6 1.5 1.6 39.7 0.0 5.2 8.0 0.0 100.0 58 Sylhet 41.1 0.0 0.0 0.0 15.1 1.6 7.7 0.0 32.8 1.7 0.0 100.0 35 Total 42.4 1.3 1.6 0.2 4.2 3.8 19.8 0.4 20.0 6.2 0.2 100.0 458 Table 16.6 shows the percent distribution of rural sample clusters by the most common transport means to the district headquarters in each division. A total of 77 percent of the people in the rural clusters go to their district headquarters by car, bus, or tempo, 12 percent go by baby taxi, and 4 percent go by motor launch. Car, bus, or tempo use is highest in Rajshahi division (90 percent), followed by Khulna (85 percent). Baby taxi use is most frequent in Dhaka (23 percent), Chittagong (14 percent), and Sylhet (11 percent). Motor launch is most used in Barisal (13 percent), followed by Chittagong (9 percent). Table 16.6 Means of transport to district headquarters Percent distribution of rural sample clusters by most common transport means to the district headquarters, according to division, Bangladesh 2011 Division Most common transport Total Number of clusters Car/ bus/ tempo Motor- cycle Motor launch Boat Rickshaw/ rickshaw van Train Baby taxi Other Missing Barisal 77.4 2.0 13.4 0.0 1.8 0.0 5.3 0.0 0.0 100.0 30 Chittagong 74.3 1.6 8.8 0.0 1.3 0.0 14.0 0.0 0.0 100.0 81 Dhaka 67.6 0.0 3.4 1.7 2.6 0.0 23.0 1.6 0.0 100.0 128 Khulna 85.3 0.0 0.0 0.0 6.5 1.7 0.0 5.0 1.5 100.0 55 Rajshahi 89.5 0.0 0.0 0.0 1.3 1.9 5.7 1.6 0.0 100.0 72 Rangpur 76.1 0.0 0.0 5.3 7.0 1.5 6.8 3.3 0.0 100.0 58 Sylhet 81.0 0.0 4.0 3.9 0.0 0.0 11.0 0.0 0.0 100.0 35 Total 77.1 0.4 3.7 1.5 2.9 0.7 11.8 1.7 0.2 100.0 458 References • 251 REFERENCES Al-Sabir, Ahmed, Shahin Sultana, Subrata K. Bhadra, and Mohammed Ahsanul Alam. 2009. Utilization of Essential Service Delivery (UESD) Survey 2008. Dhaka, Bangladesh: National Institute of Population Research and Training (NIPORT). American Heart Association. http://www.heart.org/HEARTORG/. Arifeen, S. E., T. Akhter, H. R. Chowdhury, K. M. Rahman, E. K. Chowdhury, N. Alam, D. M. Emdadul Haque, A. H. Baqui. 2005. “Causes of Death in Children under Five Years of Age.” Bangladesh Demographic and Health Survey 2004. Dhaka, Bangladesh: National Institute of Population Research and Training, Mitra and Associates, and ORC Macro. Bangladesh Bank. 2011. Annual Report 2009-2010. Dhaka, Bangladesh: Bangladesh Bank. Bangladesh Bureau of Statistics (BBS). 2007. Planning Division, Ministry of Planning. Population Census-2001, National Series, Vol. 1 Analytical Report. Dhaka, Bangladesh: BBS. Bangladesh Bureau of Statistics (BBS). 2008. Statistical Year Book of Bangladesh 2006. Dhaka, Bangladesh: BBS. Bangladesh Bureau of Statistics (BBS). 2011. Statistical Year Book of Bangladesh 2010. Dhaka, Bangladesh: BBS. Page 56. 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). 2012. Statistics and Informatics Division, Ministry of Planning. “Community Report: Dhaka Zila.” Population and Housing Census 2011. Dhaka, Bangladesh: BBS. Page 12. Baqui, A. H., R. E. Black, S. E. Arifeen, K. Hill, S. N. Mitra, and A. A. Sabir. 1998. “Causes of Childhood Deaths in Bangladesh: Results of a Nationwide Verbal Autopsy Study.” Bulletin of the World Health Organization 76:161-171. Baqui, A. H., A. A. Sabir., N. Begum, S. E. Arifeen, S. N. Mitra, and R. E. Black. 2001. “Causes of Childhood Deaths in Bangladesh: An Update.” Acta Paediatr 90:682-690. Basu, A. M. 1989. “Is Discrimination in Food Really Necessary for Explaining Sex Differentials in Childhood Mortality?” Population Studies 43(2):193-210. Benoist, B. D., E. McLean, I. Egli, I., and M. Cogswell (eds.). 2008. Worldwide Prevalence of Anaemia 1993–2005: WHO Global Database on Anaemia. Geneva, Switzerland: World Health Organization. Bhatia, S. 1989. Patterns and Causes of Neonatal and Postneonatal Mortality in Rural Bangladesh. Studies in Family Planning 20:136-146. 252 • References Black, R. E., L. H. Allen, Z. A. Bhutta, L. E. Caulfied, M. de Onis, M. Ezzati, C. Mathers, and J. Rivera, for the Maternal and Child Undernutrition Study Group. 2008. “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences.” Lancet 371:243. doi:10.1016/S0140-6736(07)61690- 0. 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. Centers for Disease Control and Prevention (CDC). 1998. Recommendations to Prevent and Control Iron Deficiency in the United States. Atlanta, GA: CDC. Centers for Disease Control and Prevention (CDC) and National Center for Chronic Disease Prevention and Health Promotion. 2009. The Power of Prevention: Chronic Disease: The Public Health Challenge of the 21st Century. Atlanta, GA:CDC. Cesar, G. V., L. Adair, C. Fall, P. C. Hallal, R. Martorell, L. Richter, H. Singh Sachdev. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” Lancet 317(9609):340- 357. Chen, L. C., M. Rahman, and A. M. Sarder. 1980. Epidemiology and Causes of Death among Children in a Rural Area of Bangladesh. International Journal of Epidemiology 9:25-33. Coates, Jennifer, Anne Swindale, and Paula Bilinsky. 2007. Household Food Insecurity Scale (HFIAS) for Measurement of Food Access: Indicator Guide. Food and Nutrition Technical Assistance (FANTA). Version 3. Washington, DC: Academy of Educational Development. http://www.fantaproject.org/downloads/pdfs/HFIAS_v3_Aug07.pdf. D’Orazio, P, R. W. Burnett, N. Fogh-Andersen, E. Jacobs, K. Kuwa, W. R. Klupmann, et al. 2005. Approved IFCC Recommendation on Reporting Results for Blood Glucose (Abbreviated). Clinical Chemistry 51(9):1573-76. D’Souza, S. 1985. Mortality Case Study, Matlab, Bangladesh. ICDDR,B Special Publication 24. Dhaka, Bangladesh: International Centre for Diarrheal Disease Research. Das Gupta, M. 1987. “Selective Discrimination against Female Children in Rural Punjab, India.” Population and Development Review 13(1):77-101. Expanded Programme on Immunization (EPI) and Directorate General of Health Services [Bangladesh]. 2004. Immunizing Children against Hepatitis B. Dhaka, Bangladesh: EPI. Fauveau, V., B. Wojtyniak, H. R. Chowdhury, and A.M. Sarder. 1994. “Assessment of Cause of Death in the Matlab Demographic Surveillance System.” In V. Fauveau (ed.), Matlab: Women, Children and Health. Dhaka, Bangladesh: International Centre for Diarrheal Disease Research, pp. 65-86. Food and Agriculture Organization of the United Nations (FAO). 2002. The State of Food Insecurity in the World 2001. 3rd ed. Rome, Italy: FAO. Fottrell. E., and P. Byass, 2010. “Verbal Autopsy: Methods in Transition.” Epidemiologic Reviews 32: 38- 55. General Economic Division (GED)/Bangladesh Planning Commission. 2012. The Millenium Development Goals Bangladesh Progress Report. Bangladesh, Dhaka: GED. http://www.undp.org.bd/info/pub/ MDG%20Progress%20Report%2011.pdf. References • 253 Government of Bangladesh (GOB). 1994. Country Report: Bangladesh. Presented at the International Conference on Population and Development, Cairo, Egypt, September 5-13, 1994. Hasan, Mahmud. 2010. HIV/AIDS: Situation and National Response. Presented on World AIDS Day, December 1, 2010. Dhaka: MOHFW. Hausmann, R., L. D. Tyson, and S. Zahidi. 2011. The Global Gender Gap Report: Ranking and Scores. Geneva. Switzerland: World Economic Forum. Hunt, P. 2009. World Food Crisis Worsens. Irish Independent. October 13, 2009. http://www.gorta.org/pdf/InTuition_13Oct09_Irish_Independent.pdf. Huq, M. N., and J. Cleland. 1990. Bangladesh Fertility Survey 1989: Main Report. Dhaka, Bangladesh: National Institute of Population Research and Training (NIPORT). Hussein A, M. A. Rahim, A. K. A. Khan, S. M. K. Ali, and S. Vaaler. 2005. “Type 2 Diabetes in Rural and Urban Population: Diverse Prevalence and Associated Risk Factors in Bangladesh.” Diabet Med 22:931- 936. Institute of Nutrition and Food Science (INFS), Dhaka University (DU), Bangladesh Small and Cottage Industries Corporation (BSCIC), Institute of Public Health Nutrition (IPHN), United Nations Children’s Fund (UNICEF), and International Council for the Control of Iodine Deficiency Disorders (ICCIDD). 2007. National Survey on Iodine Deficiency Disorders and Universal Salt Iodization in Bangladesh 2004- 05. Dhaka, Bangladesh: INFS, DU, BSCIC, IPHN, UNICEF, and ICCIDD. 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. International Council for Control of Iodine Deficiency Disorders (ICCIDD), United Nations Children’s Fund (UNICEF), and World Health Organization (WHO). 2001. Assessment of Iodine Deficiency Disorders and Monitoring Their Elimination: A Guide for Programme Managers. Geneva, Switzerland: ICCIDD, UNICEF, and WHO. International Diabetes Federation (IDF). 2011. Diabetes Atlas, 5th edition. Brussels, Belgium: IDF. Islam, M. N., and M. M. Islam. 1993. “Biological and Behavioral Determinants of Fertility in Bangladesh: 1975-1989.” In Bangladesh Fertility Survey, 1989: Secondary Analysis, 29-72. Dhaka, Bangladesh: National Institute of Population Research and Training (NIPORT). 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. Kalter, H. D., R. H. Gray, R. E. Black, and S. A. Gultiano. 1990 “Validation of Postmortem Interviews to Ascertain Selected Causes of Deaths in Children.” International Journal of Epidemiology 19:380-386. Kamal, G. M., K. Streatfield, and S. Rahman. 1994. “Causes of Death among Children in Bangladesh.” In J. Cleland, G. E. Ebanks, L. Wai, and M. A. Ali, (eds.), Secondary Analysis of Bangladesh Fertiltiy Survey. 1989 data. Dhaka, Bangladesh: National Institute of Population Research and Training. Karar, Z. A., N. Alam, and P. K. Streatfield. 2009. “Epidemiological Transition in Rural Bangladesh, 1986-2006.” Global Health Action, North America 2009. http://www.globalhealthaction.net/index.php/gha/article/view/1904. 254 • References Latif Z., A. Jain, M. Rahman. 2011. “Evaluation of Management, Control, Complications and Psychosocial Aspects of Diabetics in Bangladesh.” DiabCare Bangladesh. Bangladesh Medical Research Council Bulletin. 37:11-16. Lehman, H. P., and J. B. Henry. 2001.”SI Units.” In Clinical Diagnosis and Management by Laboratory Methods, 20th ed., J. B. Henry (ed.). Philadelphia: WB Saunders Company. Ministry of Education [Bangladesh]. National Education Policy (NEP) 2010. Dhaka, Bangladesh: Ministry of Education. Ministry of Finance (MOF) [Bangladesh]. 2012. Bangladesh Economic Review (Bangla) 2012. Dhaka, Bangladesh: MOF. Page xvi. http://www.mof.gov.bd. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2004. Bangladesh Population Policy. Dhaka, Bangladesh: MOHFW. 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]. 2004. HNP Strategic Investment Plan July 2003 – June 2010. Dhaka, Bangladesh: MOHFW. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2009. Bangladesh Population Policy. Dhaka, Bangladesh: MOHFW. http://www.dgfp.gov.bd. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2009. National Neonatal Health Strategy and Guidelines for Bangladesh. Dhaka, Bangladesh: MOHFW. Ministry of Health and Family Welfare (MOHFW) [Bangladesh], 2011. Program Implementation Plan v-1. Health, Population and Nutrition Sector Development Program (2011-2016). Dhaka, Bangladesh: MOHFW. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2011. Health, Population and Nutrition Sector Development Program (HPNSDP), (July 2011- June 2016). Volume I, Program Implementation Plan (PIP). Dhaka, Bangladesh: MOHFW. Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2011. Strategic Plan for Health, Population and Nutrition Sector Development Program (HPNSDP) 2011-2016. Dhaka, Bangladesh: MOHFW. 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 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. Mitra, S. N. 1987. Bangladesh Contraceptive Prevalence Survey -1985: Final report. Dhaka, Bangladesh: Mitra and Associates. 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. References • 255 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. Mitra, S. N., and G. M. Kamal. 1985. Bangladesh Contraceptive Prevalence Survey - 1983: Final Report. Dhaka, Bangladesh: Mitra and Associates. Mitra, S. N., C. Lerman, and S. Islam. 1993. Bangladesh Contraceptive Survey -1991: Final report. Dhaka, Bangladesh: Mitra and Associates. Mitra and Associates and Macro International. 2009. Bangladesh Demographic and Health Survey, 2007. Dhaka, Bangladesh, and Calverton, Maryland, USA: National Institute of Population Research and Training (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. Murray, C. J. L., and A. D. Lopez, eds. 1996. The Global Burden of Disease. Boston, Massachusetts: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank. 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 Ministry of Health and Family Welfare. 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), 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 (NIPORT), MEASURE Evaluation, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), and Associates for Community and Population Research (ACPR). 2008. 2006 Bangladesh Urban Health Survey. Dhaka, Bangladesh, and Chapel Hill, NC, USA: NIPORT, MEASURE Evaluation, ICDDR,B, and ACPR. 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. 256 • References Rahim, M. A., A. Hussein, A. K. A. Khan, M. A. Sayeed, S. M. K. Ali, and S. Vaaler. 2007. “Rising Prevalence of Type 2 Diabetes in Rural Bangladesh: A Population Based Study.” Diabetes Research and Clinical Practice 77:300-305. Rahman, A., and S. Chowdhury. 2007. “Determinants of Chronic Malnutrition among Preschool Children in Bangladesh.” J Biosoc Sci 39(2):161-173. 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. Comparative Studies No. 43. Voorburg, Netherlands, and London, England: International Statistical Institute and World Fertility Survey. 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. Saha, K. K., A. Bamezai, A. Khaled, A. Subandoro, R. Rawat, and P. Menon. 2011. Alive & Thrive Baseline Survey Report Executive Summary. Bangladesh. Washington, D.C.: Alive & Thrive. Salway, S., and S. M. A. Nasim. 1994. “Levels, Trends and Causes of Mortality in Children below 5 years of Age in Bangladesh: Findings from a National Survey.” Journal of Diarrheal Disease Research 12:187- 193. Snow, R. W., J. R. M. Armstrong, D. Foster, M. T. Winstanley, V. M. Marsh., C. R. Newton., C. Waruiru, I. ,Mwangi., P. A. Winstanley, and K. Marsh. 1992. “Childhood Deaths in Africa: Uses and Limitations of Verbal Autopsies.” Lancet 340: 351-355. Soleman N., D. Chandramohan, K. Shibuya. 2006. Verbal Autopsy: Current Practices and Challenges. Bulletin of World Health Organ. 84(3):239–245. U.S. Department of Health and Human Services. 2006. Public Health Service, Office of the Surgeon General. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services. United Nations (UN). 2010. Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2010 Revision. New York, NY: UN. http://esa.un.org/unpd/wpp/index.htm. United Nations Children’s Fund (UNICEF) and World Health Organization (WHO). Low Birthweight: Country, Regional and Global Estimates. New York, NY: UNICEF. United Nations Development Program (UNDP). 2007. Human Development Report 2007-2008. New York, NY: UNDP. United Nations Development Program (UNDP). 2007-2008. Human Development Report. New York: Oxford University Press. United Nations Development Program (UNDP). 2011. Human Development Report 2011. New York: Oxford University Press. References • 257 United Nations Development Program (UNDP). 2011. World Human Development Report 2011. New York, NY: UNDP. Windham, G. C., A. Eaton, and B. Hopkins. 1999. “Evidence for an Association between Environmental Tobacco Smoke Exposure and Birth Weight: A Meta-Analysis and New Data.” Paediatric and Perinatal Epidemiology 13:35-37. World Health Organization (WHO). 1999. “1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension: Guidelines Subcommittee.” Journal of Hypertension 17(2):151-185. World Health Organization (WHO). 2003. World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO. World Health Organization (WHO). 2005. Guiding Principles for Feeding Nonbreastfed Children 6 to 24 Months of Age. Geneva, Switzerland: WHO. World Health Organization (WHO). 2006. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia: Report of a WHO/IDF Consultation. Geneva: WHO. World Health Organization (WHO). 2007. Standards for Maternal and Neonatal Care. Geneva, Switzerland: WHO. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/a91272/ en/index.html. 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). 2010. Global Status Report on Noncommunicable Diseases. Geneva: WHO. World Health Organization (WHO). 2011. Non-communicable Disease Risk Factor Survey, Bangladesh 2010. Dhaka, Bangladesh: WHO Bangladesh. World Health Organization (WHO). 2011. WHO NCD Surveillance Strategy. http://www.who.int/ncd_surveillance/strategy/en/print.html. 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) and UNICEF. 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO and UNICEF. Zaman, M. M., J. Ahmed, S. R. Chowdhury, S. M. Numan, K. Parvin, and M. S. Islam. 2007. “Prevalence of Ischemic Heart Disease in a Rural Population of Bangladesh.” Indian Heart Journal. 59:239-41. Zimicki, S., L. Nahar, A. M. Sarder, and S. D’Souza. 1985. Demographic Surveillance System- Matlab.V.13. Cause of Death Reporting in Matlab: Source Book of Cause-specific Mortality Rates 1975- 81. ICDDR,B Scientific Report 63. Dhaka, Bangladesh: International Centre for Diarrheal Disease Research. Appendix A • 259 SAMPLE DESIGN AND IMPLEMENTATION Appendix A A.1 INTRODUCTION The 2011 Bangladesh Demographic and Health Survey (2011 BDHS) is the sixth DHS survey conducted in Bangladesh, following those implemented in 1993-94, 1996-97, 1999-2000, 2003-04, and 2007-08. As with the prior surveys, the main objective of the 2011 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 12-49 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. One in three households in the survey was selected for a male survey. In these households, all ever-married men age 15-54 who were usual members of the selected households or who spent the night before the survey in the selected households were eligible for individual interview. The survey collected information on their basic demographic status, use of family planning, and knowledge and attitudes toward HIV/AIDS and other sexually transmitted infections. In the households selected for the male survey, all men and women age 35 and older were eligible to participate in the biomarker component, which included blood pressure measurements, anemia and blood glucose testing, and height and weight measurements. A.2 SAMPLING FRAME The sampling frame used for the 2011 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 5.5 percent (Sylhet, the smallest) to 33.6 percent (Dhaka, the largest). In Bangladesh, 25.9 percent of the households are in urban areas: 8.4 percent are in city corporations, and 17.5 percent are in other than city corporations. 260 • Appendix A 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 3.7 11.6 15.3 84.7 100.0 6.1 Chittagong 9.9 14.2 24.1 75.9 100.0 17.2 Dhaka 15.7 24.8 40.5 59.5 100.0 33.6 Khulna 4.5 15.6 20.0 80.0 100.0 11.6 Rajshahi 2.3 15.5 17.8 82.2 100.0 14.0 Rangpur 0.0 12.6 12.6 87.4 100.0 12.1 Sylhet 5.9 10.3 16.2 83.8 100.0 5.5 Bangladesh 8.4 17.5 25.9 74.1 100.0 100.0 Source: Preparatory sampling frame of the 2011 Population Census. A.3 SAMPLE DESIGN The 2011 BDHS sample was stratified and selected in two stages. Each division was stratified into urban and rural areas. The urban areas of each division are further stratified into two strata: city corporations and other than city corporations. Because Rangpur Division has no city corporations, a total of 20 sampling strata were created. 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, using the sample allocation given in Table 2. In the second stage of selection, a fixed number—30 households per cluster—were selected with an equal probability systematic selection from the newly created household listing. A household listing operation was carried out by Mitra and Associates in all selected EAs from 22 May to 5 October 201. The listing was initially done 19 teams of two persons each. The number of teams was reduced to six towards the end of the listing operation. The survey interviewers were instructed to interview only the pre-selected households; no replacements or changes were allowed in order to prevent bias. 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 was 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 was conducted in 18,000 residential households, 6,210 in urban areas and 11,790 in rural areas. The sample was expected to result in about 18,072 completed interviews with ever-married women age 12-49, 6,426 in urban areas and 11,646 in rural areas. 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 24 24 61 85 Sylhet 10 12 22 48 70 Bangladesh 70 137 207 393 600 Appendix A • 261 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 0 720 720 1,830 2,550 Sylhet 300 360 660 1,440 2,100 Bangladesh 2,100 4,110 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 12-49 Urban + Rural Urban Rural City corporation Other than city corporation Total urban Barisal 218 465 683 1,482 2,165 Chittagong 504 520 1,024 1,748 2,772 Dhaka 714 807 1,521 1,778 3,299 Khulna 271 630 901 1,660 2,561 Rajshahi 167 702 869 1,748 2,617 Rangpur 0 745 745 1,808 2,553 Sylhet 305 378 683 1,422 2,105 Bangladesh 2,179 4,247 6,426 11,646 18,072 The sample allocations were derived using information obtained from the 2007 BDHS. Based on the 2007 data, the average number of ever-married women age 12-49 per household was assumed to be 1.10 in urban areas and 1.05 in rural areas. The household response rate was fixed at 96 percent for both urban and rural areas and the women’s individual response rate was 98 percent for both urban and rural areas. A.4 SAMPLING WEIGHT Due to the non-proportional allocation of sample to divisions and urban and rural areas, and the differences in response rates, sampling weights are required for any analysis using the 2011 BDHS data to ensure the representativeness of the survey results at national and domain levels. Because the 2011 BDHS sample is a two-stage stratified cluster sample, sampling weights were calculated based on sampling probabilities separately for each sampling stage and cluster. The following notations were used: P1hi: is the first stage sampling probability of the ith cluster in stratum h P2hi: is the 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 2011 BDHS sample was calculated as follows: M M a = P hi hih 1hi  Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, and let hig be the number of households selected in the cluster. The second stage’s selection probability for each household in the cluster was calculated as follows: 262 • Appendix A hi hi hi L gP =2 The overall selection probability of each household in cluster i of stratum h was therefore the product of the two stages of selection probabilities: hihihi PPP 21 ×= The sampling weight for each household in cluster i of stratum h was the inverse of its overall selection probability: hihi PW /1= A spreadsheet containing all sampling parameters and selection probabilities was prepared to facilitate the calculation of the design weight, which was adjusted for household and individual non- response rates to get the sampling weights for each household, woman, and man in the sample. The difference between the household sampling weight and the individual sampling weight is due to individual nonresponse rates. The final sampling weights were normalized in order to make the total number of unweighted cases equal to the total number of weighted cases at the national level. The normalized weights are relative weights, which are valid for estimating means, proportions, and ratios, but not for estimating population totals and for pooled data. Appendix B • 263 ESTIMATES OF SAMPLING ERRORS Appendix B Table B.1 List of selected variables for sampling errors, Bangladesh 2011 Variable Estimate Base population WOMEN Urban residence Proportion Ever-married women 15-49 No education Proportion Ever-married women 15-49 Secondary education or higher Proportion Ever-married women 15-49 Currently married Proportion Ever-married women 15-49 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 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 pill Proportion Currently married women 15-49 Currently using IUD 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 periodic abstinence Proportion Currently married women 15-49 Currently using withdrawal Proportion Currently married women 15-49 Using public sector source Proportion Current users of modern method Want no more children Proportion Currently married women 15-49 Want to delay at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean Ever-married women 15-49 Mothers protected against tetanus in the last birth Proportion Women with a live birth in past three years Mothers received medical care at birth Proportion Births occurring 1-35 months before survey Had diarrhea in the past 2 weeks Proportion Children under 5 Treated with oral rehydration salts (ORS) Proportion Children under 5 with diarrhea in past 2 weeks Sought medical treatment 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 Total fertility rate (3 years) Rate Women-years of exposure to childbearing Neonatal mortality rate (5 years) Rate Children exposed to the risk of mortality Post-neonatal mortality rate (5 years) Rate Children exposed to the risk of mortality Infant mortality rate (5 years) Rate Children exposed to the risk of mortality Child mortality rate (5 years) Rate Children exposed to the risk of mortality Under-5 mortality rate (5 years) Rate Children exposed to the risk of mortality Height-for-age (below -2SD) Proportion Children age 0-59 months Weight-for-height (below -2SD) Proportion Children age 0-59 months Weight-for-age (below -2SD) Proportion Children age 0-59 months BMI <18.5 Proportion Ever-married women 15-49 who were measured Anemia in children Proportion Children age 6-59 months who were tested Anemia in women Proportion Ever-married women 15-49 who were tested Has heard of HIV/AIDS Proportion Ever-married women 15-49 Knows about condoms to prevent AIDS Proportion Ever-married women 15-49 Knows about limiting partners to prevent AIDS Proportion Ever-married women 15-49 MEN Urban residence Proportion Ever-married men 15-49 No education Proportion Ever-married men 15-49 With secondary education or higher Proportion Ever-married men 15-49 Currently married Proportion Ever-married men 15-49 Ideal number of children Mean Ever-married men 15-49 Has heard of HIV/AIDS Proportion Ever-married men 15-49 Knows about condoms to prevent AIDS Proportion Ever-married men 15-49 Knows about limiting partners to prevent AIDS Proportion Ever-married men 15-49 HEALTH ISSUES SURVEY WOMEN Elevated blood pressure or taking medications Proportion All women 35+ Elevated fasting plasma glucose or taking medications Proportion All women 35+ MEN Elevated blood pressure or taking medications Proportion All men 35+ Elevated fasting plasma glucose or taking medications Proportion All men 35+ 264 • Appendix B Table B.2 Sampling errors: Total sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.260 0.003 17749 17749 0.970 0.012 0.254 0.267 No education 0.277 0.006 17749 17749 1.903 0.023 0.264 0.290 With secondary education or higher 0.423 0.008 17749 17749 2.109 0.018 0.407 0.439 Currently married (in union) 0.937 0.002 17749 17749 1.246 0.002 0.933 0.942 Currently pregnant 0.051 0.002 20676 20797 1.201 0.035 0.048 0.055 Children ever born 2.211 0.020 20676 20797 1.286 0.009 2.170 2.252 Children surviving 1.979 0.017 20676 20797 1.268 0.009 1.944 2.014 Children ever born to women over 40 4.174 0.049 4016 3982 1.495 0.012 4.075 4.273 Currently using any method 0.612 0.005 16616 16635 1.377 0.009 0.602 0.623 Currently using a modern method 0.521 0.006 16616 16635 1.424 0.011 0.509 0.532 Currently using pill 0.272 0.005 16616 16635 1.505 0.019 0.262 0.283 Currently using IUD 0.007 0.001 16616 16635 1.177 0.106 0.006 0.009 Currently using injectables 0.112 0.004 16616 16635 1.627 0.036 0.104 0.120 Currently using female sterilization 0.050 0.003 16616 16635 1.532 0.052 0.044 0.055 Currently using periodic abstinence 0.069 0.002 16616 16635 1.264 0.036 0.064 0.074 Currently using withdrawal 0.019 0.001 16616 16635 1.291 0.073 0.016 0.021 Using public sector source 0.521 0.009 8680 8659 1.698 0.017 0.503 0.539 Want no more children 0.649 0.004 16616 16635 1.174 0.007 0.640 0.658 Want to delay at least 2 years 0.198 0.004 16616 16635 1.134 0.018 0.191 0.205 Ideal number of children 2.201 0.009 17539 17590 1.812 0.004 2.183 2.219 Mothers completely protected against tetanus 0.899 0.006 4661 4652 1.396 0.007 0.887 0.911 Mothers received medical assistance at delivery 0.317 0.011 4964 4956 1.588 0.035 0.295 0.338 Had diarrhea in the last 2 weeks 0.046 0.003 8332 8395 1.190 0.061 0.041 0.052 Treated with oral rehydration salts (ORS) 0.776 0.025 395 388 1.174 0.033 0.725 0.827 Sought medical treatment 0.248 0.026 395 388 1.132 0.103 0.197 0.299 Having health card, seen 0.667 0.016 1546 1547 1.318 0.024 0.635 0.699 Received BCG vaccination 0.978 0.005 1546 1547 1.351 0.005 0.968 0.989 Received DPT vaccination (3 doses) 0.934 0.009 1546 1547 1.343 0.009 0.916 0.952 Received polio vaccination (3 doses) 0.934 0.009 1546 1547 1.355 0.010 0.916 0.952 Received measles vaccination 0.875 0.011 1546 1547 1.355 0.013 0.852 0.898 Fully immunized 0.860 0.012 1546 1547 1.355 0.014 0.835 0.884 Height-for-age (below -2SD) 0.413 0.008 7826 7861 1.429 0.020 0.397 0.429 Weight-for-height (below -2SD) 0.156 0.005 7826 7861 1.293 0.035 0.145 0.167 Weight-for-age (below -2SD) 0.364 0.008 7826 7861 1.474 0.023 0.347 0.381 Anemia children 0.513 0.013 2361 2353 1.212 0.025 0.488 0.539 Anemia women 0.424 0.009 5666 5676 1.400 0.022 0.406 0.443 BMI < 18.5 0.242 0.005 16023 16024 1.622 0.023 0.231 0.253 Has heard of AIDS 0.691 0.008 17749 17749 2.326 0.012 0.675 0.707 Knows about condoms to prevent AIDS 0.437 0.007 17749 17749 1.980 0.017 0.423 0.452 Knows about limiting partners to prevent AIDS 0.507 0.008 17749 17749 2.146 0.016 0.491 0.524 Total fertility rate (last 3 years) 2.320 0.047 58347 58465 1.376 0.020 2.227 2.413 Neonatal mortality (last 0-4 years) 32.390 2.219 8813 8860 1.093 0.069 27.952 36.827 Post-neonatal mortality (last 0-4 years) 10.117 1.121 8794 8835 1.060 0.111 7.874 12.360 Infant mortality (last 0-4 years) 42.507 2.449 8822 8868 1.086 0.058 37.608 47.406 Child mortality (last 0-4 years) 11.472 1.372 8728 8742 1.178 0.120 8.728 14.217 Under-5 mortality (last 0-4 years) 53.491 2.758 8868 8918 1.111 0.052 47.976 59.007 Elevated blood pressure or taking medications 0.315 0.009 4030 4007 1.216 0.028 0.297 0.333 Elevated fasting plasma glucose or taking medications 0.115 0.006 3733 3721 1.141 0.052 0.103 0.127 MEN Urban residence 0.280 0.008 3382 3392 1.053 0.029 0.264 0.296 No education 0.262 0.010 3382 3392 1.273 0.037 0.243 0.282 With secondary education or higher 0.405 0.011 3382 3392 1.325 0.028 0.382 0.427 Currently married (in union) 0.991 0.002 3382 3392 1.155 0.002 0.987 0.995 Ideal number of children 2.153 0.017 3356 3369 1.326 0.008 2.119 2.187 Has heard of HIV/AIDS 0.876 0.008 3382 3392 1.366 0.009 0.861 0.892 Knows condom use to prevent HIV/AIDS 0.694 0.012 3382 3392 1.496 0.017 0.670 0.718 Knows limiting partners to prevent HIV/AIDS 0.691 0.013 3382 3392 1.597 0.018 0.666 0.717 Elevated blood pressure or taking medications 0.192 0.008 3962 3925 1.224 0.040 0.176 0.207 Elevated fasting plasma glucose or taking medications 0.109 0.006 3645 3631 1.195 0.057 0.097 0.121 Appendix B • 265 Table B.3 Sampling errors: Urban sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 1.000 0.000 6179 4619 Na 0.000 1.000 1.000 No education 0.195 0.009 6179 4619 1.741 0.045 0.177 0.212 With secondary education or higher 0.550 0.016 6179 4619 2.465 0.028 0.519 0.581 Currently married (in union) 0.929 0.004 6179 4619 1.352 0.005 0.920 0.938 Currently pregnant 0.042 0.003 7457 5579 1.175 0.064 0.037 0.047 Children ever born 1.864 0.032 7457 5579 1.319 0.017 1.800 1.927 Children surviving 1.696 0.030 7457 5579 1.391 0.017 1.637 1.755 Children ever born to women over 40 3.596 0.077 1436 1056 1.560 0.021 3.442 3.750 Currently using any method 0.640 0.009 5751 4292 1.349 0.013 0.623 0.657 Currently using a modern method 0.540 0.008 5751 4292 1.243 0.015 0.523 0.556 Currently using pill 0.281 0.009 5751 4292 1.573 0.033 0.262 0.300 Currently using IUD 0.007 0.001 5751 4292 1.278 0.199 0.004 0.010 Currently using injectables 0.092 0.006 5751 4292 1.691 0.070 0.079 0.104 Currently using female sterilization 0.039 0.003 5751 4292 1.265 0.083 0.032 0.045 Currently using periodic abstinence 0.078 0.004 5751 4292 1.184 0.054 0.069 0.086 Currently using withdrawal 0.020 0.002 5751 4292 1.208 0.113 0.015 0.024 Using public sector source 0.319 0.016 3140 2316 1.928 0.050 0.286 0.351 Want no more children 0.624 0.010 5751 4292 1.493 0.015 0.604 0.643 Want to delay at least 2 years 0.206 0.008 5751 4292 1.431 0.037 0.191 0.221 Ideal number of children 2.101 0.014 6137 4600 1.768 0.007 2.074 2.129 Mothers completely protected against tetanus 0.935 0.008 1479 1068 1.172 0.008 0.919 0.950 Mothers received medical assistance at delivery 0.537 0.023 1557 1121 1.698 0.042 0.492 0.583 Had diarrhea in the last 2 weeks 0.037 0.004 2548 1871 1.144 0.117 0.029 0.046 Treated with oral rehydration salts (ORS) 0.844 0.038 108 70 1.003 0.044 0.769 0.919 Sought medical treatment 0.454 0.063 108 70 1.202 0.138 0.329 0.579 Having health card, seen 0.643 0.029 506 375 1.354 0.045 0.585 0.701 Received BCG vaccination 0.988 0.005 506 375 1.142 0.006 0.977 0.999 Received DPT vaccination (3 doses) 0.939 0.014 506 375 1.301 0.015 0.912 0.967 Received polio vaccination (3 doses) 0.938 0.014 506 375 1.295 0.015 0.910 0.966 Received measles vaccination 0.875 0.021 506 375 1.429 0.024 0.833 0.917 Fully immunized 0.865 0.021 506 375 1.408 0.025 0.823 0.908 Height-for-age (below -2SD) 0.362 0.016 2394 1709 1.494 0.043 0.331 0.393 Weight-for-height (below -2SD) 0.140 0.009 2394 1709 1.284 0.067 0.121 0.159 Weight-for-age (below -2SD) 0.280 0.013 2394 1709 1.366 0.047 0.254 0.307 Anemia children 0.463 0.025 708 498 1.280 0.054 0.413 0.513 Anemia women 0.361 0.018 1970 1468 1.673 0.050 0.324 0.397 BMI < 18.5 0.135 0.008 5631 4194 1.755 0.059 0.119 0.151 Has heard of AIDS 0.856 0.009 6179 4619 1.928 0.010 0.839 0.873 Knows about condoms to prevent AIDS 0.570 0.013 6179 4619 2.017 0.022 0.544 0.595 Knows about limiting partners to prevent AIDS 0.645 0.013 6179 4619 2.073 0.020 0.619 0.670 Total fertility rate (last 3 years) 1.951 0.066 21024 15773 1.365 0.034 1.820 2.082 Neonatal mortality (last 0-4 years) 31.568 4.237 2695 1977 1.259 0.134 23.094 40.042 Post-neonatal mortality (last 0-4 years) 10.170 2.244 2691 1966 1.145 0.221 5.682 14.659 Infant mortality (last 0-4 years) 41.738 4.637 2699 1979 1.194 0.111 32.464 51.012 Child mortality (last 0-4 years) 8.111 2.035 2696 1965 1.226 0.251 4.041 12.182 Under-5 mortality (last 0-4 years) 49.511 4.791 2710 1987 1.139 0.097 39.930 59.092 Elevated blood pressure or taking medications 0.390 0.018 1329 936 1.330 0.047 0.353 0.426 Elevated fasting plasma glucose or taking medications 0.176 0.013 1227 855 1.195 0.075 0.149 0.202 MEN Urban residence 1.000 0.000 1224 949 na 0.000 1.000 1.000 No education 0.158 0.015 1224 949 1.468 0.097 0.127 0.189 With secondary education or higher 0.544 0.023 1224 949 1.639 0.043 0.497 0.591 Currently married (in union) 0.991 0.004 1224 949 1.382 0.004 0.984 0.999 Ideal number of children 2.046 0.021 1218 944 1.331 0.010 2.005 2.087 Has heard of HIV/AIDS 0.956 0.007 1224 949 1.203 0.007 0.942 0.970 Knows condom use to prevent HIV/AIDS 0.793 0.023 1224 949 1.947 0.028 0.748 0.838 Knows limiting partners to prevent HIV/AIDS 0.751 0.023 1224 949 1.899 0.031 0.704 0.798 Elevated blood pressure or taking medications 0.242 0.012 1335 956 0.996 0.049 0.218 0.266 Elevated fasting plasma glucose or taking medications 0.151 0.014 1213 867 1.368 0.094 0.123 0.179 266 • Appendix B Table B.4 Sampling errors: Rural sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.000 0.000 11570 13130 na na 0.000 0.000 No education 0.306 0.008 11570 13130 1.883 0.026 0.290 0.322 With secondary education or higher 0.378 0.009 11570 13130 2.001 0.024 0.360 0.397 Currently married (in union) 0.940 0.003 11570 13130 1.200 0.003 0.935 0.945 Currently pregnant 0.055 0.002 13349 15222 1.172 0.041 0.050 0.059 Children ever born 2.338 0.025 13349 15222 1.249 0.011 2.287 2.389 Children surviving 2.082 0.021 13349 15222 1.212 0.010 2.040 2.125 Children ever born to women over 40 4.381 0.060 2580 2927 1.433 0.014 4.261 4.501 Currently using any method 0.603 0.006 10865 12343 1.352 0.011 0.590 0.615 Currently using a modern method 0.514 0.007 10865 12343 1.432 0.013 0.500 0.528 Currently using pill 0.269 0.006 10865 12343 1.458 0.023 0.257 0.282 Currently using IUD 0.007 0.001 10865 12343 1.128 0.125 0.006 0.009 Currently using injectables 0.119 0.005 10865 12343 1.571 0.041 0.109 0.129 Currently using female sterilization 0.053 0.003 10865 12343 1.524 0.062 0.047 0.060 Currently using periodic abstinence 0.066 0.003 10865 12343 1.268 0.046 0.060 0.072 Currently using withdrawal 0.018 0.002 10865 12343 1.288 0.091 0.015 0.022 Using public sector source 0.595 0.011 5540 6343 1.655 0.018 0.573 0.617 Want no more children 0.658 0.005 10865 12343 1.061 0.007 0.648 0.668 Want to delay at least 2 years 0.195 0.004 10865 12343 1.029 0.020 0.187 0.203 Ideal number of children 2.236 0.011 11402 12991 1.774 0.005 2.213 2.259 Mothers completely protected against tetanus 0.888 0.008 3182 3584 1.368 0.009 0.873 0.904 Mothers received medical assistance at delivery 0.252 0.012 3407 3835 1.540 0.048 0.228 0.276 Had diarrhea in the last 2 weeks 0.049 0.003 5784 6524 1.153 0.069 0.042 0.055 Treated with oral rehydration salts (ORS) 0.761 0.030 287 318 1.137 0.039 0.701 0.820 Sought medical treatment 0.203 0.026 287 318 1.057 0.130 0.150 0.255 Having health card, seen 0.675 0.019 1040 1172 1.282 0.028 0.637 0.712 Received BCG vaccination 0.975 0.007 1040 1172 1.308 0.007 0.962 0.988 Received DPT vaccination (3 doses) 0.932 0.011 1040 1172 1.309 0.012 0.911 0.954 Received polio vaccination (3 doses) 0.933 0.011 1040 1172 1.324 0.012 0.911 0.954 Received measles vaccination 0.876 0.014 1040 1172 1.305 0.016 0.848 0.903 Fully immunized 0.858 0.015 1040 1172 1.307 0.017 0.829 0.887 Height-for-age (below -2SD) 0.427 0.009 5432 6152 1.371 0.022 0.408 0.446 Weight-for-height (below -2SD) 0.160 0.006 5432 6152 1.253 0.040 0.148 0.173 Weight-for-age (below -2SD) 0.387 0.010 5432 6152 1.432 0.026 0.367 0.407 Anemia children 0.527 0.015 1653 1855 1.165 0.028 0.498 0.556 Anemia women 0.447 0.011 3696 4207 1.298 0.024 0.425 0.468 BMI < 18.5 0.280 0.007 10392 11831 1.555 0.024 0.266 0.293 Has heard of AIDS 0.633 0.011 11570 13130 2.347 0.017 0.612 0.654 Knows about condoms to prevent AIDS 0.391 0.009 11570 13130 1.971 0.023 0.373 0.409 Knows about limiting partners to prevent AIDS 0.459 0.010 11570 13130 2.146 0.022 0.439 0.479 Total fertility rate (last 3 years) 2.457 0.058 37602 42704 1.341 0.024 2.342 2.573 Neonatal mortality (last 0-4 years) 32.625 2.588 6118 6884 1.027 0.079 27.449 37.802 Post-neonatal mortality (last 0-4 years) 10.104 1.294 6103 6869 1.014 0.128 7.515 12.692 Infant mortality (last 0-4 years) 42.729 2.863 6123 6889 1.032 0.067 37.004 48.454 Child mortality (last 0-4 years) 12.453 1.667 6032 6777 1.123 0.134 9.118 15.787 Under-5 mortality (last 0-4 years) 54.650 3.273 6158 6931 1.071 0.060 48.104 61.195 Elevated blood pressure or taking medications 0.292 0.010 2701 3071 1.167 0.035 0.272 0.313 Elevated fasting plasma glucose or taking medications 0.097 0.007 2506 2866 1.118 0.069 0.083 0.110 MEN Urban residence 0.000 0.000 2158 2442 na na 0.000 0.000 No education 0.303 0.012 2158 2442 1.191 0.039 0.279 0.327 With secondary education or higher 0.351 0.012 2158 2442 1.193 0.035 0.326 0.375 Currently married (in union) 0.991 0.002 2158 2442 1.065 0.002 0.986 0.995 Ideal number of children 2.194 0.022 2138 2425 1.276 0.010 2.150 2.239 Has heard of HIV/AIDS 0.845 0.010 2158 2442 1.326 0.012 0.824 0.866 Knows condom use to prevent HIV/AIDS 0.655 0.014 2158 2442 1.352 0.021 0.628 0.683 Knows limiting partners to prevent HIV/AIDS 0.668 0.015 2158 2442 1.486 0.023 0.638 0.698 Elevated blood pressure or taking medications 0.176 0.009 2627 2969 1.258 0.053 0.157 0.194 Elevated fasting plasma glucose or taking medications 0.096 0.007 2432 2764 1.132 0.071 0.082 0.109 Appendix B • 267 Table B.5 Sampling errors: Barisal sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.166 0.006 2050 1002 0.697 0.035 0.154 0.177 No education 0.163 0.015 2050 1002 1.810 0.091 0.133 0.193 With secondary education or higher 0.461 0.020 2050 1002 1.778 0.043 0.421 0.500 Currently married (in union) 0.951 0.005 2050 1002 0.982 0.005 0.941 0.960 Currently pregnant 0.053 0.006 2393 1175 1.240 0.105 0.042 0.064 Children ever born 2.294 0.061 2393 1175 1.193 0.027 2.171 2.416 Children surviving 2.037 0.051 2393 1175 1.166 0.025 1.934 2.140 Children ever born to women over 40 4.537 0.131 459 222 1.366 0.029 4.275 4.799 Currently using any method 0.647 0.014 1948 952 1.323 0.022 0.618 0.675 Currently using a modern method 0.545 0.017 1948 952 1.540 0.032 0.510 0.580 Currently using pill 0.266 0.013 1948 952 1.340 0.050 0.240 0.293 Currently using IUD 0.007 0.002 1948 952 1.099 0.300 0.003 0.011 Currently using injectables 0.184 0.014 1948 952 1.607 0.077 0.156 0.212 Currently using female sterilization 0.028 0.005 1948 952 1.302 0.175 0.018 0.037 Currently using periodic abstinence 0.085 0.008 1948 952 1.286 0.096 0.068 0.101 Currently using withdrawal 0.014 0.003 1948 952 1.071 0.202 0.008 0.020 Using public sector source 0.610 0.023 1069 519 1.562 0.038 0.563 0.656 Want no more children 0.667 0.013 1948 952 1.262 0.020 0.640 0.694 Want to delay at least 2 years 0.221 0.012 1948 952 1.231 0.052 0.198 0.244 Ideal number of children 2.207 0.027 2028 990 1.849 0.012 2.153 2.261 Mothers completely protected against tetanus 0.889 0.018 525 260 1.348 0.021 0.852 0.926 Mothers received medical assistance at delivery 0.284 0.028 551 273 1.442 0.100 0.227 0.341 Had diarrhea in the last 2 weeks 0.049 0.008 924 464 1.109 0.163 0.033 0.065 Treated with oral rehydration salts (ORS) 0.726 0.081 47 23 1.163 0.112 0.564 0.889 Sought medical treatment 0.340 0.086 47 23 1.224 0.254 0.167 0.512 Having health card, seen 0.648 0.033 170 84 0.897 0.051 0.583 0.714 Received BCG vaccination 0.985 0.010 170 84 1.108 0.010 0.965 1.006 Received DPT vaccination (3 doses) 0.914 0.024 170 84 1.140 0.027 0.865 0.963 Received polio vaccination (3 doses) 0.920 0.023 170 84 1.099 0.025 0.875 0.966 Received measles vaccination 0.861 0.028 170 84 1.057 0.032 0.805 0.917 Fully immunized 0.833 0.032 170 84 1.117 0.038 0.769 0.896 Height-for-age (below -2SD) 0.451 0.022 870 433 1.271 0.049 0.406 0.496 Weight-for-height (below -2SD) 0.152 0.013 870 433 1.032 0.085 0.126 0.177 Weight-for-age (below -2SD) 0.400 0.019 870 433 1.141 0.048 0.361 0.439 Anemia children 0.596 0.029 275 136 0.992 0.049 0.537 0.654 Anemia women 0.456 0.027 628 306 1.334 0.058 0.403 0.509 BMI < 18.5 0.270 0.015 1793 873 1.456 0.057 0.239 0.300 Has heard of AIDS 0.707 0.022 2050 1002 2.193 0.031 0.663 0.751 Knows about condoms to prevent AIDS 0.486 0.020 2050 1002 1.808 0.041 0.446 0.526 Knows about limiting partners to prevent AIDS 0.559 0.022 2050 1002 2.003 0.039 0.515 0.603 Total fertility rate (last 3 years) 2.315 0.108 6699 3280 1.199 0.047 2.099 2.530 Neonatal mortality (last 0-4 years) 37.724 6.864 978 492 1.042 0.182 23.996 51.452 Post-neonatal mortality (last 0-4 years) 11.261 3.485 972 487 0.993 0.310 4.290 18.231 Infant mortality (last 0-4 years) 48.985 8.139 980 493 1.098 0.166 32.706 65.263 Child mortality (last 0-4 years) 14.166 4.092 977 486 1.073 0.289 5.982 22.349 Under-5 mortality (last 0-4 years) 62.456 8.758 986 496 1.122 0.140 44.940 79.973 Elevated blood pressure or taking medications 0.307 0.022 488 239 1.052 0.071 0.263 0.350 Elevated fasting plasma glucose or taking medications 0.133 0.017 441 215 1.036 0.128 0.099 0.166 MEN Urban residence 0.171 0.015 341 174 0.736 0.088 0.141 0.201 No education 0.149 0.026 341 174 1.356 0.176 0.096 0.201 With secondary education or higher 0.384 0.034 341 174 1.277 0.088 0.316 0.451 Currently married (in union) 0.989 0.006 341 174 1.091 0.006 0.977 1.001 Ideal number of children 2.133 0.038 340 173 1.201 0.018 2.056 2.209 Has heard of HIV/AIDS 0.871 0.025 341 174 1.352 0.028 0.821 0.920 Knows condom use to prevent HIV/AIDS 0.641 0.034 341 174 1.306 0.053 0.573 0.709 Knows limiting partners to prevent HIV/AIDS 0.670 0.036 341 174 1.421 0.054 0.598 0.743 Elevated blood pressure or taking medications 0.178 0.018 464 230 1.035 0.102 0.142 0.215 Elevated fasting plasma glucose or taking medications 0.124 0.016 408 203 0.947 0.125 0.093 0.155 268 • Appendix B Table B.6 Sampling errors: Chittagong sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.242 0.006 2864 3222 0.754 0.025 0.230 0.254 No education 0.248 0.016 2864 3222 1.940 0.063 0.216 0.279 With secondary education or higher 0.477 0.021 2864 3222 2.295 0.045 0.434 0.520 Currently married (in union) 0.936 0.006 2864 3222 1.270 0.006 0.924 0.947 Currently pregnant 0.054 0.004 3503 3946 1.154 0.080 0.045 0.062 Children ever born 2.378 0.059 3503 3946 1.227 0.025 2.261 2.496 Children surviving 2.139 0.051 3503 3946 1.213 0.024 2.037 2.241 Children ever born to women over 40 4.925 0.109 580 660 1.187 0.022 4.707 5.143 Currently using any method 0.514 0.011 2689 3015 1.186 0.022 0.491 0.537 Currently using a modern method 0.445 0.012 2689 3015 1.204 0.026 0.422 0.468 Currently using pill 0.223 0.010 2689 3015 1.262 0.045 0.203 0.243 Currently using IUD 0.006 0.002 2689 3015 0.997 0.238 0.003 0.010 Currently using injectables 0.115 0.008 2689 3015 1.333 0.071 0.098 0.131 Currently using female sterilization 0.045 0.005 2689 3015 1.353 0.120 0.034 0.056 Currently using periodic abstinence 0.049 0.005 2689 3015 1.189 0.101 0.039 0.059 Currently using withdrawal 0.013 0.002 2689 3015 1.067 0.176 0.009 0.018 Using public sector source 0.445 0.021 1240 1342 1.494 0.047 0.403 0.488 Want no more children 0.621 0.010 2689 3015 1.109 0.017 0.600 0.641 Want to delay at least 2 years 0.216 0.008 2689 3015 1.024 0.038 0.200 0.232 Ideal number of children 2.411 0.030 2826 3173 1.864 0.012 2.352 2.470 Mothers completely protected against tetanus 0.888 0.016 941 1083 1.574 0.018 0.856 0.921 Mothers received medical assistance at delivery 0.297 0.025 1018 1176 1.692 0.085 0.247 0.348 Had diarrhea in the last 2 weeks 0.059 0.006 1683 1946 1.017 0.098 0.048 0.071 Treated with oral rehydration salts (ORS) 0.774 0.049 100 115 1.136 0.063 0.677 0.872 Sought medical treatment 0.198 0.042 100 115 1.063 0.212 0.114 0.282 Having health card, seen 0.618 0.034 323 366 1.254 0.055 0.550 0.686 Received BCG vaccination 0.969 0.015 323 366 1.430 0.016 0.939 0.999 Received DPT vaccination (3 doses) 0.909 0.025 323 366 1.525 0.028 0.859 0.960 Received polio vaccination (3 doses) 0.920 0.025 323 366 1.566 0.027 0.871 0.969 Received measles vaccination 0.839 0.031 323 366 1.483 0.037 0.777 0.900 Fully immunized 0.818 0.031 323 366 1.422 0.038 0.756 0.880 Height-for-age (below -2SD) 0.413 0.019 1545 1773 1.463 0.046 0.375 0.451 Weight-for-height (below -2SD) 0.159 0.012 1545 1773 1.224 0.075 0.135 0.183 Weight-for-age (below -2SD) 0.374 0.020 1545 1773 1.528 0.054 0.334 0.415 Anemia children 0.516 0.034 444 509 1.328 0.065 0.449 0.584 Anemia women 0.384 0.019 888 991 1.182 0.050 0.345 0.423 BMI < 18.5 0.224 0.013 2565 2868 1.534 0.057 0.199 0.250 Has heard of AIDS 0.686 0.023 2864 3222 2.648 0.034 0.640 0.732 Knows about condoms to prevent AIDS 0.436 0.020 2864 3222 2.156 0.046 0.396 0.476 Knows about limiting partners to prevent AIDS 0.504 0.023 2864 3222 2.427 0.045 0.458 0.549 Total fertility rate (last 3 years) 2.820 0.128 9761 10987 1.404 0.045 2.565 3.076 Neonatal mortality (last 0-4 years) 21.150 3.489 1759 2025 1.042 0.165 14.172 28.129 Post-neonatal mortality (last 0-4 years) 13.370 2.691 1751 2014 1.062 0.201 7.989 18.751 Infant mortality (last 0-4 years) 34.520 4.075 1764 2031 0.978 0.118 26.371 42.670 Child mortality (last 0-4 years) 15.988 3.458 1703 1957 1.113 0.216 9.073 22.904 Under-5 mortality (last 0-4 years) 49.957 5.300 1778 2048 1.048 0.106 39.356 60.557 Elevated blood pressure or taking medications 0.263 0.019 629 721 1.066 0.072 0.225 0.301 Elevated fasting plasma glucose or taking medications 0.141 0.016 581 663 1.087 0.112 0.109 0.172 MEN Urban residence 0.287 0.015 478 519 0.743 0.054 0.256 0.318 No education 0.256 0.027 478 519 1.339 0.105 0.202 0.309 With secondary education or higher 0.371 0.030 478 519 1.344 0.080 0.311 0.430 Currently married (in union) 0.992 0.004 478 519 1.098 0.004 0.983 1.001 Ideal number of children 2.355 0.043 471 511 1.220 0.018 2.269 2.442 Has heard of HIV/AIDS 0.864 0.024 478 519 1.510 0.027 0.817 0.912 Knows condom use to prevent HIV/AIDS 0.655 0.035 478 519 1.596 0.053 0.586 0.725 Knows limiting partners to prevent HIV/AIDS 0.649 0.035 478 519 1.585 0.053 0.580 0.719 Elevated blood pressure or taking medications 0.168 0.019 560 618 1.182 0.112 0.131 0.206 Elevated fasting plasma glucose or taking medications 0.151 0.015 517 568 0.962 0.100 0.121 0.181 Appendix B • 269 Table B.7 Sampling errors: Dhaka sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.407 0.007 3062 5736 0.818 0.018 0.393 0.422 No education 0.281 0.013 3062 5736 1.572 0.045 0.255 0.307 With secondary education or higher 0.418 0.016 3062 5736 1.815 0.039 0.385 0.450 Currently married (in union) 0.930 0.005 3062 5736 1.069 0.005 0.920 0.940 Currently pregnant 0.053 0.004 3570 6702 1.078 0.076 0.045 0.061 Children ever born 2.155 0.042 3570 6702 1.143 0.020 2.070 2.240 Children surviving 1.924 0.036 3570 6702 1.114 0.019 1.853 1.996 Children ever born to women over 40 4.115 0.112 705 1316 1.436 0.027 3.891 4.340 Currently using any method 0.610 0.011 2844 5334 1.149 0.017 0.589 0.631 Currently using a modern method 0.511 0.011 2844 5334 1.219 0.022 0.488 0.534 Currently using pill 0.277 0.012 2844 5334 1.406 0.043 0.253 0.301 Currently using IUD 0.005 0.001 2844 5334 1.109 0.290 0.002 0.008 Currently using injectables 0.091 0.008 2844 5334 1.550 0.092 0.075 0.108 Currently using female sterilization 0.046 0.005 2844 5334 1.310 0.112 0.036 0.056 Currently using periodic abstinence 0.078 0.005 2844 5334 1.071 0.069 0.068 0.089 Currently using withdrawal 0.018 0.003 2844 5334 1.238 0.169 0.012 0.025 Using public sector source 0.452 0.019 1455 2725 1.468 0.042 0.414 0.490 Want no more children 0.640 0.009 2844 5334 1.025 0.014 0.621 0.658 Want to delay at least 2 years 0.203 0.008 2844 5334 1.012 0.038 0.188 0.218 Ideal number of children 2.160 0.017 3056 5724 1.543 0.008 2.127 2.194 Mothers completely protected against tetanus 0.924 0.012 752 1418 1.211 0.013 0.900 0.947 Mothers received medical assistance at delivery 0.315 0.022 801 1510 1.308 0.071 0.271 0.360 Had diarrhea in the last 2 weeks 0.040 0.006 1376 2601 1.066 0.145 0.028 0.052 Treated with oral rehydration salts (ORS) 0.876 0.044 54 104 0.990 0.050 0.788 0.964 Sought medical treatment 0.262 0.064 54 104 1.073 0.245 0.134 0.391 Having health card, seen 0.639 0.035 254 478 1.156 0.055 0.569 0.709 Received BCG vaccination 0.984 0.008 254 478 0.993 0.008 0.969 1.000 Received DPT vaccination (3 doses) 0.939 0.015 254 478 0.962 0.016 0.908 0.969 Received polio vaccination (3 doses) 0.935 0.016 254 478 1.006 0.018 0.902 0.968 Received measles vaccination 0.866 0.022 254 478 1.013 0.025 0.823 0.909 Fully immunized 0.850 0.024 254 478 1.062 0.029 0.801 0.899 Height-for-age (below -2SD) 0.433 0.017 1318 2469 1.256 0.040 0.398 0.468 Weight-for-height (below -2SD) 0.157 0.011 1318 2469 1.082 0.069 0.135 0.178 Weight-for-age (below -2SD) 0.366 0.018 1318 2469 1.313 0.050 0.330 0.403 Anemia children 0.477 0.026 390 738 1.036 0.054 0.425 0.529 Anemia women 0.431 0.020 982 1850 1.284 0.047 0.391 0.472 BMI < 18.5 0.236 0.012 2758 5166 1.516 0.052 0.211 0.260 Has heard of AIDS 0.751 0.015 3062 5736 1.902 0.020 0.722 0.781 Knows about condoms to prevent AIDS 0.474 0.015 3062 5736 1.622 0.031 0.445 0.503 Knows about limiting partners to prevent AIDS 0.552 0.016 3062 5736 1.779 0.029 0.520 0.584 Total fertility rate (last 3 years) 2.232 0.087 10064 18856 1.156 0.039 2.057 2.406 Neonatal mortality (last 0-4 years) 35.923 4.888 1465 2764 0.973 0.136 26.146 45.700 Post-neonatal mortality (last 0-4 years) 7.673 2.170 1452 2738 0.952 0.283 3.333 12.013 Infant mortality (last 0-4 years) 43.596 5.377 1465 2764 0.988 0.123 32.841 54.350 Child mortality (last 0-4 years) 10.945 2.939 1440 2718 1.045 0.269 5.067 16.824 Under-5 mortality (last 0-4 years) 54.064 6.089 1473 2779 1.003 0.113 41.885 66.243 Elevated blood pressure or taking medications 0.335 0.020 694 1294 1.110 0.058 0.296 0.374 Elevated fasting plasma glucose or taking medications 0.121 0.013 650 1215 0.999 0.103 0.096 0.146 MEN Urban residence 0.454 0.019 586 1095 0.939 0.043 0.415 0.492 No education 0.260 0.019 586 1095 1.067 0.074 0.221 0.299 With secondary education or higher 0.439 0.024 586 1095 1.168 0.055 0.391 0.486 Currently married (in union) 0.985 0.005 586 1095 0.954 0.005 0.976 0.995 Ideal number of children 2.146 0.039 585 1092 1.064 0.018 2.069 2.224 Has heard of HIV/AIDS 0.920 0.013 586 1095 1.135 0.014 0.894 0.945 Knows condom use to prevent HIV/AIDS 0.720 0.026 586 1095 1.386 0.036 0.668 0.771 Knows limiting partners to prevent HIV/AIDS 0.721 0.027 586 1095 1.476 0.038 0.666 0.776 Elevated blood pressure or taking medications 0.195 0.016 685 1268 1.050 0.081 0.163 0.226 Elevated fasting plasma glucose or taking medications 0.108 0.015 637 1187 1.189 0.136 0.078 0.137 270 • Appendix B Table B.8 Sampling errors: Khulna sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.216 0.012 2640 2139 1.464 0.054 0.193 0.240 No education 0.235 0.013 2640 2139 1.594 0.056 0.209 0.261 With secondary education or higher 0.471 0.015 2640 2139 1.528 0.032 0.441 0.500 Currently married (in union) 0.933 0.006 2640 2139 1.244 0.006 0.921 0.945 Currently pregnant 0.038 0.004 3026 2445 1.286 0.117 0.029 0.046 Children ever born 2.016 0.042 3026 2445 1.178 0.021 1.933 2.100 Children surviving 1.833 0.036 3026 2445 1.147 0.020 1.762 1.905 Children ever born to women over 40 3.618 0.093 635 515 1.326 0.026 3.431 3.805 Currently using any method 0.667 0.013 2462 1996 1.327 0.019 0.642 0.693 Currently using a modern method 0.561 0.014 2462 1996 1.394 0.025 0.533 0.589 Currently using pill 0.289 0.011 2462 1996 1.235 0.039 0.266 0.312 Currently using IUD 0.009 0.002 2462 1996 1.078 0.224 0.005 0.013 Currently using injectables 0.116 0.010 2462 1996 1.586 0.088 0.095 0.136 Currently using female sterilization 0.058 0.008 2462 1996 1.616 0.131 0.043 0.074 Currently using periodic abstinence 0.069 0.007 2462 1996 1.299 0.096 0.056 0.082 Currently using withdrawal 0.033 0.004 2462 1996 1.116 0.121 0.025 0.041 Using public sector source 0.548 0.023 1370 1120 1.699 0.042 0.503 0.594 Want no more children 0.669 0.010 2462 1996 1.069 0.015 0.649 0.690 Want to delay at least 2 years 0.190 0.009 2462 1996 1.176 0.049 0.171 0.208 Ideal number of children 2.062 0.017 2629 2131 1.576 0.008 2.028 2.097 Mothers completely protected against tetanus 0.905 0.015 551 441 1.212 0.017 0.874 0.935 Mothers received medical assistance at delivery 0.490 0.028 578 463 1.315 0.058 0.433 0.546 Had diarrhea in the last 2 weeks 0.026 0.005 946 767 0.962 0.192 0.016 0.036 Treated with oral rehydration salts (ORS) 0.670 0.101 25 20 1.058 0.150 0.469 0.872 Sought medical treatment 0.193 0.077 25 20 0.958 0.397 0.040 0.346 Having health card, seen 0.719 0.039 182 144 1.138 0.054 0.642 0.797 Received BCG vaccination 0.991 0.007 182 144 0.974 0.007 0.978 1.005 Received DPT vaccination (3 doses) 0.972 0.013 182 144 1.027 0.013 0.946 0.997 Received polio vaccination (3 doses) 0.972 0.013 182 144 1.027 0.013 0.946 0.997 Received measles vaccination 0.942 0.019 182 144 1.084 0.020 0.904 0.980 Fully immunized 0.935 0.020 182 144 1.073 0.021 0.896 0.975 Height-for-age (below -2SD) 0.341 0.018 910 744 1.120 0.051 0.306 0.376 Weight-for-height (below -2SD) 0.146 0.015 910 744 1.293 0.104 0.115 0.176 Weight-for-age (below -2SD) 0.291 0.018 910 744 1.181 0.063 0.255 0.328 Anemia children 0.542 0.031 263 225 1.033 0.057 0.481 0.603 Anemia women 0.374 0.023 872 708 1.399 0.061 0.329 0.420 BMI < 18.5 0.190 0.011 2449 1989 1.355 0.056 0.168 0.211 Has heard of AIDS 0.791 0.014 2640 2139 1.821 0.018 0.763 0.820 Knows about condoms to prevent AIDS 0.477 0.016 2640 2139 1.685 0.034 0.444 0.510 Knows about limiting partners to prevent AIDS 0.568 0.018 2640 2139 1.917 0.033 0.531 0.605 Total fertility rate (last 3 years) 1.888 0.088 8519 6909 1.209 0.046 1.713 2.063 Neonatal mortality (last 0-4 years) 31.764 7.256 987 801 1.108 0.228 17.251 46.276 Post-neonatal mortality (last 0-4 years) 4.402 2.205 983 801 1.053 0.501 0.000 8.812 Infant mortality (last 0-4 years) 36.166 7.297 987 801 1.071 0.202 21.572 50.760 Child mortality (last 0-4 years) 4.467 1.899 980 801 0.998 0.425 0.668 8.265 Under-5 mortality (last 0-4 years) 40.471 7.575 990 803 1.097 0.187 25.321 55.620 Elevated blood pressure or taking medications 0.367 0.023 617 509 1.205 0.063 0.321 0.413 Elevated fasting plasma glucose or taking medications 0.072 0.011 592 488 1.014 0.150 0.051 0.094 MEN Urban residence 0.225 0.022 530 430 1.193 0.096 0.181 0.268 No education 0.215 0.023 530 430 1.295 0.108 0.169 0.261 With secondary education or higher 0.444 0.026 530 430 1.207 0.059 0.391 0.496 Currently married (in union) 0.987 0.005 530 430 1.042 0.005 0.977 0.997 Ideal number of children 1.990 0.036 530 430 1.252 0.018 1.919 2.062 Has heard of HIV/AIDS 0.948 0.011 530 430 1.186 0.012 0.925 0.971 Knows condom use to prevent HIV/AIDS 0.810 0.021 530 430 1.236 0.026 0.768 0.852 Knows limiting partners to prevent HIV/AIDS 0.862 0.020 530 430 1.347 0.023 0.821 0.902 Elevated blood pressure or taking medications 0.234 0.022 627 515 1.294 0.095 0.190 0.279 Elevated fasting plasma glucose or taking medications 0.076 0.009 598 492 0.855 0.122 0.057 0.094 Appendix B • 271 Table B.9 Sampling errors: Rajshahi sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.174 0.006 2590 2646 0.793 0.034 0.163 0.186 No education 0.304 0.018 2590 2646 1.957 0.058 0.269 0.340 With secondary education or higher 0.390 0.020 2590 2646 2.065 0.051 0.350 0.430 Currently married (in union) 0.955 0.004 2590 2646 0.979 0.004 0.947 0.963 Currently pregnant 0.048 0.004 2885 2962 1.040 0.085 0.040 0.056 Children ever born 2.126 0.048 2885 2962 1.373 0.023 2.031 2.222 Children surviving 1.902 0.043 2885 2962 1.429 0.023 1.815 1.989 Children ever born to women over 40 3.670 0.118 610 597 1.590 0.032 3.434 3.906 Currently using any method 0.673 0.016 2463 2526 1.712 0.024 0.641 0.706 Currently using a modern method 0.583 0.015 2463 2526 1.545 0.026 0.552 0.613 Currently using pill 0.312 0.014 2463 2526 1.504 0.045 0.284 0.340 Currently using IUD 0.014 0.003 2463 2526 1.155 0.197 0.008 0.019 Currently using injectables 0.107 0.009 2463 2526 1.392 0.081 0.089 0.124 Currently using female sterilization 0.053 0.006 2463 2526 1.253 0.107 0.042 0.064 Currently using periodic abstinence 0.063 0.006 2463 2526 1.145 0.089 0.052 0.075 Currently using withdrawal 0.022 0.003 2463 2526 1.124 0.152 0.015 0.028 Using public sector source 0.582 0.022 1427 1472 1.676 0.038 0.539 0.626 Want no more children 0.663 0.010 2463 2526 1.020 0.015 0.644 0.683 Want to delay at least 2 years 0.182 0.007 2463 2526 0.920 0.039 0.167 0.196 Ideal number of children 2.099 0.023 2578 2633 2.037 0.011 2.053 2.146 Mothers completely protected against tetanus 0.879 0.015 590 618 1.106 0.017 0.849 0.908 Mothers received medical assistance at delivery 0.309 0.031 617 646 1.616 0.100 0.247 0.370 Had diarrhea in the last 2 weeks 0.047 0.009 1024 1087 1.286 0.186 0.029 0.064 Treated with oral rehydration salts (ORS) 0.560 0.093 45 51 1.273 0.165 0.375 0.746 Sought medical treatment 0.190 0.054 45 51 0.963 0.285 0.081 0.298 Having health card, seen 0.689 0.043 211 218 1.364 0.063 0.603 0.776 Received BCG vaccination 0.974 0.017 211 218 1.524 0.017 0.941 1.007 Received DPT vaccination (3 doses) 0.953 0.022 211 218 1.386 0.023 0.909 0.997 Received polio vaccination (3 doses) 0.945 0.022 211 218 1.321 0.024 0.900 0.990 Received measles vaccination 0.907 0.031 211 218 1.480 0.034 0.845 0.968 Fully immunized 0.898 0.031 211 218 1.436 0.035 0.836 0.960 Height-for-age (below -2SD) 0.337 0.020 935 986 1.318 0.060 0.296 0.377 Weight-for-height (below -2SD) 0.164 0.018 935 986 1.445 0.111 0.128 0.200 Weight-for-age (below -2SD) 0.342 0.020 935 986 1.314 0.060 0.301 0.383 Anemia children 0.493 0.032 287 293 1.076 0.065 0.429 0.557 Anemia women 0.441 0.023 831 847 1.307 0.051 0.395 0.486 BMI < 18.5 0.248 0.013 2361 2408 1.442 0.052 0.222 0.274 Has heard of AIDS 0.629 0.022 2590 2646 2.279 0.034 0.586 0.673 Knows about condoms to prevent AIDS 0.408 0.019 2590 2646 1.989 0.047 0.370 0.447 Knows about limiting partners to prevent AIDS 0.453 0.019 2590 2646 1.923 0.042 0.415 0.491 Total fertility rate (last 3 years) 2.118 0.108 8230 8415 1.470 0.051 1.902 2.334 Neonatal mortality (last 0-4 years) 38.684 5.899 1087 1158 1.022 0.153 26.885 50.483 Post-neonatal mortality (last 0-4 years) 12.606 3.137 1098 1172 0.945 0.249 6.331 18.880 Infant mortality (last 0-4 years) 51.290 6.874 1088 1158 1.047 0.134 37.543 65.037 Child mortality (last 0-4 years) 12.863 3.595 1086 1156 1.033 0.279 5.673 20.052 Under-5 mortality (last 0-4 years) 63.493 7.137 1093 1164 1.009 0.112 49.219 77.766 Elevated blood pressure or taking medications 0.301 0.019 569 570 1.022 0.064 0.262 0.339 Elevated fasting plasma glucose or taking medications 0.119 0.016 518 522 1.083 0.133 0.087 0.150 MEN Urban residence 0.171 0.013 529 556 0.772 0.074 0.146 0.197 No education 0.297 0.023 529 556 1.171 0.078 0.251 0.344 With secondary education or higher 0.381 0.027 529 556 1.267 0.070 0.328 0.435 Currently married (in union) 0.998 0.002 529 556 1.086 0.002 0.993 1.002 Ideal number of children 2.068 0.040 524 552 1.570 0.019 1.988 2.148 Has heard of HIV/AIDS 0.849 0.022 529 556 1.437 0.026 0.804 0.894 Knows condom use to prevent HIV/AIDS 0.683 0.026 529 556 1.259 0.037 0.632 0.734 Knows limiting partners to prevent HIV/AIDS 0.695 0.031 529 556 1.521 0.044 0.634 0.756 Elevated blood pressure or taking medications 0.166 0.017 571 584 1.122 0.103 0.132 0.201 Elevated fasting plasma glucose or taking medications 0.101 0.013 518 526 0.957 0.126 0.075 0.126 272 • Appendix B Table B.10 Sampling errors: Rangpur sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.129 0.004 2457 2039 0.559 0.029 0.121 0.136 No education 0.341 0.017 2457 2039 1.785 0.050 0.307 0.375 With secondary education or higher 0.378 0.017 2457 2039 1.698 0.044 0.345 0.411 Currently married (in union) 0.945 0.005 2457 2039 1.181 0.006 0.935 0.956 Currently pregnant 0.050 0.004 2756 2294 0.898 0.074 0.042 0.057 Children ever born 2.258 0.045 2756 2294 1.142 0.020 2.169 2.348 Children surviving 2.014 0.038 2756 2294 1.111 0.019 1.939 2.089 Children ever born to women over 40 3.997 0.094 560 455 1.145 0.024 3.809 4.185 Currently using any method 0.694 0.011 2309 1927 1.182 0.016 0.671 0.716 Currently using a modern method 0.607 0.014 2309 1927 1.389 0.023 0.579 0.635 Currently using pill 0.308 0.012 2309 1927 1.236 0.039 0.284 0.332 Currently using IUD 0.005 0.002 2309 1927 1.304 0.369 0.001 0.009 Currently using injectables 0.161 0.013 2309 1927 1.682 0.080 0.136 0.187 Currently using female sterilization 0.066 0.010 2309 1927 1.835 0.144 0.047 0.085 Currently using periodic abstinence 0.070 0.007 2309 1927 1.242 0.094 0.057 0.083 Currently using withdrawal 0.013 0.003 2309 1927 1.156 0.210 0.008 0.018 Using public sector source 0.629 0.022 1401 1170 1.724 0.035 0.584 0.674 Want no more children 0.676 0.012 2309 1927 1.210 0.017 0.652 0.699 Want to delay at least 2 years 0.192 0.009 2309 1927 1.040 0.044 0.174 0.209 Ideal number of children 2.144 0.016 2440 2026 1.447 0.008 2.112 2.177 Mothers completely protected against tetanus 0.921 0.013 591 491 1.153 0.014 0.895 0.947 Mothers received medical assistance at delivery 0.287 0.024 618 513 1.274 0.083 0.240 0.335 Had diarrhea in the last 2 weeks 0.041 0.008 1059 891 1.253 0.201 0.025 0.058 Treated with oral rehydration salts (ORS) 0.808 0.075 41 37 1.227 0.092 0.659 0.957 Sought medical treatment 0.309 0.088 41 37 1.118 0.286 0.132 0.486 Having health card, seen 0.764 0.034 180 148 1.059 0.044 0.697 0.832 Received BCG vaccination 0.984 0.010 180 148 1.058 0.010 0.964 1.004 Received DPT vaccination (3 doses) 0.961 0.016 180 148 1.088 0.016 0.929 0.992 Received polio vaccination (3 doses) 0.960 0.016 180 148 1.087 0.017 0.928 0.992 Received measles vaccination 0.929 0.020 180 148 1.047 0.022 0.888 0.969 Fully immunized 0.922 0.021 180 148 1.058 0.023 0.879 0.965 Height-for-age (below -2SD) 0.429 0.017 1014 859 1.084 0.040 0.395 0.463 Weight-for-height (below -2SD) 0.132 0.013 1014 859 1.225 0.099 0.106 0.158 Weight-for-age (below -2SD) 0.345 0.017 1014 859 1.092 0.049 0.311 0.378 Anemia children 0.577 0.029 311 268 1.040 0.050 0.520 0.635 Anemia women 0.495 0.021 791 664 1.164 0.042 0.454 0.536 BMI < 18.5 0.271 0.012 2280 1884 1.277 0.044 0.247 0.294 Has heard of AIDS 0.549 0.023 2457 2039 2.295 0.042 0.502 0.595 Knows about condoms to prevent AIDS 0.368 0.018 2457 2039 1.894 0.050 0.331 0.404 Knows about limiting partners to prevent AIDS 0.420 0.020 2457 2039 1.986 0.047 0.380 0.459 Total fertility rate (last 3 years) 2.100 0.086 7775 6452 1.245 0.041 1.928 2.271 Neonatal mortality (last 0-4 years) 27.042 5.766 1120 934 1.049 0.213 15.509 38.574 Post-neonatal mortality (last 0-4 years) 8.661 3.123 1126 940 1.036 0.361 2.415 14.908 Infant mortality (last 0-4 years) 35.703 6.379 1120 934 1.033 0.179 22.944 48.462 Child mortality (last 0-4 years) 6.225 2.333 1117 940 1.091 0.375 1.558 10.892 Under-5 mortality (last 0-4 years) 41.706 6.721 1122 936 1.063 0.161 28.263 55.148 Elevated blood pressure or taking medications 0.343 0.026 530 437 1.186 0.074 0.292 0.394 Elevated fasting plasma glucose or taking medications 0.090 0.015 485 399 1.089 0.169 0.059 0.120 MEN Urban residence 0.119 0.009 534 442 0.610 0.072 0.102 0.137 No education 0.297 0.022 534 442 1.123 0.075 0.252 0.341 With secondary education or higher 0.388 0.022 534 442 1.040 0.057 0.344 0.432 Currently married (in union) 1.000 0.000 534 442 na 0.000 1.000 1.000 Ideal number of children 2.066 0.021 532 440 0.953 0.010 2.025 2.107 Has heard of HIV/AIDS 0.770 0.023 534 442 1.249 0.030 0.725 0.816 Knows condom use to prevent HIV/AIDS 0.650 0.025 534 442 1.206 0.038 0.601 0.700 Knows limiting partners to prevent HIV/AIDS 0.567 0.029 534 442 1.337 0.051 0.510 0.625 Elevated blood pressure or taking medications 0.224 0.020 571 488 1.162 0.089 0.184 0.264 Elevated fasting plasma glucose or taking medications 0.091 0.014 528 454 1.164 0.156 0.063 0.119 Appendix B • 273 Table B.11 Sampling errors: Sylhet sample, BDHS 2011 Variable R SE N WN DEFT SE/R R-2SE R+2SE WOMEN Urban residence 0.156 0.005 2086 967 0.673 0.034 0.145 0.166 No education 0.348 0.023 2086 967 2.249 0.067 0.301 0.395 With secondary education or higher 0.317 0.021 2086 967 2.056 0.066 0.275 0.359 Currently married (in union) 0.914 0.007 2086 967 1.160 0.008 0.900 0.928 Currently pregnant 0.073 0.005 2731 1274 1.070 0.070 0.063 0.084 Children ever born 2.402 0.063 2731 1274 1.007 0.026 2.276 2.528 Children surviving 2.115 0.059 2731 1274 1.089 0.028 1.996 2.233 Children ever born to women over 40 4.937 0.149 466 217 1.270 0.030 4.640 5.235 Currently using any method 0.448 0.014 1901 884 1.206 0.031 0.420 0.475 Currently using a modern method 0.352 0.014 1901 884 1.262 0.039 0.324 0.380 Currently using pill 0.190 0.014 1901 884 1.521 0.072 0.163 0.218 Currently using IUD 0.006 0.002 1901 884 1.121 0.342 0.002 0.009 Currently using injectables 0.049 0.007 1901 884 1.462 0.147 0.035 0.064 Currently using female sterilization 0.046 0.006 1901 884 1.216 0.127 0.034 0.058 Currently using periodic abstinence 0.081 0.008 1901 884 1.199 0.092 0.066 0.096 Currently using withdrawal 0.011 0.003 1901 884 1.124 0.239 0.006 0.017 Using public sector source 0.507 0.029 718 311 1.542 0.057 0.450 0.565 Want no more children 0.639 0.012 1901 884 1.058 0.018 0.616 0.663 Want to delay at least 2 years 0.156 0.009 1901 884 1.113 0.059 0.138 0.175 Ideal number of children 2.463 0.042 1982 914 2.113 0.017 2.379 2.546 Mothers completely protected against tetanus 0.837 0.019 711 342 1.347 0.022 0.800 0.875 Mothers received medical assistance at delivery 0.244 0.024 781 375 1.486 0.096 0.197 0.292 Had diarrhea in the last 2 weeks 0.060 0.008 1320 639 1.258 0.138 0.044 0.077 Treated with oral rehydration salts (ORS) 0.847 0.047 83 38 1.171 0.055 0.754 0.940 Sought medical treatment 0.353 0.055 83 38 1.005 0.155 0.244 0.463 Having health card, seen 0.721 0.034 226 109 1.155 0.047 0.654 0.789 Received BCG vaccination 0.960 0.014 226 109 1.119 0.015 0.932 0.989 Received DPT vaccination (3 doses) 0.889 0.027 226 109 1.326 0.031 0.835 0.944 Received polio vaccination (3 doses) 0.879 0.028 226 109 1.322 0.032 0.823 0.935 Received measles vaccination 0.829 0.029 226 109 1.193 0.035 0.770 0.888 Fully immunized 0.801 0.035 226 109 1.336 0.043 0.732 0.871 Height-for-age (below -2SD) 0.493 0.024 1234 596 1.600 0.048 0.446 0.540 Weight-for-height (below -2SD) 0.184 0.013 1234 596 1.145 0.069 0.159 0.209 Weight-for-age (below -2SD) 0.449 0.021 1234 596 1.464 0.048 0.407 0.492 Anemia children 0.495 0.028 391 185 1.110 0.056 0.439 0.551 Anemia women 0.397 0.027 674 310 1.406 0.067 0.344 0.451 BMI < 18.5 0.352 0.019 1817 837 1.724 0.055 0.314 0.391 Has heard of AIDS 0.581 0.023 2086 967 2.143 0.040 0.534 0.627 Knows about condoms to prevent AIDS 0.313 0.017 2086 967 1.642 0.053 0.279 0.346 Knows about limiting partners to prevent AIDS 0.401 0.020 2086 967 1.881 0.050 0.361 0.441 Total fertility rate (last 3 years) 3.066 0.112 7621 3551 1.222 0.037 2.842 3.290 Neonatal mortality (last 0-4 years) 44.862 7.221 1417 686 1.173 0.161 30.421 59.304 Post-neonatal mortality (last 0-4 years) 14.232 3.304 1412 683 1.017 0.232 7.624 20.840 Infant mortality (last 0-4 years) 59.094 7.972 1418 687 1.170 0.135 43.150 75.039 Child mortality (last 0-4 years) 12.380 3.421 1425 685 1.159 0.276 5.539 19.221 Under-5 mortality (last 0-4 years) 70.743 8.879 1426 691 1.215 0.126 52.986 88.500 Elevated blood pressure or taking medications 0.248 0.025 503 235 1.286 0.100 0.198 0.298 Elevated fasting plasma glucose or taking medications 0.115 0.013 466 219 0.893 0.115 0.088 0.142 MEN Urban residence 0.166 0.012 384 175 0.611 0.070 0.142 0.189 No education 0.331 0.033 384 175 1.363 0.099 0.265 0.397 With secondary education or higher 0.339 0.028 384 175 1.164 0.083 0.283 0.395 Currently married (in union) 0.986 0.007 384 175 1.115 0.007 0.973 1.000 Ideal number of children 2.516 0.065 374 170 1.420 0.026 2.386 2.645 Has heard of HIV/AIDS 0.823 0.028 384 175 1.430 0.034 0.767 0.879 Knows condom use to prevent HIV/AIDS 0.561 0.036 384 175 1.413 0.064 0.490 0.633 Knows limiting partners to prevent HIV/AIDS 0.537 0.034 384 175 1.322 0.063 0.469 0.604 Elevated blood pressure or taking medications 0.150 0.022 484 221 1.321 0.144 0.107 0.194 Elevated fasting plasma glucose or taking medications 0.127 0.016 439 201 0.999 0.124 0.095 0.158 Appendix C • 275 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 2011 Age Women Men Age Women Men Number Percent Number Percent Number Percent Number Percent 0 854 2.1 918 2.5 36 458 1.1 329 0.9 1 795 2.0 762 2.0 37 425 1.1 314 0.8 2 815 2.0 788 2.1 38 409 1.0 374 1.0 3 928 2.3 1,005 2.7 39 417 1.0 245 0.7 4 879 2.2 909 2.4 40 673 1.7 906 2.4 5 721 1.8 822 2.2 41 441 1.1 258 0.7 6 943 2.3 1,006 2.7 42 416 1.0 375 1.0 7 1,069 2.7 1,042 2.8 43 350 0.9 245 0.7 8 1,052 2.6 1,025 2.7 44 327 0.8 198 0.5 9 860 2.1 929 2.5 45 473 1.2 770 2.1 10 1,116 2.8 1,082 2.9 46 335 0.8 246 0.7 11 782 1.9 875 2.3 47 359 0.9 311 0.8 12 974 2.4 1,008 2.7 48 399 1.0 424 1.1 13 841 2.1 838 2.2 49 311 0.8 129 0.3 14 883 2.2 821 2.2 50 85 0.2 818 2.2 15 900 2.2 793 2.1 51 153 0.4 109 0.3 16 844 2.1 738 2.0 52 418 1.0 429 1.1 17 837 2.1 587 1.6 53 338 0.8 167 0.4 18 998 2.5 784 2.1 54 312 0.8 166 0.4 19 804 2.0 402 1.1 55 460 1.1 508 1.4 20 925 2.3 726 1.9 56 264 0.7 195 0.5 21 740 1.8 378 1.0 57 189 0.5 183 0.5 22 875 2.2 617 1.7 58 185 0.5 228 0.6 23 854 2.1 532 1.4 59 110 0.3 80 0.2 24 741 1.8 486 1.3 60 639 1.6 725 1.9 25 813 2.0 783 2.1 61 84 0.2 57 0.2 26 746 1.9 524 1.4 62 142 0.4 183 0.5 27 708 1.8 421 1.1 63 70 0.2 46 0.1 28 674 1.7 687 1.8 64 65 0.2 75 0.2 29 622 1.6 236 0.6 65 441 1.1 608 1.6 30 642 1.6 1,112 3.0 66 42 0.1 70 0.2 31 573 1.4 200 0.5 67 30 0.1 50 0.1 32 527 1.3 563 1.5 68 44 0.1 68 0.2 33 497 1.2 312 0.8 69 29 0.1 29 0.1 34 478 1.2 223 0.6 70+ 1,339 3.3 1,594 4.3 35 588 1.5 935 2.5 Don’t know/ missing 3 0.0 1 0.0 Total 40,133 100.0 37,381 100.0 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. 276 • Appendix C Table C.2.1 Age distribution of eligible and interviewed women De facto household population of women age 10-54, ever-married 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 2011 Age group Household population of women age 10-54 Ever-married women age 10-54 Interviewed women age 15-49 Percentage of eligible women interviewed Number Percentage 10-14 4,597 109 na na na 15-19 4,383 2,001 1,956 11.1 97.7 20-24 4,135 3,580 3,505 19.8 97.9 25-29 3,564 3,451 3,379 19.1 97.9 30-34 2,717 2,685 2,641 14.9 98.3 35-39 2,297 2,282 2,234 12.6 97.9 40-44 2,206 2,199 2,143 12.1 97.4 45-49 1,878 1,871 1,814 10.3 96.9 50-54 1,305 1,304 na na na 15-49 21,180 18,069 17,672 100.0 97.8 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of women and interviewed women are household weights. Age is based on the household questionnaire. na = Not applicable Table C.2.2 Age distribution of eligible and interviewed men De facto household population of men age 10-59, ever-married men age 10-59, interviewed men age 15-54 and percent distribution and percentage of eligible men who were interviewed (weighted), by five-year age groups, Bangladesh 2011 Age group Household population of men age 10-59 Ever-married men age 10-59 Interviewed men age 15-54 Percentage of eligible men interviewed Number Percentage 10-14 1,536 3 na na na 15-19 1,131 22 19 0.5 88.7 20-24 941 285 255 6.5 89.4 25-29 888 649 581 14.7 89.6 30-34 800 717 641 16.3 89.4 35-39 699 685 641 16.2 93.5 40-44 659 655 594 15.1 90.7 45-49 661 655 609 15.4 93.1 50-54 638 637 604 15.3 94.8 55-59 343 342 na na na 15-54 6,417 4,305 3,945 100.0 84.9 Note: The de facto population includes all residents and nonresidents who stayed in the household the night before the interview. Weights for both household population of men and interviewed men are household weights. Age is based on the household schedule. na = Not applicable Appendix C • 277 Table C.3 Completeness of reporting Percentage of observations missing information for selected demographic and health questions (weighted), Bangladesh 2011 Subject Percentage with information missing Number of cases Month only (births in the 15 years preceding the survey) 0.28 27,894 Month and year (births in the 15 years preceding the survey) 0.02 27,894 Age at death (deceased children born in the 15 years preceding the survey) 0.09 1,935 Age/date at first union1 (ever-married women age 15-49) 0.46 17,749 Age/date at first union (ever-married men age 15-54) 0.94 3,997 Respondent’s education (ever-married women age 15-49) 0.00 17,749 Respondent’s education (ever-married men age 15-54) 0.00 3,997 Diarrhea in last 2 weeks (living children 0-59 months) 0.32 8,395 Height (living children age 0-59 months from the Household Questionnaire) 5.94 8,604 Weight (living children age 0-59 months from the Household Questionnaire) 4.81 8,604 Height or weight (living children age 0-59 months from the Household Questionnaire) 6.03 8,604 Anemia (living children age 6-59 months from the Household Questionnaire) 8.08 2,560 Anemia (ever-married women from the Household Questionnaire) 4.64 5,863 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 2011 Calendar year Number of births Percentage with complete birth date1 Sex ratio at birth2 Calendar year ratio3 L D T L D T L D T L D T 2011 1,311 35 1,347 100.0 100.0 100.0 114.2 180.5 115.6 na na na 2010 1,593 62 1,655 100.0 100.0 100.0 98.8 130.1 99.8 na na na 2009 1,499 68 1,568 100.0 100.0 100.0 96.0 160.8 98.1 89.2 91.5 89.3 2008 1,770 87 1,857 100.0 100.0 100.0 104.9 76.8 103.4 107.2 95.6 106.6 2007 1,802 114 1,915 100.0 100.0 100.0 107.3 146.0 109.2 107.4 113.3 107.7 2006 1,585 114 1,699 100.0 100.0 100.0 115.5 107.4 115.0 88.2 96.2 88.7 2005 1,793 123 1,916 99.7 98.5 99.6 102.4 109.2 102.8 100.4 93.5 99.9 2004 1,986 149 2,135 99.7 98.3 99.6 102.0 85.9 100.8 106.5 113.0 106.9 2003 1,937 141 2,078 99.7 99.1 99.7 104.3 117.9 105.1 102.9 91.1 102.0 2002 1,779 160 1,940 99.5 99.8 99.5 106.3 187.6 111.2 92.3 101.2 93.0 2007-2011 7,975 366 8,342 100.0 100.0 100.0 103.9 127.3 104.8 na na na 2002-2006 9,081 686 9,767 99.7 99.1 99.7 105.6 118.6 106.5 na na na 1997-2001 8,553 834 9,386 99.6 98.3 99.5 107.4 106.3 107.3 na na na 1992-1996 6,739 927 7,666 99.3 98.1 99.2 95.8 112.5 97.7 na na na <1991 8,811 2,019 10,829 98.9 97.8 98.7 109.2 110.7 109.5 na na na All 41,159 4,832 45,991 99.5 98.3 99.4 104.7 112.5 105.5 na na na na = Not applicable 1 Both year and month of birth given 2 (Bm/Bf)x100, where Bm and Bf are the numbers of male and female births, respectively 3 [2Bx/(Bx-1+Bx+1)]x100, where Bx is the number of births in calendar year x 278 • Appendix C Table C.5 Reporting of age at death in days Distribution of reported deaths under one month of age by age at death in days and the percentage of neonatal deaths reported to occur at age 0-6 days, for five-year periods of birth preceding the survey (weighted), Bangladesh 2011 Age at death (days) Number of years preceding the survey Total 0-19 0-4 5-9 10-14 15-19 <1 101 129 124 94 447 1 36 76 62 55 229 2 18 12 21 16 67 3 32 39 35 41 147 4 19 7 16 20 61 5 8 13 17 20 58 6 7 9 10 15 42 7 8 24 21 22 75 8 3 8 11 13 34 9 3 5 4 7 20 10 6 1 5 9 21 11 5 9 7 5 26 12 3 2 9 10 24 13 1 3 5 3 11 14 2 5 10 6 24 15 2 13 8 12 35 16 1 2 0 3 7 17 0 8 2 3 12 18 1 1 2 2 5 19 3 0 4 6 13 20 2 5 1 2 10 21 4 4 6 4 18 22 3 2 5 8 18 23 0 1 0 2 3 24 2 3 2 4 10 25 1 3 1 3 8 26 1 1 2 1 5 27 0 2 0 2 4 28 1 4 4 2 12 29 1 4 6 3 12 30 0 0 1 2 3 Missing 0 2 0 0 2 Total 0-30 273 394 399 396 1,462 Percentage early neonatal1 80.6 72.2 71.4 66.0 71.9 1 (6 days / 30 days) * 100 Appendix C • 279 Table C.6 Reporting of age at death in months Distribution of reported deaths under age 2 by age at death in months and the percentage of infant deaths reported to occur at age under 1 month, for five-year periods of birth preceding the survey, Bangladesh 2011 Age at death (months) Number of years preceding the survey Total 0-190-4 5-9 10-14 15-19 <1a 273 396 399 396 1,464 1 19 38 49 46 153 2 18 22 25 21 86 3 7 13 26 36 82 4 3 9 14 22 49 5 9 10 18 18 55 6 6 16 19 22 63 7 4 14 12 11 41 8 6 5 8 10 28 9 3 9 17 8 36 10 1 4 10 9 24 11 4 9 7 7 27 12 3 7 18 17 44 13 2 4 5 5 16 14 2 4 2 11 18 15 2 1 1 4 8 16 2 1 3 2 8 17 1 9 2 3 14 18 3 21 24 23 71 19 2 2 1 6 11 20 1 0 0 0 1 21 3 3 2 3 11 22 0 4 1 0 5 23 0 1 0 1 2 Total 0-11 353 545 605 605 2,107 Percentage neonatal1 77.4 72.7 66.0 65.4 69.5 a Includes deaths under one month reported in days 1 (Under one month / under one year) * 100 Appendix D • 281 WHOLE BLOOD GLUCOSE VALUES Appendix D Table D.15.5.1 Fasting whole blood glucose values and treatment status by background characteristics: Women Prevalence of diabetes, percent distribution of women age 35 and older by fasting whole blood glucose (FWBG) values and treatment status, and percentage with normal whole blood glucose values and taking medication, by background characteristics, Bangladesh 2011 Background characteristics Preva- lence of diabetes1 <3.9 mmol/L (Below normal) 3.9-6.0 mmol/L (Normal) 6.1-6.9 mmol/L (Prediabetic) ≥7 mmol/L (Elevated FWBG) Total Normal FWBG and taking medi- cation Number of women Taking medi- cation Not taking medi- cation Taking medi- cation Not taking medi- cation Taking medi- cation Not taking medi- cation Taking medi- cation Not taking medi- cation Age 35-39 5.7 0.1 6.5 0.3 80.7 0.8 7.1 1.4 3.0 100.0 1.3 789 40-44 6.5 0.0 6.4 1.5 78.8 0.6 8.3 2.3 2.2 100.0 2.0 712 45-49 5.8 0.2 6.7 0.4 78.8 0.5 8.8 1.4 3.2 100.0 1.1 603 50-54 6.9 0.0 6.0 1.4 77.4 0.5 9.6 2.6 2.5 100.0 1.9 421 55-59 10.2 0.3 5.1 1.5 73.5 1.2 11.2 3.6 3.6 100.0 3.0 370 60-69 8.8 0.0 6.4 2.6 77.9 1.1 6.9 2.0 3.0 100.0 3.8 501 70+ 6.2 0.1 8.5 2.0 76.5 0.4 8.7 1.3 2.4 100.0 2.5 425 Residence Urban 11.9 0.0 5.1 2.6 73.7 2.2 9.2 3.6 3.5 100.0 4.8 872 Rural 5.4 0.1 6.9 0.9 79.5 0.3 8.2 1.5 2.6 100.0 1.3 2,950 Division Barisal 6.5 0.3 5.8 0.4 74.5 0.2 13.2 1.4 4.2 100.0 0.8 220 Chittagong 7.8 0.0 4.9 0.7 74.5 1.0 12.8 2.7 3.2 100.0 1.8 677 Dhaka 8.0 0.0 5.6 2.3 80.0 1.2 6.4 2.2 2.4 100.0 3.4 1,245 Khulna 4.0 0.0 4.2 0.4 85.7 0.4 6.2 1.3 1.9 100.0 0.8 493 Rajshahi 8.9 0.4 8.9 1.8 75.5 0.1 6.7 2.2 4.4 100.0 2.3 539 Rangpur 3.7 0.2 12.8 0.2 74.0 0.2 9.6 0.8 2.3 100.0 0.6 424 Sylhet 6.2 0.0 4.8 1.3 80.4 0.6 8.7 2.4 1.9 100.0 1.9 224 Education No education 4.4 0.1 6.5 0.7 80.5 0.4 8.5 0.8 2.5 100.0 1.2 2,224 Primary incomplete 7.8 0.1 7.5 1.8 75.6 0.5 9.1 2.9 2.4 100.0 2.5 780 Primary complete1 14.0 0.0 5.7 4.7 74.4 0.5 5.9 4.8 3.9 100.0 5.2 303 Secondary incomplete 11.2 0.0 6.7 0.4 73.4 2.7 8.6 4.2 4.0 100.0 3.0 331 Secondary complete or higher2 13.6 0.0 3.7 2.5 74.7 2.0 8.0 4.5 4.6 100.0 4.5 185 Wealth quintile Lowest 3.1 0.2 6.3 0.4 81.7 0.3 8.9 0.1 2.1 100.0 0.9 732 Second 2.3 0.0 10.2 0.5 78.0 0.4 9.6 0.0 1.4 100.0 0.9 717 Middle 5.2 0.3 6.0 0.7 82.5 0.0 6.4 0.5 3.6 100.0 1.0 770 Fourth 8.1 0.0 6.1 2.0 77.8 0.4 8.0 2.9 2.7 100.0 2.4 800 Highest 15.0 0.0 4.4 2.6 71.3 2.3 9.3 6.0 4.1 100.0 4.9 802 Nutritional status Thin (BMI <18.5) 2.9 0.1 7.6 0.8 82.2 0.2 7.3 0.4 1.5 100.0 1.1 1,119 Normal (BMI 18.5-24.9) 6.5 0.1 6.7 0.9 78.5 0.5 8.3 2.1 2.9 100.0 1.5 2,022 Overweight (BMI 25.0-29.9) 14.5 0.0 4.0 3.8 72.9 2.4 8.6 4.2 4.1 100.0 6.2 533 Obese (BMI ≥30.0) 15.4 0.0 5.5 1.6 61.6 1.4 17.5 4.1 8.3 100.0 3.0 138 Total 6.9 0.1 6.5 1.3 78.2 0.7 8.4 2.0 2.8 100.0 2.1 3,822 Note: Total includes 6 pregnant and postpartum women and 3 women with out of range nutritional status. 282 • Appendix D Table D.15.5.2 Fasting whole blood glucose values and treatment status by background characteristics: Men Prevalence of diabetes, percent distribution of men age 35 and older by fasting whole blood glucose (FWBG) values and treatment status, and percentage with normal whole blood glucose values and taking medication, by background characteristics, Bangladesh 2011 Background characteristics Preva- lence of diabetes1 <3.9 mmol/L (Below normal) 3.9-6.0 mmol/L (Normal) 6.1-6.9 mmol/L (Prediabetic) ≥7 mmol/L (Elevated FWBG) Total Normal FWBG and taking medi- cation Number of men Taking medi- cation Not taking medi- cation Taking medi- cation Not taking medi- cation Taking medi- cation Not taking medi- cation Taking medi- cation Not taking medi- cation Age 35-39 3.1 0.0 7.9 0.4 82.4 0.3 6.6 0.9 1.6 100.0 0.6 626 40-44 4.7 0.0 7.3 0.2 80.5 0.7 7.5 0.5 3.2 100.0 0.9 607 45-49 7.4 0.0 5.2 1.4 79.6 0.7 7.9 2.4 2.9 100.0 2.1 563 50-54 6.1 0.0 6.9 0.2 80.1 0.9 7.0 2.0 3.0 100.0 1.1 592 55-59 10.2 0.0 6.5 1.3 70.5 0.6 12.8 3.8 4.5 100.0 1.9 298 60-69 7.0 0.3 6.8 1.8 74.0 1.1 12.2 2.2 1.6 100.0 3.2 555 70+ 7.8 0.2 6.1 1.3 76.7 0.3 9.5 1.9 4.0 100.0 1.8 479 Residence Urban 10.2 0.2 6.9 1.7 74.9 1.1 8.0 3.6 3.7 100.0 3.0 888 Rural 5.0 0.0 6.6 0.6 79.4 0.5 8.9 1.2 2.6 100.0 1.2 2,832 Division Barisal 6.7 0.0 5.7 1.4 76.2 0.3 11.5 1.0 4.0 100.0 1.7 208 Chittagong 8.2 0.0 4.4 0.5 75.5 1.3 12.0 3.1 3.2 100.0 1.8 579 Dhaka 6.3 0.1 5.1 1.2 80.5 0.8 8.1 2.1 2.0 100.0 2.1 1,212 Khulna 4.9 0.0 5.4 0.4 84.7 0.2 5.0 1.6 2.8 100.0 0.6 499 Rajshahi 6.0 0.0 11.0 0.7 73.8 0.4 9.3 1.4 3.4 100.0 1.1 543 Rangpur 5.1 0.2 11.6 0.7 76.1 0.2 7.2 0.6 3.5 100.0 1.0 475 Sylhet 6.6 0.0 4.1 1.9 77.8 0.8 11.5 1.7 2.2 100.0 2.7 205 Education No education 3.6 0.1 7.1 0.4 80.1 0.0 9.2 0.7 2.4 100.0 0.5 1,358 Primary incomplete 4.4 0.0 7.1 0.6 79.1 0.3 9.4 1.2 2.4 100.0 0.9 933 Primary complete1 7.9 0.3 5.1 0.8 77.7 0.7 9.3 2.2 3.9 100.0 1.8 443 Secondary incomplete 10.5 0.0 6.4 2.3 76.0 1.5 7.1 3.8 2.9 100.0 3.9 552 Secondary complete or higher2 11.2 0.0 6.6 1.4 75.1 2.0 7.1 3.7 4.0 100.0 3.4 435 Wealth quintile Lowest 3.0 0.0 5.0 0.3 82.8 0.2 9.2 0.5 2.0 100.0 0.4 740 Second 3.8 0.0 8.4 0.4 79.6 0.0 8.2 0.0 3.4 100.0 0.4 721 Middle 3.7 0.0 7.5 0.3 80.3 0.3 8.5 1.1 2.0 100.0 0.6 722 Fourth 5.7 0.1 7.6 0.8 77.5 0.5 9.2 1.3 2.8 100.0 1.5 761 Highest 14.4 0.2 5.2 2.5 72.0 2.1 8.4 5.9 3.8 100.0 4.8 777 Nutritional status Thin (BMI <18.5) 2.9 0.1 6.4 0.5 81.6 0.1 9.1 0.4 1.9 100.0 0.7 1,093 Normal (BMI 18.5-24.9) 6.3 0.1 7.3 1.0 78.3 0.5 8.2 2.0 2.7 100.0 1.6 2,279 Overweight (BMI 25.0-29.9) 15.5 0.0 4.2 1.2 70.0 3.2 10.3 4.5 6.6 100.0 4.4 317 Obese (BMI ≥30.0) (23.1) (0.0) (3.7) (6.0) (55.6) (1.7) (17.6) (9.5) (5.9) 100.0 (7.7) 32 Total 6.2 0.1 6.7 0.9 78.4 0.6 8.7 1.8 2.8 100.0 1.6 3,721 Note: Figures in parentheses are based on 25-49 unweighted cases. Appendix E • 283 PERSONS INVOLVED IN THE SURVEY Appendix E Members of the Technical Review Committee and the Technical Working Group Technical Review Committee (TRC) Dr. Shelina Afroza, Director General, NIPORT Chairman Deputy Secretary (Program), Ministry of Health and Family Welfare Member Deputy Chief (Health), Ministry of Health and Family Welfare Member Deputy Chief (Family Welfare), Ministry of Health and Family Welfare Member Deputy Chief, Population Planning Wing, Planning Commission Member Director (Planning and Research), Directorate General of Health Services Member Director (MIS), Directorate General of Health Services Member Director, National AIDS/STD Program (NASP), Directorate General of Health Services Member Line Director (MC-RH), Directorate General of Family Planning Member Director (Planning), Directorate General of Family Planning Member Director (MIS), Directorate General of Family Planning Member Director, Census Wing, Bangladesh Bureau of Statistics Member Prof. M. Kabir, Department of Statistics, Jahangeernagar University Member Prof. Sekandar Hayat Khan, ISRT, Dhaka University Member Prof. A.K.M. Nurun Nabi, Department of Population Sciences, Dhaka University Member Prof. Nitai Chakraborty, Department of Statistics, Dhaka University Member Representative, WHO, Dhaka Member Representative, UNFPA, Dhaka Member Health Manager, UKAID, British High Commission, Dhaka Member Representative, World Bank, Dhaka Member Representative, GIZ, Dhaka Member Representative, JICA, Dhaka Member Chief, Health and Nutrition, UNICEF Member Dr. Kanta Jamil, Senior Monitoring, Evaluation and Research Advisor, Office of Population, Health, Nutrition and Education, USAID, Bangladesh Member Dr. Ahmed Al-Sabir, Representative, MEASURE Evaluation Member Chief of Party, Smiling Sun Franchise Program (SSFP) Member Dr. Ishtiaq Mannan, Chief of Party, MCHIP Member Mr. Toslim Uddin Khan, General Manager (Program), Social Marketing Company (SMC) Member Dr. Laura Reichenbach, Sr. Scientist & Head, RH Unit, ICDDR,B Member Dr. Peter Kim Streatfield, Director, CPUCC, ICDDR,B Member Dr. Shams El Arifeen, Director, CCAH, ICDDR,B Member Representative, 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) Dr. Shelina Afroza, Director General, NIPORT Chairman Mr. Md. Rafiqul Islam Sarker, Director (Research), NIPORT Member Dr. Peter Kim Streatfield, Director, CPUCC, ICDDR,B Member Dr. Shams El Arifeen, Director, CCAH, ICDDR,B Member Dr. Laura Reichenbach, Sr. Scientist & Head, RH Unit, ICDDR,B Member Dr. Kanta Jamil, Senior Monitoring, Evaluation and Research Advisor, Office of Population, Health, Nutrition and Education, USAID, Bangladesh Member Dr. Ahmed Al-Sabir, Representative, MEASURE Evaluation Member Representative, ICF International, USA Member Mr. S.N. Mitra, Executive Director, Mitra and Associates Member Mr. Subrata K. Bhadra, Sr. Research Associate, NIPORT Member-Secretary 284 • Appendix E NIPORT Professionals Dr. Shelina Afroza Mr. K C Mondal Mr. Md. Rafiqul Islam Sarker Dr. A M M Anisul Awwal Ms. Shahin Sultana Mr. Subrata K. Bhadra ICF International Staff Dr. Pav Govindasamy Ms. Sri Poedjastoeti Ms. Monica Kothari Ms. Anjushree Pradhan Mr. Ruilin Ren Ms. Adrienne Cox Mr. Trevor Croft Mr. Binyam Woldemicheal 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 Ms. Sayera Banu Mr. Monir Hossain Bhuiyan Appendix E • 285 FIELD STAFF Quality Control Officers Mr. Anisur Rahman Mr. Sankar Ch. Banik Mr. Rabiul Alam Mr. Sanjoy Bhowmik Mr. Rofiqul Islam Mr. Billal Hossain Mr. Sultan Mahmud Mr. Mokbul H. Sharif Mr. Golgar Hossain Mr. Shafi Ahmed Ali Siddik Mr. Mojibur Rahman Mr. Zahurul Islam (Rana) Mr. Mizanur Rahman Ms. Asma Akter Mr. Awlia Hasan Ms. Nurunnahar Mr. Balayet Hossain Ms. Nasrin Akhter Mr. Samsul Islam Ms. Marjina Mr. Proksh Biswas Mr. Mominuzzaman HOUSEHOLD LISTING HOUSEHOLD/WOMEN/MEN SURVEY Listing Supervisors Male Supervisors Mr. Almas Sikder Mr. Bazer Ali Mr. B.M. Mostafizur Rahman Mr. Elias Kabir Mr. Habibur Rahman Mr. Firoz Khan Mr. Ruhul Amin Mr. Hasan Al Mamun Mr. Zahangir Alam Mr. Johurul Islam (Lal) Mr. Shafiqul Islam Mr. Liazul Islam Mr. Mijanur Rahman Listers/Mappers Mr. Moneruzzaman Mr. Sheikh Moniruzzman Mr. Noor Shabir Siddiquee Mr. S.M. Murad Mr. Nurul Islam (Siraj) Mr. Nayeem Uddin Mr. Nurul Lslam (Jam) Mr. Rased-Al-Azad Mr. Rezaul Islam Mr. Tafazzal Hossain Mr. Sabbir Habibullha Ch. Mr. Nurul Islam Mr. Shahinul Islam Mr. Sardar Humayan Kabir Mr. Sohel Hossain Mr. Mainuddin Shahin Mr. Mostak Ahmed (Jahid) Mr. Motahar Hossain Mr. Mahbubur Rahman Akunda Mr. Sekender Ali Badsha Mr. Atiqul Islam Mr. Imranur Hossain Mr. Abdul Motaleb Mr. Alimul Haque Milki Mr. Akthauzzaman Mr. Sheikh Mustafizur Rahman Mr. Ferdous Rahman Female Field Editors Mr. Rafiqul Alam Ms. Afsana Ferdushi Mr. Molla Ikramul Ms. Alafa Khatun (Bina) Mr. Abdul Kalam Azad Ms. Arifa Khanom Mr. Eahsanul Hoque Ms. Rabia Khatun Mr. Hafizur Rahman Ms. Bobita Khatun Mr. Saifuzzaman Ms. Dipali Roy Mr. Al Amin Ms. Mehrun Nesa (B) Mr. Sohel Rana Ms. Mousumi Akter Mr. Yakub Biswas Ms. Razia Sultana Mr. Dablur Rahman Ms. Rozina Parvin Mr. Mostafizur Rahman Ms. Rubina Afroj Mr. Khairul Anam Ms. Shamima Afroz Shumi Mr. Emran Hossain Shohag Ms. Sharifa Begum 286 • Appendix E Ms. Shipu Rani Halder Female Interviewers Ms. Shuraya Akter Ms. Shahajadi Begum Ms. Umme Habiba (Urmee) Ms. Suraya Begum Ms. Taslima Bente Ansari Ms. Amana Akter Bithi Ms. Marjan Begum Ms. Sahnaj Parvin Ms. Shilpi Adhikari Ms. Jesmin Dipa Biswas Ms. Nazmun Nahar Male Interviewers Ms. Khadiza Akter Mr. Mahmudul Hasan (Ch.) Ms. Lina Akther Mr. Saiful Islam (Ant) Ms. Hasina Khatun Mr. Jahangir Hossain Ms. Umme Habiba Zaman Mr. Anjan Kumar Bhakta Ms. Rahima Khatun Mr. Zahangir Alom (Raj) Ms. Fahima Khatun (Raj) Mr. Alomgir Hossain Ms. Rokshana Begum (Ritu) Mr. Mehedi Hasan Ms. Saida Sultana Naju Mr. Rezwanul Karim Ms. Golnahar Khatun Mr. Koyes Ahmed Ms. Rashida Akter Mr. Saikat Rana Dey (Sumit) Ms. Nasrin Yesmin Shikha Mr. Safiqul Islam Ms. Sabitri Sikder Mr. Kamruzzaman Ms. Zinna Tara Mr. Ashikur Rahman Ms. Madhabi Rani Nath Mr. Saidur Rahman Ms. Tamina Khanam Mr. Abdul Kadir Ms. Anzira Khatun Mr. Emran Hossain Shohag Ms. Mukul Akter Mr. A.M. Shakawat Hossain Ms. Airin Ara Mr. Milon Kumar Ms. Papia Sultana Mr. Jabed Mollah Ms. Juma Akther Mr. Abdullah Al Razin Ms. Nasid Pervin Mr. Musfiqur Rahaman Ms. Masuda Khatun Mr. Maynul Haque Ms. Umme Salma Mr. Sudeb Sukul Ms. Nusrat Jahan Mr. Jahangir Alam (Nao) Ms. Sheuli Akter Mr. Nadim Hossain Ms. Nadira Akhtar Mr. Nasiruzzaman Ms. Shamima Yesmin (Rina) Mr. Sapan Kumar Hera Ms. Kanig Fatema Mr. Mahafizur Rahman Ms. Nasima Akter Mr. Atiqul Islam Ms. Tambia Akther Mr. Sumon Kumar Saha Ms. Shapna Begum Mr. Abdul Sattar Ms. Islama Khatun Mr. Saidur Rahman Ms. Sathi Rani Mr. Azadul Haque Ms. Kulsum Khatun Mr. Sariful Islam Ms. Sumi Khatun (Rong) Mr. Alimul Haq Milki Ms. Farida Easmin Mr. Imranur Hossain Ms. Rokeya Akter Mr. Shafiqul Islam Ms. Asma Pervin Mr. Mahfuzur Rahman Ms. Aklima Khatun Mr. Rezwanul Hoque Ms. Asma Akter Mr. Jahangir Alam Ms. Ayesha Siddika Mr. Zahidul Islam Ms. Akther Zahan Mr. Abdul Qader Ms. Hasnat Jahan Mr. Abdul Awal Ms. Jebunnesa Ms. Roksana Parvin Appendix E • 287 Ms. Shirin Akter Ria Health Technicians Ms. Sultana Razia Mr. A K.M. Mostafijur Rahman Ms. Khaleda Akter Mr. Sanowar Hossain Ms. Thamina Akther Mr. Anowar Hossain Ms. Laboni Yesmin (Pab) Mr. Baloy Chand Sikder Ms. Salina Akther Mr. Biplob Kumar Sarkar Ms. Laboni Yesmin (Kus) Mr. Dipak Bhakta Ms. Nasrin Akter (Chandpur) Mr. Khandoker Shariful Alam Ms. Sharmin Asrafi Mr. Minarul Islam Ms. Nahida Akter Hena Arzuman Mr. Rahul Amin Khan Ms. Asma Begum (Nar) Mr. S.M.A. Hanan Ms. Tuli Rani Das Mr. Samiuzzaman Imran Ms. Sanjida Akter Mr. Sazedur Rahman Ms. Fozilatunnesa Ms. Khanak Sharif Ms. Tangina Akter Ms. Sabekun Nahar Ms. Marjina Khatun (J) Ms. Tania Khanam Ms. Fatema Khatun Mr. Uttam Kumar Haldar Ms. Meherunnesa (Kustia) Mr. Almas Uddin Ms. Jesmin Akther Mr. Emran Mia Ms. Jeasmin Akter (Com) Mr. Maksudur Rahman Ms. Fahima Khatun (Jamal) Ms. Anita Mandal Computer Programmer Ms. Noazesh Afroz Mr. Shishir Paul Ms. Azijun Nahar Ms. Rozina khatun Data Entry Operators Ms. Maryna Parvin Ms. Jharna Rani Deb Ms. Sajeda Khatun Ms. Roksana Khatun Ms. Shamoly Akther Ms. Nasrin Mahmud Ms. Umme Kulsum Ms. Sangita Modak Ms. Minara Akter Mr. Pranab Das Ms. Armina Nahar Mr.Ripon Barman Ms. Alora Sultana Mr. Khandoker Ibnejayed Ms. Zolly Pervin Mr. Shamsul Arefin Ms. Tania Akter Mr. Sharif Hossain Tokder Ms. Beauty Khatun Mr. Amran Hossain Ms. Madhuri Lata Dhali Ms. Hosneara Office Editors Ms. Nihar Sultana Ms. Nusrat Jahan Ms. Topha Khatun Ms. Shahanaj Sultana Ms. Anfira Khatun Ms. Nabila Nusrat Jahan Ms. Soriya Khatun Ms. Romana Sultana Ms. Sima Rani Roy Ms. Farzana Mehanaz Ms. Papri Akter Ms. Radia Zafar Ms. Rekha Rani Bachar Ms. Selina Akter Administrative staff Ms. Dilruba Akter Mr. S. Fuad Pasha, Deputy Project Director-Admin. Ms. Lipi Khatun Mr. Joynal Abdin, Secretary Ms. Marium Nessa Mr. Bimal Chandra Datta, Accounts Officer Ms. Homayra Khanam Ms. Farzana Begum Ms. Sirajum Monira Ms. Khaleda Begum Appendix F • 289 QUESTIONNAIRES Appendix F BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2011 HOUSEHOLD QUESTIONNAIRE NIPORT, MOHFW, and 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 HOUSEHOLD SELECTED FOR MEN'S SURVEY (YES=1, NO=2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTERVIEWER VISITS FINAL VISIT DATE DAY MONTH YEAR INTERVIEWER'S NAME INT. NUMBER RESULT* RESULT NEXT VISIT: DATE TOTAL NUMBER TIME OF VISITS *RESULT CODES: TOTAL PERSONS 1 COMPLETED IN HOUSEHOLD 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT TOTAL 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME WOMEN 12-49 YR 4 POSTPONED 5 REFUSED TOTAL 6 DWELLING VACANT OR ADDRESS NOT A DWELLING MEN 15-54 YR 7 DWELLING DESTROYED 8 DWELLING NOT FOUND TOTAL ADULTS 9 OTHER 35+ YEARS (SPECIFY) LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE TECHNICIAN NAME NAME SUPERVISOR FIELD EDITOR 3 ALTITUDE (METER) 2 0 1 1 EDITOR OFFICE KEYED BY 1 2 HEALTH • 291Appendix F INTRODUCTION AND CONSENT GIVE CARD WITH CONTACT INFORMATION SIGNATURE 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 the person listed on this card. 292 • Appendix F HOUSEHOLD SCHEDULE IF AGE 12 IF AGE 5 YEARS IF AGE 8 OR OLDER OR OLDER OR OLDER LINE USUAL RESIDENTS AND AGE EVER ATTENDED CURRENT/RECENT CURRENT NO. VISITORS SCHOOL SCHOOL ATTENDANCE 1 IF 95 OR MORE, 1 = CURRENTLY SEE CODES SEE CODES RECORD MARRIED BELOW. BELOW. '95'. 2 = DIVORCED/ SEE CODES AFTER LISTING THE SEPARATED/ BELOW. NAMES AND RECORDING DESERTED/ WIDOWED FOR EACH PERSON, ASK 3 = NEVER- QUESTIONS 2A-2C TO BE MARRIED SURE THAT THE LISTING IS COMPLETE. SEE CODES BELOW. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-22 FOR EACH PERSON. M F Y N Y N IN YEARS Y N LEVEL CLASS Y N LEVEL CLASS Y N 01 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 02 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 03 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 04 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 05 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 06 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 07 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 08 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 09 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 10 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD CODES FOR Qs. 10 AND 12: EDUCATION 01 = HEAD 08 = BROTHER OR SISTER LEVEL CLASS 02 = WIFE OR HUSBAND 09 = OTHER RELATIVE 1 = PRIMARY 00 = LESS THAN 1 YEAR COMPLETED 03 = SON OR DAUGHTER 10 = ADOPTED/FOSTER/ 2 = SECONDARY (USE '00' FOR Q. 10 ONLY. 04 = SON-IN-LAW OR STEPCHILD 3 = HIGHER THIS CODE IS NOT ALLOWED DAUGHTER-IN-LAW 11 = NOT RELATED 6 = PRE-PRIMARY FOR Q. 12) 05 = GRANDCHILD 98 = DON'T KNOW 8 = DON'T KNOW 06 = PARENT 98 = DON'T KNOW 07 = PARENT-IN-LAW TO HEAD OF HOUSEHOLD How old is (NAME)? What is (NAME)'s current marital status? 8 SEX Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. 2 Did (NAME) stay here last night? Is (NAME) male or female? MARITAL STATUS RELATIONSHIP 75 6 Does (NAME) usually live here? RESIDENCE What is the relationship of (NAME) to the head of the household? 4 THE RELATIONSHIP AND SEX STATUS 9 What is the highest level of school (NAME) has attended? 133 Has (NAME) ever attended school? IF AGE 5-24 YEARS Is (NAME) currently working? What is the highest class (NAME) completed at that level? Did (NAME) attend school at any time during the (2010- 2011) school year? During this/that school year, what level and class [is/was] (NAME) attending? 11 1210 WORK • 293Appendix F 0-4 YEARS BIRTH REGIS- CHILDREN WOMEN 15 16 17 18 19 20 21 22 CIRCLE CIRCLE CIRCLE HEIGHT BLOOD PRESSURE HEIGHT HEIGHT HEIGHT LINE LINE LINE WEIGHT BLOOD GLUCOSE WEIGHT WEIGHT WEIGHT NUMBER NUMBER NUMBER ANEMIA BLOOD PRESSURE BLOOD PRESSURE OF ALL OF ALL OF ALL BLOOD GLUCOSE BLOOD GLUCOSE IF NO, PROBE: EVER- EVER- CHILDREN MARRIED MARRIED AGE 0-5 WOMEN MEN AGE AGE CIRCLE CIRCLE CIRCLE CIRCLE CIRCLE 12-49 15-54 LINE LINE LINE LINE LINE IF NUMBER NUMBER NUMBER NUMBER NUMBER HOUSEHOLD EVER- EVER- EVER- OF ALL OF ALL 1 = HAS SELECTED MARRIED MARRIED MARRIED EVER- MEN CERTIFICATE FOR WOMEN WOMEN WOMEN MARRIED AGE 2 = REGISTERED MALE AGE AGE AGE MEN 35 + 3 = NEITHER SURVEY IF 12-49 35 -49 50 + AGE 8 = DON'T COLUMN 7 IS IF COL. 4 IS 2 IF COL. 4 IS 2 IF COL. 4 IS 2 AND 15-34 KNOW 0 TO 5 AND AND IF COL. 7 IS 50 + AND IF COL. 4 IS 1 IF COL. 4 IS 1 AND IF COL. 7 IS 12 - 49 IF COL. 7 IS 35 - 49 IF COL. 8 IS 1 or 2. AND IF COL. 7 IS 35 +. AND AND NEVER- IF COL. 7 IS 15-34 IF COL. 8 IS 1 OR 2. IF COL. 8 IS 1 OR 2. MARRIED AND WOMEN IF COL. 8 IS 1 OR 2. AGE 35+ IF COL. 4 IS 2 AND IF COL. 7 IS 35+ AND IF COL. 8 IS 3. 01 01 01 01 01 01 01 01 02 02 02 02 02 02 02 02 03 03 03 03 03 03 03 03 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 06 06 06 06 06 06 06 06 07 07 07 07 07 07 07 07 08 08 08 08 08 08 08 08 09 09 09 09 09 09 09 09 10 10 10 10 10 10 10 10 ELIGIBILITY WOMEN MEN INTERVIEW BIOMARKERS IF AGE Has (NAME)'s birth ever been registered with the civil authority? 14 ALL HOUSEHOLDS WOMEN MEN HOUSEHOLDS SELECTED FOR MEN'S SURVEY TRATION Does (NAME) have a birth certificate? 294 • Appendix F IF AGE 12 IF AGE 5 YEARS IF AGE 8 OR OLDER OR OLDER OR OLDER LINE USUAL RESIDENTS AND AGE EVER ATTENDED CURRENT/RECENT CURRENT NO. VISITORS SCHOOL SCHOOL ATTENDANCE 1 IF 95 OR MORE, 1 = CURRENTLY SEE CODES SEE CODES RECORD MARRIED BELOW. BELOW. '95'. 2 = DIVORCED/ SEE CODES AFTER LISTING THE SEPARATED/ BELOW. NAMES AND RECORDING DESERTED/ WIDOWED FOR EACH PERSON, ASK 3 = NEVER- QUESTIONS 2A-2C TO BE MARRIED SURE THAT THE LISTING IS COMPLETE. SEE CODES BELOW. THEN ASK APPROPRIATE M F Y N Y N Y N LEVEL CLASS Y N LEVEL CLASS 11 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 12 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 13 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 14 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 15 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 16 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 17 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 18 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 19 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 20 1 2 1 2 1 2 1 2 1 2 1 2 GO TO 13 GO TO 13 TICK HERE IF CONTINUATION SHEET USED CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD CODES FOR Qs. 10 AND 12: EDUCATION 01 = HEAD 08 = BROTHER OR SISTER LEVEL CLASS 02 = WIFE OR HUSBAND 09 = OTHER RELATIVE 1 = PRIMARY 00 = LESS THAN 1 YEAR COMPLETED YES NO 03 = SON OR DAUGHTER 10 = ADOPTED/FOSTER/ 2 = SECONDARY 04 = SON-IN-LAW OR STEPCHILD 3 = HIGHER DAUGHTER-IN-LAW11 = NOT RELATED 6 = PRE-PRIMARY YES NO 05 = GRANDCHILD 98 = DON'T KNOW 8 = DON'T KNOW 98 = DON'T KNOW 06 = PARENT 07 = PARENT-IN-LAW YES NO (USE '00' FOR Q. 10 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 12) Is (NAME) currently working? 13 ADD TO TABLE ADD TO TABLE ADD TO TABLE TO HEAD OF 2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here? 2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed? Is (NAME) male or female? THE RELATIONSHIP AND SEX Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household. 2 3 HOUSEHOLD SEX 2A) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed? MARITAL WORK STATUS RELATIONSHIP What is the relationship of (NAME) to the head of the household? RESIDENCE 4 Does (NAME) usually live here? IF AGE 5-24 YEARS How old is (NAME)? 11 12 STATUS Has (NAME) ever attended school? What is the highest level of school (NAME) has attended? 9 What is (NAME)'s current marital status? 8 IN YEARS Did (NAME) stay here last night? 5 6 7 Did (NAME) attend school at any time during the (2010- 2011) school year? During this/that school year, what level and class [is/was] (NAME) attending? What is the highest class (NAME) completed at that level? 10 • 295Appendix F 0-4 YEARS BIRTH REGIS- CHILDREN WOMEN 15 16 17 18 19 20 21 22 CIRCLE CIRCLE CIRCLE HEIGHT BLOOD PRESSURE HEIGHT HEIGHT HEIGHT LINE LINE LINE WEIGHT BLOOD GLUCOSE WEIGHT WEIGHT WEIGHT NUMBER NUMBER NUMBER ANEMIA BLOOD PRESSURE BLOOD PRESSURE OF ALL OF ALL OF ALL BLOOD GLUCOSE BLOOD GLUCOSE IF NO, PROBE: EVER- EVER- CHILDREN MARRIED MARRIED AGES 0-5 WOMEN MEN AGE AGE CIRCLE CIRCLE CIRCLE CIRCLE CIRCLE 12-49 15-54 LINE LINE LINE LINE LINE IF NUMBER NUMBER NUMBER NUMBER NUMBER HOUSEHOLD EVER- EVER- EVER- OF ALL OF ALL 1 = HAS SELECTED MARRIED MARRIED MARRIED EVER- MEN CERTIFICATE FOR WOMEN WOMEN WOMEN MARRIED AGE 2 = REGISTERED MALE AGE AGE AGE MEN 35 + 3 = NEITHER SURVEY IF 12-49 35 -49 50 + AGE 8 = DON'T COLUMN 7 IS IF COL. 4 IS 2 IF COL. 4 IS 2 IF COL. 4 IS 2 AND 15-34 KNOW 0 TO 5 AND AND IF COL. 7 IS 50 + AND IF COL. 4 IS 1 IF COL. 4 IS 1 AND IF COL. 7 IS 12 - 49 IF COL. 7 IS 35 - 49 IF COL. 8 IS 1 or 2. AND IF COL. 7 IS 35 +. AND AND NEVER- IF COL. 7 IS 15-34 IF COL. 8 IS 1 OR 2. IF COL. 8 IS 1 OR 2. MARRIED AND WOMEN IF COL. 8 IS 1 OR 2. AGE 35+ IF COL. 4 IS 2 AND IF COL. 7 IS 35+ AND IF COL. 8 IS 3. 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 13 13 13 13 13 13 13 13 14 14 14 14 14 14 14 14 15 15 15 15 15 15 15 15 16 16 16 16 16 16 16 16 17 17 17 17 17 17 17 17 18 18 18 18 18 18 18 18 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 Does (NAME) have a birth certificate? Has (NAME)'s birth ever been registered with the civil authority? IF AGE TRATION ELIGIBILITY INTERVIEW BIOMARKERS WOMEN MEN 14 ALL HOUSEHOLDS HOUSEHOLDS SELECTED FOR MEN'S SURVEY WOMEN MEN 296 • Appendix F 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 CODING CATEGORIES What do you usually do to make the water safer to drink? Do you share this source with other households? Do you do anything to the water to make it safer to drink? 0 How long does it take to go there, get water, and come 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? • 297Appendix F 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 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 A table? TABLE . . . . . . . . . . 1 2 A chair? CHAIR . . . . . . . . . . 1 2 An electric fan? ELETRIC FAN . . . . . . . . . . 1 2 A DVD/VCD player? DVD/VCD PLAYER . . . . . . . . . . 1 2 A water pump? WATER PUMP . . . . . . . . . . 1 2 111 ELECTRICITY . . . . . . . . . . . . . . . . . . . . . . . . . 01 LPG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02 NATURAL GAS . . . . . . . . . . . . . . . . . . . . . . . 03 BIOGAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 KEROSENE . . . . . . . . . . . . . . . . . . . . . . . . . 05 COAL, LIGNITE