Bonswana - Demographic and Health Survey -1989

Publication date: 1989

DHS Botswana Family Health Survey II 1988 Lesetedinyana T. Lesetedi Gaboratanelwe D. Mompati Pilate Khulumani Gwen N. Lesetedi Naomi Rutenberg Central Statistics Office Ministry of Finance and Development Planning Gaborone, Botswana Family Health Division Ministry of Health Gaborone, Botswana Institute for Resource Development ] Macro Systems, Inc. Columbia, Maryland USA August 1989 This report presents the findings of the Botswana Family Health Survey II (BFHS-II). implemented by the Government of Botswana, through the Family Health Division of the Ministry of Health and the Central Statistics Office of the Ministry of Finance and Development Planning in 1988. The survey is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information on this survey can be obtained from the Central Statistics Office, Ministry of Finance and Development Planning, Private Bag 0024, Gaborone, Botswana or the Family Health Division, Ministry of Health, P.O. Box 992, Gaborone, Botswana. The Botswana Family Health Survey II was carried out with the assistance of the Institute for Resource Development (IRD), a Macro Systems company with headquarters in Columbia, Maryland. Funding for the survey was provided by the U.S. Agency for International Development (Contract No. DPE-3023-C-00-4083-00). Additional information about the DHS Program can be obtained by writing to: DHS Program, IRD/Macro Systems, Inc., 8850 Stanford Boulevard, Suite 4000, Columbia, Maryland 21045, USA (Telephone: 301-290-2800, Fax: 301-290-2999, Telex: 87775). FOREWORD The Botswana Family Health Survey II was a collaborative effort between the Ministry of Health, the Central Statistics Office, and the Institute for Resource Development Inc. The survey is part of the worldwide Demographic and Health Surveys (DHS) programme, which is designed to collect data on fertility, family planning, and maternal and child health which is critical to the measurement of the Maternal and Child Health Family Planning Programme performance, future direction and emphasis. The timely data generated by the survey is most welcome, for it comes at a time when current demographic trends and the impact of problems associated with rapid population growth can no longer be underplayed. Given its scope and representativeness, and also given what the programme has achieved over the years, the present survey results will provide policy-makers and programme managers with a clear indication of issues and problems which need to be vehemently addressed and will also assist in determining strategies, both short term and long term, to be considered in tackling the emerging fertility problems of the 1990s, particularly among teens. It is my belief that although the national family planning programme has made tremendous achievements over the years, this is not to say that profound challenges do not lie ahead of us. Male involvement in family planning and teenage fertility programmes are critical challenges which will need mobilisation of more financial resources and skilled manpower for effective programme support. Such inevitable programme expansion is required, if our national resources are to balance with our socioeconomic needs and development, and thus have a positive impact on the welfare of every Motswana. As the Government of Botswana is fully committed to shifting greater emphasis for family planning programmes to the community (e.g., through community-based distribution systems) as well as to the individual, the challenge for the national family planning programme is to continue to provide reliable, high quality services to meet the needs of continuing users and the growing number of potential users. I would therefore remind all those concerned that the availability of resources together with current and accurate BFHS-II data will undoubtedly expedite achievement of our goals and enhance formulation of more comprehensive, meaningful, and cost-effective family planning and population policies. I would also like to take this opportunity to encourage those who have worked tirelessly to improve the status of the national family planning programme and also urge them to sustain the momentum of the programme. iii Finally, let me point out that this survey clearly demonstrates how two government ministries plus an external institution can cooperate to produce work of excellent quality, for the mutual benefit of not only themselves but many others. All the institutions and individuals who were involved in the survey are congratulated. Ministry of Health P.O. Molosi Permanent Secretary iv ACKNOWLEDGEMENTS The Central Statistics Office and the Primary Health Care Department of the Ministry of Health would like to express their sincere gratitude to the following: . The Family Health Division staff for their constant support throughout the duration of the survey. . The Central Statistics Office staff who worked diligently towards the successful and timely completion of the survey. . The District Commissioners and their members of staff for their administrative support to the CHIPS teams when undertaking the fieldwork and also the Chiefs and other tribal authorities for affording hospitality to these teams. . The Botswana Institute of Administration and Commerce (BIAC) and the Statistics Department of the University of Botswana for providing training facilities for the training of enumerators and supervisors. . The finance section of the Ministry of Finance and Development Planning for administering the funds for the survey. . USAID/Botswana staff and the Institute for Resource Development/Macro Systems, Inc. 7. The interviewers for their diligent work. . Last, but not least, we profusely express our gratitude to all respondents of this survey for their cooperation and patience in responding to a long interview for without them there would have been no survey. Central Statistics Office Ministry of Finance and Development Planning G. M. Charumbira Government Statistician Ministry of Health Assistant Director of Health Services - Primary Health Care V PREFACE The Botswana Family Health Survey II (BFHS-II) globally known as the Demographic and Health Surveys (DHS) Program is part of a world-wide survey programme that is funded by the United States Agency for International Development (USAID). The BFHS-II was a national sample survey designed to provide information on fertility, family planning, and health in Botswana. The BFHS-II involved interviewing a randomly selected group of women between 15 and 49 years of age. These women were asked questions about their background, the children they had given births to, their knowledge and use of family planning methods, some health matters and other information which will be helpful to policy-makers and administrators in the health and family planning areas. This report should provide a wealth of information for the study of demographic trends and infant and child mortality, and the interaction between family planning and child health. The impact of the Botswana Family Planning Programme can also be evaluated through these data in conjunction with other data sources like the 1981 Census, the 1984 Botswana Family Health Survey and the 1987 Botswana Demographic Survey. Central Statistics Office Ministry of Finance and Development Planning G. M. Charumbira Government Statistician vii CONTENTS Page FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix L IST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv L IST OF F IGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii RESUME AND RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv MAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiv CHAPTER 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 GEOGRAPHY, CL IMATE, AND ECONOMY . . . . . . . . . . . . . . . . . . . 1 POPULAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NAT IONAL HEALTH PR IORIT IES . . . . . . . . . . . . . . . . . . . . . . . . . . 2 MATERNAL AND CHILD HEALTH/FAMILY PLANNING PROGRAMME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 POPULAT ION POL ICY AND PROGRAMMES . . . . . . . . . . . . . . . . . . 6 OBJECT IVES OF THE BOTSWANA FAMILY HEALTH SURVEY II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 BACKGROUND CHARACTERIST ICS OF RESPONDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 CHAPTER 2 EXPOSURE TO PREGNANCY, BREASTFEEDING AND POST-PARTUM INSUSCEPT IB IL ITY . . . . . . . . . . . . . . . . . . . . . . . . 11 ix 2.1 2.2 2.3 CHAPTER 3 3.1 3.2 3.3 3.4 3.5 CHAPTER 4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Page CURRENT UNION STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 AGE AT F IRST SEXUAL INTERCOURSE . . . . . . . . . . . . . . . . . . . . 14 OTHER FACTORS AFFECT ING EXPOSURE TO THE R ISK OF PREGNANCY: BREASTFEEDING AND POST-PARTUM INSUSCEPT IB IL ITY . . . . . . . . . . . . . . . . . . . . . . . . 15 FERT IL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . 21 FERT IL ITY LEVELS AND TRENDS . . . . . . . . . . . . . . . . . . . . . . . . 21 CURRENT PREGNANCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 CHILDREN EVER BORN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 AGE AT F IRST B IRTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 TEENAGE PREGNANCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 FAMILY PLANNING KNOWLEDGE AND USE . . . . . . . . . . . . . . . . 33 KNOWLEDGE OF FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . 34 KNOWLEDGE OF SOURCES FOR FAMILY PLANNING METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 ACCEPTABIL ITY OF METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . 37 EVER USE OF FAMILY PLANNING METHODS . . . . . . . . . . . . . . . 38 CURRENT USE OF FAMILY PLANNING METHODS . . . . . . . . . . . 41 CURRENT SOURCE OF SUPPLY OF FAMILY PLANNING METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 REASONS FOR D ISCONTINUATION AND NONUSE OF FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4.8 4.9 4.10 CHAPTER 5 5.1 5.2 5.3 5.4 Page INTENTIONS TO USE FAMILY PLANNING IN THE FUTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 ACCEPTABIL ITY OF MEDIA MESSAGES ON FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 APPROVAL OF FAMILY PLANNING BY RESPONDENTS AND PARTNERS . . . . . . . . . . . . . . . . . . . . . . . . . . 55 FERTIL ITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 DES IRE FOR ADDIT IONAL CHILDREN . . . . . . . . . . . . . . . . . . . . . 59 FUTURE NEED FOR FAMILY PLANNING . . . . . . . . . . . . . . . . . . . 63 IDEAL NUMBER OF CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . 64 UNPLANNED AND UNWANTED FERT IL ITY . . . . . . . . . . . . . . . . . 66 CHAPTER 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 MORTAL ITY AND HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 LEVELS AND TRENDS IN INFANT AND CHILDHOOD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 SOCIOECONOMIC D IFFERENTIALS IN INFANT AND CHILDHOOD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 INFANT AND CHILDHOOD MORTAL ITY BY DEMOGRAPHIC CHARACTERIST ICS . . . . . . . . . . . . . . . . . . . . . . . 72 CHILDREN EVER BORN AND SURVIV ING . . . . . . . . . . . . . . . . . . 74 ANTENATAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 ASSISTANCE AT DEL IVERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 POSTNATAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 IMMUNISAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 xi 6.9 6.10 6.11 6.12 CHAPTER 7 7.1 7.2 7.3 7.4 7.5 7.6 Page DIARRHOEA PREVALENCE AND TREATMENT . . . . . . . . . . . . . . 81 ORT KNOWLEDGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 FEVER PREVALENCE AND TREATMENT . . . . . . . . . . . . . . . . . . . 85 RESP IRATORY ILLNESS PREVALENCE AND TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 KNOWLEDGE OF A IDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 KNOWLEDGE OF A IDS TRANSMISS ION . . . . . . . . . . . . . . . . . . . . 90 KNOWLEDGE OF R ISK GROUPS . . . . . . . . . . . . . . . . . . . . . . . . . . 92 SOURCE OF INFORMATION ABOUT A IDS . . . . . . . . . . . . . . . . . . 94 KNOWLEDGE OF WAYS TO AVOID A IDS . . . . . . . . . . . . . . . . . . . 94 A I ' I ' I TUDE OF PEOPLE TOWARDS A IDS . . . . . . . . . . . . . . . . . . . 95 APPENDIX A A.1 A.2 A.3 A.4 A.5 SURVEY DES IGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 SURVEY ORGANIZAT ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 SAMPLE DES IGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 SURVEY INSTRUMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 F IELDWORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 DATA PROCESSING AND REPORT WRIT ING . . . . . . . . . . . . . . . 105 APPENDIX B SAMPL ING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 xii Page APPENDIX C QUEST IONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . 119 APPENDIX D DEF IN IT IONS AND CONCEPTS . . . . . . . . . . . . . . . . . . . . . . . . . . 159 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 xiii LIST OF TABLES Page Table 1.1 Table 1.2 Table 2.l Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 3°1 Percent Distribution of Women 15-49 by Background Characteristics, 1981 Census, 1984 BFHS, and 1988 BFHS- I I . . . . . . o , . o , . . , o . . , . . . o , o o , . , ° o , . , * , . . , . . ° , . . ° , . , , . . 8 Percent Distribution of Women by Education, According to Age, Urban-Rural Residence, and Religion, BFHS-II 1988 . . . . . . . . . . . 10 Percent Distribution of All Women by Current Marital Status, According to Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . 11 Percent Distribution of Never-Married Women Who Have Ever Had Sexual Intercourse, According to Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Percentage of Women Having Sexual Intercourse in the Month Preceding the Survey by Current Marital Status, According to Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Percent Distribution of All Women by Age at First Sexual Intercourse and Median Age at First Sexual Intercourse, According to Current Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . 14 Median Age at First Sexual Intercourse among Women 20-49, by Current Age and Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Percentage of Births in the Last 36 Months Whose Mothers are Still Breasffeeding, Post-partum Amenorrheic, Abstaining, and Inusceptible to Pregnancy, by the Number of Months since Birth, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Mean Number of Months of Breastfeeding, Post-partum Amenorrhea, Post-partum Abstinence, and Post-partum Insusceptibility, by Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Total Fertility Rates for Calendar Year Periods and for Five Years Preceding the Survey, and Mean Number of Children Ever Born to Women 45-49 Years of Age, by Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 21 XV Page Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 4.1 Table 4.2 Age-Specific Fertility Rate (per 1,000 women) for Five-Year Periods Preceding the Survey, by Age of Woman at Birth, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Percent of All Women who were Pregnant at the Time of the Survey, by Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Percent Distribution of All Women, Women Ever in Union, and Women Never in Union by Number of Children Ever Born and Mean Number of Children Ever Born, According to Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Percent Distribution of All Women by Age at First Birth and Median Age at First Birth, According to Current Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Median Age at First Birth Among Women 25-49, by Current Age and Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Percentage of Teenagers 15-19 Who are Mothers or Pregnant with their First Child, and Mean Age at First Pregnancy, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Percentage of Teenagers 15-19 Who are Mothers, 1971 to 1988, According to Urban-Rural Residence . . . . . . . . . . . . . . . . . . . . . . 30 Percentage of Teenagers 15-19 Who Left School Due to Pregnancy, and Percentage Who Left School Who Were Readmitted, According to Age and Residence, BFI-IS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Percentage of All Women and Women Currently In Union Who Know a Family Planning Method and Who Know a Source (For Information or Services), by Specific Method, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Percentage of All Women Who Know at Least One Modern Method of Family Planning and Who Know a Source for a Modern Method, by Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 xvi Page Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Percent Distribution of Women Who Know a Family Planning Method by Supply Source They Would Use if They Wanted the Method, According to Specific Method, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Percent Distribution of Women Who Know a Family Planning Method by Main Problem Perceived in Using the Method, According to Specific Method, BFHS-II 1988 . . . . . . . . . . . . . . 38 Percentage of All Women and Women in Union Who Have Ever Used a Family Planning Method by Specific Method and Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Percent Distribution of All Women by Number of Living Children at Time of First Use of Contraception, According to Current Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Percent Distribution of All Women and Women Who Have Ever Used Periodic Abstinence by Knowledge of the Fertile Period During the Ovulatory Cycle, BFHS-II 1988 . . . . . . . . . . . . . . . . . 41 Percent Distribution of All Women and Women in Union by Current Use of Specific Family Planning Methods, According to Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Percent Distribution of Sterilised Women by Age and Median Age at the Time of the Sterilisation, and Percent Distribution of Sterilised Women by Number of Children and Mean Number of Children at the Time of Sterilisation, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Percent Distribution of All Women and Women in Union by the Family Planning Method Currently Used, BFHS 1984 and BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Percent Distribution of All Women by Current Use of Specific Family Planning Methods, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 45 Percentage of All Women Currently Using a Modern Method of Family Planning, According to Selected Background Characteristics, BFHS 1984 and BFHS-II 1988 . . . . . . . . . . . 47 xvii Page Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 4.19 Table 4.20 Table 4.21 Percent Distribution of Current Users by Most Recent Source of Supply or Information, According to Specific Method, BFHS II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Percent Distribution of Women Who Have Discontinued a Contraceptive Method in the Last Five Years by Main Reason for Last Discontinuation, According to Specific Method, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Percent Distribution of Non-Pregnant Women Who Are Sexually Active and Who Are Not Using Any Contraceptive Method by Attitude Toward Becoming Pregnant in the Next Few Weeks, According to Number of Living Children, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Percent Distribution of Non-Pregnant Women Who Are Sexually Active and Who Are Not Using Any Contraceptive Method and Who Would be Unhappy if They Became Pregnant by Main Reason for Nonuse, According to Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Percent Distribution of Women Who Have Had Sexual Intercourse Who Are Not Currently Using Any Contraceptive Method, by Intention to Use in the Future, According to Number of Living Children, BFHS-II 1988 . . . . . . . . . . . . 54 Percent Distribution of Women Who Have Had Sexual Intercourse Who Are Not Using a Contraceptive Method but Who Intend to Use in the Future, by Preferred Method, According to Whether They Intend to Use in the Next 12 Months or Later, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Percentage of All Women Who Believe That it is Acceptable to Have Messages About Family Planning on the Radio, at Kgotla, and at School, by Age, BFHS-II 1988 . . . . . . . . . . . . . 55 Percent Distribution of All Women Knowing a Contraceptive Method by Attitude Toward the Use of Family Planning, According to Residence, BFHS-II 1988 . . . . . . . . . . . . 56 Percent Distribution of Women in Union Who Know a Contraceptive Method, by the Respondent's Opinion of Partner's Attitude Toward the Use of Family Planning, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 xviii Page Table 4.22 Table 4.23 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Percent Distribution of Women in Union Who Know a Family Planning Method, by Number of Times Discussed Family Planning with Partner, According to Current Age and Education, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Percentage of Women in Union Who Know a Family Planning Method, Who Approve of Family Planning and Who Say their Partner Approves of Family Planning, and Percentage of Couples Currently Using Family Planning, by Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . 57 Percent Distribution of Women in Union by Desire for Children and Timing, According to Number of Living Children, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Percent Distribution of Women in Union by Desire for Children and Timing, According to Current Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Percentage of Women in Union Who Want No More Children (Including Sterilised Women) by Number of Living Children and Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Percentage of Women in Union Who Are in Need of Family Planning and the Percentage Who Are in Need and Who Intend to Use Family Planning in the Future by Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . 63 Percent Distribution of All Women by Ideal Number of Children and Mean Ideal Number of Children for All Women and Women in Union, According to Number of Living Children, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Mean Ideal Number of Children for All Women by Age and Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . 66 Percent Distribution of All Births in the Last Five Years by Contraceptive Practice and Planning Status, According to Birth Order, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Percent Distribution of Births in the Last 12 Months by Fertility Planning Status, According to Birth Order and Age, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 xix Page Table 5.9 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Total Wanted Fertility Rates and Total Fertility Rates for the Five Years Preceding the Survey, by Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 68 Infant and Childhood Mortality for Five-Year Calendar Period, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Infant and Childhood Mortality by Selected Socioeconomic Characteristics of the Mother, for the Ten-Year Period Preceding the Survey, BFHS 11-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Infant and Childhood Mortality by Selected Demographic Characteristics, for the Ten-Year Period Preceding the Survey. BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Mean Number of Children Ever Born, Surviving, and Dead, and Proportion of Children Dead Among Ever Born, by Age of Mother, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Percent Distribution of Births in the Last 5 Years by Type of Antenatal Care for the Mother and Percentage of Births Whose Mother Received a Tetanus Toxoid Injection, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Percent Distribution of Births in the Last 5 Years by Type of Assistance During Delivery, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 76 Percent Distribution of Births in the Last 5 Years by Type of Postnatal Care for the Mother, According to Selected Background Characteristics, BFI-IS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 77 Among All Children Under 5 Years of Age, the Percentage with Health Cards, the Percentage Who Are Immunised as Recorded on a Health Card or as Reported by the Mother and Among Children With Health Cards, the Percentage for Whom BCG, DPT, Polio and Measles Immunisations Are Recorded on the Health Card, by Age, BFFIS-II 1988 . . . . . . . . . . . . . . 79 XX Page Table 6.9 Table 6.10 Table 6.11 Table 6.12 Table 6.13 Table 6.14 Table 7.1 Among All Children 12-23 Months, the Percentage with Health Cards, the Percentage Who Are Immunised as Recorded on a Health Card or as Reported by the Mother and Among Children With Health Cards, the Percentage for Whom BCG, DPT, Polio and Measles Immunisations Are Recorded on the Health Card, According to Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Among Children Under 5 Years of Age, the Percentage Reported by the Mother to Have Had Diarrhoea in the Past 24 Hours and the Past Two Weeks, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . 82 Among Children Under 5 Years of Age Who Had Diarrhoea in the Past Two Weeks, the Percentage Consulting a Health Facility, the Percentage Receiving Different Treatments as Reported by the Mother, and the Percentage Not Consulting a Health Facility and Not Receiving Treatment, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Among Mothers of Children Under 5 Years of Age, the Percentage Who Know About ORT by Level of Education and Residence, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Among Children Under 5 Years of Age, the Percentage Who Were Reported by the Mother as Having Had Fever in the Past Four Weeks and, Among Children Who Had Fever, the Percentage Consulting a Health Facility, and the Percentage Receiving Various Treatments, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . 85 Among Children Under 5 Years of Age, the Percentage Who Were Reported by the Mother as Having Suffered from Severe Cough or Difficult or Rapid Breathing in the Past Four Weeks and, Among Children Who Suffered, the Percentage Consulting a Health Facility, and the Percentage Receiving Various Treatments, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 86 Percentage of Women Who Have Heard of AIDS, and Among Women Who Have Heard of AIDS, the Percentage Who Named Various Routes of Transmission, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . 91 xxi Page Table 7.2 Table 7.3 Table 7.4 Table 7.5 APPENDIX A Table A.1 APPENDIX B Table B. 1 Table B.2 Table B.3 Table B.4 Table B.5 Table B.6 Table B.7 Among Women Who Have Heard of AIDS, the Percentage Who Reported that Various Categories of the Population are at High Risk of Getting AIDS, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 93 Among Women Who Have Heard of AIDS, the Percentage Who Have Heard of AIDS From Various Media Sources, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Among women who have heard of AIDS, the Percentage Reporting Knowledge of Specific Ways to Avoid AIDS, According to Selected Background Characterisitcs, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Among women who have heard of AIDS, the Percentage Who Hold Various Beliefs about the Participation of a Person With AIDS in Society and the Percentage Who Think a Cure for AIDS Exists, According to Selected Background Characteristics, BFHS-II 1988 . . . . . . . . . . . . . . . . . . . . . . 97 Results of Household and Individual Interview, By Residence, BFHS-II, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Sampling Errors for Entire Population, BFHS-II, 1988 . . . . . . . . . . . . . 111 Sampling Errors for the Urban Population, BFHS-II, 1988 . . . . . . . . . . 112 Sampling Errors for the Rural Population, BFHS-II, 1988 . . . . . . . . . . . 113 Sampling Errors for the Difference Between Urban and Rural Population, BFHS-II, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Sampling Errors for Women Age 15-24, BFHS-II, 1988 . . . . . . . . . . . . 115 Sampling Errors for Women Age 25-34, BFHS-II, 1988 . . . . . . . . . . . . 116 Sampling Errors for Women Age 35-49, BFHS-II, 1988 . . . . . . . . . . . . 117 xxii LIST OF FIGURES Page Figure 1.1 Health Care Pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Figure 2.1 Union Status of Women 15-49 by Age Group . . . . . . . . . . . . . . . . . . . . 13 Figure 2.2 Mean Duration of Breastfeeding, Amenorrhoea and Post- partum Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 3.1 Children Ever Born to Women 45-49 and Total Fertility Rate 0-4 Years Before the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Figure 3.2 Age-Specific Fertility Rates, 1981 Census, 1984 BFHS, and 1988 BFHS-II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Figure 3.3 Percentage of Teenage Women Who are Mothers or Pregnant with First Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Figure 4.1 Current Use of Specific Methods of Family Planning, Women 15-49, 1984 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Figure 4.2 Current Use of Family Planning by Number of Living Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Figure 4.3 Knowledge and Use of Modern Methods of Family Planning, Women 15-49, 1984 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Figure 4.4 Source of Family Planning Supply, Current Users of Modern Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Figure 5.1 Fertility Preferences, Women in Union 15-49 . . . . . . . . . . . . . . . . . . . . 60 Figure 5.2 Fertility Preferences by Number of Living Children, Women in Union 15-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Figure 5.3 Future Need for Family Planning, Women in Union Not Using Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Figure 6.1 Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Figure 6.2 Percentage of Children 12-36 Months with Health Cards Who are Fully Immunised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 xxiii Figure 7.1 Figure 7.2 Page Percentage Who Have Heard of AIDS, Women 15-49 . . . . . . . . . . . . . . 92 Percentage Who Know a Specific Way to Avoid AIDS, Women 15-49 Who Have Heard of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 xxiv RESUME AND RECOMMENDATIONS The Botswana Family Health Survey II (BFHS-II) was conducted on behalf of the Family Health Division of the Ministry of Health by the Central Statistics Office through its Continuous Household Integrated Programme of Surveys. Financial and technical assistance for the survey was provided by the Institute for Resource Development, under a contract with the U.S. Agency for International Development, Washington. The objective of the survey was to provide information on family planning awareness, approval and use, basic indicators of maternal and child health and other topics related to family health. The survey data can also be used to evaluate progress achieved by the Maternal and Child Health/Family Planning programme since the Botswana Family Health Survey (BFHS) of 1984. A nationally representative sample of 4,368 women, age 15-49 years, was interviewed in both urban and rural areas between August and December 1988. RESUME The BFHS-II found that current fertility levels in Botswana remain high; however, the results show a decline in fertility in recent years. The total fertility rate for the five-year period prior to the BFHS-II indicates that the average woman, beginning her reproductive period at this time, would have 5 births by her 50th birthday. There are large differences in fertility by education: current fertility rates indicate that women with secondary or higher education can expect to have a total of 3,3 births in their lifetime while women with no education will have 6 births. A comparison of the fertility data from the census, the BFHS and the BFHS-II shows that total fertility dropped from 7.1 in 1981 to 6.5 in 1984 and 5.0 in 1988. Declining fertility among women at all levels of education coupled with a growing number of women achieving higher levels of education could account for the large decline in fertility. The fertility decline is occurring in the context of increasing use of modern methods of contraception. Data on fertility trends show that fertility began to decline 10-15 years before the survey, which coincides with the introduction of the family planning programme in 1973. The BFHS-II found that traditional practices of breastfeeding and post-partum abstinence continue to be important factors in protecting women from a subsequent pregnancy. However, there is evidence that the duration of these practices is being curtailed among urban women. On average, women breastfeed for 19 months, the resumption of menstruation is delayed for 12 months following childbirth and sexual relations are delayed for 13 months. xxv Taking into account the effects of both post-partum amenorrhea and abstinence, a woman is not at risk of pregnancy for an average of nearly 16 months. The duration of breastfeeding and protection from pregnancy because of post-partum amenorrhea or abstinence from sexual relations is five months longer for rural women than for urban. Furthermore, there is evidence of a decline in breastfeeding among urban women since 1984. Knowledge of family planning methods and of places to obtain them is critical in the decision whether to use family planning and which method to use. The BFHS-II found that the MCH/FP programme has been quite successful in educating women about family planning. Knowledge of modern methods of contraception is high with 95 percent of all women knowing at least one modern method. Women are most likely to know the pill, followed by the IUD, injection, and the condom. Knowledge of family planning methods has increased steadily over the past 4 years. In 1984, 75 percent of women reported knowing at least one method as compared to 95 percent in 1988. Virtually all women who had heard of a method were able to name a source for that method and most women named a government facility. Use of contraception is the most important measurement of success in a family planning programme. The BFHS-II found that more than half of Batswana women have used a modern method of family planning at sometime and three out of ten women are currently using a contraceptive method to delay or avoid a birth. Thirty-two percent of women in union and 30 percent of all women currently use a method of family planning. Since the introduction of integrated MCH/FP services in 1984, the use of modern methods of contraception increased from 16 to 30 percent, with major increases in the use of the pill, injection, and female sterilization. The use of family planning is related to a woman's residence and education. Thirty-nine percent of urban women use contraception compared with 26 percent of rural women; and contraceptive prevalence increases from 18 percent among women wJlh no education to over 40 percent among women who have secondary or higher education. Government health facilities are the major source of family planning services; 94 percent of current users obtain their method from a government facility. The BFHS-II found that women who are not currently using family planning, but do not wish to become pregnant soon, report a number of barriers to using family planning. A significant number of these women do intend to use family planning in the future. xxvi Half of the women who were not using contraception would be unhappy if they became pregnant soon. The principal reasons cited for nonuse were infrequent sex, opposition to family planning, inconvenience, cost, and opposition of partner to family planning. Five out of ten nonusers said they intend to use family planning in the future and most said they would use in the next twelve months. The BFHS-II also looked at the issue of women's perceptions about their partner's attitudes toward family planning. Within couples, male approval is much lower than that of females, although the reported level of partner's approval has increased since 1984. While 92 percent of respondents approved of family planning, only 57 percent thought their partner approved of family planning. Perception of male approval of family planning has increased since 1984, when only 40 percent of respondents reported that their partners" approved of family planning. Seven in ten women had discussed family planning with their partner in the past year and three in ten couples had more than one conversation about it. The BFHS-II results suggest that Batswana women have a growing interest in spacing births but continue to have a preference for many children. The importance of spacing births at least two years apart has become more widely known between 1984 and 1988. Twenty-one percent of women in union interviewed in the 1984 BFHS wanted to wait at least two years before their next birth compared to 29 percent in 1988. The use of contraception for delaying a first and subsequent births has clearly been adopted by younger women. For example, among women 20- 24 at the time of the survey, 50 percent had first used family planning before their first or second birth. The proportion of women in union who do not want any more children, 33 percent, is unchanged from the 1984 BFHS. Three-quarters of women said the ideal family was 4 or more children and 30 percent expressed a preference for 6 or more children. The BFHS-II documents that many women had a birth sooner that they would have liked although only a minority of women had another birth when they preferred not to have any more children. Almost half of the births in the five years before the survey were not wanted at the time they occurred, but only five percent were not wanted at all. Six out of ten first births, predominantly to teenagers, occur before they are wanted. xxvii The BFHS-II found that few Batswana women have unwanted births. If all the unwanted births in the five years before the survey had been prevented, the current fertility rate would only be 6 percent lower. Women can be considered in need of family planning if they are not currently using a method of contraception and either want no more births or want to postpone the next birth for two or more years. The BFHS-II found that 45 percent of women in union are in need of family planning. Twenty-one percent of women are in need of family planning because they want no more children and 24 percent are in need because they wish to delay their next birth. Slightly more than half of the women in need intend to use family planning. A higher proportion of women in need and who want no more children intend to use family planning than women in need who want to postpone a birth. Since teenage pregnancy places the health and welfare of teenagers and their births at risk, the Government of Botswana encourages women to wait until age 20 before their first pregnancy. The BFHS-II found that nearly one-quarter of teenagers had at least one birth and an additional 5 percent were pregnant with their first child at the time of the survey. Four in ten teenage women with no education had at least one birth compared with less than two in ten teenagers with secondary or higher education. The proportion of teenage mothers has increased from 15 percent in 1971 to 24 percent in 1988. Among teenagers who had been pregnant, the average age at first pregnancy was 16 years. Two-thirds of teenagers who did not use a method of contraception when they first had sexual intercourse said it was because they did not know about family planning. One-third of teenagers who became pregnant (9 percent of all teenage women) left school because of pregnancy. Only one-fifth of those who left school were readmitted. The BFHS-II also documents that the MCH/FP programme has made a successful contribution to the reduction of infant and child mortality, though children of mothers with no education and children born soon after a previous birth have higher mortality rates. The infant and childhood mortality rates for the five-year period preceding the BFHS-II are 37 and 16 per 1000, respectively. xxviii The extended duration of breastfeeding, widespread coverage of the immunisation program, general access to clean water, and the high usage of oral rehydration therapy for diarrhoea treatment, as well as the nutrition, health, and income generating programmes established to counter the effects of drought between 1982 and 1988, are important contributing factors to the low rate of infant and child mortality. While there is no significant difference in infant mortality between the children of urban and rural mothers, children of mothers with no education have a greater probability of dying in the first year of life than children of mothers who attended school. Infants horn after an interval of less than two years since the previous birth are twice as likely to die as infants born after an interval of two or more years. The BFHS- I I documents that maternal and child health services are widely used by women in Botswana and the programme has expanded significantly since 1984. BFHS-II found that a large proportion of births in the five years before the survey, 90 percent, received antenatal care from a doctor or a nurse. The percentage of births whose mothers received a tetanus toxoid injection during pregnancy was also high at 84 percent. Since 1984, there had been an increase in the proportion of births delivered by trained health personnel, from 66 to 77 percent. The proportion of infants and mothers receiving postnatal care rose from 54 percent in 1984 to 71 percent. Health cards were seen in the BFHS-II for 74 percent of children age 12- 23 months and mothers reported immunisations for an additional 22 percent. Among children age 12-23 with health cards, 89 percent were fully immunised. The BFHS- I I found that a significant proportion of ill children received appropriate treatment. Although a large proportion of children who suffered from diarrhoea were treated with oral rehydration therapy, of concern is the significant proportion for whom fluid and food intake was cut down during the diarrhoeal episode. Ten percent of children had diarrhoea in the two weeks before the survey. Almost half of the children with diarrhoea received oral rehydration therapy in the form of a solution prepared from a special packet of salts (ORS); one-quarter were treated with a homemade sugar and salt solution. Fluid and/or food intake was decreased for more than a third of the children with diarrhoea. The majority of children reported to have fever or respiratory illness in the four weeks before the survey were taken to health facilities for treatment. xxix The BFHS-II included questions on knowledge of AIDS, the ways the disease is transmitted, who is at highest risk, and behaviors that will help someone avoid the disease. In the absence of either a vaccine or a cure for AIDS, education about prevention is the main strategy for combatting the epidemic. Nearly all women interviewed in the BFHS-II had heard of AIDS. However, many women lack correct information or have misconceptions about the disease. Nine out of ten women had heard about AIDS. Three-quarters of women who knew about AIDS had correct information about routes of transmission. Half of the respondents thought that people who had casual contact with a person with AIDS were at high risk of contracting the disease. Most women had heard about AIDS from the radio. Over half of the women had also received some information about AIDS from a pamphlet or poster. Three-quarters of women reported AIDS could be avoided by limiting sex partners; four in ten women also mentioned the use of condoms to avoid AIDS. Selected Indicators of Progress Made Between 1984 and 1988: Total Fer t i l i ty Rate Percentage of teenagers who are mothers Family Ptanning KnowtedQe and Use Percentage of a l l women knowing a method Percentage of a l l women knowing a source Percentage of art women cur rent ly using any modern method Percentage of women in union using any modern method Ut i l i za t ion of MCH Serv ices 1984 1988 6.5 5.0 23 24 75 95 69 95 16 29 19 32 Percentage of births receiving antenatal care 90 Percentage of b i r ths having medical ly supervised de l iver ies 66 Percentage of b i r ths receiving postnatal care 54 Percentage of b i r ths v i s i ted at home by health worker immediately af ter delivery 26 92 77 71 35 XXX RECOMMF~NDATIONS The results of the 1984 BFHS showed that the Botswana MCH/FP programme has made considerable progress in providing health and contraceptive services to women of childbearing age. The 1988 BFHS (BFHS-II) confirms this and documents the further progress made between 1984 and 1988. The results of the BFHS-II indicate that utilization of MCH services has increased, along with knowledge and use of family planning. However, the 1988 findings also point to areas of the MCH/FP programme that need improvement. I. An area where additional effort is needed is in Information, Education, and Communication (also recommended in 1984): I. Counselling services should be strengthened so that they are better able to disseminate information about family planning and dispel misconceptions women have regarding the use of contraception. The strengthening of the services should be targeted not only towards clients but also health workers. . Information, education, and communication (IEC) activities at the district level need strengthening by training or designating officers specifically to carry out these services. I1. Outstanding recommendations from the 1984 BFHS should continue to receive emphasis: . Further efforts should be directed toward educating and counseling teenagers (both boys and girls) about responsible sexual behavior. . Additional attention should be placed on informing men about the health and other benefits of family planning. Emphasis should be placed on the importance of couple communication in this area and on the fact that childbearing is the joint responsibility of the couple and not the choice of the man or woman alone. . Stress should continue to be placed on the health benefits of traditional practices such as breastfeeding and post-partum abstinence. . IEC materials targeting special population subgroups, e.g., illiterate women, should be developed. . Emphasis should be placed on identifying women in need of family planning services, particularly those concerned about limiting their family size. Counseling about family planning during the provision of antenatal and post-partum services is a key mechanism in reaching these women. . Potential acceptors should be counseled about the most appropriate methods for their age, life situation and fertility intentions. . Research should be undertaken to further investigate the determinants and consequences of adolescent childbearing. xxxi . Acceptors should be informed about possible side effects associated with the method they adopt, and follow-up of acceptors should be emphasized to reduce the levels of discontinuation due to side effects. xxxii BOTSWANA ANGOLA ZAMBIA CHOBE ZIMBABWE NAMIBIA NGAMILAND CENTRAL • GHANZI GHANZI ORAPA = FRANCISTOWN SELEBI PHIKWE • SEROWE • KGALAGADI TSHABONG • KWENENG IdOLEPOLOLE • ( I KANYEm I I I LOBATSEm~ SOUTH AFRICA N y KGATLENG ~_,ABORONE xxxiv 1. BACKGROUND 1.1 GEOGRAPHY, CLIMATE, AND ECONOMY The Republic of Botswana, 582,000 square kilometres in size, lies at the centre of the Southern Africa Plateau at a mean altitude of 1,000 meters above sea level. Formerly the Bechuanaland Protectorate, it is bounded by the Republic of South Africa, Namibia, Zambia and Zimbabwe. The climate of Botswana is semi-arid. Temperatures are very high in summer and low during winter nights, often reaching sub-zero levels. Winter days are mild. Rainfall is seasonal with uneven distribution. Most rivers flow seasonally, except in the Northwest District where the major rivers are perennial. Ground water exists at varying depths in most parts of Botswana. A sand-covered thirstland, named the Kgalagadi (Kalahari) Desert, comprises 84 percent of the territory of Botswana. The soil of the Kgalagadi is sandy and of poor quality; yet, this thirstland frequently sustains abundant vegetation which contrasts with the general absence of surface water. The availability of water is a dominant factor influencing the pattern of settlement. Water is needed to support and sustain the growth of crops and grass, to supply mining and other industrial needs, and to meet the demands of human settlements. About 87 percent of the population lives in the eastern part of Botswana where rainfall is more regular, ground water is available, and the soil is relatively fertile. Drought has become a frequent occurrence in the country, and severe drought from 1982 to 1988 resulted in declining agricultural production and farm income. The semi-arid climate limits the arable land to less than 5 percent of the total land area and is a serious constraint on agricultural production. The exploitation of minerals also influences settlement patterns. Mineral prospecting is one of Botswana's principal industries. The results of the standard methods of prospecting and the more recent air survey methods have been positive. There are copper and nickel ores at Selibe Phikwe, silver ore near Francistown, manganese and traces of asbestos near Kanye, coal in Morupule and other places such as Kgaswe and, more importantly, diamonds at Orapa, Letlhakane and Jwaneng. Along the Ghanzi ridge, minerals such as asbestos, lead, zinc, and uranium may also be found. The mines and their associated activities--transport, power, communications, and the provisioning of the mine workers--are a major source of employment in Botswana. Botswana's gross domestic product (GDP) at current prices, increased from an estimated 36.6 million pula in 1966 to 1277.1 million pula in 1983/84. Mining is the largest contributor to the GDP. Agriculture's contribution to the GDP has declined substantially over the years from 25 percent in 1973/4 to 5 percent in 1983/4, while that of the mining sector has increased from 23 to 48 percent over the same period. 1.2 POPULATION The population of Botswana is relatively homogenous compared to countries of East and West Africa. When compared with nearby countries, such as Lesotho and Swaziland, however, it is more heterogeneous. Most of Batswana are Tswana speaking, There are also found in the country Bakalanga, Hambukushu, Bayei, Basarwa (with their various dialects), Baherero, Ovambo, people of European stock, and some Ndebele, Shona, Nama and other people from the neighbouring countries. According to recent censuses, the population has grown rapidly from 515,833 in 1964 to 649,083 in 1971, to 967,363 in 1981. The growth rate was 3.1 percent during the period 1964-71 and 4.1 percent during the period 1971-81. The increase cannot be fully accounted for by changes in fertility and mortality, and may be due partly to under-enumeration in the 1971 census and hidden migration into a Botswana during the 1971-81 inter-censal period. For example, fertility (measured by the crude birth rate) was estimated to be 48.7 per thousand, and mortality (measured by the crude death rate) was 13.9 per thousand during the inter-censal decade; the expected natural growth rate for this period would be 34.8 per thousand, instead of the 41.0 per thousand noted above. The natural growth rate of 3.48 percent per annum implies that the population will double every 20 years if the population continues to grow at the current rate. The total population for 1988 was estimated at 1.2 million. One of the most critical aspects of this high growth rate is that it results in an unbalanced age structure, whereby the number of children (who are dependent) is nearly equal to the number of working age adults. A sustained high birth rate also leads to an increasingly larger number of children who require food, clothing, education, health services, shelter and future opportunities for employment. The population of Botswana is distributed unevenly, with the highest concentrations in the southern and southeastern parts of the country and the lowest concentrations in the western and southwestern parts. The overall population density was 2.08 persons per square kilometre in 1988. The density varies from one region to another, being highest in the urban areas and lowest in rural areas. Within rural areas, localities with relatively good soil and water resources have a higher density than those with poorer resources. The population density has increased in all districts during the period 1971-81, though at different rates. In relative terms, only Kweneng District recorded a moderate increase (77 percent) while all other districts experienced gains in density in excess of 1130 percent during the inter-censal period. 1.3 NATIONAL HEALTH PRIORiTIP_~ When Botswana became independent in 1966, the Ministry of Health inherited a largely curative, urban health care system. Since then Botswana has adopted a primary health care strategy as the means for achieving health for all. Gradually, services have been altered to reflect this approach with an emphasis on prevention of disease and promotion of health. National health priorities, by order of importance, are listed in the National Development Plan VI (1985-91) as: 2 Primary Health Care, Training and Manpower Development, Planning and Statistics, Hospital Services, and Technical Support Services. Under Primary Health Care (PHC), the Government's top priority, the expansion of services to reach all communities, especially those in the remote areas, is emphasized. More health posts are being staffed with enrolled nurses in order to increase the range of services that can be provided in these facilities on a daily basis. Another area of emphasis of the Botswana PHC programme is community participation and involvement. The training of family welfare educators receives considerable attention, as it is this cadre which is responsible for mobilizing communities to participate in health activities. 1A MATERNAL AND C I~.D HEALTH/FAMILY PLANNING PROGRAMME The maternal and child health/family planning (MCH/FP) programme is a major component of PHC; its tasks under the current National Development Plan include: Promotion of MCH/FP, with follow-up, and participation at the home level through the strengthening of family welfare educators in this area and data collection and use; Increased knowledge of and support for MCH/FP care which is effective, efficient, and acceptable at the community level; Identification of high risk groups among pregnant women, mothers, and children, and appropriate intervention; Protection of the health of mothers and infants through family planning services so that each family will be of a reasonable size, corresponding to its socio-economic and health conditions; and Continuation of the Expanded Programme on Immunization. Maternal and child health/family planning services in Botswana originated in 1967, when several women in Francistown asked the Government Surgeon for contraceptives. These supplies were obtained from the International Planned Parenthood Association (IPPF) which subsequently began a pilot project in 1969 to introduce family planning in Serowe, a large village in the Central District. Six middle-aged women with children were trained as volunteer family welfare educators by an IPPF visiting team. In addition to human reproduction and family planning, the training included other subjects such as immunisations, breastfeeding, nutrition, child and maternal care, environmental sanitation, prevention of some major diseases and communication skills. Thus, from the beginning, family planning in Botswana has been integrated into the general context of maternal and child health and has never been a separate programme. 3 In 1973, the Maternal and Child Health/Family Planning (MCH/FP) Unit was formed in the Ministry of Health and a national programme was established. Family planning activities have been integrated into MCH services since the beginning of the national programme in 1973 because of their benefits to the health and welfare of families. The policy of the Government of Botswana affirms that these services be available to every family: "It is the basic right of every family to determine for itself how many children to have and when to have them. If couples are to exercise the choice of determining the number and spacing of their children, then public health agencies must provide them with the services, supplies and information on how to plan families" (Ministry of Health, 1976, p.i). As a key component of the MCH/FP programme, it was decided to train 60 family welfare educators each year. Since 1973, more than 600 family welfare educators have successfully been trained by the MCH/FP Unit. Their role in the communities which select them is largely educational and motivational. In 1979, the Maternal and Child Health/Family Planning Unit joined with the Nutrition Unit and Health Education Unit to form the Family Health Division. The main objectives of the Family Health Division are to reduce sickness and death among mothers, children and infants, to promote reproductive health, and to promote the physical and psychological health and development of children and adolescents. In order to achieve these objectives, health workers provide several services including antenatal care, supervised deliveries in health facilities, postnatal care, and family planning. They also vaccinate against infectious diseases, monitor the growth and development of children by periodic weighing and examination, supervise children's health in schools and encourage the community to participate in the health care of families. MCH/FP services are available at all health facilities which provide curative and preventive care for the family. Since 1973, the number of service points has increased dramatically from 50 to more than 441 permanent facilities (see Figure 1.1). Emphasis has been placed on ensuring preventive care close to the predominantly rural population rather than on developing large, urban curative units. Participation is fostered through health education disseminated by home visits, school health education, village meetings, volunteer efforts, and the mass media. Until 1984 family planning services were offered at only specified times during the week, as were child welfare, antenatal, postnatal, and other services. A typical mother would have to attend clinic sessions two to three times each month, once for antenatal services, again for child welfare services, and a third time for family planning services. In order to increase the accessibility of services, the MCH/FP Unit tested the integration of these services on a daily basis at several clinics late in 1984. From the initial pilot projects in two clinics in the Southeast District, integrated services have been extended to all parts of the country, such that today over 77 percent of clinics offer integrated services. With this approach, the entire family can obtain MCH/FP services on one day. Initial studies show that this approach has many advantages for both health personnel, service users, and the community. The years after 1984 have seen an intensification of training in MCH/FP, both within and outside the country, with the aim of improving the quality of services. Many health workers have attended courses, seminars and workshops in the following areas of MCH/FP: integrated MCH/FP, counselling, contraceptive technology update, family planning clinical skills, family planning logistics, 4 Figure 1.1 Health Care Pyramid l / \ I Source : Med ica l S ta t i s t i cs Uni t , 1989 Refer ra l Hosp i ta l s - 3 Dis t r i c t Hosp i ta l s - 12 Hea l th Cent res - 13 C l in ics - 163 (58 w i th matern i ty ) Hea l th Poets - 291 (137 w i th nurses ) family life education, fertility management, and maternal and child nutrition. Training has not been limited to service providers; National Health Institute (NHI) tutors have also received training. Furthermore, family planning has been integrated into the NHI curriculum. Much progress has been made in reaching the populations in need of MCH/FP services, and many targets set in the 1979-1985 National Development Plan were met or exceeded by the end of the plan period. For the current National Development Plan (NDP VI 1985-91), the MCH/FP targets are: Infant Mortality Rate Women of reproductive age using modern methods of family planning Pregnant women attending antenatal clinics Supervised deliveries New-born babies with birth weight of at least 2500 grams Children under one year of age fully immunised Below 50/1000 live births 25% 98% 70% 90% 75% In order to improve the quality and safety of family planning services in Botswana, the Family Health Division developed the Family Planning Policy Guidelines and Service Standards 5 in October 1987. These guidelines took effect in May 1988. The guidelines and standards, which were discussed at a national workshop and at interdistrict workshops held for most districts, have been welcomed by health workers. A clinical procedures manual for family planning has also been developed and is in final draft form. For a family planning programme to succ, e~d there should be an uninterrupted flow of family planning commodities. To facilitate this, a drug and family planning logistics manual has been developed, and is nearing completion. Information, education, and communication (IEC) is a very important component of any MCH/FP programme. Although many IEC activities in support of MCH/FP have been undertaken over the years, it is necessary to strengthen them further. In 1987, the Ministry of Health engaged a consultant to develop a three-year IEC programme to further promote MCH/FP activities. The design of this programme has been completed and--despite a shortage of manpower--implementation has started. Teenage pregnancy continues to be a major concern in Botswana. In order to prepare teachers to teach family life education (FLE) to school children, two courses have been held, one for primary school teacher trainers and their education officers, and another for secondary school teachers and their education officers. The goal is for teachers and education officers trained in the two courses to form a core of trainees who, with support from the Family Health Division, will be responsible for training teachers in their areas. Already, district-level FLE workshops for teachers have been held in five districts. 1.5 POPULATION POLICY AND PROGRAMMES In the past decade, key government officials, political leaders and chiefs have become concerned about the implications of rapid population growth in meeting overall development objectives. These concerns have been expressed through different media i.e. newspaper articles, speeches, and conference and workshop reports. Key government officials have attended international conferences, where concerns about population and development were expressed, e.g., the Second African Conference on Population and Development held in Arusha, Tanzania in January 1984, the International Conference on Population held in Mexico City, Mexico in August 1984, and the All-African Population and Development Conference for Parliamentarians held in Harare, Zimbabwe. These conferences stressed the need for governments to develop population policies and implementation strategies. In Botswana, workshops and conferences on population and development have been held to further sensitize policy makers on population and development matters. A seminar was held for policy makers and implementors in October 1985 to disseminate the results of the Botswana Family Health Survey of 1984. In September 1986, a conference on Population and Development for Parliamentarians and Chiefs was held. Another conference on the same subject was held for permanent secretaries and senior public officers in June 1987. These conferences called for the development of clear policies on population and development as well as teenage fertility. Also emanating from the conference for Parliamentarians and Chiefs has been the establishment of a National Parliamentary Council on Population and Development, whose mandate is to sensitize legislators and individual constituencies to population and development issues in the country. In 6 January 1989, the Government of Botswana created an Interministerial Programme Steering Committee on Population and Development to develop and implement a national population policy. 1.6 OBJEt;I'IVES OF THE BOTSWANA FAMII.y HEALTH SURVEY II The Botswana Family Health Survey II (BFHS-II) was conducted on behalf of the Family Health Division of the Ministry of Health by the Central Statistics Office,through the Continuous Household Integrated Programme of Surveys. It was carried out as a sequel to the 1984 Botswana Family Health Survey and in conjunction with the second round of the 1987 Botswana Demographic Survey (BDS). Financial and technical assistance for the survey was provided by the Demographic and Health Surveys Programme at the Institute for Resource Development (IRD), under a contract with the United States Agency for International Development. The objectives of the BFHS-II are to provide information on family planning awareness, approval and use, basic indicators of maternal and child health, and other topics related to family health. In addition, the BFHS-II complements the data collected in the BDS, by obtaining information needed to explore trends in fertility and mortality, and to examine the factors that influence these basic demographic indicators, particularly, the proximate determinants of fertility. Specific objectives are: To collect information on fertility and family planning; To find out what type of women are likely to have more or fewer children or to use or not use family planning; To collect information on certain health-related matters such as antenatal checkups, supervised deliveries, postnatal care, brcastfeeding, immunisation, and diarrhoea treatment; To develop skills in conducting periodic surveys designed to monitor changes in demographic rates, health status, and the use of family planning; and To provide internationally comparable data which can be used by researchers investigating topics related to fertility, mortality and maternal-child health. 1.7 BACKGROUND CHARACTERISTICS OF RESPONDENTS The Botswana Family Health Survey II identified 4,648 eligible women and of these 4,368 women were successfully interviewed: 2,258 women residing in the urban areas and 2,110 in the rural areas. This section presents the distribution of the women interviewed for the BFHS-II by selected demographic and socioeconomic characteristics, as well as a comparison with the same information from previous sources as a measure of the quality of BFHS-II data. A description of the characteristics of the surveyed women provides a background for interpretation of survey findings for the report, while a discussion of the associations among some of the background variables is useful for an understanding of the data. 7 Table 1.1 Percent O is t r idut ion of Women 15-49 by Background Character ist ics , 1981 Census, 1984 BFHS, and 1988 BFHS-II Weighted Unweighted Number Number Background 1981 1984 1988 of Women of Women Character ist ic Census BFHS BFHS-II BFHS-I I BFHS-ll Age 15-19 23.4 19.5 21.6 937 946 20-24 21.6 22.0 21.1 926 949 25-29 17.0 18.3 19.4 846 880 30-34 12.0 13.8 14.9 653 644 35-39 9.8 11.3 10.7 465 455 40-44 8.6 9.0 6.7 290 2?3 45-49 7.4 6.1 5.7 251 221 Union Status Never in union 54.1 29.0 52.9 2312 2283 CurrentLy in union 40.8 65.1 39.0 1708 I734 Formerty in union 5.1 5.9 8.0 349 351 Residence Urban 21.2 23.6 30.1 1316 2258 Rurat 78.8 76.4 69.9 3052 2110 Levet of Education No Education 35.3 30.8 24.0 1045 899 Incomptete Primary 34.8 29.3 24.6 10?3 1042 Comptete Primary 21.1 24.0 25.5 1115 1164 Secondary or Higher 8.8 16.0 25.9 1135 1263 Totat 100.0 100.0 100.0 ~368 4368 Table 1.1 compares the age distribution of the women in the BFHS-II sample with the distribution of women 15-49 in the 1981 census and 1984 Botswana Family Health Survey (BFHS). The BFHS-II sample has a greater concentration of women at the ages 20-34 than the other two data sets. There is apparent under-sampling of teenagers in both the 1984 BFHS and the 1988 BFHS-II. An examination of the distribution of household members by age and sex enumerated in the BFHS-II household listing indicates a greater than expected number of women in the 10- 14 age group for females and a dearth in the 15-19 age group. Some interviewers may have recorded women in the 15-19 year age group as having a younger age in the household listing in order to make them ineligible for the individual interview and thus lighten their work load. Similarly, it was also found that females in the 45-49 age group was under-enumerated relative to the 50-54 age group. The greater concentration of women in the prime reproductive ages in the BFHS-II may also result from the fact that interviewers were more successful in interviewing women in selected households in the urban areas, where more young women are found. One consequence of the greater concentration of younger women is that estimates of contraceptive prevalence may be higher, and fertility lower, than if more older women had been interviewed. 8 The distribution of women by marital status in the BFHS-II is similar to that found in the 1981 census, whereas the 1984 BFHS classified a much greater proportion of women as currently in union. The 1984 BFHS included two additional probes to determine how many women reporting their marital status as separated, divorced, widowed, or single were actually living with a partner at the time of the interview. In response to these probes, almost half of the women who initially did not report themselves as married or in a consensual union said that they were currently living with a partner, resulting in a much higher estimate of the proportion currently in union. Table 1.1 shows a rapid increase in the proportion of the Batswana population living in urban areas. The proportion of respondents residing in urban areas increased from 21 percent in 1981 to 24 percent in 1984, and rose to 30 percent by 1988. However, the BFHS-II may include a slightly greater proportion of urban women than is found in the population. There has also been a increase in the education of women in the 1980s. Only 30 percent of women 15-49 at the time of the 1981 census reported that they had completed primary school or higher, compared with more than 50 percent of women in the BFHS-II. In 1981, 35 percent of women of reproductive age had not attended any school; by 1988, only 24 percent had received no education. The final two columns of Table 1.1 show the weighted and unweighted number of women. Weighting of data is necessary to compensate for differences in the selection probabilities and response rates. The weights are determined in such a way that the total number of weighted cases equals the total number of women interviewed. Therefore, for most of the sample, the weighted number of cases can serve as a rough guide for the actual number of cases. The main exceptions are when results are tabulated by the criteria used to define the sampling domains, in this case urban or rural residence, or any characteristics strongly associated with urban-rural residence. All results presented in this report are weighted and only the weighted number of cases is shown. Table 1.2 shows the distribution of the surveyed women by education and according to age, urban-rural residence, and religion. Education is a major factor which determines the level of participation of women in the various sectors of the modcrn economy. Generally, women in Botswana play an active and significant role in the educational system both as students and as teachers. For the last ten years, female students have dominated the primary and junior secondary school system. However, this situation changes at senior secondary and higher levels of education. The percent of women by education according to age cohort shows the increasing level of education among Batswana women. The percent of women with no education drops dramatically with decreasing age and, conversely, the proportion with at least completed primary schooling rises. As expected, urban women are better educated than their rural counterparts. The data also show variations in education by religion. Women who belong to the Spiritual-African Church, or profess to have no religion, have substantially less education than Catholic or Protestant women. 9 Table 1.2 Percent O is t r ibut ion of women by Education, According to Age, Urban-Rural Residence, and Rel ig ion, BFHS-ii 1988 Education Number Background No incomplete Complete Secondary of Character ist ic Education Primary Primary or Higher Total go~en Age 15-19 5.5 19.6 37.1 37.8 100.0 937 20-24 15.3 16.8 32.4 35.5 100.0 926 25-29 29.5 18.7 27.3 24.5 100.0 846 30-34 34.5 26.3 18.9 20.3 100.0 653 35-39 34.5 35.6 17.9 12.1 100.0 464 40-44 33.2 45.4 8.5 12.9 100.0 290 45-49 47.8 42.3 2.0 7.9 100.0 251 Residence urban 13.1 22.3 29.1 35.5 100.0 1316 Rural 28.6 25.5 24.0 21.9 100.0 3052 Rel ig ion Sp i r i tua l - Afr ican 24.1 26.7 28.1 21.1 100.0 1869 Protestant 15.1 23.2 24.2 37.5 100.0 980 Cathol ic 12.2 21.7 23.8 42.3 100.0 391 Other 6.4 19.3 15.2 59.1 100.0 50 No Rel ig ion 36.8 23.4 23.4 16.5 100.0 1075 Total 23.9 24.6 25.5 26.0 100.0 4368 10 2. EXPOSURE TO PREGNANCY, BREASTFEEDING AND POST-PARTUM INSUSCEPTIBILITY The proximate determinants of fertility which have the greatest effect on exposure to pregnancy are the proportion of a woman's life spent in marriage or sexual unions, breastfeeding practices and their effect on delaying the return of menstrual periods after a birth, and the practice of abstaining from sexual relations following a birth. This chapter presents data on each of these fertility determinants and discusses their contribution to reducing the time that women are at risk of a pregnancy during the reproductive ages. 2.1 CURRENT UNION STATUS The demographic significance of union patterns derives from the fact that most childbearing occurs in the context of formal or informal unions. Therefore, marriage and cohabitation are primary indicators of exposure to the risk of pregnancy, and important for understanding fertility. In Botswana, however, a union is not prerequisite to childbearing. Many women bear children before entering a stable union, visiting relationships are common, and many women have children in the context of such unions. Unfortunately, the BFHS-II only obtained information about unions in which the woman was married or living with a partner. Thus, in addition to the standard indicator of current marital status, we also present in this chapter data on sexual activity. Problems exist with both measures as proxies for exposure to the risk of pregnancy. Current marital status underestimates the proportion of women exposed, because it does not take into account the large proportion of women in stable relationships that do not involve cohabitation. On the other hand, relying on reports of sexual activity may overestimate exposure, because women who ever had sexual intercourse, or even had sexual intercourse in the last month, may not have regular sexual relations. Table 2.1 Percent Distribution of All Women by Current Marital Status, According to Age, BFHS-I! 1968 Current Marital Status Never L iv ing Age Married Married Together Widowed Divorced Separated Total Number of Worn 15-19 93.9 3.0 2.8 0.0 0.1 0.3 100.0 937 20-24 69.7 14.3 11.4 0.0 0.7 3.9 100.0 926 25-29 43.3 33.6 16.1 0.7 2.2 4.2 100.0 846 30-34 30.4 43.7 14.7 1.0 5.1 5.1 100.0 653 35-39 25.1 49.3 13.3 2.8 3.9 5.6 100.0 464 40-44 16.3 54.3 8.5 6.2 5.8 6.7 100.0 290 45-49 20.2 47.4 8.7 11.0 8.2 4.5 100.0 251 Tota l 52.9 28.3 10.8 1.6 2.6 3.8 100.0 4368 11 In the BFHS-II, women were asked if they had ever been married or had lived with a man. Those who replied that they had were asked about their current marital status. Table 2.1 shows that 53 percent of the women reported that they had never been married or lived with a man. Of the remaining 47 percent, 28 percent said they were currently married, 11 percent were living with a partner though not married, and the remainder (8 percent) were widowed, divorced, or separated. The proportion of women reporting themselves to be currently in union in the BFHS-II is similar to the figure reported from the 1981 Census, but lower than the proportion reported in the 1984 BFHS. That survey included two additional probes to determine how many women reporting their marital status as separated, divorced, widowed or single, were actually living with a partner at the time of the interview. In response to these probes, almost half of the women not initially reporting themselves as married or in a consensual union said that they were living with a partner. The 1984 BFHS shows that 79 percent of all women were currently in union compared to 39 percent for the BFHS-II. Tabte 2.2 Percent Distribution of Never-Married Women Who Have Ever Had Sexual Intercourse, According to Age, 8FHS-II 1988 Ever Had Never Had Number Sexual Sexual of Age Intercourse Intercourse Tota[ Wo~en 15-19 64.0 36.0 100.0 880 20-24 97.7 2.3 100,0 646 25-29 99,3 0.7 100.0 366 30-34 100.0 0.0 100.0 199 35-39 97.6 2.4 I00.0 116 40-44 100.0 0.0 I00.0 54 45-49 100.0 0.0 100.0 51 Tota[ 85.4 14.6 100.0 2311 It is likely that many of the women in the BFHS-II who had never lived with a partner had a current or past regular sexual relationship. Table 2.2 shows the percentage of never-married women who have had sexual intercourse by age, and Figure 2.1 shows the percent distribution of women by marital status, with never-married women divided into those with sexual experience and those without. As seen in Table 2.2, among women age 20 or older who report themselves as never having been married or in union, nearly all have had sexual intercourse. Adding the never- married women who have had sexual intercourse to those women who report themselves to be currently or previously in a union gives an estimate of the maximum number of women exposed to the risk of pregnancy. This percentage is 92 percen,, a result which is only slightly higher that the 90 percent who reported themselves to be currently or previously in union in the 1984 BFHS. Table 2.3 shows the proportion of women who had sexual intercourse in the month before the survey by current union status. As expected, the majority of women who are married or living together with a man were sexually active, with 70 percent of these women reporting sexual 12 intercourse in the month before the interview. More surprisingly, almost half of never-married women and women formerly in union also reported sexual intercourse in the month before the interview. 100 80 60 40 20 0 Percent Figure 2.1 Union Status of Women 15-49 by Age Group m . . . . . . . . . . . . \ \ \ ~\\\\\\\\\\% 40-44 15-19 20-24 25-29 30-34 Age Group 35-39 m Never In un ion r~ Marr ied / In union Sexually experienced m Wld /D Iv /Sep @ k\\\\\\\\\\\\~ 45-49 BFHS-II 1988 Table 2.3 Percentage of Women Having Sexual In tercourse in the Month Preceding the Survey by Current Mar i ta l Status, According to Age, BFNS-II 1988 Never In Cur rent ly Formerly Art Age Union** %n Union in Union Women 15-19 40.5 65.1 * 28.2 20-24 45.9 66.8 50.6 50.8 25-29 58.5 66.4 57.5 62.2 30-34 57.1 70.2 62.7 65.4 35-39 45.3 74.4 43.0 63.0 40-44 42.0 67.9 31.4 56.3 45-49 36.6 74.4 28.5 55.9 Total 47.4 69.5 46.0 52.3 • Fewer than 20 cases. • * Excludes women who have not yet had sexuat in tercourse . 13 In sum, while formal marriage is far from universal in Botswana, by age 20 a large proport ion of Batswana women are regularly sexually active and exposed to pregnancy. To restrict the analysis of fertility and its determinants to women married or living with a partner, would underestimate the level of fertility and focus on a group that is not representative of the childbearing population. Thus, wherever possible, in the remainder of the report, analysis of fertility and its determinants will focus on all women, or all women who have ever had intercourse. The inclusion of all women who have ever had sexual intercourse may exaggerate the population at risk of a pregnancy by including some women who are not engaged in regular sexual relations. Nonetheless, the results of the 1984 BFHS and data on sexual intercourse from the BFHS-II show that most women over the age of 20 have a regular sexual partner, or are sexually active, and thus are at risk of a pregnancy. 2.2 AGE AT F IRST SEXUAL INTERCOURSE If childbearing occurs predominantly in marriage, then the age at which a woman first enters a formal or consensual union is an indicator of the beginning of her reproductive life. However, as discussed above, childbearing is by no means restricted to unions in Botswana. In fact, the median age at first union, which is around 24 years of age, is five years after the median age at first birth. Rather than focus on age at first union, this section looks at the age at first sexual intercourse. These data should be viewed with some caution. In many cases, the respondent reported her age at first sexual intercourse to be the same as her age at the time of her first birth. In most cases this would be impossible if one allows for a nine month period of pregnancy between the first sexual intercourse and the first birth. In the cases where an adjustment of one year would make the data consistent, this adjustment was made. If the inconsistency could not be resolved by lowering the age at first sexual intercourse by one year, the response was coded as inconsistent. Six percent of all responses to the question on age at first sexual intercourse were coded as inconsistent. Table 2.4 shows that seven percent of women had sexual intercourse before age 15, sixty percent were sexually active by their 18th birthday, and over eighty percent had their first sexual intercourse before age 20. It is unclear whether the age at first sexual intercourse has changed in recent years. On the one hand, 11 percent of the respondents in the 1984 BFHS reported having sexual intercourse before age 15, compared to 7 percent in the 1988 BFHS-II. On the other hand, in the BFHS-II, more women were sexually active before age 15 in the 15-19 age group than in the 20-24 group and there is no change in the proportion of women who initiated sexual relations before age 18, among women currently age 20-24 and women 25 and older. Table 2.5 presents the median age at first sexual intercourse by selected background characteristics. The median age is the exact age by which 50 percent of a cohort of women have had their first sexual intercourse. Only women 20-49 are included in this table since the median age at first intercourse for teenagers is influenced by the proportion that have not yet become sexually active. The median age at first sexual intercourse is 17.3, the same as in the 1984 BFHS. There is little difference in the age at which women have their first sexual experience. When older women, who initiated sexual intercourse 20-25 years ago, and younger women, who only recently became sexually active are compared, there is little difference in the age at which sexual activity 14 Table 2.4 Percent D is t r ibut ion of ALl Wotnen by Age at F i r s t Sexual Intercourse and MecHan Age at F i r s t Sexuat Intercourse, According to Current Age, 8FHS-II 1988 Never Had Humber Current Sexual Age at F i r s t Sexual intercourse of Median Age intercourse <15 15-17 18-19 20-21 22-24 25+ Total Woe~n Age 15-19 34.4 8.3 50.6 6.7 0.0 0.0 0.0 100.0 922 20-24 1.7 6.7 58.2 25.9 6.9 0.6 0.0 100.0 888 17.2 25-29 0.4 8.0 56.6 26.1 7.2 1.6 0.1 100.0 781 17.1 30-]4 0.0 7.5 55.4 26.0 7.5 3.3 0.3 100.0 602 17.3 35-39 0.7 7.5 54.2 27.3 7.1 2.7 0.5 100.0 434 17.2 40-44 0.0 8.2 50.9 26.6 9.4 3.4 1.5 100.0 270 17.3 45-49 0.0 2.0 46.8 32.5 13.0 3.0 2.5 100.0 229 18.1 Total 8.2 7.3 54.3 22.2 6.0 1.6 0.4 100.0 4126" * ExcLudes 242 women whose age at f i r s t intercourse was inconsistent with age at f i r s t b i r th . - Omitted due to censoring. began. Residence is not associated with the age at first sexual intercourse; however, there are differentials between educational groups. Women with no education generally become sexually active one year earlier than women with some secondary education. TabLe 2.5 Median Age at F i rs t Sexual Intercourse among No~nen 20-49, by Current Age and Selected Background Character ist ics, BFNS-Ii 1988 Background Current ARe Total Character ist ic 20-24 25-29 30-34 55-39 40-44 45-49 20-49 Residence Urban 17,3 17.2 17.3 17.5 17.7 17.7 17.3 Rural 17.2 17.1 17.4 17.0 17.2 18.1 17.5 Education No Education t6.7 16.5 16.9 16.8 17.5 17.8 16.9 Incomplete Primary 16.5 17.0 16.8 16.9 17.0 18.0 17.0 Complete Primary 17.4 17.3 17.6 17.7 17.5 * 17.4 Secondary or Higher 17,6 18.0 18.4 18.1 17.8 * 17.9 Total 17.2 17.1 17.3 17.2 17.3 18.1 17.3 , Fewer than 20 cases. 2.3 OTHER FACqORS Alvt,-le.;CrING EXPOSURE TO THE RISK OF PREGNANCY: BRE.ASII--EEDING AND POST-PARTUM INSUSCEFIIBII.rIY Breastfeeding is widely practised in Botswana. In recent years, the Botswana Breastfeeding Promotion and Protection Group--whose activities include organizing seminars, counselling, training of health workers, and development of materials on breastfeeding--has placed emphasis on advising 15 mothers on the benefits of the practise. Women are encouraged to breastfeed for two years after the birth. The Botswana government supports breastfeeding by allowing working mothers one hour a day additional time off for breastfeeding until their child's first birthday. Table 2.6 Percentage of Births in the Last 36 Months Whose Mothers are St i l l Breastfeeding, Post-partum Amenorrheic, Abstaining, and Insusceptible to Pregnancy, by the Number of Months s ince Birth, @FHS-II 1988 Months S t i l l S t i l l S t i l l Number since Breast- Amenor- S t i l l lnsuscep- of Birth feeding rheic Abstaining t ibte Births Less than 2 90.8 93.4 98.2 98.2 114 2-3 96.6 81.2 92.8 95.6 137 4-5 87.1 71.4 76.5 89.5 133 6-7 89.5 60.8 59.1 76.7 113 8-9 90.1 61.6 53.8 75.2 126 10-11 86.4 48.5 50,0 65.1 115 12-13 73.0 29.9 34.1 52.0 138 14-15 72.0 33.6 30.9 51,0 96 16-17 58.1 19.9 25.5 33.9 114 18-19 48.3 14.3 19.2 28.6 113 20-21 25.4 3.2 5.3 7.9 99 22-23 16.6 2.2 5.8 8.0 91 24-25 16.5 1.5 4.6 6.1 95 26-27 6.8 1.5 3.7 5.2 94 28-29 3.6 2.6 4.9 6.2 113 30-31 7.4 0.6 2.8 3.3 105 32-33 0.6 1.6 2.2 3.8 92 34-35 0.6 0.0 0.0 0.0 100 Total 51.9 32.2 34.6 42.7 1968 Table 2.6 shows that almost all Batswana babies are breastfed, most through the first year of life and well into the second. Almost three-quarters of children age 12-13 months are still being breastfed, and almost half of those 18-19 months are breastfed. These results are virtually identical to those from the 1984 BFHS, which showed that 73 percent of women breastfed for at least one year and 49 percent breastfed until the child was at least 18 months. By lengthening the duration of post-partum amenorrhea--the period after a birth during which the women does not ovulate and hence is not at risk of becoming pregnant--breastfeeding may have a significant effect on the spacing of births. The effect of breastfeeding on post-partum amenorrhea depends both on the duration of the breastfeeding, and whether breastfeeding is supplemented with other liquids or foods. As expected, in view of the near universality and long duration of breastfeeding among Batswana mothers, the return of menstruation is delayed for a long time after each birth. Table 2.6 shows that 60 percent of mothers 6-7 months post-partum are still amenorrheic. This figure drops to 30 percent among mothers 12-13 months post-partum and to less than 15 percent among mothers 18-19 months post-partum. 16 Cultural values and customs which govern the resumption of sexual activity following childbirth have a significant impact on the health of the mother and child by delaying future pregnancies. These customs are common in Botswana. For example, the custom of "ootsetsi" requires the mother and child to stay in a special confinement room for at least three months to ensure normal growth of the child and recovery of the mother after the birth. Among some ethnic groups, it is customary to refrain from sexual relations while breastfeeding. Due mainly to such cultural practices, Botswana women report long periods of sexual abstinence following childbirth. Sixty percent of women 6-7 months post-partum are still abstaining. Among women 12-13 months post-partum, one third have not resumed sexual relations, and among those 18-19 months post-partum, nearly 20 percent are still refraining from sexual intercourse. The final column of Table 2.6 provides information about the proportion of mothers who are insusceptible to pregnancy, either because their period has not returned since their last birth, or because they are practicing sexual abstinence. The table shows that more than half of mothers 12-13 months post-partum are not yet at risk of a pregnancy, either because of post-partum amenorrhea or abstinence. The proportion of mothers who are insusceptible drops off rapidly after 12 months; among mothers 18-19 months post-partum less than 30 percent are insusceptible and among those 24-25 months post-partum, only 6 percent are protected from becoming pregnant by post-partum amenorrbea or abstinence. Table 2.7 Mean Humber of Months of Breastfeeding, Post-partum Amenorrhea, Post-partum Abstinence, and Post-partum insuscept ib i l i ty , by Selected Background Character ist ics, BFHS-I! 1988 Number Background Breast* Amenor - Insuscep- of Character ist ic feeding rheic Abat inence t ib i l i ty B i r ths Age <30 19.1 11.6 13.9 16.1 1293 30+ 18.3 11.6 10.6 14.8 698 Residence Urban 14.7 8.5 9.4 11.9 504 Rural 20.2 12.6 13.8 16.9 1487 Education No Education 20.2 12.6 11.6 16.0 570 Incomplete Primary 20.3 12.6 14.2 16.8 488 Complete primary 18.0 10.7 12.3 14.9 523 Secondary or Higher 16.1 10.1 13.0 14.7 409 Total 18.8 11.6 12.7 15.6 1990 17 24 18 12 6 0 Figure 2.2 Mean Duration of Breastfeeding, Amenorrhoea and Post-partum Abstinence Months Total Urban Rural t_ Breastfeeding ~ Amenorrhoea n Abstinence I I I BFHS-II 1988 Table 2.7 provides estimates of the mean duration in months of breastfeeding, post-partum amenorrhea, post-partum abstinence, and post-partum insusceptibility by selected background characteristics. These estimates were calculated using the "prevalence/incidence" method borrowed from epidemiology. The mean duration of breastfeeding (or amenorrhea, abstinence, etc.) is calculated by dividing the prevalence of the behavior by the incidence. Prevalence is defined as the number of women currently breastfeeding (or amenorrheic, abstaining, etc.) and incidence is the average number of births per month. This average is calculated on the basis of the number of births over 36 months to overcome problems of seasonality and fluctuations in the number of monthly births over short periods. A major advantage of the prevalence/incidence method over life table calculations is that it relies only on the mother's current status, e.g., breastfeeding or not, amenorrheic or not, etc., rather than on retrospective information on the number of months breastfeeding and other post-partum behaviors were practised. The means in Table 2.7 confirm that relatively long durations of breastfeeding and post- partum amenorrhea and abstinence are practiced in Botswana. The mean duration of breastfeeding is nearly 19 months. On average, the resumption of menstruation is delayed for 12 months following childbirth and sexual relations for 13 months. Taking into account the effect of both post-partum amenorrhea and abstinence, a woman is not at risk of pregnancy for an average of nearly 16 months. Younger women breastfeed for a slightly longer period than older women. Younger women also abstain from sexual relations for a longer period, contributing to a period of post-partum insusceptibility that is more than 16 months on average. This is encouraging, since a decrease in the duration of post-partum insusceptibility among younger women--which is often found as young 18 women become more educated, move to urban areas, and abandon traditional post-partum practices--would put a greater burden on the family planning programme to compensate for the increased risk of another pregnancy following shortly after the previous. As seen in Figure 2.2, rural women in Botswana have considerably longer periods of breastfeeding, post-partum amenorrhea, and abstinence from sexual relations than urban women. Consequently, the period of post-partum insusceptibility is five months longer for rural women than urban. Furthermore, there is evidence of decline in breastfeeding in the urban areas of Botswana. The median duration of breastfeeding among urban women interviewed in the 1984 BFHS was 17.6 months. The mean duration calculated from the 1988 data was 14.7 months, t There are small differences in post-partum insusceptibility by level of education. On average, women with less education breastfeed for longer periods and thus have a longer duration of amenorrhea. A comparison of the effects of residence and education on post-partum insusceptibility suggests that aspects of urban life, more than higher levels of educational attainment, cause erosion of traditional practices which protect a woman from another pregnancy for several months after a birth. These results suggest that the MCH/FP programme must work to maintain the customary post-partum practices which contribute significantly to the well being of mother and child by delaying the next pregnancy. : The median duration of breastfeeding from the 1984 BFHS data was calculated by life table techniques while the mean duration from the 1988 BFHS-II survey was calculated using the incidence/prevalence method described in the text. Differences in the estimation techniques would underestimate the decline, since the mean duration is usually longer than the median duration--women who breastfeed for very long periods will affect the estimate of the mean but not the median. The median and mean duration of breastfeeding for rural women, 20.2 months, is identical in the two surveys. 19 3. FERTILITY This chapter contains a discussion of levels, trends, and differentials in fertility in Botswana. The BFHS-II questionnaire included questions on the total number of live births and surviving children a woman had over her lifetime, as well as a detailed birth history. Each respondent was asked about the number of sons and daughters living with her, sons and daughters living away, and sons and daughters who died. Then the respondent was asked to provide a complete maternity history, including the sex of the child, date of birth, survival status, and current age or age at death. 3.1 FERTILITY LEVELS AND TRENDS Table 3.1 and Figure 3.1 present data on current fertility by selected background characteristics of the respondents. The measure of current fertility is the total fertility rate. This represents the total number of births a woman would have by age 50 if she had children at the same rate as women currently in each age group. To indicate recent trends in fertility, the total fertility rate is shown for the calendar periods 1982-1984 and 1985 through the time of the survey in 1988. In order to examine differentials in recent fertility levels according to background characteristics, the total fertility rate is also shown for the 5-year period before the survey. The fourth column contains the mean number of children ever born to women 45-49 years of age which serves as a measure of cumulative fertility for women close to the end of their childbearing years. Table 3.1 Background Character ist ics Total Fer t i l i ty Rates for Calendar Year Periods and for Five Years Preceding the Survey, and Mean Number of Children Ever Born to Women 45-49 Years of Age, by Selected Background Character ist ics, BFHS-II 1988 Mean Number of Total Fer t i l i ty Rates: Chi ldren 0-4 Years Ever Born 1985- 1982- Before to Won~n 1988 1984 Survey Age 45-49 Residence Urban 3.9 5.0 4.1 5.3 Rural 5.4 6.1 5.4 5.9 Education No Education 5,9 7.1 6.0 6.2 Incomplete Primary 5.2 5.9 5.2 5.6 Complete Primary 4.7 5.0 4.6 5.0 Secondary or Higher 3.4 3.6 3.3 4.1 Total 4.9 5.9 5.0 5.8 Fertility in Botswana remains high. The total fertility rate for the five-year period prior to the survey is 5.0 children per women. The fertility of urban women is lower than that of rural 21 7 6 5 4 3 2 1 Figure 3.1 Children Ever Born to Women 45-49 and Total Fertility Rate 0 -4 Years Before the Survey No. of Children TOTAL Urban Rural /i None h Primary Primary Secondary~ RESIDENCE EDUCATION [ ~ CEB m TFR i BFHS-II 1988 Fertility in Botswana remains high. The total fertility rate for the five-year period prior to the survey is 5.0 children per women. The fertility of urban women is lower than that of rural women. At current fertility rates, urban women can expect to have four children, while rural women will have more than five. The largest differences in fertility are by level of education. Women with secondary or higher education have a total fertility rate of only 3.3, while the total fertility rate of women with no education, 6 births per woman, is almost twice as high. The survey results show a recent decline in fertility in Botswana. One indicator of this decline is the difference between current fertility, as measured by the total fertility rate, and the cumulative fertility of women currently at the end of their childbearing years, represented by the mean number of children born to women 45-49. This latter measure reflects the fertility levels prevailing in the past when these women passed through their childbearing years. At 5.8 births per woman, cumulative fertility is almost one birth higher than the current total fertility rate of 5.0. Another indicator of recent fertility decline is the drop in the fertility rate from 5.9 in the period 1982-1984 to 4.9 in the next three-year period. This is an exceptionally steep rate of decline. An examination of the birth history data shows heaping of births in 1982 and a deficit of births for the previous year. Some of the births reported to have occurred in 1982 probably occurred prior to that year, causing fertility for the period 1982-1984 to be overestimated. Nonetheless, it is clear that there was a significant decline in fertility in the recent period. 22 Fertility has declined more among urban than rural women. This is expected, since the opportunities for employment and other factors associated with urban life generally have a negative effect on fertility. A comparison of the TI'Rs for the two periods preceding the survey by level of education shows a much greater decline in fertility between the period 1982-1984 and 1985- 1988 for women with no education and incomplete primary school, than for women who have completed primary school. However, fertility in the earlier period for less educated women is most likely overestimated because of misreporting of birth dates by these women. If the mean number of children ever born to women 45-49 is compared to the fertility rate for the five-year period preceding the survey, it appears that women at all levels of education less than secondary have experienced similar declines in fertility, while fertility has declined the most among women with more than secondary education. Figure 3.2 Age-Specific Fertility Rates 1981 Census, 1984 BFHS, and 1988 BFHS-II Births per 1,000 women 300 200 100 0 I I b i I 15-19 20-24 25-29 30-34 35°39 40-44 45-49 Age Group 1981 Census* 1984 BFHS --~--- 1988 BFHS-II *Adjusted rates Figure 3.2, a comparison of the fertility data from the BFHS-II with the 1981 census and the 1984 BFHS, shows a large decline in fertility for women of all ages except teenagers. The adjusted total fertility rate was 7.1 in 1981 and 6.5 in 1984, compared with 5.0 in 1988. A more detailed analysis of the fertility data from the three surveys is necessary in order to determine if such a sharp decline in fertility actually occurred over the last ten years, or whether one or more of the rates is inaccurate. However, preliminary analysis suggests that declining fertility among women of all socioeconomic groups, measured by level of education, and a shift to a greater concentration of women at higher levels of education could account for the large decline in fertility. 23 Furthermore, the fertility decline is occurring in the context of increasing use of modem methods of contraception in Botswana. The complete birth history data can be used to analyze trends in fertility for successive five- year periods in the past. Omission of births and incorrect reporting of birth dates can affect the accuracy of trends, and the trends derived from birth history data should be viewed with caution. Table 3.2 shows the age-specific fertility rates for five-year periods preceding the survey. There are indications that fertility began to decline some 10-15 years before the survey, about the same time the Family Planning Programme was introduced in 1973. The trend in the period rates also suggests that fertility decline has accelerated in recent years. TabLe 3.2 Age-Specific Fert iL i ty Rate (per 1,000 women) for Five-Year Periods Preceding the Survey, by Age of Woman at Birth, SFHS-II 1988 Maternal Number of Years Preceding Survey Age 0-4 5-9 10-14 15-19 20-24 25°29 30-34 132 121 106 (58) 289 282 (266) 244 (233) (251) 15-19 125 150 167 20-24 212 258 286 25-29 202 256 287 30-34 191 242 226 35-39 148 170 (217) 40-44 63 (124) 45-49 (38) Note: Figures in parenthesis are based on par t ia l l y truncated information. 3.2 CURRENT PREGNANCY Table 3.3 looks at data on current pregnancy, a measure of immediate future fertility. The data on those currently pregnant also gives an indication of the demand for antenatal services. There is likely to be some under-reporting of current pregnancies, due to embarrassment or uncertainty, particularly among women in the first three months of pregnancy. Seven percent of the women in the survey reported being pregnant. The proportion pregnant was highest in the 25-29 age group. 3.3 CttI I .DREN EVER BORN Data collected on the number of children ever born can be used to examine levels and patterns of cumulative fertility in Botswana. In the BFHS-II questionnaire, the total number of children ever born is ascertained by a series of questions designed to maximize recall. The number of children ever born is a measure of lifetime fertility and reflects the accumulation of births in the past. While such information may have limited relevance to the current situation, the data provide insight into fertility patterns by age, which is important for understanding current fertility. 24 Table 3.3 Percent of A[[ Nomen who ~ere Pregnant at the Time of the Survey, by Age, BFHS- I 1 1988 Number Percent of Age Pregnant Nomen 15-19 5.5 937 20-24 8.0 926 25-29 10.2 846 30-34 8.0 653 35°39 6.6 464 40-44 3.9 290 45-49 1.4 251 Total 7.1 4368 Table 3.4 presents the number of children ever born, for all women and for women ever in a union and never in a union. The distribution of children born to women never in union emphasizes the significant amount of childbearing that occurs outside of unions. Women in Botswana have an average of 2.6 children. Fertility increases rapidly with age. The average number of live births is one for women in their early twenties, more than two for women in their late twenties, and almost four for women 30-34. Women 45-49, who are nearing the end of their childbearing years, have an average of almost six births. The proportion of childless women declines rapidly with age, to a level of three percent among women 45-49 years old. This is in the expected range of 3-5 percent and suggests that primary sterility is not a factor influencing fertility levels in Botswana. Among women ever in union (including currently married women, those living with a partner, and women who are widowed, divorced or separated), 42 percent of the teenagers 15-19 have never had a child; 47 percent have had one child, and 12 percent have had two. The majority of women ever in union have had at least two children by age 25 and three by age 30. Only six percent of women ever in union are childless, while almost half have had four or more children. The mean number of children born among women ever in a union is 3.9. Slightly more than three-quarters of never-married teenagers have never had a child, 19 percent have had one child and two percent have had two children. However, by age 25 the majority of never-married women have had at least one child. At the younger ages, never-married women have had, on average, one-half fewer births than their married peers; the difference is one birth by age 30, and almost two births by the end of the childbearing years. While the mean number of children ever born to women never in union is less than half that of women in union, this is due partly to the fact that young women make up a larger proportion of the never-married group. 25 Table 3.4 Percent D is t r ibut ion of A l l Women, Women Ever in Union, and Women Never in Union by Number of Children Ever Born and Mean Nun~ber of Children Ever Born, According to Age, BFHS-II 19~ Number of Children Ever Born Age None I 2 3 4 5 6 7 8 9 At{ Women Number of 10+ Total Women Mean 15-19 76.5 21.0 2.3 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 937 0.3 20-24 25.4 42.5 23,6 7.1 1.4 0.0 0.0 0.0 0.0 0.0 0.0 100.0 926 1,2 25-29 5.8 18.8 26.4 24.4 16.6 5.7 1.6 0.3 0.3 0.0 0.0 100.0 846 2.5 30-34 5.4 6.2 12.9 22.0 19.0 19.0 9.8 4.2 0.8 0.5 0.1 100.0 653 3.7 35-39 1.4 5.3 7.2 10.2 15.6 14.7 18.6 12.4 9.2 4.1 1.4 100.0 464 5.1 40-44 4.9 3.9 10.0 11.3 8.5 10.0 12.6 12.3 11.8 7.2 7.7 100.0 290 5.4 45-49 3.2 5.2 7.1 }'.7 11.5 13.3 13.2 9.5 7.4 11.7 10.3 100.0 251 5.8 Total 24,4 19.2 14.4 11.8 9.2 6.9 5.3 3.4 2.4 1.7 1.3 100.0 4368 2.6 women Ever in Union DJ 15-19 41.6 46.7 11.}" 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 57 0.7 20-24 16.3 33.9 34.9 13.8 1.2 0.0 0.0 0.0 0.0 0.0 0,0 100.0 280 1.5 25-29 3.}' 13.8 22.4 28.0 19.7 9.1 2.5 0.3 0.5 0.0 0.0 100.0 480 2.9 30-34 4,3 5.3 10.2 19.9 18.8 21.0 13.6 5.2 1.2 0.4 0.1 100.0 455 4.0 35-39 1.1 3.3 5,}' 6.8 14.7 15.8 21.7 13.3 11.2 4.7 1.8 100.0 348 5.5 40-44 2.7 3.6 7,6 11.3 8.3 10.5 13.4 11.8 13.2 8.2 9.4 100.0 236 5,8 45-49 3.5 5.8 5.8 8.0 9.9 12.5 13.0 10.4 6.8 12.5 11.9 100.0 200 5.9 Total 6.0 11.8 15.0 16.0 13.3 11.9 10.0 5,8 4.5 3.0 2.6 100.0 2056 3.9 Women Never in Union 15-19 78.6 19.4 1.7 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 880 0.2 20-24 29.4 46.2 18.6 4.2 1.4 0.0 0.0 0.0 0.0 0.0 0.0 100.0 646 1.0 25-29 8.5 25.3 31.6 19.8 12.6 1.3 0.6 0.4 0.0 0.0 0.0 100.0 366 2.1 30-34 0.0 8.2 19.3 26.9 19.4 14.4 1,0 2.0 0.0 0.7 0.0 100.0 198 3.0 35-39 2.5 11.2 11.7 20.5 18.2 11.5 9.2 9.7 3.0 2.5 0.0 I00.0 116 4.0 40-44 14,5 5.4 20.4 11.3 9.1 7.5 9.1 14.5 5.4 2.7 0.0 100.0 54 3.8 45-49 2.3 2.9 12.0 6.9 17.7 16.6 13.7 5.7 9.7 8.6 4.0 100.0 51 5,2 Total 40.6 25.8 13.9 8.1 5.6 2.6 1.2 1.2 0.5 0.4 0.1 100.0 2312 1.4 3.4 AGE AT FIRST BIRTH The onset of childbearing is an important demographic indicator. Postponement of first births can make a large contribution to overall fertility decline. Furthermore, the proportion of women who become mothers before the age of 20 is a measure of the magnitude of teenage pregnancy, which is regarded as a major health and social problem in many countries including Botswana. Tabte 3.5 Percent D is t r ibut ion of ALl Women by Age at F i r s t B i r th end Median Age at F i r s t B i r th , According to Current Age, BFHS-|I 1988 Median Number Age at Current No Age at First girth Totot of First Age girths <15 15-17 1a-19 20-21 22-24 25+ Percent Worn Birth 15-19 76.5 0.9 16.6 5.9 0.0 0.0 0.0 100.0 937 20-24 25.4 1.6 24.0 29.1 15.5 4.4 0.0 100.0 926 19.7 25-29 5.8 3.8 26.8 30.5 20.6 9.9 2.5 100.0 846 19.2 30-34 5.4 2.6 24.8 32.9 17.7 10.7 5.9 100.0 653 19.3 35-39 1.4 2.2 24.5 29.7 19.9 14.9 7.3 100.0 464 19.6 40-44 4.9 1.6 18.4 29.8 21.6 11.0 12.8 100.0 290 20.0 45-49 3.2 2.4 13.6 22.5 23.2 15.0 19.9 100.0 251 20.9 Total 24.4 2.1 22.2 24.7 14.8 7.6 4.1 100.0 4368 - Omitted due to censoring. The percent distribution of all women by current age and age at first birth is shown in Table 3.5. The median age at first birth for the age groups in which more than fifty percent of the women have had a birth are shown in the final column of Table 3.5. Very few women report having their first birth before age 15. The majority of first births occur between age 15 and 20. The median age at birth in Botswana is slightly under twenty years. There appears to be no significant difference in median age between older women who had their first child many years ago and younger women who had their first birth recently. It is likely that the later age at first birth reported by older women is due to misreporting of the dates of first births. Table 3.6 presents the median age at first birth for different age groups and compares age at entry into motherhood for different sub-groups of the population. There is no significant difference in age at first birth between urban and rural women. The effect of secondary and higher education on delaying the age at first birth, however, is pronounced. The median age at first birth for women who have attended secondary school is at least one year later for all cohorts. 3.5 TEENAGE PREGNANCY Since pregnancy before the age of 20 places the health and welfare of teenagers and their births at risk, the policy of the Government of Botswana is to encourage individuals and families to delay the first pregnancy until that age. There is growing concern in Botswana at what is perceived as being a disturbingly high and increasing rate of teenage pregnancy. The subject of 27 Table 3.6 Median Age at First Birth Among Women 25-49, by Current Age and Selected Background Characteristics, BFHS-II 1988 Background Current ARe Characteristic 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 19.5 19.4 19.5 20.2 20.7 20.7 19.7 Rural 19.7 19.1 19.3 19.5 19.9 20.9 19.6 Education No Education 19.0 18.5 18.9 19.3 19.9 21.2 19.1 Incomplete Primary 18.9 18.7 18.8 19.2 19.6 20.3 19.2 Complete Primary 19.5 19.3 19.2 20.1 21.1 * 19.5 Secondary or Higher 20.7 20.5 20.8 21.9 21.7 * 20.8 Total 19.7 19.2 19.3 19.6 20.0 20.9 19.6 * Fewer than 20 cases. teenage pregnancy has received wide publicity because of the public's concern over the number of cases of school dropouts and reports of baby dumping. Several organizations, including the Botswana Family Welfare Association, the Young Women Christian Association, the Women Affairs Unit, and the Maokaneng Radio Programme, have introduced programmes to educate youth about the risk of becoming pregnant during their teens and provide information and counselling to teenagers on how to avoid pregnancy. Other programmes provide classes for teenage mothers or carry out studies to assess the extent and impact of teenage pregnancy. The BFHS-II included questions on the circumstances at the time women became pregnant for the first time. All respondents were asked if they ever left school because of pregnancy and, if so, did they return to school. Respondents who were not married at the time they had their first birth were asked about the use of family planning when they first had sexual intercourse, their parents' reaction to their pregnancy, and whether they or their child had a continuing relationship with the father of the child. Selected results from these questions are presented in this section. It is anticipated that a full report on teenage pregnancy in Botswana, based on the BFHS-II findings, will be published at a later date. Table 3.7 and Figure 3.3 show the percentage of teenagers who are mothers, by background characteristics. Nearly one-quarter of teenagers have had at least one birth and an additional five percent were pregnant with their first child at the time of the survey. If only those teenagers who have initiated sexual relations are considered (two-thirds of all teenagers), the proportion who have had a birth or were pregnant at the time of the interview is 43 percent. Among teens who have been pregnant at least once, the average age at first pregnancy is 16 years. 28 Table 3.7 Percentage of Teenagers 15-19 ~dho are Mothers or Pregnant with their First Child, and Mean Age at F irst Pregnancy, Accordingto Se[ected BackgroundCharacteristics, BFH$-II 1988 Percentage Who Are: Background Pregnant with Number of Mean Age at Characteristic Mothers First Child Teenagers 1st Pregnancy Age 15 5.1 0.9 160 14.3 16 9.9 1.1 211 14.8 17 26.5 5.9 127 15.3 18 33.2 7.8 244 16.2 19 39.2 7.7 196 17.0 Residence Urban 21.0 5.2 291 16.2 Rural 24.6 4.7 646 16.1 Level of Education No Education 40.1 6.8 51 16.0 Incomplete Primary 29.1 3.9 184 15.6 Complete Primary 23.6 4.5 348 16.2 Secondary or Higher 18.0 5.4 354 16.4 Total 23.5 4.9 938 16.1 Figure 3.3 Percentage of Teenage Women Who are Mothers or Pregnant with First Child Percent 50 40 30 20 10 0 Total 15 16 17 18 19 None Primary Primary Secondary* AGE EDUCATION I m Mothers ~ Pregnant w/ let child BFHS-II 1988 29 There is an inverse relationship between teenage parenthood and education. Among teens with no education, 40 percent have had at least one birth, compared to 18 percent of women with secondary or higher education. Surprisingly, the average age at first pregnancy is only slightly higher for women with complete primary or higher education than for women with incomplete primary or no education. The trend since 1971 in the proportion of teenage mothers is shown for all teenagers and according to urban-rural residence in Table 3.8. There is a definite upward trend in the proportion of teenage mothers. The proportion increases from 15 percent in 1971 to 24 percent in 1988. Trend data according to place of residence is available since 1981. The data show that the proportion of teenage mothers has increased in both urban and rural areas. Table 3 .8 Percentage of Teenagers 15-19 Who are Mothers, 1971 to 1988, According to Urban-Rural Residence Urban Rural Total 1971 NA NA 15.4 1981 17.4 21.1 20.3 1984 17,6 24,6 22.6 1988 21.0 24.8 23.7 NA Not ava i lab le Source: 1971 and 1981 Populat ion Census 1984 Botswana Family Health Survey One of the principal concerns about teenage pregnancy in Botswana is its impact on drop- out rates of teenage girls. Table 3.9 shows that 9 percent of teenagers left school because of pregnancy. These women constitute one-third of all teenagers who have ever been pregnant. The proportion who left school because of pregnancy is greatest among women age 18 at the time of the survey. Women in urban areas were more likely to drop out of school, probably because urban women generally stayed in school longer and thus were more likely to face a conflict between their pregnancy and school. About one-fifth of the teens who left school due to pregnancy were readmitted. 30 Table 3.9 Percentage of Teenagers 15-19 Who Left School Due to Pregnancy, and Percentage Who Left School Who Were Reaclnitted, According to Age and Residence, BFHB-i! 1988 Left School Nuttier Because of Readmitted of Pregnancy to School Teenagers Age 15 2.0 0.0 160 16 6.0 4.6 211 17 10.3 20.0 127 18 15.1 23.6 244 19 10.7 37.5 196 Residence urban 10.6 26.9 291 Rural 8.7 20.5 646 Toter 9.3 22.8 937 31 4. FAMILY PLANNING KNOWLEDGE AND USE Family planning activities have been integrated into maternal and child health services in Botswana since the beginning of the national programme in 1973. The policy of the Government affirms that these services be available to every family and it is the basic right of each family to determine the number of children and when to have them. Family planning services are available at all levels of health care including private doctors and pharmacies, although the majority of the services are provided by more than 440 public health facilities. Since 1984, family planning services have been available on a daily basis along with other curative and preventive services. The family planning programme offers a wide range of modern contraceptive methods: Oral Contraceptives (Pill), Intra-Uterine Device (IUD), Depo-Provera Injection, Condom, Diaphragm, Contraceptive Foam and Jelly, and Female and Male Sterilisation. Health facilities charge a nominal fee of 40 thebe, about 20 US cents, for out-patient consultations, including family planning services; condoms are provided without charge. Participation in the family planning programme is fostered by health education disseminated through home visits, kgotla, volunteer efforts, the media, schools, and talks at health facilities. The Family Health Division is in the process of developing alternative distribution outlets for contraceptives: a new programme offers condoms at the work place in selected private sector industries and plans are underway to launch a condom vending machine pilot project. This chapter looks at several aspects of the knowledge and use of family planning among Batswana women. It begins with an appraisal of the knowledge of family planning methods and sources of supply, and then presents findings on past and current use of contraception. The latter part of the chapter focuses on reasons for nonuse and discontinuation of contraception, intention to use in the future, attitudes of respondents toward family planning, and the acceptability of various sources of family planning messages. These topics are of practical use to policy and programme staff in several ways. The early sections concern the main pre-condition to adoption of contraception, knowledge of methods and sources of supply. Levels of contraceptive use provide the most obvious and widely accepted criteria of success for any family planning programme. Practical problems with particular methods, or more general doubts about family planning, that might prevent a woman from using contraception, are potential obstacles to further advances in the programme. Survey findings on these topics can guide administrators in the improvement and expansion of family planning services. Data on attitudes towards family planning and acceptability of media messages on family planning are useful in guiding the content of information and education campaigns and targeting groups 33 according to their need for information and the type of sources from which they are comfortable receiving information. 4.1 KNOWI.FJ')GE OF FAMILy PLANNING Knowledge of family planning methods and of places to obtain them are crucial elements in an individual or couple's decision whether to use family planning and which method to use. Presumably, improved knowledge of family planning methods will be followed by greater use. Data on knowledge of family planning methods were obtained by first asking respondents to name all the different ways that a woman or man could delay or avoid a pregnancy. If a respondent did not spontaneously name a particular method, the method was described by the interviewer and the respondent was asked if she recognized the method. Probing was used to collect data on 10 methods: pill, IUD, injection, diaphragm/foam/jelly (vaginal methods), condom, female sterilisation, male sterilisation, periodic abstinence (rhythm), withdrawal and prolonged abstinence. In addition, provision was made in the questionnaire to record any other methods, e.g., folk methods, spontaneously named by the respondent. For each modern method I named or recognized, the respondent was asked where she would go if she wanted to obtain that method. If the respondent knew of periodic abstinence, she was asked where she would go to obtain advice about the method. Finally, for all methods that the respondent knew, she was asked what problem, if any, she associated with the use of that method. The percentages of all women and women currently in union who know each method of family planning and a source for that method are shown in Table 4.1. Knowledge of modern methods of contraception is high in Botswana with 95 percent of all women knowing at least one modern method of family planning. Women not currently in union were as likely to know methods of family planning as women in union. Knowledge has increased steadily since the BFHS was conducted in 19847 In 1984, 75 percent of the women reported knowing at least one modern method of contraception, compared to 95 percent in 1988. Women are most likely to have heard of the pill, followed by the IUD, injection, and the condom. These were also the methods most often recognized in 1984. However, among all women, pill knowledge rose from 72 to 94 percent, IUD knowledge from 66 to 89 percent, knowledge of injection from 62 to 88 percent, and condom knowledge from 48 to 87 percent. Male sterilisation, diaphragm, foam, and jelly, and female sterilisation are the least known of the modern methods. The low level of knowledge of vaginal methods can be attributed to the lack 1 Modern methods of family planning include the pill, IUD, injection, diaphragm/foam/jelly, condom, and female and male sterilisation. 2 The 1984 BFFIS differed somewhat from the BFHS-II in the manner in which information on contraceptive knowledge was collected. In both surveys, women were first asked to name all the family planning methods that they knew. Interviewers then probed to find out if women recx)gnized methods they had not mentioned spontaneously. In the 1984 BFHS, the interviewers used only the name of the method when they probed; in the BFHS-II both the name and a brief description were used. Some of the difference in knowledge between the two surveys may be related to differences in the probing techniques. 34 Table 4.1 Percentage of At[ Women end Wo~nen Currently In Union ~/ho Know a FamiLy PLanning Method and ~¢no Know a Source (For Information or Services), by Specif ic Method, BFHS-II 1988 Know Method Know Source Womn Wu~en All Currently ALL CurrentLy Method Women in Union Wo¢nen in Union Any Method 95,4 94.8 94.8 94.3 Any Modern Method 95,1 94.4 94.7 94.2 Pitt 94,5 93.6 94.0 93.5 IUD 89,4 89.5 88.5 89.2 Injection 87,6 89.4 87.1 89.2 Diaphragm/Foam/JeLLy 50,9 51.3 50.4 51.1 Condom 87,4 87.1 85.8 86.1 FemaLe $ter i l i sa t ion 57,6 66.6 56.5 65.7 Mate S ter i t i sa t ion 23.2 24.7 22.8 24.2 Any Trad i t iona l Method 41,5 45.6 21.0 21.9 Periodic Abstinence 23,0 23.8 21.0 21.9 Withdrawal 252 29.1 Other 3,1 3.9 Abstinence 27,5 32.8 Number 4368 1708 4368 1708 - Question not asked. of attention paid to these methods by health workers. While health workers are instructed to provide information on all methods offered by the programme, in practice emphasis is on temporary methods which are perceived to be both effective and easy to use, such as the pill, IUD, and injection. Although knowledge of vaginal methods and female and male sterilisation continues to lag behind that of other modern methods, knowledge of these methods also rose significantly between 1984 and 1988. Traditional methods were named less frequently in the 1988 survey than in 1984. Reported knowledge about traditional methods is particularly sensitive to the degree of probing and it is possible that differences in questionnaire design account for the lower reporting of these methods in the BFHS-II. However, it is logical that there would be a reduction in the dissemination of information about these methods as modern methods become more accessible. Lack of knowledge of sources for methods is not an obstacle to use in Botswana. Columns two and four of Table 4.1 show that virtually all women who have heard of a method were able to name a source for that method. This is not surprising, as the government health network is widely recognized as a source for all health care including family planning. The percentages of all women knowing a modern method of family planning and a source for that method by selected background characteristics are presented in Table 4.2. There is little variation in knowledge of methods and sources among sub-groups of Batswana women. There are no differences in the level of knowledge by whether the respondent is currently or was formerly 35 in union, or has never been in union. Except for the oldest women, more than 90 percent of women regardless of age know a modern method and a source. The highest level of knowledge is found in the 25-29 age group. Respondents residing in rural areas show only a slightly lower level of knowledge than urban dwellers. Looking at the data on knowledge by level of education, respondents with no education are less knowledgeable about methods or sources in comparison with the remainder of women who have attended school. Table 4.2 Percentage of All Women Who Know at Least One Modern Method of Family Planning and Who Know a Source for a Modern Methnd, by Selected Background Characteristics, BFHS-II 1988 Know Number Background Modern Know of Characteristic Method Source women Union Status Never in Union 95.8 95.2 2312 Currently in Union 94.4 94.2 1708 PrevicaJsLy in Union 94.4 g4.4 349 Age 15-19 94.0 92.8 937 20-24 96.9 96.5 926 25-29 97.9 97.7 B46 30-34 95.7 95.7 653 35-39 95.5 95.5 464 40-44 91.9 91.7 290 45-49 84.9 84.9 251 Residence Urban 98.5 98.4 1316 Rural 93.7 93.2 3052 Education No Education 86.9 86.2 1045 Incoraptete Primary 95.1 94.5 1073 Co~plete Primary 98.6 98.3 1115 Secondary or Higher 99.4 99.3 1135 Total 95.1 94.7 43~ 4.2 KNOWI.FDGE OF SOURCES FOR FAMILY PLANNING ME-IHODS Table 4.3 shows that most women who know a method named the government clinic as the source of supply, although government health posts are the most common type of public health facility. It appears that many respondents did not differentiate between a health post and a clinic and simply referred to their local health facility as a clinic. Private doctors and clinics and pharmacies play a minor role in supplying methods in Botswana. The popularity of government facilities is undoubtably due to the fact that they are easily accessible and that family planning services are provided free or at a very low cost. 36 Table 4.3 Percent Distril~Jtion of Women I/no Kno~ a Famity Planning Method by Supply Source They Would Use i f They Wanted the Method, According to Specific Nethod, BFHS-II 1988 Family Planninq Method Known Diaphragm/ Female Note Supply Source Foam/ S ter i t i - Ster f t i - Periodic Named Pi t t IUD Injection Je l ly Condom sation sation Abstinence* Governn~nt Health Post 2.2 1.4 1.5 1.6 2,0 0.2 0.4 2.5 Government Cl inic 87.2 81.4 81.9 83.9 84,0 22.1 21.2 63.9 Government Hospitst/ 9.0 15.3 15.3 12.2 10.2 74.7 74.7 13.2 Health Centre Private Doctor/Clinic 0.7 0.9 0.7 0.9 0,5 0.8 1.9 2.3 Pharmacy 0.3 0.0 0.0 0.4 1.4 0.1 0.0 0.1 Other 0.0 0.0 0.0 0.0 0,0 0.0 0.2 9.1 None 0.0 0.0 0.0 0.0 0,0 0.0 0.0 0.2 Oon't knom 0.4 0.7 0.3 0.6 1.2 1.3 1.2 2.5 Nissing 0.1 0.3 0.3 0.4 0,6 0.7 0.3 6.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Nunt~er of Wo~en 4126 3905 3828 2225 3817 2517 1012 1004 * Refers to source for information about the method. Slightly over 20 percent of the women who knew about female or male stcrilisation reported the government clinic as a potential source of the operation. However, sterilisations are carried out only in health centres and hospitals. These women may be misinformed about obtaining female or male sterilisation at a government clinic or, again, they may not be clearly differentiating between various types of health facilities. 43 ACCEPTABILITY'OF ME-mHODS In order to identify potential obstacles to the wider use of family planning methods, women in the BFHS-II who reported knowing a method of contraception were asked what was the main problem, if any, they perceived in using the method. Table 4.4 shows the distribution of women who have heard of a method, by the main problem they perceive in using the method. As can be seen in Table 4.4, only a minority of women reported knowing of problems with methods. The proportion reporting "no problem" with the method ranges from 16 percent for injection to 69 percent for prolonged abstinence. Additionally, many women answered "don't know" when asked about problems with specific methods: 18 percent for periodic abstinence to 63 percent for the diaphragm/foam/jelly. Nevertheless, significant minorities of women reported concerns about specific methods. One in three women who know the pill, IUD, or injection reported that health concerns were the major problem with the method. One-quarter of the women who know about female or male sterilisation reported the irreversibility of the method as a problem. One in seven women who know about periodic abstinence or withdrawal reported that they were ineffective. More women than one would expect, 9 percent, considered the IUD to be ineffective. Another unexpected result is that 9 percent of women who know about injection reported the 37 main problem to be that the method was permanent. This suggests that some women are misinformed about the efficacy and reversibility of these contraceptive methods. Table 4.4 Percent D is t r ibut ion of Women Who Know a Family Planning Method by Main Problem Perceived in Using the Method, According to Specif ic Method, 8FHS-II 1988 FamiLy Planning Method Known Oiaphragr~/ Fe~te ~ate Periodic Main ProbLem Foam/ S ter i t - S ter i t - Abst i - With- AbSti- Perceived P i t t IUD In jec t ion Jet ty condom isat ion isat ion hence drawat nence No prob't em 38.4 19.2 16.1 22.1 42.3 23.9 22.5 52.4 /*9.3 68.8 Not e f fec t ive 3.9 8.6 1.4 6.4 7,7 1.0 0.9 16.8 15.8 6.6 Partner disapproves 0.3 0.3 0.1 0.3 1.3 0.2 0.7 2.0 2.2 1.7 Health concerns 34.3 34.1 34.0 5.0 7,2 14,7 11.1 1.5 2.4 1.6 Access/avai tabi [ i ty 0.0 0.0 0.2 0.0 O.O 0.4 0.3 0.0 0.1 0.0 Costs too much 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Inconvenient to use 0.6 0.8 0.5 2.6 2.7 0.0 0.1 1.1 3.0 1.8 Method permanent 0.4 0.1 8.4 0.2 0.1 22.3 27.9 0.1 0.2 0.0 Other 0.3 0.4 0.6 0.2 0.4 0.3 0.0 0.3 0.7 0.0 Don't know 21.7 36.2 38.7 63.0 57.5 36.2 35.9 24.3 24.9 17.9 Missing 0.1 0.1 0.2 0.2 0.6 1.0 0.5 1.5 1.2 1.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of Women 4126 3905 3828 2225 3817 2517 1012 1004 1099 1202 The fact that the respondents did not mention cost, access, or availability as a problem reinforces the impression that the majority of the population is aware of the widespread availability of family planning services in the country. It is also interesting to note that few women reported partner's disapproval to be a problem in using any of the methods. 4.4 EVER USE OF FAMILY PLANNING METHODS More than half of Batswana women have used a modern method of family planning at some time. Table 4.5 shows that the method used by most women, 46 percent, was the pill. The IUD has been used by 13 percent of women, and contraceptive injection by 10 percent. The least used modern methods are vaginal methods and male sterilisation. Ever use of traditional methods is much lower than that of modern methods. The pill has been widely used among women in all age groups with the highest percentage of ever-use among women aged 25-29. IUD use has been concentrated among women currently between the ages of 25 and 34, while injection has been used mostly by women over age 35. This age pattern of method use reflects the general practice of the family planning programme to recommend the pill to childless women, the IUD to younger women with children, and injection to women over 35. The number of living children at the time of the first use of family planning is an indicator of whether contraception is being adopted to delay or limit births. Table 4.6 presents the percent 38 Table 4.5 Percentage of ALL Women and Wo~en in Union Who Have Ever Used a Family Planning Method by Specif ic Method and Age, BFHS-I! 1988 Family PLanning Method Ever Used Any Any Tra- Diaphragm/ Female Mate Number Any Modern d i t ionat Foam Ster i t i - s te r i t i - Periodic With- Abst i - of Age Method Method Method P i l l IUD in jec t ion Jetty Condom sation sat ion Abstinence drawa[ Other nence Women ALL Women 15-19 26.5 25.5 2.8 19.5 1.6 0,2 0.4 7.2 0.0 0.0 1.7 0.7 0.0 1.5 937 20-24 60.3 58.9 9.5 52.4 10.9 4.4 0.3 11.6 0.0 0.2 4,9 2.7 0.4 5.3 926 25-29 73.2 72.1 13.8 65.6 19.8 11.6 0.4 11.1 0.5 0.0 4.9 5.5 1.3 6.9 846 30-34 70.1 67.9 13.1 58.0 23.5 15.2 1.3 12.1 2.0 0.2 4.4 5.4 0.9 9.0 653 3•-39 65.3 63.5 13.6 51.5 19.1 23.1 1.0 8.8 5.9 0.4 4.4 5.6 1.1 7.6 464 40-44 55.0 52.3 12.1 36.1 12.4 20.7 1.2 8.6 11,4 0.6 4.0 5.6 1.2 8.4 290 45-49 40.2 31.1 14.6 21.4 7.9 10.0 1.9 5.5 7.3 0.8 7.3 6.9 1.0 9.4 251 Total 56.0 54.1 10.3 45.8 13.3 9.9 0.7 9.8 2.2 0.2 4.2 4.0 0.7 6.0 4368 Wo~en In Union 15-19 36.6 33,9 7.5 23.7 0.0 1.1 0.0 12.4 O.O 0.0 3.8 6.4 0.0 3.8 54 20-24 59,5 57.2 11.7 50.7 15.6 6.5 1.1 6.8 0.0 0.0 5.5 4.3 0.5 5.2 238 25-29 68.6 67.6 13.9 61.1 17.9 14.0 0.8 10.5 1.0 0.0 4.5 5.6 1.1 7.2 420 30-34 69.9 66.7 14.6 55.2 23.9 16.9 1.9 13.3 1.9 0.3 4.9 5.9 1.0 10.9 382 35-39 68.1 66.7 12.7 54.1 20.1 23.3 1.1 8.7 7.3 0.7 5.4 5.9 1.6 5.8 290 40-44 56.6 52.3 14.5 31.8 13.4 18.8 1.1 9.7 15.7 1.0 4.9 5.9 1.0 9.7 182 45-49 40.8 30.7 15.5 19.8 8.1 10.5 2.9 8.9 8.5 0.4 7.0 7.8 0.4 9.7 140 Total 63.0 60.1 13.5 49.4 17.4 15.0 1.3 10.1 4.3 0.3 5.1 5.8 1.0 7.9 1706 distribution of all women by the number of living children at the time they first used family planning. In interpreting the data in Table 4.6, it is important to keep in mind that the family planning programme in Botswana is only 15 years old, and as such, older women had little access to contraception when they were bearing their first children. Table 4.6 Percent D is t r ibut ion of A l l ~o~nen by Number of L iv ing ch i ldren at Time of F i rs t Use of Contraception, According to Current Age, BFHS-11 1988 Current Age Number of L iv in R Chi ldren Number Never of Used None 1 2 3 4+ Nissing Total Women 15-19 73.5 19.6 6.3 0.2 0.0 0.0 0.4 100.0 937 20-24 39.7 20.4 30.6 7.4 1.2 0.5 0.2 100.0 926 25-29 26.8 7.3 32.7 19.1 8.6 5.2 0.3 100.0 846 30-34 29.9 6,4 19.5 20.3 11,3 12.3 02 100.0 653 35-39 34.7 3.4 11.0 10.5 12.6 27.4 0.4 100.0 464 40-44 45.0 4.2 8.5 5.2 9.0 27.4 0.7 100.0 290 45-49 59.8 3.1 7.5 2.9 8.4 18.3 0.0 100.0 251 Total 44.0 11.7 19.2 10.0 6.0 8.7 0.3 100.0 4368 The use of contraception for delaying a first birth and spacing subsequent births has clearly been adopted by younger women. Twenty percent of women age 15-24 used a contraceptive method before their first birth. Thirty percent of women age 20-29 adopted contraception to delay their second birth. The use of family planning for spacing purposes is consistent with the policy of the family planning programme, which is to provide family planning services "to benefit the health and welfare of individuals and of the families". In practice, this means an emphasis on family planning for spacing rather than limiting purposes. A basic knowledge of the reproductive cycle and the fertile period are important for the successful practice of periodic abstinence. In the BFHS-II, women were asked when during the menstrual cycle they thought a woman has the greatest chance of becoming pregnant. Table 4.7 presents the distribution of all women, and those women who have ever used periodic abstinence, by the time during the ovulatory cycle when they think a woman is most likely to get pregnant. Although the interviewers provided an additional probe, many respondents had great difficulty in answering this question. The majority of the women responded "don't know". It is difficult to ascertain whether they really did not know or they could not understand the question. Ever-users of periodic abstinence appear to have at least understood the question, suggesting that they had some knowledge of the existence and importance of the fertile period. Three-quarters of ever-users of periodic abstinence provided an answer to the question, although only 8 percent gave the correct answer, "in the middle of the cycle". This lack of knowledge about the ovulatory cycle is an issue which needs to be addressed, not only for users of periodic abstinence--for whom the correct knowledge is critical to successful use of the method--but also for all women to educate them about their physiology. 40 Table 4.7 Percent D is t r ibut ion of A l l Women and Women Who Have Ever Used Periodic Abstinence by Knowledge of the Fer t i le Period During the Ovulatory Cycle, BFHS-%! 1988 Periodic A l l Al~tinence Fer t i l e Period Women Users During her period 1.2 1.4 Just after her period has ended 15.2 34.7 Middle of the cycle 3.4 7.6 Just before her period begins 10.4 22.1 At any time 5.5 5.1 Other 0.4 1.4 Don't know 63.8 27.2 Missing 0.2 0.3 Total 100.0 100.0 Number of Women 4368 182 4.5 CURRENT USE OF FAMILY PLANNING M~- IHODS Table 4.8 shows that 33 percent of women in union and 30 percent of all women were currently using contraception at the time of the BFHS-II. Virtually all use is modern methods. Nearly half of current users rely on the pill. Of the rest, most are using the IUD, injection, and female sterilisation (the latter method being concentrated among women in union). Both prevalence and method mix vary with age. Younger and older women are less likely to use family planning than women in the mid-childbearing years. The pill and IUD are the principal methods among women under 39, whereas injection and female sterilisation are more commonly used by women age 40 and over. As seen in Table 4.9, the median age at sterilisation is 34 and, on average, a woman has 5.4 children at the time of the sterilisation procedure. The data in Tables 4.8 and 4.9 show that method use by age and parity generally follows the Botswana Family Planning Policy Guidelines, which provide the following recommendations: - All women who are under 35 years of age and for whom there are no contra- indications are eligible to use the combined oral contraceptives as a method of contraception. - ALl women with at least one living child and for whom there are no contra- indications may use an IUD. - Couples and individuals who feel they have achieved a desired family size and those who cannot use other methods may use Depo-Provera. Lactating mothers may also use Depo-Provera as a contraceptive method. - Sterilisation methods of contraception should be provided to clients who feel they have achieved a desired family size. 41 Table 4.8 Percent Distribution of ALL women and Women in Union by Current Use of Specific Family PLanning Methods, According to Age, BFHS'I I 1988 Family Ptannin 9 Method Used Any Diaphragm/ Female Male Periodic Prolongod Nunioer Any Modern %njec- Foam/ Sterili- $terili- Absti- With- Absti- Not of Age Method Method Pill IUD tion Jetty Condom sation sation nence drawal Other nence Using Total Women ALL Women DO 15-19 14.7 14.3 11.4 0.9 0.1 0.0 1.9 0.0 0.0 0.2 0.2 0.0 0.1 65.3 100.0 937 20-24 31.5 31.2 25.1 4.0 1.0 0.0 I.0 0.0 0.0 0.2 0.0 0.0 0.2 68.5 100.0 926 25-29 39.7 38.7 27.0 5.9 4.4 0.0 0.9 0.5 0.0 0.2 0.1 0.2 0.5 60.3 100.0 846 30-34 37.5 36.4 20.5 6.9 5.4 0.0 1.5 2.0 0.1 0.2 0.4 0.2 0.2 62.5 100.0 653 35-39 36.1 35.1 11.7 8.4 6.8 0.1 1.7 5.9 0.4 0.3 0.1 0.4 0.3 63.9 100.0 464 40-44 29.7 29.0 4.7 3.6 7.9 0.0 1.0 11.4 0.4 0.0 0.0 0.0 0.7 70.3 100.0 290 45-49 13.3 11.9 1.6 2.2 1.2 0.0 0.0 6.7 0.2 0.0 0.0 0.2 1.2 ~.7 100.0 251 Total 29.7 28.9 17.7 4.5 3.2 0.0 1.3 2.2 0.1 0.2 0.I 0.I 0.3 70.3 100.0 4368 Wo~en In Union 15-19 17.2 14.5 10.8 0.0 1.1 0.0 2.7 0.0 0.0 0.0 2.7 0.0 0.0 82.8 100.0 54 20-24 25.8 25.2 16.8 5.1 2.6 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.6 74.2 100.0 238 25-29 37.1 36.0 23.3 5.4 5.4 0.0 0.9 1.0 0.0 0.1 0.1 0.5 0.3 62.9 100.0 420 30-34 35.6 33.7 16.5 7.2 6.1 0.0 2.0 1.9 0.2 0.4 0.8 0.4 0.4 64.4 100.0 382 35-39 38.3 37.5 11.9 8.2 7.6 0.2 1.6 7.3 0.7 0.2 0.2 0.4 0.0 61.7 100.0 290 40-44 36.1 35.0 4.8 4.0 8.6 0.0 1.3 15.7 0.6 0.0 0.0 0.0 1.1 63.9 100.0 182 45-49 16.7 14.7 1.4 2.3 2.1 0.0 0.0 8.5 0.4 0.0 0.0 0.0 2.1 83.3 100.0 140 Total 33.0 31.7 14.8 5.6 5.4 0.0 1.3 4.3 0.3 0.2 0.3 0.3 0.5 67.0 100.0 1708 Table 4.9 Percent D is t r ibut ion of S ter i t i sed Women by Age and Median Age at the Time of the S ter i l i sa t ion , and Percent D is t r ibut ion of S ter i t i sed Women by Number of Chi ldren and Mean Number of ch i ld ren at the Time of S ter i l i sa t ion , BFHS-I! 1968 Afle at the Time of the S ter i t i sa t ion <25 25-29 30-34 35-39 40-44 Total Number Median Ster i l i sed Women 9.4 11.6 31.4 35.1 12.5 100.0 95.1 34.1 Number of Chi ldren at the Time of the S ter i t i sa t ion 0-2 3 4 5 6 7 8+ Tota[ Number Mean Steritised Women 8.8 18.6 10.1 10.7 19.5 15.8 16.5 100.0 95.1 5.4 The principal exception to compliance with the guidelines is that a significant number of women aged 35-39, and a smaller number over age 40 are currently using the pill. There are elevated health risks involved in using the pill for women over 35. The number of older women who use ~'the pill as their contraceptive method, contrary to programme guidelines, is a concern that should be addressed by programme managers. Table 4.10 Percent D is t r ibut ion of A l l Women and Women in Union by the Family Planning Method Current ly Used, BFHS 1984 and BFHS-i! 1988 A l l Women Women in Union Method BFHS BFHS-[! BFHS BFKS-ii Any Method 23.5 29.7 27.8 33.0 Any Modern Method 16.0 28.9 18.6 31.7 Pill 8.5 17.7 10.0 14.8 IUD 4.1 9.5 4.8 5.6 Injection 1.1 3.2 1.0 5.4 Diaphragm/Foam/Jet ty 0.1 0.0 0.1 0.0 Condom 1.0 1.3 1.2 1.3 Female Ster i I i sat ion 1.2 2.2 1.5 4.3 Mate S ter i t i sa t ion 0.0 0.1 0.0 0.3 Any Trad i t iona l Method 7.5 0.8 9.2 1.3 Not Current ly Using 76.5 70.3 72.2 67.0 Total 100.0 100.0 100.0 100.0 Number of Wa~en 3064 4368 2433 1708 43 Figure 4.1 Current Use of Specific Methods of Family Planning, Women 15-49, 1984 and 1988 In ject ion 5~ Pill 36% IUD 17% Other* 1C Trad. Meth. 32% BFHS 1984 Prevalence - 24% In ject ion 11 Pill 60% Trad. Meth. 3% ~ther* 12% IUD 15% BFHS-II 1988 Prevalence - 30% * Includes condom, vaginal methods, female end male sterlllsatlon Table 4.10 and Figure 4.1 compare the current use of family planning reported in the 1984 BFHS with the results from the 1988 BFHS-II. Overall, the increase in contraceptive prevalence among all women is just over six percentage points. However, use of modern methods has almost doubled, increasing from 16 to 29 percent. As seen in Figure 4.1, the major increascs are in the use of the pill, injection, and female sterilisation. IUD use rose only slightly among women in union. There appears to be no change in condom use, despite increased efforts to promote use of this method in the past few years. The low reporting of condom use may be associated with the difficulty in getting women to report use of a male method. Only one percent of the women in the BFHS-II reported using traditional methods, compared with 9 percent in 1984. Current contraceptive prevalence for all women by selected background characteristics is shown in Table 4.11. Differences in contraceptive prevalence by marital status are small, though use is slightly higher among currently married women. There are significant differences in overall contraceptive use between urban and rural dwellers. Thirty-nine percent of urban women use contraception, compared with 26 percent of rural women. The majority of users in both urban and rural areas rely on the pill. Urban women are more likely to use the IUD, while injection is more common among rural women. 44 TabLe 4.11 Percent D is t r ibut ion of ALl gon~n by Current Use of Speci f ic Family Planning Methods, According to Selected Background Characterist ics, BFHS-ii 1988 Family Plannin 9 Hethod Used Any Female Mate Any Tradi- Number Background Any Modern S ter i l i - S ter i l i - t iona[ Not of Character ist ic Method Method P i l l ILID in jec t ion Conclm sation sat ion Method Using Total Women (.h Union Status Never In Union 27.3 26.9 20.5 3.3 1.5 1.3 0.4 0.0 0.4 72.7 100.0 2312 Current ly In Union 33.0 31.7 14.8 5.6 5.4 1.3 4.3 0.3 1.3 67.0 100.0 1708 Previously in Union 29.5 28.9 13.9 6.9 3.5 0.9 3.7 0.0 0.6 70.5 100.0 349 Residence Urban 38.8 38.2 23.6 7.3 2.7 2.0 2.4 0.2 0.6 61.2 100.0 1316 Rural 25.8 24.9 15.2 3.3 3.4 0.9 2.1 0.0 0.9 74.2 100.0 3052 Education No Education 18.4 17.4 8.7 2.1 4.7 0.3 1.6 0.0 1.0 81.6 100.0 1045 Incomplete Primary 26.4 25.8 13.6 4.1 4.2 0.5 3.4 0.0 0.5 73.6 100.0 1073 Colnp[ ete primary 31.7 31.1 21.3 4.3 2.7 1.5 1.3 0.0 0.6 68.3 100.0 1115 Secondary or Higher 41.3 40.3 26.3 7.3 1.4 2.5 2.4 0.4 1.0 58.7 100.0 1135 Number of Living Children None 14.2 13.6 11.0 0.9 0.0 1.6 0.1 0.0 0.6 85.8 100.0 1109 I 30.6 30.4 24.1 3.8 0.8 1.4 0.2 0.0 0.2 69.4 100.0 660 2 38.9 37.2 25.7 5.3 3.1 1.4 1.4 0.2 1.7 61.1 100.0 658 3 41.7 41.2 23.8 8.6 4,3 0.9 3.3 0.2 0.5 58.3 100.0 536 4 or more 33.0 32.1 12.3 5.9 7.3 0.9 5.5 0.2 0.9 67.0 100.0 1205 Rel ig ion Sp i r i tua l /A f r i can 27.2 26.4 16.7 4.6 2.7 1.1 1.3 0.0 0.8 72.8 100.0 1669 Protestant 33.6 33.1 19.7 4.6 3.8 1.5 3.4 0.1 0.5 66.4 100.0 980 Cathol ic 42.0 40.0 24.0 6.0 2.9 2.8 3.9 0.5 2.0 58.0 100.0 391 Other 38.1 32.8 9.4 9.6 2.9 3.5 6.4 1.2 5.3 61.9 100.0 50 No Net ig ion 25.6 25.2 15.8 3.3 3.5 0.7 1.8 0.1 0.4 74.4 100.0 1075 Total 29.7 28.9 1;'.7 4.5 3.2 1.3 2.2 0.1 0.8 70.3 100.0 4368 The use of family planning is related to a woman's level of education. Prevalence increases from 18 percent among women with no education to over 40 percent among women who have some secondary or higher education. The variation in method mix according to education is related to the interaction between age and educational level. Older women are concentrated among the least educated and younger women among the most educated. Hence, women with no education, who are older, are more likely to be using injection, while women with primary or higher education, who are younger, are more likely to be using the pill or IUD. The reliance on contraception for spacing can be clearly seen in the variation in the use of specific methods by number of living children shown in Figure 4.2. Fourteen percent of childless women are using contraception to delay a first birth. These women rely mainly on the pill. Prevalence is twice as high (31 percent) for women with one child. Again, the principal method is the pill, though about one-tenth of users have adopted the IUD. The use of family planning peaks among women with two or three children. Among these users, the proportion relying on the pill declines slightly, IUD use increases, and injection is added to the method mix. Finally, among women with four or more children, pill and IUD use decline, the use of injection increases, and one out of six users has chosen female sterilisation. 0 1 2 3 4* Figure 4.2 Current Use of Family Planning by Number of Living Children No. of Living Children 0 10 20 30 40 50 Percent R Pill ~-~ IUO J Female Ster. ~ Other Injection i BFHS-II 1988 46 With regard to religion, Protestant and Catholic women are more likely to use contraception than women belonging to the Spiritual/African churches or who report no religion. While the lower use among women of the Spiritual/African Church is more likely due to associated socioeconomic characteristics--such as lower education (see Table 1.2)--rather than to religion per 5e, the findings suggest that the churches are a potential way of reaching these women. Table 4.12 Percentage of Al l Wo~en Currently Using a Nndern Nethod of Family Planning, According to Selected Background Characteristics, gFHS 1984 and BFHS-i! 1988 Currently Using Background Rodern Rethnd Characteristic BFHS BFHS-H Union Status Never In Union 2.5 26.9 Currently In Union 18.6 31.7 Previously In Union 10.4 28,9 Age 15-19 11.4 14.3 20-24 21.6 31.2 25-29 23.4 30.7 30-34 25.0 36.4 35-39 17.4 35.1 40-44 8.8 29.0 45-49 7.5 11.9 Residence Urban 25.4 38,2 Rural 13.2 24.9 Education No Education 715 17.4 Incomplete Primary 14.9 25.8 complete Primary 20.9 31.1 Secondary or Higher 27.6 40.3 Number of Living Children None 5.0 13.6 I 17.5 30.4 2 20.6 37.2 3 25.0 41.2 4 or more 17~5 32.1 Religion Spir i tual /Afr ican 16.9 26.4 Protestant 21.1 33.1 Catholic 22.3 40.0 Other 14.4 32.8 No Religion 9.5 25.2 Tote[ 16.0 28.9 47 Table 4.12 shows the percentage of all women and women currently in union using a modern method of family planning according to selected background characteristics, for 1984 and 1988. Contraceptive prevalence among women never in union and women previously in union has risen sharply since 1984. Caution should be used in comparing the data for women never in union, as the definition used in the 1984 BFHS is much more likely to restrict this category to women who are not sexually active, while the definition used in the BFHS-II includes many sexually active women. Prevalence among women never in union increased from 3 to 27 percent, while prevalence among women previously in union increased from 10 to 29 percent. The impact of introducing family planning services on a daily basis most likely had a large impact on women not currently in union, as this change removed the potential for embarrassment if seen going to the clinic on the days when it was known that only family planning services were being offered. lOO 80 60 40 20 o_ / Figure 4.3 Knowledge and Use of Modern Methods of Family Planning, Women 15-49, 1984 and 1988 Percent BFHS 1984 BFH8-11 1988 Know method ~ Ever used method ~11 Currently using Contraceptive prevalence has increased dramatically among women between the ages of 20 and 45, with more modest gains among the youngest and oldest women. The use of family planning increased significantly both among urban and rural women and among all women for all levels of education and religious backgrounds. One of the largest relative gains was made among women with no children, for whom use of modern family planning methods trebled since 1984. 48 Figure 4.3 summarizes the changes in knowledge and use of modern methods of family planning between 1984 and 1988. In 1984, three-quarters of Batswana women knew at least one modern method of family planning, but only one-third had ever used a modern method and half of those women, 16 percent of all women, were currently using a modern method. By 1988, knowledge of modern methods was virtually universal. Slightly more than half of all women had used at least one modern method and almost 30 percent were using a modern method of family planning at the time of the survey. 4.6 CURRENT SOURCE OF SUPPLY OF FAMILY PLANNING METHODS Family planning services are available on a daily basis at all levels of the government health care delivery system--hospitals, health centres, clinics, health posts, and mobile stops. Most family services are offered by nurses who have been trained in MCH/FP and who are responsible for prescribing pills, inserting IUDs and performing post-insertion check-ups, giving injections, monitoring clients for any contra-indications or side effects and advising women who experience side effects. The family welfare educator, who usually is the sole staff member of the health post, distributes condoms and foam and resupplies pills to users who have experienced no problems. The family welfare educator also can provide the first cycle of pills to new acceptors; however, new acceptors must be examined by a nurse before being resupplied. Outside of the public health care delivery system, contraceptive methods also can be obtained from private doctors and pharmacies. There are no private non-profit organizations providing family planning services in Botswana. Table 4.13 Percent D is t r ibut ion of Current Users by Most Recent Source of Supply or information, According to Specif ic Method, BFHS I t 1988 Supply Methods C l in ic Methods Female Source of Injec- S ter i L i - A l l Supply P i t t Condom t ion Total IUD sat ion Total Hethods Government Health Post 2.5 5.2 4.2 2.9 0.7 0.0 0.5 2.4 Government C l in ic 85.0 58.4 77.5 82.4 67.5 0.0 44.8 73.6 Government Hospital 8.9 6.3 14.0 9.5 25.2 91.4 46.9 18.2 or Health Centre Pr ivate Doctor Z.O 1.1 4.0 2.2 6.5 7.9 7.6 3.5 or C l in i c Pharmacy 1.2 11.6 0.0 1.7 0.0 0.0 0.0 1.3 Other 0.3 3.2 0.0 0.4 0.0 0.6 0.2 0.3 Don~t know 0.0 14.2 0.0 0.8 0.0 0.0 0.0 0.6 Missing 0.1 0.0 0.4 0.1 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of Current 774 55 139 968* 196 95 296** 1264 Users * l~L~es one d iaphra~ user. ** Includes four women who reported that their current method was mate steritisation. 49 As shown in Table 4.13 and Figure 4.4, government clinics and hospitals are the major source of contraceptives. The major source of supply methods, i.e., pill, condom, and injection are government clinics. Health posts are most likely under-reported because respondents may not differentiate between a clinic and a health post. The reported source of clinical methods is split between government clinics and hospitals. Private providers, doctors and pharmacies, are the source of only 4 percent of users of supply methods, principally condom users, and 8 percent of users of clinical methods. Fourteen percent of condom users did not know the source, probably because they were obtained by their partners. Current users of a contraception method were asked whether there was anything they particularly disliked about the services received at their current source of supply. Ninety-eight percent of the users said that they did not encounter any problems with the services. Figure 4.4 Source of Family Planning Supply Current Users of Modern Methods Other- 1% Private Doctor 4% Pharmacy 1% Government 94% • Inc ludes categories Don't Know and Missing BFHS-I11988 4.7 REASONS FOR DISCONTINUATION AND NONUSE OF FAMILY PLANNING Of primary importance to programme administrators are the reasons why family planning users stop using their adopted method. Table 4.14 considers the main reasons for discontinuing the last method, among women who have discontinued use of a method during the five years preceding the survey. The table indicates that the most common reason for discontinuing a method 50 was health concerns, mainly associated with injection (63 percent), the IUD (41 percent), and the pill (32 percent). The second most cited reason for discontinuing a method was the desire to become pregnant; 36 percent of the women discontinued using the pill and the IUD and 32 percent discontinued using a traditional method in order to become pregnant. The most commonly cited reason for discontinuing traditional methods was method failure. A high level of method failure was also reported for the pill and IUD; some of the these IUD failures might be rejection of the IUD from the uterus. Tabte 4.1& Percent bistrib~JtiOn of ~omen ~ho Rave Discontinued a Contraceptive Method in the Last Five Years by Main Reason for Last Discontinuation, According to Speci f ic Method, BFHS-II 1988 Method Discontinued Any Reason for In jec- l rad i t ions l A l l Discont inuat ion P i t t IUD t ion Condccn Method Methods To become pregnant 35.5 35.5 16.8 13.4 32.2 52.2 Method fa i tod 16.5 14.8 6.7 8.0 40.0 15.9 Partner disapproves 4.6 2.1 0.0 13.4 8.4 4.4 Health concerns 32,0 40.6 62.7 11,0 0.0 33,4 Access/availability 1.5 0.0 5.2 3.5 0.0 1.7 Inconvenient to Use 1.7 0.4 1.5 12.9 1.5 2.3 Infrequent sex 1.9 0.0 0.0 7.4 0.0 1.6 Prefer Permanent Method 0.2 1.2 0.0 7.5 3.2 0.8 Fata l i s t i c 0.2 0.0 0.0 0.0 O.O 0.1 Other 5.3 5.1 7.0 16.9 13.5 6.4 DonJt know 0.2 0.4 0.0 2.5 0.0 0.3 Missing 0.4 0.0 0.0 3.5 1.5 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 734 166 95 58 45 1121" * Includes 6 women who discontinued the diaphragm and 17 women whose last method was missing. Condom users reported a variety of reasons for discontinuing including health concerns-- as condom use is also associated with the prevention of sexually transmitted disease, some women may disapprove of condoms for fear of the implication that they have such a disease. Other reasons for discontinuing condom use are that the partner disapproves, the method is inconvenient, and preference for a more permanent method. By the latter, it is likely meant preference for a method that is not associated with coitus. The group of women who discontinued contraceptive use due to health concerns most likely encompasses both women who experienced health related problems with their family planning method or were advised against using the method, and women who discontinued due to rumors or myths which people still hold about modern family planning methods. The high levels of failure reported for the pill and the IUD suggest that women may use the method improperly. Finally, there appears to be dissatisfaction with the condom for a number of reasons. In order to sustain 51 continued use, the programme should intensify efforts to inform users about the methods they adopt and follow-up to ensure that methods are used' properly. Table 4.15 gives the distribution of non-pregnant women who are sexually active and not using any contraceptive method by whether they would be happy or unhappy if they became pregnant in the next few weeks. The table shows that a significant percentage of women (48 percent) said they would be unhappy, an indication that many women would prefer to wait before the next pregnancy. Forty-four percent of the respondents expressed a desire to become pregnant soon. Few women (8 percent) said it wouldn't matter. The majority of women with three or more children said they would be unhappy if they became pregnant in the next month. Table 4.15 Percent D is t r ibut ion of Non-Pregnant women Who Are Sexual ly Act ive and Who Are Not Using Any Contraceptive Method by At t i tude Toward Becoming Pregnant in the Next Few Weeks, According to Number of L iv ing Children, BFH5-11 19B~B Would Number Number of Not of Liv ing Chi ldren Nappy Unhappy Matter Missing Total Women Hone 50.6 44.1 5,0 0.3 100.0 536 1 56.5 33.4 7,8 2.2 100.0 300 2 51.7 38.1 10,1 0.0 100.0 218 3 37.1 53.6 7.8 1.4 100.0 183 4+ 28.7 61.5 9.4 0.4 100.0 549 Total 43.6 47.9 7.8 0.7 100.0 1784 The women that reported that they would be unhappy if they became pregnant were then asked why they were not using a method of contraception. Table 4.16 gives the distribution of non-pregnant, nonusers by age and main reason for nonuse. Women less than age 20 cited a variety of reasons for not using family planning even when they would be unhappy if they became pregnant. Twenty percent of the respondents said they were opposed to family planning, and another 10 percent said their partners or others disapprove. Seven percent said they did not know about family planning, while 15 percent feel the costs are too much--another indicator of lack of knowledge since methods are available at a nominal cost or free. An additional 7 percent cited health concerns about using family planning and 4 percent thought family planning was inconvenient. Twenty-five percent of young women could not provide a reason for nonuse of a method. Responses to a question on why the respondent did not use a method of family planning the first time she had sexual intercourse were also tabulated for women under 20. Over two-thirds of teenagers cited lack of knowledge of family planning as the reason for not using contraception at that time. Eleven percent said they were opposed to family planning and another 5 percent said their partner or others disapproved. Difficulty in getting methods, or that family planning was 52 Table 4.16 Percent Oistr ibution of Non-Pregnant ~omen kho Are Sexuaity Active and ~ho Are Not Using Any contraceptive Nethed and ~/ho Would be Unhappy i f They Became Pregnant by Nain Reason for Nonuse, According to Age, BFHS-I! 1988 Reeson for A~e Nonuse <20 20-29 30+ Totat Lack of knowledge 6.8 5.1 4.6 5.3 Opposed to family planning 19.9 14.4 12.0 14.8 Partner disapproves 1.5 8.3 8.5 6.6 Others disapprove 8.3 2.5 0.5 3.2 Infrequent sex 7.3 19.1 21.4 17.0 Post-partum/breastfeeding 3.4 1.1 0.3 1.4 Nenopeusat/subfecund 0.0 0.2 0.4 0.2 Health concerns 6.9 0.5 0.5 2.2 Access/availabil ity 0.0 0.5 0.0 0.1 Costs too much 14.8 8.6 9.1 10.5 Fata l i s t i c 0.0 0.0 1.5 0.7 Religion 0.9 1.0 1.5 1.2 Inconvenient 4.1 21.4 15.4 14.2 Other 0.6 0.0 6.6 3.0 Don't knou 25.3 16.5 16.2 18.7 Nissing 0.3 0.8 1.3 0.9 Total 100.0 100.0 100.0 100.0 Number of Woc~n 227 254 375 856 inconvenient to use, were each mentioned by 3 percent of teenagers. Eight percent said they did not know why they did not use a method at that time. A significant percentage of the women over age 20 cited inconvenience and infrequent sex as the main reason for nonuse. Opposition to family planning by the respondent or her partner were also important reasons. While only a small percentage said they do not know about family planning, a larger proportion perceived the cost to be excessive. These data suggest a number of obstacles that Batswana women perceive to be barriers to using family planning. The results imply a need for an effective information, education, and communication programme that would build acceptance of family planning, reassure women about the benefits as well as risks of family planning, portray family planning as something that is easy to use, and spread the word that family planning methods are widely available for only a nominal cost. 4.8 INTENTIONS TO USE FAMH.Y PLANNING IN THE FUTURE The data in Table 4.17 give an indication of the intent of nonusers to use a contraceptive method in the near future. More than 50 percent of the respondents indicated that they would use contraception in the future, and most said they would use in the next 12 months. Forty percent of the women do not intend to use family planning in the future and the remaining women were undecided. 53 Table 4.17 Percent D is t r ibut ion of women Who Have Had Sexual Intercourse Who Are Not Current ly Using Any Contraceptive Method, by In tent ion to Use in the Future, According to Number of L iv ing Children, BFNS-II 1988 In tent ion to Number of L iv ing Chi ldren Use in the Future None 1 2 3 4+ Total Intend to Use in Next 12 Months 41.1 57.0 Intend to Use Later 9.2 4.9 Intend to Use, Unsure about When 2.7 4.8 Unsure about Whether to Use 6.0 2.1 Does Not intend to Use 41.0 31.0 36.4 Missing 0.0 0.1 0.0 49.3 52.6 41.7 47.3 4.8 3.0 2.3 4.9 3.6 3.1 2.2 3.2 5.9 6.4 4.2 4.7 34.3 49.4 39.9 0.6 0.2 0.I Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 620 597 402 312 808 2740 Table 4.18 Percent D is t r ibut ion of Woenen Who Have Had Sexual Intercourse Who Are Not Using a Contraceptive Method but Who Intend to Use in the Future, by Preferred Method, According to ~hether They ]ntend to Use in the Next 12 Months or Later, BFHS-II 1988 Intend to Preferred Use in Next Intend to Method 12 Months Use Later Total P i t t 59.6 62.8 59.9 IUD 14.8 12.8 14.6 In jec t ion 15.9 10.7 15.4 Oiaphrag~FoanVdetty 0.4 0.0 0.4 Condom 1.0 1.1 1.0 Female S ter i t i sa t ion 1.9 2.0 1.9 Periodic Abstinence 0.2 0.0 0.1 Other 0.2 0.0 0.1 Abstinence 0.1 0.0 0.1 Oon't know 5.9 10.7 6.3 Total 100.0 100.0 100.0 Number of Women 129S 133 1428 Women who were not using contraception but who intend to use a method were asked which method they preferred. Table 4.18 presents the distribution of women according to their preferred method and whether they intend to use in the next 12 months or not. The majority of the respondents plan to use the pill, with much smaller proportions stating a preference for the IUD and injection. 54 4.9 ACCEPTABILITY OF ME~DIA MESSAGES ON FAMII.y PLANNING Information about family planning is disseminated through various channels: home visits, kgotla, schools, community meetings, work places, individual counselling, and talks at health facilities. In the BFHS-II, respondents were asked whether it was acceptable to them for family planning to be advertised through the radio, kgotla or school. Table 4.19 Percentage of Al l Women Who Believe Thet i t is Aceeptebte to Have Messages About Family Ptenning on the Radio, et Kgotla, and at School, by Age, BFHS-II 1988 Source of AQe FP Message 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Tota[ Radio 66.5 55.7 48.4 48.2 50.2 52.0 58.5 54.8 Kgotla 66.3 72.2 76.8 71.1 68.0 69.0 62.0 70.4 School 88.5 87.5 86.6 83.5 82.3 79.5 73.6 85.1 Table 4.19 shows the percentage of all women who believe it is acceptable to have family planning messages on the radio, at kgotla, and at school. The school is the most widely accepted source for family planning information with 85 percent of the respondents finding this to be an acceptable source. Fewer respondents chose the kgotla as a forum for disseminating family planning messages. The radio was less acceptable than either the school and kgotla with only 55 percent approving of the radio as a source of family planning information. The acceptance of media messages on family planning at school steadily declines with increases in age; almost 90 percent of teenagers approve of family planning messages in the school, but only about three-quarters of women over 40 approve. The kgotla is most popular among those aged 20-34, but less popular among the youngest and oldest women. Acceptance of radio has the opposite age pattern; it is most acceptable among the youngest and oldest women, and less acceptable to those between the ages of 25 and 40. 4.10 APPROVAL OF FAMILY PLANNING BY RESPONDEN'/~ AND PARTNERS Information was collected in the BFHS-II regarding whether women approve of the use of contraceptive methods and whether women currently in a union think that their partners approve of family planning. As shown in Table 4.20, 92 percent of women who know at least one method of contraception approve of family planning. The proportion of women knowing a method who approve of family planning is the same as in the 1984 BFHS. Table 4.21 presents the respondents' opinion about their partner's attitude toward the use of family planning, for all women in union. Fifty-seven percent said their partner approved, one-third thought he disapproved and 9 percent were unsure. Women in union who knew a contraceptive method were asked the number of times they discussed family planning with their partner. Inter-partner communication is an important step 55 Tabte 4.20 Percent Distr ibut ion of Art Women Kno~fng e Contraceptive Nethod by Att itude TOward the Use of Fetn|ty Planning, According to Residence, BFHS-ll 1988 Respondent,s Resider¢ e Att i tude Urban Rural Total Disapproves 6.1 7.0 6.7 Approves 93.1 91.3 91.9 Don't kno~ 0.7 1.7 1.4 Hissing 0.0 0.0 0.0 Totat 100.0 100.0 100.0 Number of Won~n 1296 2869 4166 towards eventual adoption and sustained use of family planning. Table 4.22 shows that 70 percent of women had discussed family planning with their partner at least once in the past year; more than 40 percent of the women said that they had discussed family planning with their partner once or twice in the past year and almost 30 percent had discussed it more often. This was true for women for all ages except women aged 45-49, among whom only a minority had discussed family planning with their partner. Surprisingly, education is not a factor in facilitating communication between partners about family planning; approximately the same proportions of women of all levels of education had discussed family planning with their partner in the past year. rebte 4.21 Percent Distr ibution of Wo~en in Union ~tho Know a Contraceptive Hethud, by the Respondentgs Opinion of Partner's Att itude Touard the Use of Famity Planning, BFHS-II 1988 Respondent's Opinion of Partner's Att itude Residence Toward Famfty Planning Urban Ruret Total Disapproves 24.0 36.5 32.4 Approves 65.9 52.7 57.1 Don't know 9.0 9.5 9.3 Missing 1.1 1.2 1.2 Totat 100.0 100.0 100.0 Number of Wo~en 539 1080 1619 The percentage of women in union who approve of family planning, the percentage who think their partner approves, and the percentage of those couples currently using a family planning method are shown in Table 4.23. Except among the oldest women, there is little variation in approval by the respondent by age, urban or rural residence, or level of education, with approval ranging from 85 to 95 percent among the subgroups. 56 Table 4.22 Percent Distr ibution of Women in Union Who Know a Family Planning Method, by Number of Times Discussed Family Planning with Partner, According to Current Age and Education, BFHS-II 1988 Number of Times Discussed Family Ptannin R Number Once or More of Never Twice Often Missing Total Women Age 15-19 23.4 56.1 16.4 4.1 100.0 50 20-24 22.3 48.9 25.4 3.4 I00.0 231 25-29 24.2 46.8 28.4 0.6 100.0 407 30-34 26.8 44.0 28.5 0.7 100.0 367 35-39 30.1 39.1 30,0 0.7 100.0 277 40-44 28.0 44.8 26.5 0.7 100.0 169 45-49 59.8 18.4 21.8 0.0 100.0 118 Education No Education 37.0 38.5 23.8 0.7 100.0 472 incc~T@lete Primary 29.4 41.3 27.9 1.4 100.0 487 Complete Primary 22.1 50.3 26.8 0.9 100.0 334 Secondary or Higher 21.6 45.2 31.6 1.5 100.0 326 Tots[ 28.5 43.1 27.2 1.1 100.0 1619 Table 4.23 Percentage of Women in Union Who Know a Family Planning Method, Who Approve of Family Planning and Who Say their Partner Approves of Family Planning, and Percentage of Couples Currently Using Family Planning, by Selected Background Characteristics, BFNS-H 1988 Couple Currently Number Background woman Partner Using of Characteristic Approves Approves FP Won~n Age 15-19 86.6 45.6 18.7 50 20-24 88.3 54.4 26.7 231 25-29 93.4 61.4 38.4 407 30-34 93,5 62.3 37.0 367 35-39 89.1 58.5 40.1 277 40-44 93.0 57.6 39.0 169 45-49 74.8 32.6 19.9 110 Residence Urban 92.0 65.9 41.8 539 Rural 89.6 52.7 31,3 1080 Education go Education 64.5 43.4 23.8 472 Incomplete Primary 90.2 51.0 31.0 407 Complete Primary 93.2 61.4 39.2 334 Secondary or Higher 96.3 81,9 52.0 326 Totat 90.4 57.1 34.8 1619 57 Despite the same amount of discussion of family planning between partners among all subgroups, reporting of partner's approval is higher among women 25-44 than among younger or older women and higher among the urban than rural women. Partner's approval of family planning is also influenced by the level of education, nearly doubling from 43 percent for partners of women who have no education to 82 percent for partners of women who have some secondary or higher education. Current use appears to be more closely correlated with the respondent's perception of her partner's approval of family planning than her own approval. Within each category of women shown in Table 4.23, current use is equal to about 60 percent of the level of partner's approval reported by that group of women, regardless of the level of the respondent's approval. It is impossible to know whether the partner's approval led to the adoption of a method, or whether the women began to use family planning and the partner came to accept it. While the reported level of partner's approval has increased since 1984, when 48 percent of women who knew a method said their partner approved of family planning, male approval is still much lower than that of females. Furthermore, results of the BFHS-II which relate partner's approval to current use suggest that male approval can be an important factor in adoption and sustained use of family planning. The family planning programme recognizes that efforts to build support for family planning among men have lagged behind those focussed on women. Many men are opposed to family planning simply because they have not been involved and feel excluded. Other men think family planning is dangerous because they lack information about specific family planning methods. The family planning programme needs to develop materials and intensify efforts which target males in order to build support for family planning among Batswana men and to sustain the continued growth of the use of family planning among Batswana couples. 58 5. FERTILITY PREFERENCES This chapter assesses the need for contraception among Batswana women. Several questions were included in the BFHS-II to ascertain whether the respondent wants more children; if so, how long she would prefer to wait before the next child; and if she were to start afresh, how many children in all she would want. Until very recently, the family planning programme in Botswana emphasized delay of the first pregnancy and child spacing over the limitation of family size. The extent to which this objective has been achieved will be examined in this chapter. Also examined are the extent to which unwanted pregnancies occur and the effect the prevention of such pregnancies would have on the fertility rate. These questions are of interest first, because of the concern of the Government of Botswana that couples have the freedom and ability to bear the number of children they want, when they want them, and second, because of the implications of rapid population growth in meeting overall development objectives. Information on fertility preferences has been criticized on the grounds that responses to survey questions reflect ephemeral views which are held with little conviction, and that they tend to ignore the effect of social pressures or attitudes of other family members who may significantly influence reproductive decisions. Since the family planning programme in Botswana is relatively new--as is the concept of fertility regulation for many women--the first criticism may hold. Unfortunately, we have no data to address the second objection. Since no surveys have been conducted in which both women and their partners, or other relatives, were interviewed, the extent of the effect of the husband's or other family members' attitude on family size and contraception has not been established. The inclusion of women who are currently pregnant complicates the measurement of views on future childbearing. In the case of these women, the question on desire for more children was rephrased to refer to desire for another child, after the one that they were expecting. The number of living children should therefore be taken to include the current pregnancy. 5.1 DESIRE FOR ADDITIONAL CHILDREN Table 5.1 shows the distribution of women in union by desire for children, according to the number of living children. Figure 5.1 and the last column of Table 5.1, which present the fertility preferences for all women in union, indicate that more than half of the women interviewed would like to have another child: 24 percent would like to have another child soon (within the next two years) and 29 percent want another child but want to wait at least two years. One-third of the women want no more children. The results in Table 5.1, shown graphically in Figure 5.2, suggest that Batswana women continue to have a preference for large families. Sixty percent of women with 4 living children, 44 percent of women with 5 living children, and 24 percent of women with 6 or more living children still want another child. Among those women with none or one child, the majority would like to have another birth soon--within the next two years. Most women with two or more children, who want another child, would prefer to wait at least two years before their next birth. 59 Table 5.1 Percent Distr ibut ion of Women in Union by Desire for Children end Timing, According to NCtT/oer of Living Children, BFHS-II 1988 Number of LivinR Children* Desire for Children and Timing 0 1 2 3 4 5 6+ Total Wants another within two years 63.8 48.4 25.2 21.8 20.8 15.7 7.0 23.8 Wants another after two or more years 9.5 37.2 39.5 39.7 33.9 26.0 13.8 29.2 Wants another, unsure when 9.7 4.5 4.8 2.8 6.7 2.7 2.7 4.3 Undecided 1.9 0.9 3.8 2.7 3.5 5.8 5.8 3.8 Wants no more** 1.9 5.1 22.5 26.6 29.8 44.9 62.7 32.7 Declared infecund 8.6 2.3 1.8 5.7 4.5 4.0 7.9 5.0 Missing 4.5 1.5 2.3 0.7 0.8 0.9 0.2 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of Women 104 198 272 299 254 194 386 1708 * Includes current pregnancy, ** Includes sterilised women. Figure 5.1 Fertility Preferences Women in Union 15-49 Want to Space (2 or more yrs) 29% Want No More r Sterilised 33% Want Sou,, (within 2 yrs) 24% Undec ided I f Want More 4% rant Another , Undec ided When 4% Infecund 5% BFHS-II 1988 60 Percent 1^^ Figure 5.2 Fertility Preferences by Number of Living Children Women in Union 15-49 0 1 2 3 4 5 6* Number of Living Children B~I Want no more ~ Want to apace | I Want soon ~ Undec ided BFHS- I I 1988 The proportion of women in union who do not want any more children, 33 percent, is unchanged from the 1984 BFHS. However, the importance of spacing births at least two years apart seems to have become more widely know: 24 percent of women in the BFI-IS-II said they wanted another child soon while 29 percent said they wanted to wait at least two years. By comparison, in the 1984 BFI-IS 25 percent of women wanted a child within the next two years, 12 percent said they wanted a child at any time, and only 21 percent wanted to wait at least two years. The desire for additional children is closely related to the age of the respondent. Table 5.2 indicates that the proportion wanting a child within two years decreases as age increases--from 38 percent among women age 15-19 to 16 percent for women age 45-49; while the percentage of those who do not want any more children increases with age from 11 percent among women age 15-19 to 53 percent for women 45-49. Table 5.3 shows the percentage of women who want no more children by background characteristics. Among women in union with two or three living children, women in urban areas and those with higher education were more likely to say that they did not want any more children-- i.e., that they thought 2 or 3 children were enough--than women in rural areas or with primary or less education. This may reflect the economic realities in urban areas which make children more expensive to raise, as well as the fact that education levels are higher in urban areas. However, 50 percent of women with four or more children, irrespective of residence or education, stated a preference for additional children. 61 Table 5.2 Percent D is t r ibut ion of Women in Union by Desire for Chi ldren and Timing, According to Current Age, BFHS-II 1988 Current Age Desire for Children and Timing 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Wants another within two years 38.1 30.4 25.3 23.4 19.8 20.8 15.9 23.8 Wants another a f ter two or more years 39.8 49.2 38.1 34.1 17.8 9.2 1.4 29.2 Wants another, unsure when 1.1 3.9 4.1 4.2 5.7 5.2 3.1 4.3 Undecided 1.1 2.2 4.0 4.0 3.6 3.2 7.8 3.8 Wants no more* 10.8 10.4 26.6 32.1 45.3 48.0 52.6 32.7 Declared infecund 5.4 0.6 1.3 2.1 6.9 12.1 18.2 5.0 Missing 3.8 3.3 0.6 0.3 0.9 1.4 1.0 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 54 238 420 382 290 182 140 1708 * Includes s ter i t i sed women. Table 5.3 Percentage of Women in Union Who Want No More Chi ldren ( Inc lud ing Ster i t i sed Women) by Number of L iv ing Chi ldren and Selected Background Character ist ics, BFHS-II 1988 Background Number of L iv ing Chi ldren* Characteristic None I 2 3 4+ Total Residence Urban 1.5 6.9 27.1 34.8 49.7 31.5 Rural 2.2 3.8 18.6 22.2 48.2 33.2 Education No Education 4.8 2.3 18.0 20.9 50.0 34.9 Incon~oLete Primary 0.0 1.6 19.3 26.6 49.9 37.9 Complete Primary 0.0 7.6 13.5 22.8 40.1 23.4 Secondary or Higher 2.1 7.6 32.8 36.7 50.6 30.4 Total 1.9 5.1 22.5 26.6 48.5 32.7 * Includes current pregnancy. In sum, the family planning programme appears to have bcen successful in disseminating its message on the importance of birth spacing, as indicated by the increasing proportion of women who wish to delay their next birth. However, women continue to express a desire for relatively large families of five or more children. The three tables clearly demonstrate that the desire to have more children is influenced by the number of living children, age, education and residence. 62 5.2 FUTURE NF.F.D FOR FAMILY PLANNING Table 5.4 examines the need for and the intention to use family planning among women in union according to residence and education. Women are considered to be in need of family planning if they are not currently using a method of family planning and either want no more births or want to postpone the next birth for two or more years. Some women may not have been using a method of family planning at the time of the survey because they were not at risk of a pregnancy, i.e., they were pregnant, amenorrheic or abstaining from sexual relations following a birth, or did not currently have a partner. While they are not currently at risk of getting pregnant, it is likely that they will be in the near future. The results in Table 5.4 should not be viewed as an estimate of current need for family, but rather a maximum estimate of those in need of family planning to avoid an unwanted or unplanned pregnancy, now or in the future. Table 5.4 Percentage of Women in Union Who Are in Need of Family P lanning and the Percentage Who Are in Need and Who Intend to Use Family P lanning in the Future by Setected Background Character i s t i cs , BFHS-II 1988 In Need and In Need* Intend to Use Ntl~ber Background Want Want Want Want of Characteristic no More to Space Total no More to Space Total Women Residence Urban 17.0 21.5 38.5 10.4 12.0 22.3 540 Rural 22,2 25.4 47.6 12.8 11.9 24.7 1167 Education No Education 27.1 26.7 53.7 16.1 7,6 23.8 550 Incomplete Primary 23.7 23.7 47.4 12.2 12.4 24.6 496 Complete Primary 13.7 26.9 40.6 11.0 18.2 29.2 334 Secondary or Higher 11.8 17.9 29.7 5.9 11.9 17.7 327 Total 20.6 24.2 44.7 12.0 11.9 25.9 1708 * Inc ludes women who are not us ing a method of fami ly p lann ing and who e i ther want no more b i r ths or want to postpone the i r next b i r th for twoormore years. Overall, 45 percent of the women in union are in need of family planning, because they want no more children or wish to delay the next birth for at least two years. Slightly more than half of these women are in need of family planning for postponing their next birth, while slightly less than half do not want another child. Almost one-quarter of women in union are in need of family planning and intend to use; this constitutes about half of the women in need. A higher proportion of women who want no more children and are not using a method of family planning intend to use family planning in the future, than women who want to postpone a birth. The need for family planning is greater among rural than urban women; however, the proportion in need and who intend to use is nearly the same for urban and rural women. The proportion in need of family planning is much higher among women with no education or little education (54 and 47 percent respectively) compared with those who have more education (30 63 60 40 20 0 Figure 5.3 Need for Family Planning Women in Union Not Using Contraception Percent in Need None Pr(mary None Primary ( P r imary Secondary* ( Primary Secondary* EDUCATION Intend to use [---7 Do not intend to use / BFHS-II 1988 percent for those with secondary education or higher). Unfortunately, the gap between need and intent to use is greater among those with no or little education--among whom 44 and 52 percent, respectively, of women in need intend to use, compared with 60 percent of women with secondary education or higher. As can be seen in Figure 5.3, the largest gap between need and intention to use family planning is among less educated women who want to delay their next birth. 5.3 IDEAL NUMBER OF C l t l I .DREN Table 5.5 presents the distribution of all women interviewed by the ideal number of children, according to the actual number of living children they have. The table also shows the mean ideal number of children for all women and women in union. Thus far in this chapter, interest has focussed on the respondent's wishes for children in the future, implicitly taking into account the number of children she has already borne. In ascertaining the total ideal number of children, the respondent was required to perform the more difficult task of considering abstractly and independently of her actual family size, the number of children she would choose if she were to start again. The preference for large families among Batswana women is dear: 32 percent said the ideal family size was 4 children, 12 percent said 5 children, and 30 percent expressed a preference for 6 or more children. The average ideal family size among all women was 4.7 and among women in union, 5.4. There is a correlation between actual and ideal number of children, which can be 64 Table 5.5 Percent Distr ibution of A l l Women by Ideal Number of Children end Mean Ideal Number of Children for At( Wo~en and women in Union, According to Number of Living Children, BFHS-II 1988 Ideal Number Number of Livin R Children* of Children None 1 2 3 4 5 6+ Total None 1.0 0.3 0.6 0.4 0.0 0.0 0.0 0.4 I 2.9 5.B 0.8 1.4 1.5 0.2 0.5 2.4 2 20.3 11.1 15,2 3.2 4.8 5.2 2.5 10,8 3 12.2 12.4 9.4 17.4 1.0 10.9 2.4 10.1 4 33.2 39.1 40.4 31.4 33.9 9.6 17.8 31.9 5 12.6 10.5 9.9 11.5 10.7 23.6 8.2 11.6 6+ 15.1 19.0 21.6 32.9 45.4 46.0 62.3 29.9 Non-Numeric 2.6 1.8 2.2 2.0 2.7 4.5 6.3 2.9 Response Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1028 878 665 549 427 287 533 4368 Mean (All Women) 3.9 4.2 4.3 4.8 5.4 5.6 6.5 4.7 Mean (Worsen in 4.8 5.0 4.7 4.9 5.7 5,8 6.5 5.4 Union) * Includes current pregnancy. seen in the fact that the mean number of children increases from 3.9 among women with no children to 6.5 among women with 6 or more children. There are several possible reasons for this pattern. First, to the extent that women implement their preferences, those who want large families will tend to achieve larger families. Second, women who already have large families may find it difficult to admit that they would not have some of their children if they could start again. Finally, it is possible that women with large families, who are on average older than women with smaller families, have larger ideal family sizes because they hold more traditional family size preferences than younger women. Despite the likelihood that rationalizations occur, some respondents reported an ideal family size that was smaller than their current number of children. This can be taken as an indicator of surplus or unwanted fertility. Unwanted fertility only appears to any significant degree among women with 5 or more children. Twenty-six percent of women with 5 children and 31 percent of women with 6 or more children said that if they could start their lives again they would have fewer children than their actual number. The ideal number of children is somewhat smaller than the expected family size reported in the 1984 BFHS. However, due to differences in questions asked about ideal or expected family size a direct comparison is not possible. In general, the difference is too small to conclude there has been a significant change in family size norms. Table 5.6 shows the mean ideal number of children for all women by residence and education. The mean ideal number of children clearly increases with age and decreases with education. This is consistent with the fact that many traditional Batswana women, who are generally older and less educated, believe that the more children one has the more prestige one 65 Table 5.6 Nean Ideal sumber of Children for A l l Wo~en by Age and Selected Background Characteristics, BFH$-II 1988 Background Age Character is t ic 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Residence Urban 3.8 4.2 4.4 4.7 5.1 5.0 5.7 4.4 Rural 3.6 4.3 4.9 5.4 5.9 6.3 6.3 4.9 Educ a t i on No Education 3.;~ 4.7 5.6 5.5 6.2 6.6 6.5 5.6 Incomplete Primary 3.6 4.6 4.5 5.7 5.8 6.0 6.2 5.1 Compt eta Primary 3.7 4.2 4.8 5.1 5.4 6.0 * 4.4 Secondary or sigher 3.7 3.9 4.0 4.0 4.5 3.9 * 3.9 Total 3.7 4.2 4.8 5.2 5.7 6.0 6.2 4.7 * Fewer than 20 cases. gains. There are also large differences between urban and rural women in the ideal number of children. This probably reflects the economic realities in urban areas which make children more expensive to raise, as well as the fact that education levels are higher in urban areas. 5.4 UNPLANNED AND ~ ~ FERTILITY Women who had at least one birth in the five years preceding the survey were asked whether the births were planned, i.e., that they were wanted then, wanted later, or not wanted. These questions are an indicator of the degree to which couples successfully control childbearing. In addition, the data from these questions can be used to gauge the effect of the prevention of unwanted births on period fertility. Questions on whether a pregnancy was wanted or planned are demanding for the respondent. She is required to recall accurately her wishes at one or more points in time in the last five years and to report them honestly. The danger of rationalization is present and an unwanted conception may become a cherished child. Despite these potential problems, results from a number of surveys in various countries have proved plausible. Results in Table 5.7 show that respondents are willing to report unwanted pregnancies, although the results probably underestimate the level of unwanted fertility. Table 5.7 shows that almost half of the births (48 percent) were not wanted at the time they occurred and an additional 5 percent were not wanted at all. Of the births which were wanted later, three-quarters were to women who had not used any method of family planning in the interval before the pregnancy. Forty percent of the pregnancies which occurred to women using contraception in the interval prior to that pregnancy were not wanted at the time they occurred and 7 percent were not wanted at all. These results suggest that a significant number of women experienced a contraceptive failure, or discontinued using a method because they were dissatisfied with that method, and subsequently had an unwanted pregnancy. A particularly interesting result is that 59 percent of first births occurred at a time when they were not wanted, predominantly to women who did not use contraception in the interval. The majority of first births 66 Table 5.7 Percent D is t r ibut ion of ALl g i r ths in the Last Five Years by Contraceptive Practice and Planning Status, According to g i r th Order, BFHS-I| 1988 Contraceptive Practice B i r th Order and PLanning status 1 2 3 4+ Total Non-Contraceptive In terva l ~anted ch i ld then 30.3 26.8 27.5 30.9 29.5 ~anted ch i ld Later 49.9 29.1 24.6 32.7 35.2 ChiLd not wanted 1.9 0.9 1.2 4.9 2.8 Contraceptive Interva l Wanted ch i ld then 7.5 22.8 26.9 15.9 16.8 ~anted ch i ld Later 8.8 17.3 15.8 11.3 12.5 ChiLd not wanted O.B 2.1 2.2 3.8 2.1 Unctassifiabte 0.6 0.9 1.9 1.4 1.2 Total 100.0 100.0 100.0 100.0 100.0 Number of B i r ths 897 666 548 1380 3492 occur when the mother is still a teenager. The large proportion of women who report these births as occurring too early is a cry for help in preventing early teenage births. Table 5.8 presents the percentage of women who had a birth within 12 months before the survey, according to whether the birth was planned, mistimed or unwanted. The table shows that a large proportion of pregnancies (75 percent) which occurred among teenagers were not wanted at the time they occurred. There is also a surprisingly large proportion of women age 40 and over (52 percent) who said they had wanted their last pregnancy then. The explanation in this case could be that most of these women wanted to complete their desired family size before menopause. It is possible to use the data on whether births were wanted or not (and ignoring whether they were mistimed) to calculate a total "wanted" fertility rate. This rate is calculated in the same manner as the conventional total fertility rate, except the births classified as unwanted are omitted from the numerator. Wanted fertility rates express the level of fertility that theoretically would result if all unwanted births were prevented. A comparison of the conventional total fertility rate with wanted fertility rates indicates the potential demographic impact of the elimination of unwanted births. Table 5.9 presents a comparison between the wanted fertility rate and the actual total fertility rate, by residence and education. Overall, the wanted fertility rate is only about 6 percent lower than the current total fertility rate. This is consistent with the results presented throughout this chapter that show that most Batswana women desire large families and have few unwanted births. Thus, even if all unwanted births could be eliminated, fertility in Botswana would only be slightly lower than the current rates. 67 Table 5.8 Percent D is t r ibut ion of B i r ths in the Last 12 Months by Fer t i l i ty Planning Status, According to B i r th Order end Age, BFRS-I] 1988 PlanninB Status Wanted ganted Chi ld Number B i r th Order Chi ld Chi ld Not Uncles- of and Age Then Later Wanted s i f iabte Io ta [ B i r ths Birth Order I-2 38.1 57.2 3.5 1.2 100.0 390 3+ 42.4 47.4 8.9 1.3 100.0 402 Current Age 15-19 22.2 74.7 3.2 0.0 100.0 128 20-24 39.3 55.3 4.6 0.8 100.0 250 25-29 47.1 45.4 5.0 2.5 100.0 187 30-34 48.9 45.8 3.5 1.8 100.0 114 35-39 39,2 38.8 21.2 0.7 100.0 79 40-49 52.3 35.7 10.2 1,8 100.0 34 Total 40.3 52.2 6.2 1.2 100.0 792 Table 5.9 Total Wanted Fertility Rates and Total Fer t i l i ty Rates for the Five Years Preceding the Survey, by Selected Background Character ist ics, BFHS-H 1988 Wanted Total Background Fer t i l i ty Fer t i l i ty Character ist ic Rate Rate Residence Urban 3.8 4,1 Rural 5.0 5.4 Education No Education 5.4 6.0 Incocnptete Primary 5.0 5.2 Colnplete Primary 4.4 4.6 Secondary or Higher 3.2 3.3 Total 4.7 5.0 In sum, the responses to questions on future childbearing intentions, ideal number of children, and whether recent births were unwanted or unplanned show that Batswana women continue to have a preference for many children. The ideal family size among all women was almost 5 children. However, women are clearly interested in spacing their births and report a large proportion of their births to have occurred earlier than the respondent would have liked. This problem was especially severe among teenagers, where three-quarters had a birth before they intended. A desire to delay and space births appears to be the principal motivation for the recent increase in the use of modern methods of family planning methods in Botswana. 68 6. MORTALITY AND I4 ,ALTH The main objectives of t

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