Egypt - Demographic and Health Survey -1989

Publication date: 1989

Demographic and Health Survey 1988 Egypt National Population Council @DHS Demographic and Health Surveys Institute for Resource Development/Macro Systems, Inc. Egypt Demographic and Health Survey 1988 Hussein AbdeI-Aziz Sayed Magued I. Osman Fatrna E1-Zanaty Ann A. Way Egypt National Population Council Cairo, Egypt Institute for Resource Development/Macro Systems, Inc. Columbia, Maryland USA October 1989 This report presents findings from the Egypt Demographic and Health Survey (EDHS). The survey was a collaborative effort between the National Population Council and the Institute for Resource Development/Macro Systems, Inc. (IRD). 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. Funding for the survey was provided by the Agency for International Development (Contract No. DPE-3023-C- 00-4083-00) and the Government of Egypt. Additional information on the EDHS can be obtained from the National Population Council, P.O. Box 1036, Cairo, Egypt. Additional information on the DHS Program can be obtained from the DHS Program, IRD/Macro Systems, Inc., 8850 Stanford Blvd., Suite 4000, Columbia, MD 21045, USA (Telephone 301-290-2800; Telex: 87775; FAX: 301-290- 2999). FOREWORD The 1988 Egypt Demographic and Health Survey (EDHS) is the most recent in a series of surveys carried out in Egypt to provide the information needed to study fertility behavior and its determinants, particularly contraceptive use. The EDHS findings are important in monitoring trends in these variables and in understanding the factors which contribute to differentials in fertility and contraceptive use among various population subgroups. The EDHS also provides a wealth of health-related information for mothers and their children, which was not available in the earlier surveys. These data are especially important for understanding the factors that influence the health and survival of infants and young children. In addition to providing insights into population and health issues in Egypt, the EDHS also hopefully will lead to an improved global understanding of population and health problems as it is one of 35 internationally comparable surveys sponsored by the Demographic and Health Surveys program. This report presents key results from the EDHS. It highlights basic findings relating to fertility levels, childbearing intentions, and contraceptive knowledge and use. It also looks at key maternal and health indicators including the extent to which mothers receive trained medical care during pregnancy and at the time of delivery and, for young children, the extent of immunization coverage and the prevalence and treatment of diarrheal disease. The challenge that remains is to use the information in this report as a basis for evaluating and modifying family planning and health service delivery in Egypt. The EDHS data will only truly be useful when they are employed to improve the design and implementation of population and health programs in Egypt. Finally, I would like to express my appreciation to the EDHS team for their efforts in completing the survey. Their diligence has enabled population and health policy makers and program planners to have access to this vital information in a very timely fashion. Prof. Dr. Maher Mahran Secretary General National Population Council ACKNOWLEDGEMENTS The Egypt Demographic and Health Survey (EDHS) represents the continuing commitment in Egypt to efforts to obtain data on fertility behavior and contraceptive practice. The survey also reflects the strong interest in information on key maternal health and child survival issues. The wealth of demographic and health data that the survey provides will be of great use in evaluating the performance of the family planning and health programs and in charting future directions for these programs. This important survey could not have been implemented without the participation of a large number of institutions and individuals. The National Population Council under the leadership of Prof. Dr. Maher Mahran has provided logistical support throughout the survey. Prof. Dr. Mahran has shown keen interest in the survey findings and a continuing commitment to further policy-oriented analysis. I would like to thank other institutions in Egypt for their assistance to the EDHS. Staff of the Central Agency of Public Mobilization and Statistics (CAPMAS) worked diligently to provide the census findings used in the EDHS sample selection. The Cairo Demographic Center (CDC) provided office space for the EDHS headquarters staff. International support for the EDHS is also gratefully acknowledged. U.S.A.I.D. population funds for Egypt financed the EDHS. Technical assistance and additional financial support was provided by the Institute for Resource Development through the international Demographic and Health Surveys program. Although it is not possible to acknowledge all of the individuals who contributed to the EDHS, I would like to especially thank senior members of the EDHS staff. Dr. Magued I. Osman, the EDHS Assistant Director, and Dr. Fatma Hassan E1-Zanaty, the Sampling Coordinator, were instrumental in the planning and implementation of the survey activities. Mr. Mohamed Abdel Aty, the Fieldwork Coordinator, ably supervised the field teams. Dr. Abdallah A. Abdel Ghaly coordinated the successful data processing effort. Dr. Amin Kamel Said, Dr. Effat Fakher El-Din and Dr. Abdel Monem Darwesh were instrumental in carrying out the anthropometric training. Finally, I am deeply indebted and grateful to all of the EDHS central office and field staff. Without their willing and very able assistance, the EDHS data collection and processing phases could not have been completed in such a timely fashion. Dr. Hussein Abdel-Aziz Sayed Technical Director TABLE OF CONTENTS Foreword . iii Acknowledgements . v Table of Contents . vii List of Tables . xi List of Figures . xxiii Summary of Findings . xxv Map of Egypt . xxxiv 1 BACKGROUND 2 1.1 History, Geography, and Economy . 1 1.2 Population . 2 1.3 Health Policy and Programs . 4 1.4 Population Policy and Programs . 5 1.5 Objectives of the Survey . 6 1.6 Organization of the Survey . 7 1.7 Background Characteristics of Survey Respondents . 15 MARRIAGE, BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY 2.1 Current Marital Status . 19 2.2 Age at First Marriage . 21 2.3 Breastfeeding and Postpartum Insusceptibility . 28 2.4 Differentials in Breastfeeding and Postpartum Insusceptibility . 30 3 FERTILITY 4 3.1 Fertility Levels and Differentials . 35 3.2 Current Pregnancy . 44 3.3 Children Ever Born . 45 3.4 Children Ever Born and Age at Marriage . 46 3.5 Age at First Birth . 47 3.6 Differentials in Age at First Birth . 49 KNOWLEDGE, ATr~DDES AND EXPOSURE TO FAMILY PLANNING MESSAGES 4.1 Contraceptive Knowledge . 51 4.2 Attitudinal Indicators . 58 vii 4.3 Exposure to Mass Media and Family P lanning Messages . 62 5 EVER USE OF FAMILY PLANNING 5.1 Ever Use of Fami ly P lanning . 67 5.2 First Use of Cont racept ion . 71 5.3 Fami ly P lanning Dec is ion-making . 77 5.4 D iscont inuat ion of Contracept ive Use . 80 5.5 Knowledge of Fert i le Per iod . 83 6 CURRENT USE OF FAMILY PLANNING 6.1 Levels and Trends in Cur rent Use . 85 6.2 Geograph ic Dif ferentials . 88 6.3 Other Dif ferent ials . 94 6.4 Source of Cont racept ive Method . 96 6.5 Pill Use . 99 6.6 Intent ion to Use in tile Future . 103 7 FERT IL ITY PREFERENCES, UNMET NEED AND REASONS FOR NONUSE 7.1 Desire for Addi t ional Chi ldren . 105 7.2 Ideal Number of Chi ldren . 111 7.3 Unp lanned and Unwanted Births . 115 7.4 Reproduct ive Intent ions find Contracept ive Use . 119 7.5 Reasons for Nonuse . 121 8 INFANT AND CHILD MORTAL ITY 8.1 Chi ld Survivorship . 125 8.2 Infant and Chi ld Mortal i ty . 127 8.3 Dif ferent ials in Infant and Child Mortal i ty . 129 8.4 Cause of Death . 133 9 MATERNAL AND CHILD HEALTH 9.1 Materna l Care Indicators . 137 9.2 Immunizat ion . 141 9.3 D iar rhea l Disease and Treatment . 145 9.4 Acute Resp i ra tory Infect ion find Treatment . 150 9.5 Nutr i t ional Status of Chi ldren . 152 References . 161 viii Appendix A Appendix B Appendix C Appendix D SURVEY STAFF . 163 SAMPLE DESIGN . 171 SAMPLING ERRORS . 183 SURVEY QUESTIONNAIRES . 197 ix LIST OF TABLES 1.1 1.2 1.3 1.4 1.5 1.6 1.7 2.1 2.2 2.3 2.4 2.5 Estimates of the Mid-year Population of Egypt, 1960-1976 and the 1986 Census Population . 2 Population by Urban-Rural Residence and Place of Residence, Egypt, 1986 . 3 Survey Timetable, Egypt DHS, 1988 . 7 Results of the Household and Individual Interviews by Urban-Rural Residence, Egypt DHS, 1988 . 10 Results of the Household and Individual Interviews by Place of Residence, Egypt DHS, 1988 . 11 Unweighted and Weighted Distribution of Eligible Women by Age, Urban-Rural Residence, Place of Residence, Education Level and Work Status, Egypt DHS, 1988 . 16 Percent Distribution of Respondents by Level of Education, According to Age, Urban-Rural Residence, Place of Residence and Work Status, Egypt DHS, 1988 . 17 Percent Distribution of All Women by Current Marital Status, According to Age, Egypt DHS, 1988 . 19 Percent of All Women Ever Married by Current Age, According to Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 . 21 Percent Distribution of All Women by Age at First Marriage (Including Category "Never Married") and Median Age at First Marriage, According to Current Age, Egypt DHS, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Median Age at First Marriage among All Women 20-49 by Current Age, According to Selected Background Characteristics, Egypt DHS, 1988 . 24 Percent of Ever-married Women Married for the First Time Before Age 16 by Calendar Period in Which the Marriage Took Place, According to Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 . 26 xi 2.6 2.7 2.8 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Median Age at First Marriage Among Ever-married Women by Calendar Period in Which the Marriage Took Place, According to Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 . 27 Percent of Births in the Last 36 Months Whose Mothers Are Still Breastfeeding, Postpartum Amenorrheic, Postpartum Abstaining and Insusceptible to Pregnancy, by Number of Months Since Birth, Egypt DHS, 1988 . 29 Mean Number of Months of Breastfeeding, Postpartum Amenorrhea, Postpartum Abstinence and Postpartum Insusceptibility, by Selected Background Characteristics, Egypt DHS, 1988 . 31 Total Fertility Rate for the Calendar Year Periods 1986-1988 and 1983-1985 and for the Period 0-4 Years Before the Survey, and the Mean Number of Children Ever Born to Women 40-49, by Selected Background Characteristics, Egypt DHS, 1988 . 37 Age-Specific Fertility Rate (per 1,000 Women) for the Calendar Year Periods, 1986-88 and 1983-1985 and for the Period 0-4 Years Before the Survey, Egypt DHS, 1988 . 42 Age-Period Fertility Rates (per 1,000 Women) for Five-Year Periods Before the Survey by Age of Mother at the Time of Birth, Egypt DHS, 1988 . 43 Age-Specific Fertility Rates (per 1,000 Women) and the Total Fertility Rate, Egypt DHS 1986-1988, CPS 1983-1984 and FS 1979-1980 . 44 Percent of All Women and of Currently Married Women Who Were Pregnant at the Time of the Survey by Age, Egypt DHS, 1988 . 44 Percent Distribution of All Women and Currently Married Women By Number of Children Ever Born and Mean Number of Children Ever Born, According to Age, Egypt DHS, 1988 . 45 Mean Number of Children Ever Born to Ever-married Women by Age at First Marriage, According to the Number of Years Since First Marriage, Egypt DHS, 1988 . 46 Percent Distribution of All Women by Age at First Birth (Including Category "No Births") and Median Age at First Birth, According to Current Age, Egypt DHS, 1988 . 48 xii 3.9 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 Median Age at First Birth Among Women 25-49 by Current Age, According to Selected Background Characteristics, Egypt DHS, 1988 . 49 Among Ever-married Women, Percent Knowing a Contraceptive Method by Method, Egypt DHS, 1988, CPS, 1984 and FS, 1980, and Percent Knowing a Source by Method, DHS, 1988 . 52 Among Currently Married Women, Percent Knowing at Least One Modern Contraceptive Method and Percent Knowing a Source (for Information or Services) for a Modern Method, by Selected Background Characteristics, Egypt DHS, 1988 . 54 Percent of Currently Married Women Knowing a Contraceptive Method by Method, According to Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 . 55 Percent Distribution of Ever-married Women Knowing a Contraceptive Method by the Source Where the Woman Would Go to Obtain the Method, According to Method, Egypt DHS, 1988 . 56 Percent Distribution of Ever-married Women Knowing a Contraceptive Method by the Main Problem Perceived in Using the Method, According to Method, Egypt DHS, 1988 . 57 Percent Distribution of Currently Married Women Knowing a Contraceptive Method by Wife's Attitude Toward Contraceptive Use and the Wife's Perception about the Husband's Attitude, Egypt DHS, 1988 . 58 Percent Distribution of Currently Married Women Knowing a Contraceptive Method by Frequency of Discussion about Family Planning with Husband, Egypt DHS, 1988 . 59 Percent Distribution of Currently Married Women Knowing a Contraceptive Method by the Number of Children a Woman Should Have Before Using Contraception and the Mean Number a Woman Should Have Before Using Contraception, Egypt DHS, 1988 . 59 Attitudinal Indicators for Currently Married Women Knowing a Contraceptive Method by Selected Background Characteristics, Egypt DHS, 1988 . 61 Among Currently Married Women, Percent Usually Watching Television or Listening to the Radio and Percent Exposed to a xiii 4.11 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 Family Planning Message on the Television or Radio During the Month Before the Survey, by Selected Background Characteristics, Egypt DHS, 1988 . 63 Percent Distribution of Ever-married Women by Family Planning Topic About Which They Would Like Information, Egypt DHS, 1988 . 65 Percent of Ever-married Women and Currently Married Women Who Have Ever Used a Contraceptive Method by Method According to Age, Egypt DHS, 1988 . 68 Percent of Ever-married Women Who Have Ever Used a Contracep- tive Method by Method, Egypt DHS, 1988 and CPS, 1984 . 69 Among Ever-married Women, Percent Who Have Ever Used a Contraceptive Method and, Among Ever-Users, Percent Distribution by Number of Methods Used and Mean Number of Methods Used, According to Selected Background Characteristics, Egypt DHS, 1988 . 70 Percent Distribution of Ever-users by First Method Used, According to Selected Background Characteristics, Egypt DHS, 1988 . 72 Percent Distribution of Ever-users of Modern Methods, by the Source for the Modern Method First Used, Egypt DHS, 1988 . 74 Percent Distribution of Ever-married Women by Number of Living Children at Time of First Use of Contraception, According to Current Age, Egypt DHS, 1988 . 74 Percent Distribution of Ever-users by the Number of Living Children at Time of First Use of Contraception, by Selected Background Characteristics, Egypt DHS, 1988 . 75 Percent Distribution of Ever-users by Reproductive Intention at Time of First Use of Contraception, According to the Number of Children at Time of First Use of Contraception, Egypt DHS, 1988 . 76 Percent Distribution of Ever-users by Reproductive Intention at at the Time of First Use of Contraception, According to Method First Used, Egypt DHS, 1988 . 77 Among Ever-users, Percent Discussing Decision to Use Family Planning With the Husband, a Female Relative or a Doctor, and Percent Reporting the Decision to Use Was Mainly the Wife's xiv 5.11 5.12 5.13 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Idea, the Husband's Idea or a Joint Decision, According to Selected Background Characteristics, Egypt DHS, 1988 . 78 Among Ever-users, Percent Discussing Choice of Method Prior to First Use With the Husband, a Female Relative or a Doctor, and Percent Reporting the Method Chosen Was Mainly the Wife's Idea, the Husband's Idea or a Joint Decision, According to Selected Background Characteristics, Egypt DHS, 1988 . 81 Percent Distribution of Ever-Users Who Have Discontinued Use of a Contraceptive Method in the Five Years Prior to the Survey by Main Reason for Last Discontinuation, According to Method, Egypt DHS, 1988 . 82 Percent Distribution of Ever-Married Women and Women Who Have Ever Used the Safe Period Method, by Knowledge of the Fertile Period During the Ovulatory Cycle, Egypt DHS, 1988 . 83 Percent Distribution of Currently Married Women by the Contra- ceptive Method Currently Used, Egypt DHS, 1988 and CPS, 1984 . 86 Percent Distribution of Currently Married Women Using a Contra- ceptive Method by the Method Used, Egypt DHS, 1988 and CPS, 1984 . 86 Percent Distribution of Currently Married by Contraceptive Method Currently Used, According to Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 . 88 Percent of Currently Married Women Currently Using a Contraceptive Method by Urban-Rural Residence and Place of Residence, Egypt DHS 1988 and CPS, 1984 . 89 Percent Distribution of Currently Married Women Currently Using a Contraceptive Method by the Method Used, According to Urban- Rural Residence and Place of Residence, Egypt DHS, 1988 and CPS, 1984 . 90 Percent of Currently Married Women Currently Using a Contraceptive Method by Place of Residence and Governorate of Residence, Egypt DHS, 1988 . 92 Percent of Currently Married Women Currently Using a Contraceptive Method by the Method Used, According to Urban- XV 6.8 6.9 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 Rural Residence Within Upper Egypt (Including and Excluding Giza Governorate), Egypt DHS, 1988 . 93 Percent Distribution of Currently Married Women by Contraceptive Method Currently Used, According to Selected Background Characteristics, Egypt DHS, 1988 . 95 Percent Distribution of Current Users of Modern Methods by Service Provider, According to Method, Egypt DHS, 1988 . 97 Percent Distribution of Current Users of Modern Methods by Service Provider, According to Method, Egypt DHS, 1988 and CPS, 1984 . 97 Among Pill and IUD Users, Percent Expressing Dissatisfaction with Various Aspects of Services, Egypt DHS, 1988 . 98 Percent Distribution of Current Pill Users By the Brand Used, Egypt DHS, 1988 and CPS, 1984 . 99 Percent Distribution of Pill Users by Whether They Switched Brands During Year Before the Survey, Number of Cycles Usually Purchased and Cost of a Cycle, Egypt DHS, 1988 . 100 Percent Distribution of Pill Users Unable to Show Packet by Reason for Not Having Packet Available, Egypt DHS, 1988 . 100 Percent Distribution of Pill Users Whose Pills Were Missing Out of Sequence or Whose Pill Packet Had No Pills Missing, by Reason Given For Not Taking Pills (in Sequence), Egypt DHS, 1988 . 101 Percent Distribution of Pill Users Not Taking the Pill in the Last Two Days by Reason Pill Not Taken, According to Number of Days Since Pill Taken, Egypt DHS, 1988 . 101 Percent of Pill Users Reporting That They Experienced Various Problems When Taking the Pill During the Month Before the Survey, Egypt DHS, 1988 . 102 Percent of Pill Users Reporting That They Interrupted Use Because of Various Problems During the Month Before the Survey, Egypt DHS, 1988 . 102 xvi 6.19 6.20 6.21 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 Percent Distribution of Pill Users by Action Taken the Last Time User Forgot to Take the Pill, Egypt DHS, 1988 . 102 Percent Distribution of Currently Married Women Who Are Not Currently Using ,M:y Contraceptive Method by Intention to Use in the Future, According to Number of Living Children, Egypt DHS, 1988 . 103 Percent Distribution of Currently Married Women Who Are Not Using a Contraceptive Method but Who Intend to Use in the Future by Preferred Method, According to Whether They Intend to Use in the Next 12 Months or Later, Egypt DHS, 1988 . 104 Percent Distribution of Currently Married Women by Desire for Children and the Certainty of Their Preference, According to the Number of Living Children, Egypt DHS, 1988 . 106 Percent Distribution of Currently Married Women by Desire for Children, According to Number of Living Children, Egypt DHS, 1988 . 107 Percent Distribution of Currently Married Women by Desire for Children, According to Age, Egypt DHS, 1988 . 108 Percent of Currently Married Women Who Want No More Children by Number of Living Children According to Selected Background Characteristics, Egypt DHS, 1988 . 109 Percent Distribution of Fecund Currently Married Women by Wife's and Husband's Desire for More Children, Egypt DHS, 1988 . 111 Percent Distribution of Ever-married Women by Ideal Number of Children and Mean Ideal Number of Children Among Ever- married Women and Currently Married Women by the Number of Living Children, Egypt DHS, 1988 . 112 Among Ever-married Women, Mean Ideal Number of Children by Age, According to Selected Background Characteristics, Egypt DHS, 1988 . 113 Percent Distribution of Currently Married Women Knowing About the Husband's Ideal Number of Children by the Husband's Ideal xvii 7.9 7.10 7.11 7.12 7.13 7.14 7.15 8.1 8.2 Number of Children, According to the Wife's Ideal Number of Children, Egypt DHS, 1988 . 114 Percent Distribution of All Births in the Last Five Years by Contraceptive Practice and Fertility Planning Status, According to Birth Order, Egypt DHS, 1988 . 115 Percent of Women Who Had a Birth in the Last 12 Months by Fertility Planning Status, According to Birth Order, Egypt DHS, 1988 . 116 Total Wanted Fertility Rates and Total Fertility Rates for the Five Years Prior to the Survey, by Selected Background Characteristics, Egypt DHS, 1988 . 117 Percent Distribution of Births in the Five Years Before the Survey To Women in Various High Risk Categories, by Fertility Planning Status, and Percent of All Births Which Occurred to Mothers in High Risk Categories, According to the Risk Category, Egypt DHS, 1988 . 118 Among Currently Married Women, Percent Who Are in Need of Family Planning and Percent Who Are in Need and Intend to Use Family Planning in the Future by Reproductive Intention, According to Selected Background Characteristics, Egypt DHS, 1988 . 120 Percent Distribution of Non-pregnant Women Who Are Currently Married and Who Are Not Using Any Contraceptive Method by Attitude Toward Becoming Pregnant in the Next Few Weeks, According to Number of Living Children, Egypt DHS, 1988 . 121 Percent Distribution of Non-Pregnant Women Who Are Currently Married and Are Not Using Any Contraceptive Method and Who Would be Unhappy if They Became Pregnant by Main Reason for Nonuse, According to Age, Egypt DHS, 1988 . 122 Mean Number of Children Ever Born, Surviving and Dead by Age of Mother, Egypt DHS, 1988 and the Proportion Dead Among Children Ever Born, Egypt DHS, 1988, CPS, 1984 and FS, 1980 . 126 Proportion Dead Among Children Ever Born by Urban-Rural Residence and Place of Residence, According to Age of the Mother, Egypt DHS, 1988 . 126 xviii 8.3 Infant and Childhood Mortality by Five-Year Calendar Periods, Egypt DHS, 1988 . 128 8.4 8.5 8.6 8.7 8.8 8.9 9.1 9.2 9.3 9.4 Neonatal and Post-neonatal Mortality Rates by Five-Year Calendar Periods, EDHS, 1988 . 129 Trend in Infant Mortality in Egypt, 1950-1988, Egypt DHS and FS . 129 Infant and Childhood Mortality by Selected Socioeconomic Characteristics of the Mother for the Period 1978-1988, Egypt DHS, 1988 . 131 Under Age Five Mortality Rates for Recent Calendar Periods by Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 . 132 Infant and Childhood Mortality by Selected Demographic Characteristics for the Period 1978-1988, Egypt DHS, 1988 . 133 Percent of Nonsurviving Children Born During the Five Years Before the Survey Who Died by the Symptom or Illness the Mother Reports the Child Had Before Death, According to the Age of the Child at Death, Egypt DHS, 1988 . 134 Among Births in the Five Years Before the Survey, Percent Whose Mother Received Prenatal Care by Reason for Care and Type of Health Personnel Providing Care, and Percent Whose Mother Received a Tetanus Toxoid Injection, According to Selected Background Characteristics, Egypt DHS, 1988 . 138 Among Births in the Five Years Before the Survey, Percent Distribution by the Place of Delivery and by Person Assisting With Delivery, According to Selected Background Characteristics, Egypt DHS, 1988 . 140 Percent of Children Under Age 5 Reported by Mother as Having Received Drops or an Injection to Prevent Disease by Age of Child, Egypt DHS, 1988 . 141 Percent of Children 12-23 Months Reported by Mother as Having Received Drops or an Injection to Prevent Disease by Selected Background Characteristics, Egypt DHS, 1988 . 142 xix 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 Among Children Under Age 5, Percent Having a Birth Record Seen by the Interviewer and, Among Children with a Birth Record, Percent Receiving Various Immunizations by Age of Child, Egypt DHS, 1988 . 143 Among Children 12-23 Months, Percent Having a Birth Record Seen by the Interviewer and, Among Children with a Birth Record, Percent Receiving Various Immunizations by Selected Background Characteristics, Egypt DHS, 1988 . 144 Percent of Children Under Age 5 Having a Diarrhea Episode Within the Past 24 Hours, 7 Days or Since the Preceding Ramadan, Egypt DHS, 1988 . 146 Among Children Under Age 5 with a Diarrhea Episode In the Past Seven Days, Percent With Advice Sought From Various Health Providers, Percent Receiving Various Treatments and Percent With No Opinion Sought and No Treatment Given, by Selected Background Characteristics, Egypt DHS, 1988 . 148 Among Mothers of Children Under Age 5, Percent Who Know About Oral Rehydration Therapy (ORT), and Percent Who Have a Packet Available in the Home, by Selected Background Characteristics, Egypt DHS, 1988 . 149 Among Children Under Age 5, Percent Having a Cough and Percent Having a Cough With Difficulty Breathing Within the Month Before the Interview, and, Among Children With a Cough Percent Consulting With Advice Sought From Various Health Care Providers, by Selected Background Characteristics, Egypt DHS, 1988 . 151 Percent Distribution of Measured Children by Selected Background Characteristics, Egypt DHS, 1988 . 153 Percent Distribution of Children 3-36 Months by Standard Deviation Category of Height-for-age Using the NCHS/CDC/WHO International Reference Population, According to Selected Background Characteristics, Egypt DHS 1988 . 155 Percent Distribution of Children 3-36 Months by Standard Deviation Category of Weight-for-height Using the NCHS/CDC/WHO International Reference Population, According to Selected Background Characteristics, Egypt DHS, 1988 . 158 XX 9.14 9.15 Percent Distribution of Children 3-36 Months by Standard Deviation Category of Weight-for-age Using the NCHS/CDC/WHO International Reference Population, According to Selected Background Characteristics, Egypt DHS, 1988 . 159 Weight-for-height Standard Deviation Categories Cross-Tabulated by Height-for-age Standard Deviation Categories, Using the NCHS/CDC/WHO International Reference Population, Egypt DHS, 1988 . 160 Appendix B B.1 List of Primary Sampling Units by Governorate, Egypt DHS, 1988 . 177 Appendix C C.1 List of Variables for Which Sampling Errors Are Calculated, Egypt DHS, 1988 . 187 C.2 Sampling Errors - Entire Sample, Egypt DHS, 1988 . 188 C.3 Sampling Errors by Urban-Rural Residence, Egypt DHS, 1988 . 189 C.4 Sampling Errors by Place of Residence, Egypt DHS, 1988 . 190 C.5 Sampling Errors by Age Group, Egypt DHS, 1988 . 194 xxi LIST OF FIGURES Chapter 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Marital Status by Current Age . 20 Percent Ever Married by Place of Residence . 22 Age at First Marriage by Current Age and Place of Residence . 25 Percent Married before Age 16 by Place of Residence, 1960-1984 . 27 Age at First Marriage by Calendar Period and Place of Residence . 28 Duration of Breastfeeding and Postpartum Insusceptibility by Place of Residence . 32 Duration of Breastfeeding and Postpartum Insusceptibility by Level of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Chapter 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Cumulative Fertility (CEB) and Current Fertility (TFR) . 38 Cumulative Fertility (CEB) and Current Fertility (TFR) by Place of Residence . 39 Current Fertility (TFR) by Place of Residence . 39 Cumulative Fertility (CEB) and Current Fertility (TFR) by Level of Education . 41 Current Fertility (TFR) by Level of Education . 41 Age-Period Fertility Rates . 43 Median Age at First Marriage and First Birth by Current Age . 48 Percent Giving Birth Before Age 18 by Current Age . 50 Chapter 4 4.1 4.2 4.3 4.4 Contraceptive Knowledge by Method . 53 Percent of Wives and Husbands Disappproving of Family Planning by Place of Residence . 62 Exposure to Family Planning Broadcasts by Place of Residence . 64 Exposure to Broadcast Media by Place of Residence . 64 Chapter 5 5.1 5.2 5.3 5.4 5.5 Ever Use of Contraception by Method, 1984 and 1988 . 69 Ever Use of Contraception by Place of Residence . 71 First Contraceptive Method Used by Current Age . 73 Reproductive Intention at Time of First Use of Contraception by Number of Living Children at Time of First Use . . 76 Percent Consulted Doctor Prior to Adopting Family Planning by Place of Residence . 79 xxiii 5.6 Reasons for Discontinuation Among Pill and IUD Users . 83 Chapter 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Current Use of Contraception, 1980 to 1988 . 85 Current Use of Contraception by Method, 1984 and 1988 . 87 Method Mix, 1984 and 1988 . 87 Current Use of Contraception by Method According to Place of Residence . 89 Current Use of Contraception in Rural Egypt by Place of Residence 1980-1988 . 91 Current Use of Contraception by Governorate . 93 Current Use of Contraception by Age . 94 Service Providers for Pill and IUD Users . 98 Chapter 7 7.1 7.2 7.3 Desire for Children . 107 Percent Wanting No More Children by Place of Residence . 110 Total Fertility Rates (TFR) and Total Wanted Fertility Rates (TWFR) by Place of Residence . 118 Chapter 8 8.1 8.2 Infant Mortality by Calendar Period . 130 Under Five Mortality by Place of Residence . 130 Chapter 9 9.1 9.2 9.3 Maternal Care Indicators . 139 Percent Fully Immunized by Place of Residence . 145 Percent Stunted by Place of Residence . 156 Appendk B B.1 Distribution of Sampling Points, Egypt Demographic and Health Survey, 1988 . 182 xxiv SUMMARY OF FINDINGS FERTILITY AND FAMILY PLANNING-A DECADE OF PROGRESS Declining Fertility. The Egypt Demographic and Health Survey (EDHS) documents the significant progress that has been made in the 1980s in addressing the population problem in Egypt. Fertility levels have declined steadily over the decade. At current rates, women will have an average of 4.4 births by their 45th birthday. This total fertility rate represents a decline of 15 percent from the level of 5.2 births per woman recorded in the Egypt Fertility Survey (EFS) at the beginning of the decade. Increasing Use of Contraception. The fertility decline has taken place in the context of increasing use of contraception. The EDHS found that 38 percent of married women are currently using family planning--an increase of 60 percent over the rate of 24 percent recorded in the 1980 EFS. Equally encouraging is the dramatic increase in IUD use since the middle of the decade. The percent of currently married women relying on the IUD doubled in the four-year period between the Egypt Contraceptive Prevalence Survey (ECPS) and the EDHS, increasing from 8 percent in 1984 to the current level of 16 percent. The pill continues to be widely used; according to the EDHS, 15 percent of currently married women are using the pill. Use of other modern methods remains limited, and few women rely on traditional methods. Childbearing Attitudes. Childbearing attitudes of Egyptian women are supportive of further fertility decline. Three in five women want no more children, and, among those who want another child, nearly half are interested in delaying the next birth at least two years. According to fecund married women, more than half of their husbands also desire no more children. The average ideal family size--2.9 children--is well below the current fertility rate, and more than one-third of ever-married women prefer a two-child family. Widespread Knowledge and Approval of Family Planning. Widespread knowledge and approval of family planning are also supportive of further fertility reduction. Nearly all currently married women (98 percent) know at least one contraceptive method. Efforts to broadcast family planning information through mass media, particularly television, appear to be successful in reaching women; two-thirds of currently married women reported watching a television broadcast about family planning in the month before the survey. Among women knowing about family planning, 87 percent approve of the use of contraception, and 70 percent believe their husband approves. Almost half of married women not currently using family planning indicate that they plan to adopt a method in the future. Access to Family Planning Services. Egyptian women are knowledgeable about family planning service providers; 96 percent of currently married women are able to name a source where contraceptive services are available. Both the public and private sector continue to be important in the provision of family planning services. Current users of the xxvii pill obtain their supply largely from pharmacies, while users of the IUD are about equally divided between those obtaining services from private doctors and government facilities. Nearly 20 percent of IUD users purchased the IUD at a pharmacy before having it inserted. Other Fertility Determinants. In addition to the increasing use of contraception, changes in marriage patterns are contributing to declining fertility. Women who marry at an early age tend to bear children sooner and give birth to more children than women who delay marriage. The EDHS results show that the median age at first marriage has been increasing steadily across age cohorts, from 17.4 years among women 45-49 to 19.5 years among women 25-29. By extending the period of natural infecundity following birth, breastfeeding also plays an important role in protecting women from a subsequent pregnancy. On average, women breastfeed for 17 months. As a result, the return of menstruation and, thus, the risk of another pregnancy, are delayed, on average, for 8 months following birth. CONTINUING CHAI J .I~.NGES Unwanted Fertility. Despite the clear progress in reducing fertility and increasing the use of family planning during the 1980s, the EDHS results point to a number of continuing challenges for Egypt's population program. A key concern is that, although fertility levels are declining, there remains a significant level of unwanted births. Overall, 22 percent of the births in the five-year period before the survey were not wanted. If unwanted births had been prevented, a woman would have had an average of 3.6 births during the period compared with the actual average of 4.7 births. High Risk Pregnancies. For many mothers the prevention or delay of a birth is an important health measure. Nearly 60 percent of the births occurring in the five years before the survey were the outcome of pregnancies defined as high risk, i.e., pregnancies too young (mothers under age 18), too old (mothers age 35 and over), too many (mothers with five births or more) or too soon (births which occur less than two years after the last birth). More than 30 percent of these high risk births were unwanted and 16 percent were mistimed. Need for Family Planning. Many women who currently do not want another child or who want to delay having a birth for at least two years are not using contraception. Nearly half of currently married women are potentially in need of family planning to achieve their childbearing goals--30 percent to limit further childbearing and 17 percent to space desired births. Almost 60 percent of women not currently using family planning report that they would be unhappy if they became pregnant soon. xxviii Barriers to Use of Contraception. The EDHS results provide information on a number of potential barriers to contraceptive use. One of the major obstacles is concern about side effects. Over 60 percent of women knowing about the pill consider side effects to be the main problem in using the method, and 40 percent of those using the IUD see side effects as the primary obstacle to use. For a minority of women, the husband's attitude may also be a barrier to contraceptive use. Around one in six women who knows about family planning believes that her husband disapproves of the use of contraception. Other potential barriers to use (including cost or difficulties in obtaining contraceptive services) are cited by only a few women. Nearly one-third of IUD users think the method had cost too much. Reasons for Discontinuing Use of Contraception. A key concern for the Egyptian family planning program must also be the reasons women give for discontinuing contraceptive use. Two in every five women who discontinued use of the pill or the IUD in the five years before the survey report that they stopped using the method the last time because they had experienced side effects. Among pill users, 18 percent report that they became pregnant while using the method. Problems in Using the Pill. The EDHS results indicate that many pill users fail to take the pill correctly. For some, noncompliance appears to be linked to a belief that it is necessary to take the pill only when the husband is present in the household. "Resting" from the pill is another reason frequently given for not having a pill packet or not taking the pill systematically. Short interruptions of use seem to be linked primarily to forgetting to take the pill, but side effects also lead some users to stop taking the pill. RESIDENTIAL DIFFERENTIALS Fertility. One of the major challenges facing the population program is the differentials in fertility by residence. At the rates prevailing during the calendar period 1986-1988, urban women will have an average of 3.5 births before their 45th birthday while rural women will have 5.4 births. Fertility rates also vary significantly by place of residence, averaging 3.0 births in the Urban Governorates, 4.4 births in Lower Egypt and 5.4 births in Upper Egypt. In rural Upper Egypt, the fertility rate exceeds 6 births. Use of Contraception. Underlying the fertility differentials are differentials in contraceptive use. The contraceptive use rate in urban areas (52 percent) is more than double the level in rural areas (24 percent). The use rate is highest in the Urban Governorates (56 percent) followed by Lower Egypt (41 percent) and Upper Egypt (22 percent). Within the latter two areas, the differential in the use rate for rural women is especially striking; married women in rural Lower Egypt (36 percent) are three times as likely to be using a contraceptive method as women in rural Upper Egypt (12 percent). xxix This threefold differential continues a pattern that has been apparent throughout the 1980s. Rural Upper Egypt. Rural women from Upper Egypt clearly differ from other women on a variety of attitudinal indicators. For example, much of the disapproval of contraceptive use is concentrated among women from rural Upper Egypt; almost one in five rural women knowing a contraceptive method in this region disapproves of a couple using family planning, three times the level of disapproval recorded for women in rural Lower Egypt. More than one in four women in rural Upper Egypt believes that her husband disapproves of family planning; this is more than twice the level of husband disapproval reported by women from rural Lower Egypt. Rural women in Upper Egypt are also less likely to want to stop childbearing compared with those from Lower Egypt (43 percent vs. 67 percent). They also report a higher ideal number of children than women from rural Lower Egypt (3.6 vs. 2.8 children). Despite the generally more conservative attitudes toward childbearing, many women in rural Upper Egypt have been having more children than they want. Nearly one in five births in rural Upper Egypt during the five years before the survey was reported by the mother as unwanted. If these unwanted births had been prevented, the fertility rate for the period would have been five births rather than the actual rate of more than six births. MATERNAL AND CHII.D HEALTH Infant and Child Mortality. The EDHS results indicate significant progress has been made in reducing child mortality. Infant and childhood mortality has declined from high levels in the 1970s. The mortality levels for the five-year period preceding the EDHS are 73 per thousand (infant) and 31 per thousand (childhood). Overall, under five mortality declined from 203 per thousand in 1974-1978 to 102 per thousand in 1984-1988. There are substantial differences in mortality by residence. Rural mortality is around twice the level of urban mortality. Children in Upper Egypt are at significantly greater risk of dying than children in other areas. The highest level is seen for children in rural Upper Egypt, where under five mortality exceeds 200 deaths per thousand. Both the age of the mother and the interval between births is related to child mortality. Considering age, the highest mortality risk occurs for children of very young mothers or mothers nearing the end of the reproductive period. Mortality risks for children are substantially reduced when the interval between births increases. Maternal Care Indicators. The care that a woman receives during pregnancy and at childbirth affects the health and survival of both the mother and her child. The EDHS found that many women do not receive medical care during pregnancy; only half of the XXx births during the five-year period before the survey were preceded by a prenatal checkup. When a mother receives a tetanus toxoid injection as part of prenatal care, immunity against tetanus is passed on to the baby and protects the child against neonatal tetanus, a common cause of neonatal death. Mothers received tetanus toxoid injections during pregnancy for only 11 percent of the births during the period. Women are even less likely to have medical assistance for delivery than they are to receive medical care during pregnancy. Seventy-five percent of births in the five-year period before the survey took place at home, and only one-third were assisted at delivery by a doctor or trained nurse/midwife. Immunization. One of the primary mechanisms for improving child survival is increasing the proportion of children immunized against the major preventable childhood diseases (tuberculosis, diphtheria, whooping cough, tetanus, polio and measles). The EDHS results suggest that almost all young children receive immunization against childhood illnesses. According to the mother, 93 percent of children 12-23 months have received drops or an injection to prevent disease. There is evidence, however, that many of these children have not received the full primary course of immunizations. Among children for whom an immunization record was seen, only one-third could be considered to be fully immunized. Childhood Illnesses and Treatment. Diarrheal and respiratory illnesses are among the leading causes of infant and child deaths in Egypt. The EDHS results indicate that medical advice is sought in around one in two episodes of diarrhea or respiratory illness among children under five. Almost all mothers of children under age 5 are aware of Oral Rehydration Therapy (ORT), an inexpensive and effective treatment for diarrheal illness, which has been widely promoted in Egypt. Nutritional Status. Malnutrition frequently contributes to child deaths. The EDHS found that 30 percent of children 3-36 months were stunted--short in relation to their age in comparison with an international reference population. Stunting, which is an indicator of chronic malnutrition, was more common among rural children than urban children and in Upper Egypt than in Lower Egypt. The adverse effect of closely spaced births is again apparent; children born four or more years after an older sibling are much less likely to be stunted than other children. xxxi MEDITERRANEAN SEA 5 3 24 23 2,5 26 1,8. REO SEA 19 20 21 22 Egypt U r b a.o_Qg_'~ r n o r a.t~} 1 - Ca i ro 2 - A texar ld r ta 3 - Por t ~a ld 4, - S~e/. LQwe r E ~ 5 - Damlet ta 6 - D~k~hH~ 7 - 5harKt~ 8 - Ka lyub la 9 - Ka f r E l -She ikh 1Q - Gh~irb la 11 - Menouf la 12 - Behera 13 - I smaiHa u o o~,j~F.g~t 14 - G[;~a 15 - Ben l Suef 16 - Fayoum 17 - Menya 18 - Ass iu t 19 - Souhag 20 -. Oena 21 - Aswan ~ r G o v e, JJ~,~b~Le~ 22 - New Va l ley 23 - Mat rouh 24 - Nor th SInz,~ 25 - South Sin&l 26 - Red ~ea Chapter 1 BACKGROUND 1.1 HISTORY, GEOGRAPHY AND ECONOMY Egypt, one of the most densely populated countries in the Middle East, is located on the northeast corner of the African continent. It extends from the Mediterranean Sea on the north to Sudan on the south, and from the Red Sea on the east to Libya on the west. Even though the total area of Egypt is around one million square kilometers, less than five percent of the land is inhabited. For thousands of years, the people of Egypt have derived their livelihood from cultivating the area irrigated by the Nile, whose waters have been the symbol of the life for the country. Thus, for many centuries, attention has focused on maximizing utilization of the river's water. Recently, however, the government has adopted a policy of land reclamation and fostering of new settlements in the desert. Despite these efforts, the vast majority of Egyptians continue to live either in the Nile delta located in the north (Lower Egypt) or in the narrow Nile Valley (Upper Egypt). Population density in inhabited areas exceeds 1,300 per square kilometer, although, for the country as a whole, it is around 50 per square kilometer. Administratively, modern Egypt is divided into 26 governorates. Four of these governorates are major metropolitan areas (Cairo, Alexandria, Port Said and Suez), nine are located in the Nile delta, eight are located in the Nile valley and five are frontier governorates (see map). The Egyptian economy, which is the second largest in the Middle East, has expanded steadily during the past several decades. The gross domestic product (GDP) increased from $4.6 billion in 1965 to $34.5 billion in 1986 (World Bank, 1989b). The annual rate of growth in the GDP is estimated to have been 6.8 percent in the period 1965-1980 and 6.3 percent in the period 1980-1987. Growth slowed sharply, however, during the last half of the latter period because of lower oil prices and declines in remittances received from Egyptians working abroad; in 1988, the GDP increased by only 3.2 percent (World Bank, 1989a). Despite its growth, the economy has not been able to absorb a rapidly expanding labor force. Currently, 43 percent of the labor force is employed in services, 21 percent in the industrial sector and 36 percent in agriculture. Dependency on foreign countries for agricultural products is one of the major economic problems facing Egypt. Cereal imports increased from 3.9 million to 9.3 million metric tons between 1974 and 1986 1 (World Bank, 1989b). In the same period, foreign assistance in the form of food aid increased from 0.6 to 1.8 million metric tons. 1.2 POPULATION Size, Growth and Structure Preliminary results from the 1986 Census indicate that the total population of Egypt is 48 million,' nearly double the population in 1960 (Table 1.1). Roughly half of the increase occurred in the ten-year period between the 1976 and 1986 censuses, when the population grew by more than 10 million. If it continues to grow at the annual rate observed in the 1976-1986 intercensal period, the population will nearly double again by the year 2015. Around one-fifth of the Egyptian population is found in the Urban Governorates (Table 1.2). Lower Egypt is home for about 21 million people, while 17 million live in Upper Egypt. Slightly more than one percent reside in the Frontier Governorates. The majority of the (72 percent) and Upper Egypt (68 percent). Table 1.1 Estimates of the Nid-year Population, 1960-1976, and the 1986 Census PopUlation, Egypt Totat Pol~Jtation Year ( in Thousands) 1960 26,085 1966 30,076 1976 38,198 1986 48,205 Source: Centrat Agency for Public Nobit ization and Stat ist ics (CAPMAS), 1986 and CAPHAS, 1987 population is rural, in both Lower Egypt The population of Egypt has a young age structure, as a consequence of high fertility and declining child mortality. Preliminary results from the 1986 Census indicate that one-third of Egyptians are under age 12, and 19 percent are under age 5 (Central Agency for Public Mobilization and Statistics, 1987). Other key census findings include: Among the population age 6 and over, 28 percent are participating in the labor force. The labor force participation rate among males (47 percent) is more than five times that among females (9 percent). The level of illiteracy among males is only 38 percent compared with 62 percent among females. Among the female population age 16 and older, 65 percent are married. Ninety-four percent are Muslim, with the remainder being mainly Christian. 1 This figure does not include 2.25 million Egyptians who live abroad. 2 Table 1,2 Population by Urban-Rurat Residence end Piece of Residence, Egypt, 1986 Population Residence (in Thousands) Percent Urban-Rural Residence Urban 21,183 43.9 Rural 27,022 56.1 Place of Residence urban Governoretes 9,697 20.1 Lo~er Egypt 20,876 43.3 Urban 5,755 11.9 Rural 15,121 31.4 Upper Egypt 17,067 35.6 Urban 5,399 11.2 Rural 11,668 24.2 Frontier Governorates 565 1.2 Urban 332 0.7 Rural 233 0.5 To[at 48,205 100.0 Source: Centre[ Agency for Public Hobitization and and Statist ics, 1987 Mortality In Egypt, mortality levels were high and relatively stable until after World War II, when both the crude death rate and the infant mortality rate started to decline. The crude death rate dropped from a level of 30 deaths per thousand population in the 1940s to around 15 per thousand during the sixties, before declining to the present level of less than 10 per thousand. During the same period, infant mortality fell from a level of more than 200 deaths per thousand births to 124 in the late 1970s (Bucht and E1-Badry, 1986). Mortality levels continued to decline during the 1980s, The infant mortality rate is estimated to have been 88 per thousand in 1986. Life expectancy is 62 years for females and 59 years for males (United Nations, 1989). Fertility Fertility levels also declined during the period following World War II, but at a slower pace than mortality. In the 1940s, the crude birth rate averaged just under 50 births per thousand population. By the early sixties, the crude birth rate had declined to around 45 per thousand. The slow decline continued during the late sixties and seventies. By the mid-eighties, the crude birth rate was estimated to be just under 40 per thousand (Bucht and El-Badry, 1986). 3 Internal Migration and Urbanization Due to migration from rural to urban areas, the proportion of the total Egyptian population that was urban increased steadily from 37 percent in 1960 to 44 percent at the time of the 1976 census. Preliminary results of the 1986 census suggest that the urban- rural distribution remained stable in the intercensal period. This does not necessarily indicate that the level of rural to urban migration has slowed, since the effect of greater rural outmigration may have been offset by higher fertility in rural areas compared with urban areas. International Migration The Egyptian Migration Survey estimated that the number of Egyptian emigrant workers at the beginning of 1985 was 1,210,000 (Fergany, 1987). The total number of Egyptian workers who had lived abroad during the period 1973-1985 but had returned to Egypt at the beginning of 1985 was 1,165,000. Almost all emigrant workers were male. Including dependents of these workers who also lived abroad, a total of 3,425,000 Egyptians emigrated during the period 1973-1985. Five countries received 85 percent of Egyptian emigrants during the period: Iraq, Saudia Arabia, Kuwait, Jordan and Libya. 1.3 IqF.ALTH POLICY AND PROGRAMS Egypt has long given high priority to the provision of public health services, through a national system of health facilities at all levels (central, governorate and local). Up to the mid-1980s, the public health program was curative and physician-oriented. In the health plan for the period 1960-1965, 54 percent of all resources were allocated to curative services (Ministry of Health, 1960). While this rate decreased to 46 percent in the 1977- 1981/82 plan (Ministry of Health, 1977), it increased again to 54 percent in the 1982/83- 1986/87 health plan (Ministry of Health, 1982). The main objective of health policies during the 1960s and 1970s was to increase coverage of the health care system. As a result, during those two decades, there was a tremendous increase in the number of health units, hospitals, clinic beds, paramedical staff, and physicians. Rural health units increased from 733 in 1960 to 2,519 in 1982. The average population served by the health units decreased from 21,992 in 1960 to 9,576 in 1982. The number of physicians per 1,000 population increased from 4.4 in 1960 to 11.8 in 1980. The 1960s and 1970s were also characterized by a commitment to large-scale construction projects. The early 1960s witnessed a campaign to build new general hospitals, chest disease hospitals and health institutes. In the 1970s, attention focused on efforts to renovate public hospitals as well as technical institutes (United States Department of Health, Education and Welfare, 1975). 4 Despite the commitment to improving the coverage and services of the health care system, health care delivery in Egypt still faces significant problems. Both health facilities and manpower tend to be unevenly distributed, clustering in urban areas, especially in Cairo and Alexandria. For example, the average number of hospital beds per 10,000 population is 3.8 in Cairo and 2.8 in Alexandria compared with 1.6 in Lower Egypt and 1.2 in Upper Egypt. Moreover, in Ministry of Health hospitals, there has been an overall decrease in the ratio of beds per 10,000 population, from 1.4 in 1960 to 1.3 in 1986. There has recently been an increasing emphasis on primary health care, with the adoption of new approaches emphasizing child survival interventions, the control of diarrheal diseases and the strengthening of rural health services. Priorities of Egyptian health policy in the 1980s include: an emphasis on preventive care; a focus on the reduction of mortality and morbidity rates through prevention of childhood and endemic diseases and of excess fertility; an expansion of the national health care financing system, emphasizing cost recovery and greater participation by the private sector; and an emphasis in biomedical research on the problems of mothers and children (United States Agency for International Development, 1987). 1.4 POPULATION POLICY AND PROGRAMS Egypt has a long history of support for efforts to control the country's rapid population growth. Family planning services were first offered in the 1950s through experimental and pilot projects instituted in clinics in selected areas under the auspices of the National Commission for Population Matters; responsibility for these projects was later transferred to established voluntary organizations such as the Egyptian Association for Population Studies, the forerunner of the Egyptian Family Planning Association. Revitalized governmental concern led in the mid-1960s to the establishment of the Supreme Council for Family Planning and its secretariat, the Family Planning Board. The scope of activities of these organizations was later broadened to include population as well as family planning. AS an interministerial commission, the Supreme Council's mandate was to formulate policies, coordinate family planning activities and evaluate performance in meeting objectives. The strong government support for population and family planning activities was evidenced again in 1984 when a National Population Conference was held and the National Population Council was established. The chairmanship of the Council and its structure reflected the continuing commitment of the government to dealing with Egypt's population problem. Population and family planning targets, which were first established in the late 1960s, were included in three policy documents published in 1973, 1980 and 1986. In the policy statement, an overall goal was set of reducing population growth to around 2.1 5 percent by the year 2001. To accomplish this objective, the crude birth rate would be reduced to 28.5 births per thousand. In addition, the policy set objectives for improving population characteristics (e.g., raising literacy) and the spatial distribution (National Population Council, 1986). Improving the accessibility and availability of contraceptive services has been one of the central goals of the Egyptian family planning program over the almost 25 years of its existence. Contraceptive services are currently available from a network of around 4,000 government operated facilities, including hospitals, Maternal and Child Health (MCH) centers and family planning clinics. In addition to these clinic-based providers, contraceptive methods including the IUD as well as the pill and other supply methods are sold in more than 4,000 pharmacies throughout Egypt at nominal government-subsidized prices. Private physicians play a key role in the delivery of family planning services in Egypt, and the Egyptian Family Planning Association, a private voluntary family planning association, operates a network of urban clinics. Community-based programs have been used to promote family planning acceptance among both urban and rural residents. The long commitment to efforts to reduce population growth in Egypt showed signs of success by the middle of the 1980s, with the prevalence of contraceptive use reaching a level of 30 percent in 1984 and fertility levels falling. Nevertheless, family planning program efforts in Egypt in the early 1980s were classified as "weak" in comparison to that in other countries (Mauldin and Lapham, 1984). Of particular concern was the substantial difference in the level of family planning use between couples living in Lower Egypt and Upper Egypt (Sayed et al., 1985). Recently, governmental efforts to deliver contraceptive services have been strengthened. Political leaders frequently speak out in support of family planning, and the National Population Council is providing the leadership in coordinating a more decentralized approach to service delivery that is emphasizing governorate-level initiatives for tackling the population problem (Gillespie et al., 1989). 1.5 OBJECFIVES OF THE SURVEY The Egypt Demographic and Health Survey (EDHS) has as its major objective the provision of current and reliable information on fertility, mortality, family planning, and maternal and child health indicators. The information is intended to assist policy makers and administrators in Egyptian population and health agencies to: (1) assess the effect of ongoing family planning and maternal and child health programs and (2) improve planning for future interventions in these areas. The EDHS provides data on topics for which comparable data are not available from previous nationally representative surveys, as well as information needed to monitor trends in a number of indicators derived from earlier surveys, in particular, the 1980 Egypt Fertility Survey (EFS) and the 1980 and 1984 Egypt Contraceptive Prevalence Surveys (ECPS). Finally, as part of the worldwide Demographic 6 Table 1.3 Survey Timetable, Egypt DHS 1988 Activity Starting Date Duration General Preparation July 1987 1 month Development of the Sample Design Mapping (Rural Areas) Quick Count (Urban Areas) Recruitment and Training of Listing Staff Listing and Relisting Sample Selection Questionnaire Design Preparation of Training Manuals and Other Documents Printing of Pretest Materials Pretest Finalization of Questionnaire Recruitment of Field Staff Printing Survey Materials Training of Fieldwork Staff Fieldwork Reinterviewing Office Editing Data Entry Computer Editing Preliminary Report Preparation Detailed Tabulations Final Report Preparation January 1988 3 months April 1988 3 months June 1988 3 months August 1988 6 weeks September 1988 1 month October 1988 1 month November 1987 3 months May 1988 3 months May 1988 1 month June 1988 2 weeks September 1988 1 month September 1988 1 month September 1988 1 month September 1988 5 weeks October 1988 3 months December 1988 1 month November 1988 3 months November 1988 3 months December 1988 3 months March 1989 1 month June 1989 1 month July 1989 4 months and Health Surveys (DHS) program, the EDHS is intended to add to an international body of data, which can be used for cross-national research on these topics. 1.6 ORGANIZATION OF THE SURVEY The Egypt DHS was carried out by the National Population Council (NPC) with financial support from the United States Agency for International Development (U.S.A.I.D.). The Institute for Resource Development (IRD), a Macro Systems Company, provided technical assistance for the survey through the Demographic and Health Surveys program. The timetable for the survey is detailed in Table 1.3. The organization, training and supervision of the staff participating at the various stages of the survey are described below. Appendix A includes a list of the EDHS staff. Sample Design and Implementation Geographical Coverage. The EDHS was carried out in 21 of the 26 governorates in Egypt. The Frontier Governorates (Red Sea, New Valley, Matrouh, North Sinai and South Sinai), which represent around two percent of the total population in Egypt, were excluded from coverage because a disproportionate share of EDHS resources would have been needed to survey the dispersed population in these governorates. The EDHS sample was designed to provide separate estimates of all major parameters for: the national level, the Urban Governorates, Lower Egypt (total, urban and rural) and Upper Egypt (total, urban and rural). In addition, the sample was selected in such a fashion as to yield a sufficient number of respondents from each governorate to allow for governorate-level estimates of current contraceptive use. In order to achieve the latter objective, sample takes for the following governorates were increased during the selection process: Port Said, Suez, Ismailia, Damietta, Aswan, Kafr El-Sheikh, Beni Suef and Fayoum. Sampling Plan. The sampling plan called for the EDHS sample to be selected in three stages. The sampling units at the first stage were shiakhas/towns in urban areas and villages in rural areas. The frame for the selection of the primary sampling units (PSU) was based on preliminary results from 1986 Egyptian census, which were provided by the Central Agency for Public Mobilization and Statistics. During the first stage selection, 228 primary sampling units (108 shiakhas/towns and 120 villages) were sampled. The second stage of selection called for the PSUs chosen during the first stage to be segmented into smaller areal units and for two of the areal units to be sampled from each PSU. In urban PSUs, a quick count operation was carried out to provide the information needed to select the secondary sampling units (SSU) while for rural PSUs, maps showing the residential area within the selected villages were used. Following the selection of the SSUs, a household listing was obtained for each of the selected units. Using the household lists, a systematic random sample of households was chosen for the EDHS. All ever-married women 15-49 present in the sampled households during the night before the interviewer's visit were eligible for the individual interview. Quick Count and Listing. As noted in the discussion of the sampling plan, two separate field operations were conducted during the sample implementation phase of the EDHS. The first field operation involved a quick count in the shiakhas/towns selected as PSUs in urban areas. Prior to the quick count operation, maps for each of the selected shiakhas/towns were obtained and divided into approximately equal-sized segments, with 8 each segment having well-defined boundaries. The objective of the quick count operation was to obtain an estimate of the number of households in each of the segments to serve as the measures of size for the second stage selection. A review of the preliminary 1986 Census population totals for the selected shiakhas/towns showed that they varied greatly in total size, ranging from less than 10,000 to more than 275,000 residents. Experience in the 1984 Egypt Contraceptive Prevalence Survey, in which a similar quick count operation was carried out, indicated that it was very time-consuming to obtain counts of households in shiakhas/towns with large populations. In order to reduce the quick count workload during the EDHS, a subsample of segments was selected from the shiakhas/towns, with 50,000 or more population. The number of segments subsampled depended on the size of the shiakha. Only the subsampled segments were covered during the quick count operation in the large shiakhas/towns. For shiakhas with less than 50,000 population, all segments were covered during the quick count. Prior to the quick count, a one-week training was held, including both classroom instruction and practical training in shiakhas/towns not covered in the survey. The quick count operation, which covered all 108 urban PSUs, was carried out between June and August 1988. A group of 62 field staff participated in the quick count operation. The field staff was divided into ten teams, each composed of one supervisor and three to four counters. As a quality control measure, the quick count was repeated in 10 percent of the shiakhas. Discrepancies noted when the results of the second quick count operation were compared with the original counts were checked. No major problems were discovered in this matching process, with most differences in the counts attributed to problems in the identification of segment boundaries. The second field operation during the sample implementation phase of the survey involved a complete listing of all of the households living in the 456 segments chosen during the second stage of the sample selection. Prior to the household listing, the listing staff attended a one-week training course, which involved both classroom lectures and field practice. After the training, the 14 supervisors and 32 listers were organized into teams; except in Damietta and Ismailia, where the listers work on their own, each listing team was composed of a supervisor and two listers. The listing operation began in the middle of September and was completed in October 1988. Segments were relisted when the number of households in the listing differed markedly from that expected based on: (1) the quick count in urban areas or (2) the number of households estimated from the information on the size of the inhabited area for rural segments. Few discrepancies were noted for urban segments. Not surprisingly, more problems were noted for rural segments since the estimated size of the segment was not based on a recent count as it was for the urban segments. All segments where major 9 Table 1.4 Results of the HOUsehold and Individual Interviews by Urban-Rural Residence, Egypt DHS, 1988 Result Urban Rural Total HOUSEHOLD INTERVIEWS: completed 91.7 94.9 93,1 No Competent Respondent at Home 0.1 0.2 0,2 Household Not Found 0.2 0.1 0.2 Postponed 0.0 0.0 0.0 Refused 0.4 0.1 0.2 Household Absent(I) 2.5 1.2 2.0 Vacant/Not a Dwell ing(I) 1.6 2.0 1.7 Dwelling Destroyed(I) 0.0 0.1 0.0 Other(1) 3.4 1.4 2.5 Total Percent 100.0 100.0 100.0 Number of Households Sampled Number of E l ig ib le Households Nunt~er of Households Interviewed 5,855 4,673 10,528 5,412 4,455 9,867 5,370 4,435 9,805 Household Response Rate 99.2 99.6 99.4 INDIVIDUAL INTERVIEWS= Completed 98.1 97.8 97.9 Not at ho~e 1.1 1.2 1.2 Postponed 0.1 0.0 0.1 Refused 0.2 0.2 0.2 Part ly completed 0.0 0.1 0.0 Other 0.4 0.7 0.6 Total Percent 100.0 100.0 100.0 Number of E l ig ib le Wot~n Ident i f ied 4,495 4,600 9,095 Number of E l ig ib le Wcc~en Interviewed 4,409 4,502 8,911 Individual Response Rate 98.1 97.9 98.0 Overall Response Rate 97.3 97.4 97.4 (1) Excluded from calculation of the household response rate differences were noted in the matching process were relisted in order to resolve the problems. Coverage of the Sample. A total of 10,528 households was selected for the EDHS sample. Table 1.4 indicates that 661 of the selected households were considered to be ineligible for interview because no household member had slept in the dwelling on the night before the interview, the dwelling in which the selected household had resided was vacant or destroyed or the household could not be contacted for other reasons. Among the remaining 9,867 eligible households, 9,805, or 99 percent, were successfully interviewed. 10 Table 1.5 Results of the Houeehotd and Individual Interviews by PLace of Residence, Egypt DHS, 1988 Number of Households E l ig ib le Women Household Individual PLace of Interview Response {denti- Interview Response Residence Sampled ELigible Completed Rate fied Completed Rate Urban Governorates 3,140 2,851 2,824 99.0 2,330 2,279 97.8 Cairo 1,714 1,554 1,538 99.0 1,223 1,196 97.8 Alexandria 845 773 768 99.4 643 631 98.1 Port Said 300 273 2?2 99.6 248 240 96.8 Suez 281 251 246 98.0 216 212 98.2 Lower Egypt 3,754 3,601 3,585 99.6 3,502 3,446 98.4 Damietta 309 291 266 98.3 263 259 98.5 Dakahtia 634 601 598 99.5 541 525 97.0 Sharkie 565 544 542 99.6 563 561 99.6 Katyubia 460 441 437 99.1 428 418 97.7 Kefr El-Sheikh 274 265 265 100.0 258 257 99.6 Gharbia 552 539 539 100.0 497 493 99.2 Nenoufia 379 368 367 99.7 355 345 97.2 Behera 446 436 435 99.8 483 474 98.1 Ismeitia 135 116 116 100.0 114 114 100.0 Upper Egypt 3,634 3,415 3,396 99.4 3,263 3,186 97.6 Giza 772 725 722 99.6 647 635 98.2 Beni Suef 339 323 323 100.0 328 326 99.4 Feyoum 314 300 299 99.7 295 292 99.0 Menya 636 609 607 99.7 605 594 98.2 Assiut 443 412 409 99.3 418 406 97.1 Souhag 450 427 419 98.1 368 353 95.9 Qena 3?7 346 344 99.4 358 350 97.8 Aswan 303 273 2?3 100.0 244 230 94.3 Total 10,528 9,867 9,805 99.4 9,095 8,911 98.0 As noted, an eligible respondent for the individual survey was defined as an ever- married woman between the ages of 15 and 49 years who was present in a sampled household during the night before the household interview. A total of 9,095 eligible res- pondents was identified, and 8,911 (98 percent) of these women were interviewed. The overall response rate, which is the product of the household and individual response rates, was 97 percent in the EDHS. There was almost no variation in the household, individual or overall response rates between urban and rural areas. By governorate, the household response rate ranged from 98 percent in Suez to 100 percent in Kafr El-Sheikh, Gharbia, Ismailia, Fayoum and Aswan while individual response rate varied from 94 percent in Aswan to 100 percent in Ismailia (Table 1.5). Further details on the sample design are included in Appendix B. Sampling errors for selected variables are presented in Appendix C. 11 Ouestionnaire Development and Pretest The EDHS involved both a household and an individual questionnaire. These questionnaires were based on the DHS model "A" questionnaire for high contraceptive prevalence countries. Additional questions on a number of topics not covered in the DHS questionnaire were included in both the household and individual questionnaires. The questionnaires were pretested in June 1988, following a one-week training for supervisors and interviewers. Three supervisors and seven interviewers participated in the pretest. Interviewer comments and tabulations of the pretest results were reviewed during the process of modifying the questionnaires. An English translation of the final Arabic language questionnaire is included in Appendix D. The EDHS household questionnaire obtained a listing of all usual household members and visitors and identified those present in the household during the night before the interviewer's visit. For each of the individuals included in the listing, information was collected on the relationship to the household head, age, sex, marital status, educational level, occupation and work status. In addition, questions were included on the mortality experience of sisters of all household members age 15 and over in order to obtain data to estimate the level of maternal mortality. The maternal mortality questions were administered in a randomly selected subsample of one in two households. Finally, the household questionnaire also included questions on characteristics of the physical and social environment of the household (e.g., availability of electricity, source of drinking water, household possessions, etc.), which are assumed to be related to the health and socioeconomic status of the household. The individual questionnaire was administered to all ever-married women aged 15- 49 present in the household during the night before the interviewer's visit. It obtained information on the following topics: Respondent's background; Reproductive behavior; Knowledge and use of contraception; Contraceptive use history; Family planning and childbearing attitudes; Husband's and parents' statuses; Maternal health and breastfeeding; Child health and cause of death; Weight and height of children. The anthropometric data were collected in the same sample of households from which the maternal mortality data were obtained. Children age 3-36 months born to women interviewed in the individual survey were weighed and measured. 12 Data Collection Activities Staff Recruitment. Candidates for the positions of interviewer and field editor were identified in two ways. First of all, advertisements in newspapers attracted a number of applicants. The Ministry of Social Affairs (MOSA) nominated an equal number of its female personnel, who were working to fulfill the mandatory one-year period of governmental service for university graduates. All candidates for the field staff positions were interviewed, and only those who were qualified were accepted in the training program. For those MOSA personnel who were accepted and completed interviewer training successfully, work on the EDHS was credited toward the required service period. All candidates for interviewer and field editor positions were recent university graduates. Another basic qualification was a willingness to work in any of the governorates covered in the survey. With few exceptions, interviewers who had previous experience in surveys were not accepted in the training program. This decision was taken to reduce any bias that might result from their previous experience and to ensure that all trainees had a similar background. Training Materials. A variety of materials were developed for use in training personnel involved in the fieldwork. A lengthy interviewer manual giving general guidelines to follow in conducting an interview, as well as specific instructions for asking particular questions in the questionnaire, was prepared and given to all fieldwork staff. In addition, a chart to convert months from the Islamic calendar to the Gregorian calendar was designed for the five-year period before the EDHS and distributed to all fieldworkers. Other training materials included special manuals describing the duties of the team supervisors and the rules for field editing. Instructions regarding the anthropometric data collection were included in a manual that was made available to the interviewers who were trained as measurers and the team supervisors. Supervisor and Interviewer Training. Interviewer training for the EDHS data collection began in the first week of October 1988. A special training program for supervisors started one week earlier. This training focused specifically on the supervisor's duties, but also covered the questionnaire in order to give supervisors a head start prior to the main fieldwork training program. The training program, which was held in Cairo for four weeks, included: general lectures related to fertility, family planning and public health; specific sessions with visual aids on how to fill out the questionnaire; opportunities for role playing and mock interviews; three days of field practice in areas not covered in the survey; and six quizzes. 13 Trainees who failed to show interest in the survey, did not attend the training program on a regular basis or failed the first three tests were disqualified immediately. At the beginning of the third week of the training, a preliminary list including the best 15 trainees was prepared. Those trainees were further examined in order to select the 12 field editors. A special four-session training was held for the field editors following their selection. About 30 trainees were selected for anthropometric training. This training included both classroom lectures and practice measurement in a nursery school. At the end of the program the twenty best trainees were selected to serve as measurers during the EDHS fieldwork. At the end of the training course, 87 of the 100 candidates originally recruited for the interviewer training were selected to work as field editors, interviewers and measurers in the EDHS fieldwork. An additional five trainees were asked to stand by as back-ups. Fieldwork. Fieldwork for the survey including initial interviews, callbacks and reinterviews began on October 29, 1988 and was completed on January 27, 1989. A total of 105 staff, including one fieldwork coordinator, one assistant fieldwork coordinator, 16 supervisors, 12 field editors and 74 interviewers were responsible for the data collection. The supervisors were male, while field editors and interviewers were female. The field staff was divided into 12 teams; each team had a supervisor, a field editor and four to six interviewers. Usually two of the interviewers in the team and the field editor were specially trained to collect the weight and height measurements. During the fieldwork, two teams worked in Cairo and another team covered Alexandria. Each of the other nine teams was responsible for the interviewing in two to three governorates. After the initial fieldwork was completed, a random sample of five percent of the households selected in the original EDHS sample were reinterviewed as a quality control measure. Household and individual questionnaires which were incomplete or had errors that could not be corrected in the office were also assigned for callbacks. Special teams were organized to handle callbacks and reinterviews. During the reinterview and callback phase of the survey, interviewers were not allowed to work in the governorates in which they had participated in the initial fieldwork. Data Processing Activities Office Editing. The central office of the EDHS was responsible for collecting completed questionnaires from supervisors as soon as a cluster was completed. Questionnaires were coded and reviewed for consistency and completeness by office editors. To provide feedback for the field teams, the office editors were asked to write a summary report of problems for each PSU. The report was then reviewed by one of the two senior staff assigned to supervise the work of the office editors. When there were 14 serious errors found in one or more questionnaires from a cluster, the team supervisor was contacted in order to ensure that the problem would not occur in other clusters in which the team was working. Machine Entry and Editing. The data were entered and edited on microcomputers using the Integrated System for Survey Analysis (ISSA), a package program specially developed to process DHS data. ISSA allows range, skip and most consistency errors to be detected and corrected at the entry stage, substantially reducing the time required for the processing of data. The machine entry and editing phase began while interviewing teams were still in the field. The data entry personnel used six IBM-compatible microcomputers to process the EDHS questionnaires. Working six days per week in two shifts, they completed the machine entry and editing of the data in three months. 1.7 BACKGROUND CHARACTERISTICS OF SURVEY RESPONDENTS The distribution of the sample population by age, residence, education and employment status is shown in Table 1.6. Among the ever-married women interviewed in the EDHS sample, three in five respondents are 30 years or older. Considering their residence, 48 percent are from urban areas, while 52 percent live in rural areas. Roughly equal proportions live in Lower Egypt (39 percent) and Upper Egypt (37 percent), while nearly one in four respondents is from one of the four urban governorates (Cairo, Alexandria, Port Said and Suez). Table 1.6 also shows that one in two respondents has never attended school. Among those attending school, around half have not completed the primary level, and only one in three attained the secondary level. Only one in five respondents is working. Among those who say they are doing some work, only 60 percent are paid in cash for the work that they do. Among those not currently working 30 percent indicate that they would be interested in working for cash in the future if a good opportunity was available. Table 1.7 gives an overview of the relationship between the level of education and other background characteristics. The proportion of ever-married women who are not educated exhibits a U-shaped curve with relation to age. This should not be interpreted as a decline in educational attainment among young females. Since the sample includes only ever-married women, the high proportion who never attended school can be attributed to the fact that these women married earlier than other women in the age cohort, and thus, are more likely to have less education than their late-marrying counterparts, for whom part of the delay in marrying can be attributed to school attendance. Women who marry early also are more likely to be from rural areas, where female educational attainment is low. 15 Table 1.6 Unweighted and Weighted Distr ibut ion of Ever-married Women by Age, Urban-Rural Residence, Place of Residence, Education Level and Work Statue, Egypt DHS, 1988 Number Percent Background Characteristic Unweighted Weighted Weighted Age 15-19 418 422 4.7 20-24 1,402 1,417 15.9 25-29 1,679 1,669 18.7 30-34 1,567 1,557 17.5 35-39 1,597 1,605 18.0 40-44 1,219 1,207 13.5 45-49 1,029 1,034 11.6 Urban-Rural Residence Urban 4,409 4j305 48.3 Rural 4,502 4,606 51.7 Place of Residence Urban Governorates 2,279 2,141 24.0 Lower Egypt 3,646 3,505 39.3 Urban 1,035 1,019 11.4 Rural 2,411 2,486 27.9 Upper Egypt 3,186 3,265 36.6 Urban 1,095 1,145 12.8 Rural 2 ,~1 2,120 23.8 Education Level No Education 4,429 4,530 50.9 some Primary 2,087 2,059 23.1 Primary through Secondary 886 859 9.6 Completed Secondary/Higher 1,507 1,463 16.4 Work Status Working for Cash 1,130 1,109 12.4 Working, Not Paid in Cash 673 694 7.8 Not Working 7,108 7,108 79.8 Interested in Work 2,141 2,155 24.2 Not Interested in Work 4,967 4,953 55.6 Total 8,911 8,911 100.0 Note: Al l ever-married women present in the sampled household on the night before the interviewer's v i s i t were e l ig ib le for the individual interview. The table indicates that the level of education varies greatly according to residence. One in three urban women received no formal education, compared with two in three in rural areas. The educational attainment of urban women varies by place of residence, with nearly 75 percent of women in the Urban Governorates having attended at least some school, compared with only around 65 percent of urban women in Lower Egypt and less than 60 percent among urban women in Upper Egypt. There are also striking region- 16 Table 1.7 Percent Distri)~Jtion of Respondents by Level of Education, According to Age, Urban-Rural Residence, Place of Residence end Work Status, Egypt DHS, 1988 Primary Compteted Number gackgro~Jt~d No some ThrcK~h Secondary/ Total of Characteristic Educati~ Primary Sc~ct~dary Higher Percent Women Age 15-19 59.8 18.7 15.5 6.0 100.0 422 20-24 49.3 22.4 8.7 19.6 100.0 1,417 25-Z~; 43.6 24.4 8.7 23.3 100.0 1,669 30-34 42.9 26.5 9.5 21.1 100.0 1,557 35-39 53.0 22.5 10.4 14.1 100.0 1,605 40-44 57.3 20.0 10.7 11.9 100.0 1,207 45-49 62.0 23.0 7.9 7.0 100.0 1,034 Url0qm-gurel Residence Urban 32.9 24.5 14.6 28.0 100.0 4,305 Ruret 67.6 21.8 5.0 5.6 100.0 4,606 PIEce of Residence Urban Goverr~rates 27.4 26.2 17.7 28.7 100.0 2,141 Lower Egypt 54.5 23.4 7.3 14.8 100.0 3,505 Urban 34.6 22.0 11.5 31.8 100.0 1,019 Rural 62.6 23.9 5.6 7.8 100.0 2,486 Upper Egypt 62.3 20.8 6.8 10.1 100.0 3,265 Urban 41.8 23.7 11.4 23.1 100.0 1,145 Rural 7"5.5 19.2 4.3 3.0 100.0 2,120 Work Status Working for Cash 18.4 7.1 4.5 70.0 100.0 1,109 Working, Not Paid in Cash 69.1 24.2 4.1 2.6 100.0 694 got Working 54.1 25.5 11.0 9.4 100.0 7,108 interested in Work 44.7 25.8 11.7 17.8 100.0 2,155 Not Interested in Work 58.2 25.4 10.7 5.7 100.0 4,953 TOTE[ 50.8 23.1 9.6 16.4 100.0 8,911 al differences among rural women in the level of educational attainment. Only one in four women in rural Upper Egypt has attended school compared with one in three women in rural Lower Egypt. Paid employment, not unexpectedly, is largely confined to women with a secondary education. Women interested in paid employment also are somewhat more likely than other women to have attended school. 17 Chapter 2 MARRIAGE, BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY Marriage is a primary indicator of women's exposure to the risk of pregnancy. This is particularly true in a country like Egypt where childbearing is confined to marital unions. Thus, a study of the patterns of marriage is essential to understanding fertility patterns and to formulating policies to reduce fertility. In examining marriage patterns, this chapter considers not only a woman's current marital status but also the age at which she first married. Several other variables--breastfeeding, postpartum amenorrhea and postpartum abstinence--which help to determine fertility levels by influencing exposure to the risk of pregnancy within marriage are also examined. By extending the interval between births, the latter variables contribute to improved health and survival for infants and young children, topics which are explored further in the final chapters of this report. 2.1 CURRENT MARITAL STATUS Table 2.1 shows the current marital status distribution of women in Egypt. This table, like a number of other tables in this and the next chapter, refers to all women. Since only ever-married women were interviewed individually in the Egypt DHS, the total Table 2.1 Percent D is t r ibut ion of Al l Wo~en by Current Haritat Status, According to Age, Egypt DHS, 1988 Number Never Total of Age Harried Married Widowed Divorced Percent W(xnen 15-19 84.5 15.3 0.0 0.2 100.0 2,718 20-24 40.3 57.7 0.6 1.4 100.0 2,374 25-29 15.6 81.2 1.3 1.8 100.0 1,978 30-34 5.1 89.7 2.5 2.7 100.0 1,642 35-39 2.2 89.6 5.8 2.4 100.0 1,640 40-44 1.5 85.0 11.5 2.0 100.0 1,226 45-49 1.8 80.2 16.2 1.8 100.0 1,OS3 Tota l 29.5 65.1 3.9 1.6 100.0 12,631 19 100 80 60 40 20 0 Figure 2.1 Marital Status by Current Percent of All Women l 15-19 20-24 25-29 30-34 35-39 AGE Age BIB Never married Widowed N 40-44 45-49 Currently married Divorced i Egypt DHS 1988 number of women is estimated based on information obtained in the household question- naire on the marital status of all females age 15-49.1 Two-thirds of women 15-49 in Egypt are currently married, 30 percent have never been married, while the rest (5 percent) are either widowed or divorced. The proportion of women who have never married decreases with age, from 84 percent of women 15-19 to five percent of women 30-34 (Figure 2.1). Marriage is nearly universal among the oldest cohorts, with less than two percent of women age 35 and over never having married. As expected, the proportion widowed increases with age, up to a maximum of 16 percent at age 45-49. Relatively few women in any age group are divorced; the proportion divorced peaks at under three percent among women 30-34. A woman's place of residence is closely associated with the likelihood that she has married. Table 2.2 shows that rural women, particularly those living in Upper Egypt, are more likely than urban women to have married. Among all women 15-49, the proportion To derive these estimates, the ratio of all women to ever-married women enumerated in the household schedule was calculated at each single year of age for each category of background characteristic (e.g., urban or rural, working or not working, etc.). These ratios were then applied to the number of ever-married women interviewed individually in order to expand the denominators to represent all women. 20 Table 2.2 Percent of A l l Women Ever Married by Current Age, According to Urban-Rural Residence and Place of Residence, Egypt DH$, 1988 Urban Lower Egypt Upper Egypt Gover- Age Urban Rural norates Total Urban Rural Total Urban Rural Total 15-19 T.1 23.2 4.2 13.6 7.8 15.8 24.9 11.3 32.9 15.5 20-24 43.6 75.5 35.7 67.0 53.2 72.2 70.2 52.4 60.2 59.7 25-29 77.5 91.8 70.6 90.0 86.4 91.5 89.4 85.3 92.0 84.3 30-34 93.7 96.4 91.7 96.3 96.9 96.0 96.4 95.5 97.0 94.9 35-39 97.1 98.6 96.0 98.4 98.7 98.3 98.6 97.7 99.2 97.8 40-44 98.1 98.6 97.3 99.2 99.2 99.4 98.1 98.7 97.7 98.5 45-49 98.3 98.2 98.2 97.2 97.1 97.4 99.2 99.4 99.2 98.2 Total 66.0 75.3 63.1 71.5 69.4 72.4 75.2 69 .1 79.0 70.6 NtJ~ioer of Wo~nen 6,521 6,116 3,394 4,903 1,469 3,434 4,540 1,658 2,~2 12,631 ever married ranges from only 63 percent of women living in the Urban Governorates to a high of nearly 80 percent among women from rural Upper Egypt. Residential differentials in the proportion ever married are particularly striking for young women. For example, in the 15-19 age group, only one in 14 urban women has married compared to around one in four rural women. Moreover, while regional differences among urban women in this age category are relatively minor, the proportion ever married among women in rural Upper Egypt (33 percent) is more than twice the proportion among women in rural Lower Egypt (16 percent) (Figure 2.2). In the 20-24 age group, more than three-quarters of rural women have married compared to only one- third of women in the Urban Governorates and one-half of the women in other urban areas. Even in the 25-29 age group, where the majority of women from all regions have married, women from the Urban Governorates are more than twice as likely as women from other urban areas, and nearly four times as likely as rural women, to be single. These figures suggest that urban women, particularly those living in the Urban Governorates, are more likely to delay marriage than are rural women, especially those living in Upper Egypt. Data on the age at first marriage for women in the sample which are presented in the next section confirm these patterns. 2.2 AGE AT FIRST MARRIAGE Information on age at first marriage was collected by asking each ever-married woman for the date (month and year) when she began living with her first husband. If a woman could not remember the date of marriage, then she was asked how old she was when she first married. Among ever-married women, 48 percent were able to give both 21 100 80 60 40 20 0 Figure 2.2 Percent Ever Married by Place of Residence Percent of All Women 15-24 Urban Governorate8 Lower Egypt Lower Egypt Upper Egypt Upper Egypt Urban Rural Urban Rural RESIDENCE I 15-19 ~ 20-24 / Egypt DHS 1988 the month and year when they first married, 35 percent knew only the year and 16 percent were only able to report how old they were when they first married. Less than one percent of the women were unable to provide the date or age when they married; for these women a date was imputed, based on the woman's age and the date of her first live birth. Any analysis of the patterns in age at first marriage must take into account the fact that the data on age at marriage are censored, i.e., the data are incomplete since information on the age at marriage is available only for women who have ever been married. Since never-married women in any age group will marry at later ages than those who are already married, the data on age at first marriage from the ever-married group will give a downwardly biased picture of the pattern of age at entry into marriage for the age group. The effect is greatest in the youngest age groups where a significant proportion of women has never married. In describing trends and differentials in the age at first marriage, the median is preferred to the mean, because it is not affected by censoring; the median is fixed once 50 percent of a group have married and, in contrast to the mean, it will not increase as never-married women in the group continue to marry. In the following discussion, cohort patterns in the age at first marriage are described first, using information for all women in the sample. Attention then shifts to the topic of early marriage and the trend across calendar periods in the age at first marriage. For the latter analysis, only ever-married women are considered. 22 Table 2.3 Percent D is t r ibut ion of At [ gomen by Age at F i rs t Marriage ( inc lud ing Category =1Never Married") and Median Age at F i r s t Marriage, According to Current Age, Egypt DHS, 1988 Age at F i rs t Marr iage Number Never Under 25 and Total of Median Age Married 16 16-17 18-19 20-21 22-24 Over Percent Women Age 15-19 64.5 6.7 6.4 2.3 0.0 0.0 0.0 100.0 2,718 -- 20-24 40.2 15.0 15.6 15.0 9.5 4.7 0.0 100.0 2,374 20.8 25-29 15.6 21.8 17.5 16.0 12.8 11.8 6.5 100.0 1,978 19.5 30-34 5.1 26.3 16.6 15.4 11.9 14.0 12.6 100.0 1,642 19.0 35-39 2.2 28.4 19.6 15.6 10.4 12.0 11.8 100.0 1,640 18.2 40-44 1.5 30.2 22.0 15.0 10.9 10.9 9.5 100.0 1,226 17.8 45-49 1.8 35.4 20.3 14.6 10.1 8.8 9.0 100.0 Io053 17.4 Total 29.5 20.4 15.6 12.2 8.6 7.9 5.9 100.0 12,631 -- Note: The median is defined as the exact age at which 50 percent of women married For the f i r s t t ime. - - Omi t ted due to because tess than 50 percent ever married Cohort Patterns The legal age at marriage in Egypt is 16 for females and 18 for males. Table 2.3 shows that one-fifth of all Egyptian women 15-49 married for the first time before age 16, nearly half married before age 20 and about two-thirds married before age 25. There has been a steady decline over time in early marriage (before age 16). While one in three women 40-49 married before 16 years of age, only one in seven women 20-24 married before her sixteenth birthday. Early marriage is even less common among women 15-19, although the final figure is not certain since some unmarried women who were age 15 at the time of the survey may marry before their 16th birthday. Nevertheless, it is surprising that young women are still marrying before the legal age. Table 2.4 shows the variation in the median age at first marriage across age cohorts for various subgroups. No medians are presented for women 15-19 because more than 50 percent of this cohort have never married. For some subgroups, more than 50 percent of women 20-24 have never married so the median age at marriage for women 20-24 in the subgroup is not shown. In order to avoid the slight bias that the inclusion of women 20-24 from these subgroups would have on the median age for the subgroup as a whole, the medians presented in the total column in Table 2.4 are limited to women 25-49. 23 Table 2.4 Median Age at First Marriage Among All Women 25-69 by Current Age, According to Selected Beckground Characteristics, Egypt DHg, 19~ Current Age Background Total Characteristic 20-26 25-29 30-]4 ]5 - ]9 40-44 45-49 25-49 Urban-Rural Residence Urban - - 21.8 21.4 20.2 18.9 18.0 20.4 Rural 18.6 17.5 17.1 16.7 16.7 16.8 17.0 Place of Residence urban Oovernorates - - 23.1 22.2 20.9 18.8 18.2 21.1 Lower Egypt - - 18.9 18.6 17.9 18.1 17.8 18.4 Urban - - 21.6 20.8 20.5 19.8 17.7 20.5 Rural 19.5 17.9 17.8 17.2 17.3 17.8 17.6 Upper Egypt 18.6 17.7 17.5 16.9 16.8 16.5 17.1 Urban - - 20.0 19.5 18,5 18,0 17.7 18.8 Rural 17.5 16.9 16.7 16.1 16,2 15.9 16.4 Education NO Education 17.7 17.0 17.1 17.0 16,7 16.8 16.9 Some Primary 18.6 18.0 18.1 18.0 18,0 17.1 18.0 Primary through Secondary - - 19.7 20.0 19.1 19,4 19.4 19.5 Ceelpleted Secondary/Higher -- 24.9 24.8 24.7 23,9 24.4 24.7 Work Status Working for cash - - 25.4 24.5 24.1 23,3 22.0 24.5 Not working - - 18.4 18.1 17.7 17.2 17.2 17.8 Total -- 19.5 19.0 18.2 17,8 17.4 18.5 -- amitted because less than 50 percent ever marris~d The results in Table 2.4 indicate that the average Egyptian woman married for the first time while she was still in her teens. The trend, however, is toward later marriage. The median age at first marriage increases steadily across age cohorts, from 17.4 years among women 45-49 to 19.5 years among women 25-29. Urban women marry considerably later, on average, than rural women, and this differential has been increasing over time. The median age at first marriage in urban areas is three years higher than in rural areas. While there has been a trend toward later marriage across age cohorts for both urban and rural women, the median age at first marriage has undergone an increase of nearly four years in urban areas compared to about one year in rural areas. Within each residential category, there are differences across geographic areas in the age at which women first marry (Figure 2.3). For example, the median age at first marriage for rural women is more than one year higher in Lower Egypt than in Upper Egypt. Similarly, women in the Urban Governorates marry one year later, on average, than women from urban Lower Egypt and more than two years later than women from 24 Figure 2.3 Age at First Marriage by Current Age and Place of Residence Median Age Among All Women 23 21 19 17 151 , , p 25-29 30-34 35-39 40-44 AGE o Urban Gov. " Lower Urban . Lower Rural --~-- Upper Urban n Upper Rural 45 -49 Egypt DH8 1988 urban Upper Egypt. The differences among urban women are due to differences in the pace at which the age at first marriage has been rising in the three areas. Across age cohorts, the largest increase in the median age at first marriage--nearly five years--occurred in the Urban Governorates (from 18.2 for women 45-49 to 23.1 for women 25-29). Smaller increases are observed for urban Lower Egypt (3.9 years) and urban Upper Egypt (2.3 years). Rural women marry at considerably younger ages than urban women in both Lower Egypt and Upper Egypt. For rural women in both regions, there has been a gradual increase in the age at first marriage, with the pace of the increase accelerating over the past decade, particularly among women from Lower Egypt. In Lower Egypt, the difference in the median age at first marriage between women 25-29 and women 20-24 is 1.6 years, more than twice the difference in the median age at first marriage for women in these cohorts in rural Upper Egypt. The comparatively slow pace of change among rural women in Upper Egypt will be observed in other indicators throughout this report. The level of education has a clear effect on age at marriage. A difference of about eight years in the median age at first marriage is found between women with no education and women who have completed secondary school. Interestingly, within any education group, there is relatively little increase in the median age at first marriage across age cohorts. This suggests that the upward trend in the age at first marriage over time is primarily a consequence of increasing educational attainment among younger women. 25 Table 2.5 Percent of Ever-married Women Married for the F i rs t Time Before Age 16 by Calendar Period in Which the Marriage Took Place, According to Urban-Rural Residence and Place of Residence, Egypt DHS, 1988 Calendar Periocl Urban Lower Egypt Upper Egypt Goyer- Urban Rural norates Total Urban Rural Total Urban Rural Total 1960-1964 1965 - 1969 1970-1974 19T5-197'9 1980-1984 33.9 46.4 31.8 39.5 32.6 41.6 47.4 39.0 52.1 40.3 24.1 46.9 17.2 37.2 27.7 40.8 46.2 32.0 54.T 36.2 18.5 41.4 14.2 32.0 21.5 36.4 38.8 23.3 47.8 30.4 14.1 37.5 9.8 25.5 12.3 31.6 36.9 24.5 43.7 25.6 9.5 26.3 5.3 16.9 8.4 20.4 28.9 19.2 33.9 18.2 Trend Across Calendar Periods Early Marriage. Table 2.5 looks at the proportion of ever-married women who married before the legal age of 16 according to the calendar-year period in which the marriage occurred for a 25-year period, beginning in 1960 and ending in 1984. 2 The results provide a further indication of the trend away from early marriage; since the 1960s, there has been a steady decrease in the proportion of marriages in which the bride was below the legal age at marriage, from 40 percent in the early 1960s to under 20 percent in the early 1980s. The decrease in the rate of early marriage is particularly striking among women living in the Urban Governorates (Figure 2.4). The proportion of first marriages in which the bride had not yet celebrated her 16th birthday exceeded 30 percent in the early 1960s compared to only five percent in the early 1980s. The momentum of the trend away from early marriage was almost as rapid in urban Lower Egypt, while a somewhat slower pace is observed for rural Lower Egypt and urban Upper Egypt. Again rural Upper Egypt exhibited the slowest rate of change. Among women marrying for the first time during the early 1980s, around one-third in rural Upper Egypt were married before age 16 compared to only about one-fifth in rural Lower Egypt. z The proportion marrying for the first time before age 16 is not presented in Table 2.5 for the periods 1985-1988 and 1955-1959 because the data for these periods are incomplete and the results would, therefore, be biased. With regard to the most recent period (1985-1988), there are two sources of potential bias: (1) some women age 15 who were not married at the time of the interview may have gone on to marry before the end of 1988 and (2) women under age 15 who married before the legal age in the period 1985-1988 were not interviewed. Similarly, information for the period 1955-1959 is not shown because women age 50 and over who may have married during the latter period also were not eligible for interview in the survey. 26 60 50 40 30 20 10 0 Figure 2.4 Percent Married Before Age 16 by Place of Residence, 1960-1984 Percent of Ever-married Women Urban Governoratee I mm 1960-1964 Lower Egypt Lower Egypt Upper Egypt Upper Egypt Urban Rural Urban Rural RESIDENCE k ~] 1970-1974 ~ 198o-1984 I Egypt DHS 1988 Median Age. The trend across calendar periods in tee median age at first marriage for ever-married women illustrates again the steady increase in the age at marriage that has been occurring in Egypt over the past 25 to 30 years (Table 2.6). The median age at first marriage rose from less than 17 years in the early 1960s to 19 years in the early 1980s. The increase in the median age at first marriage is again more striking in urban Table 2.6 Redian Age st First Marriage Among Ever-married Women by Calendar Period in Which the Marriage Took Place, According to Urban-Rural Residence and Place of Residence, Egypt DNS, 1988 Urban Lower Egypt Upper Egypt Calendar Gover- Period Urban Rural norates Total Urban Rural Total Urban Rural Total 1960-1964 17.1 16.2 17.3 16.7 17.2 16.6 16.1 16.6 15.9 16.6 1965-1969 18.4 16.2 18.8 16.9 18.2 16.6 16.3 17.7 15.8 17.1 1970-1974 19.4 16.6 19.5 18.1 20.5 17.2 16.9 18.4 16.1 17.9 1975-1979 20.5 16.9 21.1 18.0 20.6 17.2 17.1 18.6 16.5 18.3 1980-1984 21.2 17.5 21.8 18.7 20.7 18.0 17.6 20.0 16.9 19.0 Note: The median is defined as the exact age at which 50 percent of uo~en married for the f i r s t time. 27 Figure 2.5 Age at First Marriage by Calendar Period and Place of Residence Median Age Among Ever-married Women 23 21 19 17 15 . : : : : : : : ?~ . o . i ~ . . . . ~ - I I I 1960-64 1965-69 1970-74 1975-79 1980-84 o Urban Gov. ~ Lower Urban -'*-- Upper Urban ~ Upper Rural o Lower Rural Egypt DHS 1988 areas, particularly the Urban Governorates, than in rural areas (Figure 2.5). The slow pace of change in rural Upper Egypt is also further illustrated by the fact that the median age at first marriage increased by only one year over the 25-year period covered in Table 2.6, from just under 16 years in the early 1960s to just under 17 years in the early 1980s. The median age at first marriage in rural Lower Egypt also changed slowly over the period, but the overall increase (1.4 years) was greater than in rural Upper Egypt. 2.3 BREASTFEEDING AND POSTPARTUM INSUSCEPTIBILITY Three other variables for which information is collected in the EDHS--breastfeeding, postpartum amenorrhea and postpartum sexual abstinence--play an important role in determining fertility levels by influencing the duration of the period following the birth in which a woman is not susceptible to the risk of another pregnancy. Table 2.7 presents cross-sectional data on the proportion of births whose mothers were found to be still breastfeeding, postpartum amenorrheic, abstaining and insusceptible. It should be noted that the information in Table 2.7 is birth-based rather than woman-based, i.e., a woman who had more than one live birth during the 36 months preceding the survey is included as many times as the number of births she had. However, twins are counted as a single birth. Because the data are obtained for births at a single point in time rather than for an actual cohort over time, the number of cases in the duration categories may be small. 28 Table 2.7 Percent of Births in the Last 36 Months Whose Mothers Are St i l t Breestfeeding, Postpartum Amenorrheic, PostPartum Abstaining and Insusceptible to Pregnancy, by Number of Months Since Birth, Egypt DHS, 1988 Months St i l t St i t t s t i l t Number Since Breast- Amenor- St i l t lnsuscep- of Birth feeding rheic Abstaining t ib le(1) Births Less than 2 90.4 92.8 74.0 94.1 264 2-3 89.9 69.2 19.8 71.7 343 4-5 80.2 51.1 6.4 53.8 274 6-7 83.0 41.3 7.3 44.1 254 8-9 84.3 37.8 8.4 41.4 265 10-11 76.1 30.8 5.1 33.2 304 12-13 68.1 21.3 5.5 23.6 377 14-15 63.2 16.3 2.8 17.8 324 16-17 60.7 13.0 4.8 17.0 262 18-19 50.1 8.2 4.5 12.0 222 20-21 39.5 5.7 2.0 7.0 234 22-23 29.9 6.0 1.8 7.5 284 24-25 12.2 2.1 2.2 3.6 283 26°27 11.7 1.3 1.0 2.0 330 28-29 11.0 3.8 2.2 5.5 296 30-31 6.2 2.4 1.6 3.6 278 32-33 7.6 1.6 1.2 2,8 282 34-35 3.0 0.7 1.7 2.5 298 Total 48.2 22.6 8.3 24.7 5,174 (I) Amenorrheic, abstaining or both. As a result, the proportions do not always decline in a steady fashion at increasing durations since birth as would be expected. To help minimize such fluctuations, the births are grouped in two-month intervals. Durations of breastfeeding are fairly long. Table 2.7 indicates that more than two- thirds of babies born around a year before the survey are still being breastfed, and 30 percent of those who are approaching their second birthday continue to be breastfed. Breastfeeding for more than two years is uncommon, however. Fewer than one in ten babies 24 months and older is being breastfed. As expected, almost all mothers experience postpartum amenorrhea until the second month after delivery. The proportion drops considerably after the second month, although nearly one-third of the mothers who delivered 10-11 months ago were still amenorrheic. Table 2.7 shows a loose association between breastfeeding and amenorrhea, which is not surprising since breastfeeding tends to suppress the return of menstruation following a birth. Breastfeeding, however, does not provide reliable protection against conception after the first few months. For example, the proportion of births whose mothers are 29 amenorrheic is only half as large as the proportion being breastfed at 6-7 months and only one-quarter as large at 14-15 months. The proportion of babies whose mothers practice sexual abstinence after their birth decreases even faster than the proportion whose mothers breastfeed or are amenorrheic. The proportion drops to only 20 percent by the second or third month after delivery. Finally, Table 2.7 also provides information about the proportion insusceptible to pregnancy because of either postpartum amenorrhea or postpartum sexual abstinence (or both). The proportion exceeds 70 percent at 2-3 months after delivery, then drops off rapidly to around 40 percent by 8-9 months. Thus, the majority of women become susceptible to the risk of another pregnancy within nine months after giving birth. If, as the information in Chapter 7 suggests, many of these women do not want another child, they should be encouraged to adopt family planning. Mothers wanting another child should also be encouraged to use family planning in order to ensure a safe interval between births. 2.4 DIFFERENTIAl-q IN BREASTFEEDING AND POSTPARTUM INSUSCEFHBILITY Estimates of the mean duration of breastfeeding, postpartum amenorrhea and postpartum abstinence for various subgroups are presented in Table 2.8. The estimates are based on the prevalence-incidence method, in which the prevalence of each factor (the total number of women breastfeeding, amenorrheic, etc.) is divided by the incidence (the average number of births per month over the 36-month period). The results indicate that the mean duration of breastfeeding is 17.3 months. The mean duration of amenorrhea is 8.2 months, roughly half the breastfeeding duration. The mean length of insusceptibility (9.2 months) is only slightly longer than the mean length of amenorrhea because few couples abstain for long periods. Very little difference in the mean duration of breastfeeding, postpartum amenorrhea or postpartum abstinence is observed between younger and older mothers. Urban-rural differences, however, are substantial. Rural mothers breastfeed their children about three months longer than urban mothers. An even larger difference (4 months) is observed for the duration of postpartum amenorrhea. A similar pattern is found in both Upper and Lower Egypt; however, the difference in the breastfeeding period between rural and urban inothers is much smaller in Upper Egypt than in Lower Egypt (Figure 2.6). The Urban Governorates exhibit the shortest duration of breastfeeding of all areas (14.2 months). Education has a negative effect on the duration of breastfeeding. Children of mothers with no education are breastfed longer than children of educated mothers (Figure 2.7). The mean period of postpartum amenorrhea and postpartum abstinence is also longer for less educated mothers. Part of the reason for the negative relationship between 30 Table 2.8 Mean Number of Months of Breastfeeding, Postpartum Amenorrhea, Postpartum Abstinence and Postpartum Insusceptibility, by Selected Background Characteristics, Egypt DRS, 1988 Number Background Breast- Amenor- Absti ~ Insuscep- of Characteristic feeding rhea nence tibility(1) Births Age 15-29 17.5 8.1 3.2 9.1 3,113 30-49 17.1 8.3 3.2 9.3 2,105 Urban-Rural Residence Urban 15.5 6.0 2.7 6.9 2,134 Rural 18.6 9.7 3.6 10.7 3,084 Place of Residence Urban Governorates 14.2 5.3 2.6 6.2 975 Lower Egypt 17.6 8.1 2.7 8.9 2,096 Urban 15.2 5.6 2.4 6.2 536 Rural 18.4 8.9 2.9 9.8 1,560 Upper Egypt 18.5 9.6 4.0 10.7 2,147 Urban 17.7 7.2 3.0 8.4 623 Rural 18.9 10.6 4.4 11.7 1,524 Education No Education 18.1 9.4 3.5 10.5 2,682 Some Primary 16.8 7.7 3.1 8.8 1,215 Primary through Secondary 17.5 7.7 3.6 8.4 440 Con~oleted Secondary/Nigher 15.7 5.4 2.5 5.9 882 Work Status Working for Cash 15.9 6.1 3.2 7.1 548 Working, Not Paid in Cash 18.0 9.3 2.7 10.5 462 Not Working 17.5 8.3 3.3 9.3 4,208 interested in Working 16.8 7.7 3.1 8.8 1,252 Not Interested in Working 17.8 8.6 3.3 9.5 2,956 Total 17.3 8.2 3.2 9.2 5,218 Note: Inctudes births occurring during the period 1-36 months before the survey. The mean number of months is calculated using a "prevalence-incidence" approach (see text). (1) Amenorrheic, abstaining or both. education and the duration of breastfeeding, which has been observed in many developing countries, can be traced to the greater likelihood that women with higher education are employed in positions with regular working hours that keep them away from home. As a result these women are unable to breastfeed their children on a regular basis. Table 2.8 indicates that the duration of breastfeeding and postpartum amenorrhea is somewhat shorter among women working for cash. Shorter breastfeeding is not, how- ever, characteristic of unpaid workers since they usually work at home or they can keep 31 20 Figure 2.6 Duration of Breastfeeding and Postpartum Insusceptibility by Place of Residence Mean Duration in Months 15 10 5 0 Urban Lower Egypt Lower Egypt Upper Egypt Upper Egypt Governorate8 Urban Rural Urban Rural RESIDENCE I m Breastfeeding ~ Insusceptibility / I Egypt DH$ 1988 Figure 2.7 Duration of Breastfeeding and Postpartum Insusceptibility by Level of Education Mean Duration in Months 20 15 10 5 0 No Education Some Comp Prim/ Comp Sec/ Primary Some Sec Higher EDUCATION I m Breastfeeding ~ Insusceptibility Egypt DHS 1988 32 their babies with them when they work. Among women who were not working, those women interested in paid work breastfed their children and experienced postpartum amenorrhea for an average of one month less than those who were not interested in paid employment. In summary, children in Egypt are breastfed for an average of 17 months and this practice, by extending the period of postpartum amenorrhea, causes women to be insusceptible to pregnancy for nine months following a birth. However, more modern women (urban, educated women working for cash) wean their children at an earlier age and are, therefore, insusceptible for a shorter period after each birth. If other women eventually follow the lead of the more modern mothers, then there will be a greater need for contraception to prevent unplanned pregnancies, and children may be subject to increased health risks if weaning occurs at earlier ages in the future. 33 I Chapter 3 FERTILITY Monitoring change in fertility levels and differentials has been one of the primary reasons for conducting a series of demographic surveys in Egypt during the last decade. Of particular concern has been the impact of increasing use of family planning as well as changes in the other proximate determinants of fertility. The EDHS continues in this tradition, by providing the data needed to monitor fertility behavior in the late 1980s. 3.1 FERTILITY LEVELS AND DIFFERENTIAl Aq As in many other countries, prevailing norms in Egypt place a high value on children and greatly enhance the position of fertile women, especially in rural areas. For this reason, fertility levels have traditionally been high, as documented by previous surveys. In this section of the report, EDHS data are used to look at levels, trends and differentials in current and cumulative fertility levels. B'trth History Data The fertility data from the EDHS are based on responses to a series of questions designe d to provide information on the number and timing of births. All respondents were asked first about the total number of live births and surviving children. In addition, a full birth history was collected from each woman, including the name, sex, and date (month and year) of each live birth; the age at death for children who died; and whether or not living children were residing with their mother. Fertility data collected through the EDHS birth history have a number of limitations. First, because the upper limit on eligibility for the survey was 49 years, the age-specific fertility rates for older age groups become progressively more truncated further back in time, i.e., births to some women in those cohorts during the time periods in question are excluded from the calculation of fertility rates because the women were age 50 and over at the time of the EDHS and, thus, not interviewed in the survey. Estimation of fertility levels can be affected by underreporting of the number of children ever born, while errors in the reporting of birth dates can distort trends in fertility over time. Such problems are more common in countries with moderate levels of female illiteracy like Egypt, especially among older women. To ensure the quality of the fertility data, the EDHS interviewers were trained to probe carefully to be sure that all births were 35 reported and to verify birth dates by checking birth records? Both the month and year of birth were reported for 62 percent of all births, and, for an additional 25 percent, the year of birth and the age of the child were reported. For most of the remaining eases, the child's age was given. 2 The birth date information in the EDHS is more complete than in previous surveys; in the Egypt Fertility Survey (EFS), for example, both the month and year of birth were reported for only 41 percent of births (Goldman et al., 1985). Current and Cumulative Fertility Table 3.1 presents data on current and cumulative fertility patterns in Egypt. The total fertility rate (TFR), which is the measure of current fertility, represents the average number of births a woman would have at the end of her reproductive life if she had children according to the age-specific fertility rates prevailing during a given period. The first two columns of Table 3.1 show total fertility rates for all women 15-443 for two calendar periods, 1986-1988 and 1983-1985, while the third column shows the total fertility rates for the five-year period before the survey. The final column in Table 3.1 presents the mean number of children ever born (CEB) to all women 40-49. The latter indicator, which is a measure of cumulative fertility, is the product of the past childbearing behavior of these women who are nearing the end of their reproductive lives. The current trend in fertility in Egypt can be assessed by comparing the TFRs for the two calendar periods, while a comparison of the total fertility rate with the measure of completed family size provides a rough indication of the trend in fertility levels over the past several decades. Fertility remains high in Egypt although there is evidence that it has declined significantly from the level prevailing in the past (Figure 3.1). The TFR for the five-year period before the survey is 4.7 births per woman, more than one child lower than the mean number of children ever born to women 40-49 (6.0 children). The EDHS results also suggest that fertility is continuing to decline; the TFR for the 1986-1988 period (4.4 births) is nearly 10 percent lower than the TFR for the period 1983-1985 (4.8 births). Residential Differentials. Urban fertility is substantially lower than rural fertility, with a difference of more than two children observed in the TFR for the five-year period before the survey between urban women (3.7 births) and rural women (5.7 births). It is 1 Although no information was available on the proportion of total births for which a birth certificate was seen, birth records were seen for about half the children 12-59 months. See Chapter 9 for a discussion of the availability of birth certificates. 2 When a complete date was not reported, the missing information (month only or month and year) was imputed. Fertility rates shown in the report are based on these imputed dates. 3 Throughout this chapter, whenever an estimate is based on all women, information on the marital status and age of all females 15-49 is used to derive the all women denominator, using the procedures described in Chapter 2. 36 Table 3.1 Total Fer t i l i ty Rate for the calendar Year Perieds 19~-19~ and 1983-1985 and For the Peried 0-4 Years Before the Survey, and the Mean Number of Children Ever Born to Women 40-49, by Selected Background Characteristics, Egypt DHS, 1988 Mean Total Fer t i l i ty Rates( l ) Number of Children 0-4 Years Ever Born Background 1986- 1983- Before the to Women Character ist ic 19~(2) 1985 Survey Age 40-49 Residence Urban 3.48 3.75 3.69 5.18 Rural 5.35 6.08 5.73 6 .~ Place of Residence Urban governorates 3.01 3.41 3.26 4.91 Lower Egypt ~.45 5.18 4.83 6.23 Urban 3.81 3.93 3.95 5.18 Rural 4.73 5.75 5.22 6.72 Upper Egypt 5.39 5.66 5.60 6.49 Urban 4.17 4.32 4.35 5.70 Rural 6.15 6.50 6.38 7.02 Education NO Education 5.38 5.99 5.73 6.56 Some Primary 4.76 5.28 5.09 5.94 Primary through Secondary 3.61 4.05 3.79 4.91 Completed Secondary/Higher 3.15 3.03 3.23 3.27 Work Status Working for. Cash 2.91 3.30 3.15 4.25 Not Working 4.60 5.12 4.90 6.17 Total 4.38 4.85 4.66 5.96 (1) Based on births to women 15-44 years (2) includes 1989 up to the survey date also evident that urban women have been leading the transition to lower fertility. Among urban women, the TFR for the five-year period prior to the survey is 29 percent lower than the mean number of children ever born to women 40-49, while, for rural women, the implied longterm decline in fertility is only half as great (16 percent). However, the urban-rural differential may be beginning to narrow as the EDHS results indicate that, in the most recent period, the pace of fertility decline has been somewhat more rapid among rural than urban women. The rural TFR for the period 1986-1988 (5.4 births) was 12 percent lower than the TFR for the period 1983-1985 (6.1 births), while the urban TFR declined by only seven percent between the two recent calendar periods. Table 3.1 also shows that the Urban Governorates, Lower Egypt and Upper Egypt are at different stages of the fertility transition. The TFR for the five-year period before the survey is 3.3 births per woman for the Urban Governorates compared with 4.8 births 37 8 Figure 3.1 Cumulative Fertility (CEB) and Current Fertility (TFR) Births per Woman 6 4 2 0 CEB TFR TFR 40-49 1983-1985 1986-1988 Egypt DHS 1988 for Lower Egypt and 5.6 births for Upper Egypt. Much of the fertility differential between Lower Egypt and Upper Egypt is due to the higher level of rural fertility in Upper Egypt. The TFR for urban Upper Egypt is 4.4 births compared with 4.0 births in urban Lower Egypt, while the TFR for rural Upper Egypt is 6.4 births compared to 5.2 births in rural Lower Egypt. Historically, the Urban Governorates have experienced the fastest decline in fertility as evidenced in the fact that the five-year TFR is one-third lower than the mean children ever born (CEB) to women 40-49 (Figure 3.2). In contrast, for Lower Egypt, the difference between the TFR and the CEB is only around 20 percent, while, for Upper Egypt, it is less than 15 percent. Currently, the pace of fertility decline is most rapid in Lower Egypt, where the TFR dropped from 5.2 to 4.4 births between 1983-1985 and 1986- 1988, a decrease of 14 percent (Figure 3.3). A fairly similar rate of decline was observed for the Urban Governorates (12 percent), while Upper Egypt continues to lag behind. The slow rate of fertility decline in Upper Egypt can largely be traced to the very slow pace of change in rural areas in this region. The longterm fertility decline implied in the comparison of the five-year TFR with the mean CEB for women 40-49 has been only around 10 percent in rural Upper Egypt compared with more than 20 percent in urban Upper Egypt and urban and rural Lower Egypt. In recent years, the fertility decline in rural Upper Egypt has been occurring at a somewhat faster pace than in urban areas in either region, but much more slowly than in rural Lower Egypt. 38 8 F igure 3.2 Cumulative Fertility (CEB) and Current Fertility (TFR) by Place of Residence Births per Woman 6 4 2 0 Urban Governoratee Lower Egypt Lower Egypt UDDer Egypt Upper Egypt Urban Rural Urban Rural RESIDENCE * 0-4 yeerabetoreeurvey l mCEB 40"49 ~TFR* ~ Egypt DHS 1988 8 F igure 3 .3 Current Fertility (TFR) by Place of Residence Births per Woman 6 4 2 0 Urban Governorates Lower Egypt Urban RESIDENCE I m TFR 1983-1985 ~ TFR 1986-1988 Lower Egypt UDDer Egypt Upper Egypt Rural Urban Rural i Egypt DHS 1988 39 In summary, fertility levels have been declining in all geographic areas in Egypt, with the transition to lower fertility occurring at a faster pace among urban women, especially those living in the Urban Governorates, than among rural women. The rate of the fertility decline among rural women varies significantly by region. The longterm decline among women living in rural Lower Egypt has been similar to that observed among women living in urban areas outside the Urban Governorates, while the recent decline in rural Lower Egypt has outpaced even the rate of decline in the Urban Governorates. In rural Upper Egypt, however, while fertility has been declining, the pace of the longterm decline has been only about half that observed in the other areas, and recently the rate of decline has been only about one-third that observed in rural Lower Egypt. Socioeconomic Differentials. Table 3.1 also shows that fertility levels are negatively related to the education level of women. For the five-year period prior to the survey, the highest fertility level (5.7 births) is observed for women with no education. Fertility decreases rapidly with increasing education from 5.1 births for women who have not completed primary school to 3.8 births among women who have completed primary school and 3.2 births for women with a secondary school education. Lower fertility has apparently characterized women with secondary education for some time; the TFR for the five-year period prior to the survey is virtually identical to the mean children ever born to women 40-49 (Figure 3.4). Among the other education groups, the rate of fertility decline has been greatest over time for women who completed primary school. More recently, the pace of fertility decline has been similar among women in all the education groups except women with secondary education, among whom fertility levels have remained stable (Figure 3.5). On average, women who work for cash are having 3.2 births compared to 4.9 births among women who are not working or who are employed without pay. For both groups, fertility has been declining over time, with working women leading the transition to lower fertility. Age Pattern of Fertility The recent trend in fertility levels can be further examined by looking at changes in the age pattern of fertility (Table 3.2). The tendency for women to have children early in the reproductive period is clear, a pattern which is consistent with the fertility curve observed in most developing countries. The age-specific rates for the five-year period before the survey indicate that fertility is low among women 15-19, increases significantly among women 20-24 and peaks among women in the 25-29 age group. Approximately half of all current childbearing is to women 20-29. The concentration of fertility in the first half of the childbearing period despite the rise in the age at marriage, is an indicator of the emphasis placed in Egyptian society on bearing children soon after marriage. 40 Figure 3.4 Cumulative Fertility (CEB) and Current Fertility (TFR) by Level of Education Births per Woman 8 6 4 2 0 NO Education • 0-4 years before survey Some Primary Comp Prim/ Comp Sec/ Some Sec Higher EDUCATION BIBIB CEB 40-49 ~ TFR* Egypt DHS 1988 Figure 3.5 Current Fertility (TFR) by Level of Education Births per Woman 8 6 4 2 0 No Education Some Primary Comp Prim/ Comp Sec/ Some Sec Higher EDUCATION m TFR 1983-1985 ~ TFR 1986-1988 i Egypt DHS 1988 41 Tabte 3.2 Age-Specific Fer t iL i ty Rates (per 1,000 Women) for the Cater Year Per i ls 1980-1988 and 1983-1985 end for the Period 0-4 Years Before the Survey, Egypt OHS, 1988 0-4 Years 1986- 1983- Before the Age 1988(1) 1985 Survey 15-19 72 95 83 20-24 220 250 237 25-29 243 258 251 30-34 182 205 198 35-39 118 115 120 40-44 41 47 44 45-49 6 I 5 Total Fer t i t i ty Rates: 15-44 4.38 4.85 4.66 15-49 4.41 4.86 4.69 ( I ) Inctudes 1989 up to the survey date The narrowing of the childbearing period can also be seen by examining the decline in fertility between 1983-1985 and 1986-1988. The age-specific fertility rates declined in almost all age groups, but the decline was most rapid in the youngest group (24 percent). This probably reflects the decreasing tendency to early (teenage) marriage described in Chapter 2. Finally, although the peak childbearing period is concentrated among women 20- 29, it is important to note that, according to the schedule of age-specific rates prevailing in the five years before the survey, around one in eleven births occurs to women in their teens and almost one in five births occurs to women 35 years and older. Studies have shown that, for both mothers and their children, the morbidity and mortality risks associated with pregnancy are greatest for women in these age groups. Longterm Trend in the Age Pattern The birth history data collected in EDHS allow a more detailed examination of fertility trends during the 30-year period before the survey. The age-period fertility rates derived from the birth history are shown in Table 3.3 for successive five-year periods before the survey by the mother's age at the time of the birth.' As noted earlier, one of ' To compute the numerator for these rates, births were classified by the segment of time preceding the survey (e.g., 0-4 years, 5-9 years, etc.) and by the age of the mother at the time of the birth. The denominator is the number of women-years lived in the specified five-year age interval for each time segment. 42 Tabte 3.3 Age-Peried Fer t i t i ty Rates (per 1,000 Wotnen) for Five-Year Periods Before the Survey by Age of Nother at the Time of the Bi r th , Egypt DHSo 1988 Number of Years Before Survey Age at B i r th 0-4 5-9 10-14 15-19 20-24 25-29 30-34 15-19 83 107 136 153 177 171 (161) 20-24 237 250 276 302 325 (334) - - 25-29 251 279 293 308 (316) . . . . 30-34 198 204 224 (228) . . . . . . 35-39 120 122 (150) . . . . . . . . 40-44 44 (48) -. . . . . . . . . . 45 -49 (5) . . . . . . . . . . . . Cumutative Fer t i t i ty , 15-34 3.8 4.2 4.6 5.0 . . . . . . Note: F igures in parentheses are based on par t ia t ty t runcated in format ion. - - Not ca lcu la ted due to age t runcat ion the drawbacks in using these data for examining fertility trends is that the rates for the older age groups in Table 3.3 become progressively more truncated further back in time. For example, rates cannot be calculated for the 45-49 age group for the period 5-9 years before the survey, because women who would have been 45-49 at that time were 50-54 years old at the time of the EDHS and, consequently, not interviewed in the survey. Partially truncated rates are shown in parentheses. Table 3.3 confirms the declin- ing trend in the age-specific rates. The most rapid decline has been in the youngest age groups, supporting the observation about the narrowing in the prime childbearing period (Figure 3.6). This decline is con- sistent with the trend toward delayed marriage. Another indicator of the downward trend in fertility is the de- crease in the cumulative fertility rate for women 15-34. This rate declined from 5.0 births for the period 15-19 years before the EDHS to 3.8 births for the five-year period immediately prior to the survey. Figure 3.6 Age-Period Fertility Rates 400 Births per 1,000 Women 2 0 0 ~ ~ 3 0 0 . . - . . . . . . . . . . . . . 15-19 20-24 25-29 30-34 35-39 40-44 AGE i _ _ k 0-4 years - - - - 5-9 years ~ 10-14 years | I 15-19 years - 20-24 years Egypt DHS 1988 43 Tables 3.2 and 3.3 use in- formation collected in the EDHS to examine the trend in fertility over time. In exploring the fer- tility trend, another approach is to compare the rates obtained from the EDHS with estimates from other sources, including the 1980 Fertility Survey and the 1984 Contraceptive Prevalence Survey. Table 3.4 presents the age-specific and total fertility rates for the three surveys. It is important to bear in mind in comparing these rates that both the EFS and EDHS rates are derived from birth history data while the ECPS rate is based on information obtained through a question about the date of the last live birth. Table 3.4 Age-Specific Fer t i l i ty Rates (per 1,000 Women) and the Total Fer t i l i ty Rate, Egypt OHS 1986-1988, CPS 1983-1984 and FS 1979-1980 EFS ECPS EDHS 1979- 1983- 1986- Age 1980(1) 198/-*(2) 1988(3) 15-19 78 73 72 20-24 256 205 220 25-29 280 265 243 30-34 239 223 182 35-39 139 151 118 40-44 53 42 41 45-49 12 13 6 Total Fer t i l i ty Rates: 15-44 5.22 4.79 4.38 15-49 5.28 4.85 4.41 (1) Haltouda, A. M. e ta [ . , 1983, Volume 11, Table 4.16 (2) Unpublished resul ts (3) Includes 1089 up to the survey date The trend in fertility rates from the three surveys is downward. The TFR decreases by 16 percent, from a level of 5.2 births at the time of the EFS in 1979-1980 to 4.4 births in the three-year period before the EDHS in 1986-1988. This again suggests that Egypt has experienced a steady decline in fertility during the 1980s. 3.2 CURRENT PREGNANCY The percent currently pregnant can be taken as an indicator of recent fertility levels. However, this measure must be treated with caution since it suffers from underreporting, either because the woman is unaware (uncer- tain) that she is pregnant, especially during the first three months, or because she is embarrassed to admit that she is pregnant. Overall, 12 percent of currently married women were pregnant at the time of the survey (Table 3.5). Pregnancy was highly concentrated in the safer period of the child- Table 3.5 Percent of A l l Wor~n and of Current ly MarriedWomen Who Were Pregnant at the Time of the Survey by Age, Egypt DHS 1988 Current ly A l l Married Age Women women 15-19 3.6 23.5 20-24 12.9 22.4 25-29 13.8 17.0 30-34 10.5 11.7 35-39 6.1 6.8 40"44 3.0 3.5 45-49 0.5 0.6 Total 7.9 12.1 44 bearing ages, namely among women 20-34 years. However, one in ten women age 35 and over, a high risk category, was pregnant. 3.3 CHI I .DREN EVER BORN Data on the number of children ever born to the women interviewed in the EDHS are presented in Table 3.6 for all women and currently married women. These data reflect the cumulative outcome of the childbearing experience of the EDHS respondents over their entire reproductive lives up to the point of interview. The results indicate that Egyptian women have given birth to an average of 2.8 children. Since fertility levels have been high in the past, the number of children ever born increases rapidly with age. On average, cumulative fertility increases by about one child for each five-year age group except for women 40-49. Women 45-49, who are nearing the end of their reproductive years, have had an average of 6.1 births. About 15 percent of these women have given birth to ten or more children. TabLe 3.6 Percent Distr ibut ion of Al l Women and Currently Married Women By Number of Children Ever Born and Mean Number of Children Ever Born, According to Age, Egypt DHS, 1988 Number of Children Ever Born Number 10 or of ABe None 1 2 3 4 5 6 7 8 9 more Tote[ Women Mean ALL Women 15-19 92.3 5.6 1.8 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0 100.0 2,718 0.1 20-24 51.4 17.7 16.3 9.1 3.8 1.2 0.3 0.1 0.0 0.0 0.0 100.0 2,374 1.0 25"29 23.1 10.9 18.3 17.6 13.8 9.1 4.8 1.7 0.6 0.1 0.1 100.0 1,978 2.5 30-34 10.3 6.2 14.6 17.4 16.0 12.8 9.7 6.8 3.2 1.6 1.3 100.0 1,642 3.8 35-39 4.8 2.7 8.5 13.4 13.6 13.4 13.4 9.8 9.0 5.7 5.7 100.0 1,640 5.2 40-44 4.3 2.7 6.0 10.2 13.5 11.6 11.6 11.4 9.9 7.0 11.9 100.0 1,226 5.8 45-49 4.4 2.4 5.4 8.1 9.8 11.3 12.7 12.5 10.6 8.2 14.6 100.0 1,053 6.1 Tote[ 35.9 7.9 10.4 10.2 8.8 7.1 6.0 4.6 3.5 2.3 3.3 100.0 12,631 2.8 Currently Married W(~l~en 15-19 50.3 36.5 11.5 1.2 0.5 0.0 0.0 0.0 0.0 0.0 0.0 100.0 416 0.7 20-24 18.5 28.9 27.7 15.7 6.4 2.0 0.5 0.2 0.1 0.0 0,0 100.0 1,369 1.7 25-29 8.2 12.5 21.3 21.2 16.8 11.0 5.9 2.1 0.7 0.1 0.1 100.0 1,607 3.0 30-34 4.5 5.8 14.9 18.6 17.5 13.9 10.6 7.5 3.6 1.7 1.4 100.0 1,473 4.1 35-39 2.5 2.1 8.4 13.3 13.5 13.9 13.8 10.3 9.6 6.3 6.1 100.0 1,470 5.4 40-44 2.3 2.7 5.7 10.3 12.6 11.4 11.7 12.1 10.5 7.2 13.4 100.0 1,042 6.0 45-49 2.6 2.0 4.9 8.0 9.7 11.3 12.2 13.0 11.3 9.1 15.8 100.0 844 6.4 Total 9.1 11.1 14.8 14.7 12.5 10.1 8.4 6.5 5.0 3.3 4.7 100.0 8,221 4.0 45 The proportion childless among women nearing the end of the reproductive period provides an indication of the low level of primary sterility, since, in Egypt, prevailing norms do not support voluntary childlessness. Less than three percent of currently married women 45-49, and only four percent of all women in the same age group, have not had any children. Finally, one important goal of the family planning program is to prevent infant and maternal deaths by assisting women to avoid high risk pregnancies. Evidence suggests that pregnancies among women who have already had five or more births are associated with increased mortality and morbidity for both the mother and the child. The results in Table 3.6 show that many women, particularly those in the older age groups, are in this high parity risk category. Overall, more than one in four women has had five or more births. By age, the proportion with five or more births increases from less than 20 percent among women under 30 to 35 percent in the 30-34 group. Among women age 35 and over, who already are at greater pregnancy risk because of their age, the proportion in the high parity risk group increases from nearly 60 percent in the 35-39 cohort to 70 percent among women 45-49. 3.4 CHII .I)REN EVER BORN AND AGE AT MARRIAGE Table 3.7 provides information on the mean number of children ever born to ever- married women by the duration and age at first marriage. The table permits an assessment of the relationship between the age at first marriage and the level of marital childbearing. The expectation is that women who marry early will bear more children since they will have more years of exposure to the risk of pregnancy than women who marry later. The population as a whole exhibits the expected pattern; the mean number Table 3.7 Mean Number of Chi ldren Ever Born to Ever-marrled Women by Age at F i rs t Marriage, According to the Number of Years Since F i rs t Marriage, Egypt DHS, 1988 Age at First Marriage Years Since F i rs t Under 25 and Marriage 16 16-17 18-19 20-21 22-24 over Tote[ 0-4 1.0 1.0 1.0 1.0 1.0 0.9 1.0 5-9 2.6 2.7 2.7 2.6 2.4 2.2 2.6 10-14 4.1 4.1 4.0 3.7 3.5 2.9 3.8 15-19 5.4 5.6 5.2 4.7 4.3 3.3 5.1 20-24 6.8 6.1 5.7 5.2 5.0 4.0 6.0 25-29 7.2 6.6 6.3 5.7 5.1 6.7 30 or mre 7.3 6.8 6.7 7.2 Total 5.3 4.3 3.8 3.2 2.8 2.1 4.0 46 of children ever born decreases from 5.3 among women who married before age 16 to 2.1 among women married at age 25 and older. To some extent this pattern is due to the fact that women who marry early tend to be older, and, thus, have had more time to have children; the duration of marriage is directly associated with the mean number of children ever born, ranging from one child among women married less than five years to 7.2 children among women married 30 or more years. Fertility at most marriage durations is inversely related to the age at first marriage. Among women married less than five years, there is, however, no association between the age at first marriage and the mean number of children ever born. Irrespective of the age at first marriage, women who married less than five years ago have given birth to one child on the average, suggesting that most women bear a child soon after marriage. This indicates the importance of children in the context of Egyptian families. The impact of age at first marriage can be seen in the cumulative fertility level for women married 5-9 years, but is more noticeable for those married 10 years or more, especially among women who married after age 20. For example, the depressing effect on lifetime fertility of increases in the age at marriage is evident in the variation in the mean number of children ever born among women married for 30 or more years; those who were married at age 16-19 have had around 6.7 children while women who were married before the legal age of 16 years have 7.3 children (Table 3.7). For women who first married 20-24 years ago, the mean number of children ever born declines from nearly seven children among those women who married before age 16 to only four children among women who delayed marriage until they were age 25 or older. 3.5 AGE AT FIRST BIRTH The age at which childbearing is initiated is an important demographic and health indicator that is affected by changes in the age at first marriage. The age at first birth also influences the level of completed fertility. Table 3.8 shows the percent distribution of all women by the woman's current age and age at first birth. For women 25 years and over, the median age at first birth is presented in the last column of the table. Overall, the median age at first birth for women age 25-49 is 20.8 years. The median age increases from 20 years for women in their forties to around 21.5 years for women in their late twenties and early thirties. This trend is consistent with the increase in the age at first marriage in recent years (Figure 3.7). On average, the median age at first birth is about two years higher than the median age at first marriage (see Table 2.3). It should be noted that around eight percent of all women gave birth to their first child before age 16. The incidence of very early childbearing has decreased over time. About one in every eight women age 45-49 had their first birth before age 16 compared to less than one in ten women age 25-34 and one in twenty women age 20-24. Less than 47 Table 3.8 Percent D is t r ibut ion of A l l Woolen by Age at F i r s t B i r th ( Inc lud ing Category "No B i r ths" ) and Nedian Age at F i rs t B i r th , According to Current Age, Egypt DHB, 1988 Age at F i rs t B i r th Number Current No Under 25 end Total of Median Age B i r ths 16 16-17 18-19 20-21 22-24 over Percent Wo~en Age 15-19 92.3 1.9 4.0 1.8 0.0 0.0 0.0 100.0 2718 -* 20-24 51.4 4.8 10.3 15.6 12.3 5.7 0.0 100.0 2374 -- 25-29 23.1 9.0 12.4 16.5 14.4 15.7 8.8 100.0 1978 21.7 30-34 10.3 9.3 13.3 17.2 13.3 18.0 18.8 100.0 1642 21.6 35-39 4.8 11.7 17.0 17.2 16.0 15.8 17.4 100.0 1640 20.5 40-44 4.3 12.2 17.6 20.0 14.8 15.5 15.7 100.0 1226 20.0 45-49 4.4 12.6 16.7 20.5 16.5 13.8 15.4 100.0 1053 20.0 Total 35.9 7.7 11.8 14.0 11.2 10.6 8.9 100.0 12631 Note: The median age is defined as the age at which 50 percent of the women have had s b i r th . -- Omitted due to censoring Figure 3.7 Median Age at First Marriage and First Birth by Current Age Median Age Among A l l Women 23 21 19 17 15 25-29 30-34 35-39 40-44 AGE m F i r s t Mar r iage ~ F i r s t B i r th 45-49 / Egypt DH8 1988 48 two percent of women 15-19 at the time of the survey had already had a child before their 16th birthday. The incidence of first births to women under age 18 is considerably greater, although it has also been decreasing over time. The percentage of women whose first birth occurred before age 18 was around 30 percent for women in their late thirties and forties, over 20 percent for women 25-34 and only 15 percent for women in their early twenties (Figure 3.8). Although the rate is clearly declining, the proportion of births occurring to women under age 18 remains high, representing a serious health and social problem that needs to be addressed. 3.6 DIFFERENTIAl S IN AGE AT FIRST BIRTH Table 3.9 summarizes the changes in the median age at first birth among women 25-49 by current age and background characteristics. Overall, there is a difference of about three years in the median age at first birth between women living in urban areas Table 3.9 Nedian Age at F i r s t B i r th Among Wo~en 25-49 by Current Age, According to SeLected Background Character ist ics, Egypt DHSo 1988 Current Age Background Total Character ist ic 25-29 30-34 35-39 40-44 45-49 25-49 Urban-Rural Residence Urban 24.0 23.3 22.2 21.0 20.3 22.4 Rural 19.6 19.7 19.0 19.0 19.8 19.4 Place of Residence Urban Governorates 25.1 24.2 22.8 20.8 20.4 23.0 Lower Egypt 21.1 20.6 19.9 20.3 19.9 20.4 Urban 23.5 22.7 22.1 22.0 19.6 22.4 Rural 20.0 19.8 19.2 19.4 20.0 19.7 Upper Egypt 20.1 20.3 19.5 19.2 19.9 19.8 Urban 22.1 21.9 20.8 20.1 20.5 21.1 Rural 19.3 19.6 18.7 18.7 19.5 19.2 Education No Education 19.3 19.6 19.2 19.0 19.6 19.3 So~e Primary 20.4 19.9 20.3 19.9 19.7 20.1 Primary through Secondary 21.5 21.8 20.8 21.0 21.6 21.3 Completed Secondary/Higher 25.6 25.3 25.3 25.1 25.2 25.3 Nork Status Working for Cash 25.8 25.3 25.1 24.9 24.5 25.2 Not Working 20.7 20.3 19.9 19.5 19.8 20.1 TotBt 21.7 21.6 20.5 20.0 20.0 20.8 Note: The median age is defined as the age at which 50 percent of the ~omen have had a b i r th . 49 40 Figure 3.8 Percent Giving Birth Before Age 18 by Current Age Percent of All Women 30 20 10 20-24 25-29 30-34 35-39 40-44 45-49 AGE Egypt DHS 1988 (22.4 years) and in rural areas (19.4 years). While the median age at first birth has changed very little over time in rural areas, it has increased steadily in urban areas from about 20 years for women 45-49 to 24 years for women 25-29. Regional differences are substantial. The median age at first birth is highest in the Urban Governorates (23 years), followed by urban areas in Lower and Upper Egypt (22.4 and 21.1 years, respectively), and finally rural areas in these regions (19.7 and 19.2 years, respectively). The overall difference between Upper and Lower Egypt is less than one year (20.4 years in Lower Egypt compared with 19.8 years in Upper Egypt). The median age at first birth has increased in all urban areas while rural areas have not shown any significant changes. It should he noted, however, that the median age at first birth in rural areas is slightly higher in Lower Egypt than in Upper Egypt for all cohorts. Education has a strong inverse relationship with the median age at first birth, which increases from 19.3 years for women with no education to 25.3 years for women who have completed at least a secondary education. Although women in the highest education groups had their first child at a relatively late age, there is an unusually short gap between their marriage and their first birth (see Tables 2.4 and 3.9). Within education groups, there has been little (if any) increase in the median age at first birth across cohorts. Therefore, most of the overall increase in the median age at first birth is attributable to increases in educational attainment over time. 50 Chapter 4 KNOWLEDGE, ATI'ITUDES AND EXPOSURE TO FAMILY PLANNING MESSAGES Among the prerequisites for adoption of family planning are sufficient knowledge about contraceptive methods to allow a potential acceptor to make an informed choice about the method to use, information about where methods are available and a positive attitude toward the use of family planning. This chapter looks at how widespread knowledge and approval of family planning are among Egyptian women. The chapter also considers how well efforts to disseminate information on family planning through broadcast media are succeeding in reaching women of childbearing age. 4.1 CONTRACEPTIVE KNOWLEDGE Familiarity with contraceptive methods and places to obtain methods are preconditions to use. The EDHS provides information on the level of knowledge for both methods and service providers. Data on method knowledge were obtained by asking the respondent to name the methods or ways to avoid pregnancy which she had heard about. If a respondent did not spontaneously mention a particular method, the interviewer read a description of the method and the respondent was asked if she recognized that method. Descriptions were included in the questionnaire for seven modern methods (the pill, IUD, injection, condom, vaginal methods (foam, cream or jelly), female sterilization and male sterilization) and three traditional methods (safe period, withdrawal and prolonged breastfeeding). In addition to these methods, the respondent had an opportunity to mention any other methods about which she had heard. For any modern method the respondent recognized, she was asked about where she would go to obtain the method if she wanted to use it. In the case of the safe period, she was asked from where she would seek advice about using the method. Finally, while lack of information about a specific contraceptive method or about a service provider offering the method are obvious barriers to use of the method, there are many other factors including concerns about side effects or the effectiveness of the method which can stand in the way of a woman adopting a particular method. To obtain information on other obstacles to use, ever-married women who have heard of a method were also asked about the main problem (if any) with using the method. Level of Contraceptive Knowledge Knowledge of contraceptive methods is widespread. Nearly all ever-married women know about at least one method (Table 4.1). In general, modern methods are more likely 51 Table 4.1 Among Ever-marriod Women, Percent Knowing e Contraceptive Nethod by Hethod, Egypt DHS, 198~, CPS, 198~ and FS, 1980, and Percent Knowing a Source by Nethod, DES, 1968 Know Nethod Know Source EDHS ECPS EFS EDHS Neth~ 1988 1984(I) 19~(2) 1968 Any Nethod 98.0 85.4 89.7 95.2 Any Nodern Nethod 97.8 85.2 NA 95.2 PiLL 97.4 84.9 89.4 93.9 IUD 93.3 74.9 69.6 87.2 Inject ion 60.5 35.3 15.6 47.9 Vaginal Methods 39.6 27.8 13.8 36.6 Condom 43.3 21.5 25.9 40.2 Female S ter i l i za t ion 53.5 20.5 42.5 50.2 NaLe Ster iL i za t ion 9.6 5.3 6.0 8.4 Any Trad i t iona l Method 67.3 30.0 NA Safe Period 22.1 11.3 14.0 20.0 Withdrawal 13.4 6.9 9.8 -- Prolonged Sreastfeedin9 64.8 24.7 NA -- Other Methods 4.6 1.3 NA -- Nunlber of Wo~en 8,911 10,013 8,788 8,911 Rote: Differences in data co l lec t ion methods may af fect comparisons (see text ) . NA - Not ava i lab le -- Rot appl icable (1) Sayed et a t . , 1985, Tables 7.1 and 7.2 (2) Natioucla et e l . , Volume IV, Tables 4.2.1-1A to be recognized than traditional methods (98 percent vs. 67 percent). Considering individual methods, the pill is the most widely known modern method (97 percent), followed by the IUD (93 percent), injection (60 percent) and female sterilization (54 percent). Prolonged breastfeeding, the most widely known traditional method, is recognized by more women (65 percent) than any modern contraceptive methods except the pill and IUD. Other traditional methods (including the safe period method and withdrawal) are known by less than 25 percent of women. Using information from the 1980 Fertility Survey (EFS) and the 1984 ContraceptiVe Prevalence Survey (ECPS), Table 4.1 shows the upward trend in the level of contraceptive knowledge during the 1980s. Overall, the percent of ever-married women knowing any 52 100 Figure 4.1 Contraceptive KnowLedge by Method Percent of Ever-married Women 80 60 40 20 0 Any Modern Pill IUD Injection Female Method Sterilization METHOD Know Method & Source ~ Know Method Only ~ Egypt DHS 1988 method increased from 90 percent in 1980 to 98 percent in 1988. ~ The pill was the most widely recognized method in all three surveys. Egyptian women have clearly become more aware of family planning methods other than the pill since 1980. Increases in the percent of ever-married women saying that they knew about the method are particularly striking in the case of the IUD, injection, vaginal methods, and the condom. Egyptian women are well-informed about family planning service providers; 95 percent of ever-married women can name a source from which contraceptive methods are available (Table 4.1). Women knowing a method are most likely to know about a service provider for the pill and least likely to name a source for injection (Figure 4.1). Even in the case of injection, however, eight in ten women knowing about the method were able to name a service provider where injection was available. 1 The ECPS differed somewhat from the EFS and the EDHS in the manner in which the information on contraceptive knowledge was obtained. In all three surveys, the respondent was first asked to name all the methods that she knew. The interviewer then probed to find out whether the respondent recognized methods which she had not spontaneously mentioned. In the ECPS, the interviewers used only the name when probing while, in the EFS and the EDHS, both the name of the method and a brief description were used. The fact that ECPS knowledge levels are somewhat lower for some methods than the levels in the earlier EFS may be related to differences in the probing techniques between the two surveys. 53 Differentials in Contraceptive Knowledge Table 4.2 shows the percent knowing any modern method and the percent knowing any source for a modern method among currently married women, controlling for selected background characteristics. The results confirm that contraceptive knowledge is wide- spread among all groups. Differentials in method knowledge by age, place of residence, educational level and work status are generally minimal, with 95 percent of women in all subgroups able to name a modern method. There is somewhat greater variability in the proportions identifying a service provider, but even for this indicator, 90 percent or more of the women in all subgroups except rural Upper Egypt are able to name a source for at least one method. Table 4.2 Among Current[y Married Wo~en, Percent Knowing at Least One Modern Contraceptive Method end Percent Knowing e Source ( for information or Services) for a Modern Method, by Selected Background Characteristics, Egypt DHS, 1988 Know Number Background Modern Know of Characteristic Method Source women Age 15-19 96.9 91.6 416 20-24 97.8 95.7 1,369 25-29 98.9 97.2 1,607 30-34 98.4 96.6 1,473 35-39 98,9 96.7 1,470 40-44 97.9 95.7 1,042 45-49 96.7 93.2 844 Urban-Rural Residence Urban 99.4 98.8 4,006 Rural 96.9 93.1 4,215 Place of Residence Urban Governorates 99.7 99.3 1,996 Lower Egypt 99.0 98.0 3,230 Urban 99.8 99.3 952 Rural 98.6 97.5 2,278 Upper Egypt 96.2 91.3 2,995 Urban 98.6 97.3 1,058 Rural 94.9 88.0 1,937 Education Level NO Education 96.9 93.5 4,105 Less than Primary 99.0 97.4 1,895 Primary through Secondary 99.9 99.2 804 Completed Secondary/Higher 99.7 99.5 1,417 Work Status Working for Cash 99.9 99.6 985 Working, Not Paid in Cash 98.9 97.6 657 Not Working 97.8 95.2 6,579 interested in Work 98.8 96.7 1,960 Not Interested in Nork 97.6 94.5 4,619 Tote( 98.2 95.9 8,221 54 Table 6.3 Percent of Currently Married Won~n Knowing a Contraceptive Method by Method, According to Urban-Rural Residence arid Place of Residence, Egypt DH$, 1968 Urban Lo~er Egypt upper Egypt Gover- Method Urban Rural notates Tote[ Urban Rural Total Urban Rural Total Any Method 99.5 97.2 99.8 99,1 99,8 98.9 96.6 98.6 95.2 98.3 Any Modern Method 99.6 96.9 99.7 99.0 99,8 98.6 96.2 98.6 94.9 98.2 PiLL 99.2 96.6 99.4 98.5 99,& 98.2 915.1 98.6 94.7 97,9 I~ 97.7 90.2 98.5 93.6 96,2 92.5 91.2 97.T 87.6 93.9 Inject ion 68.2 55.9 65.0 61.5 68,7 58.5 61).3 T3.8 52.9 61.9 Vagina[ Methods 55.8 26.9 58.9 38.4 53,0 32.3 31.8 52.3 20.6 41.0 Condom 65.4 24.9 70.3 39.3 60.3 30.6 33.2 60.5 18.3 44.6 Female Ster i l i za t ion 66.4 43.2 70.2 56.9 64,7 53.6 41.4 60.6 30.9 54.5 Male Ster i l i za t ion 14.5 5.6 15.6 8.6 16.3 6.2 7.5 12.6 6.8 9.9 Any Tradit ional Method 79.4 57.4 87.2 61.9 66.2 60.2 62.0 76.5 54.1 68.1 Safe Period 37.6 8.8 42.4 16.8 32.5 10.3 16.3 33.1 7.1 22.8 Withdrawal 22.6 5,6 26.1 13.1 26.0 7.7 6.6 13.0 3.1 13.9 Prolonged Breastfeeding 76.0 55.7 83.5 59.5 62.3 58.4 60.1 74.1 52.5 6/+.8 Other Methods 6.2 3.0 7.5 2.1 1.6 2.3 5.3 8.1 3.7 4.6 gunther of Wo~en 4,006 4,215 1,996 3,230 952 2,278 2,995 1,058 1,937 8,221 Although most Egyptian women are familiar with the pill and the IUD, there is greater variability in the recognition of other methods. Currently married women living in urban areas are, for example, more than twice as likely as rural women to know about the condom or vaginal methods (Table 4.3). Women from rural Upper Egypt are particularly limited in their recognition of methods other than the pill or the IUD; only one in two knows about the injection, and fewer than one in three has heard about the condom, vaginal methods or female sterilization. Perceived Source of Supply Table 4.4 presents the percent distribution of women knowing contraceptive methods by the service provider from which they say that they would obtain the method. Pharmacies stand out as the most frequently cited source for the pill (80 percent), condom (88 percent) and vaginal methods (85 percent). Pharmacies (45 percent) and private physicians (22 percent) are seen as the principal source for injection. Private physicians are the main perceived source (45 percent) for the IUD, followed by government sources (hospitals, MCH centers or FP clinics) (29 percent). In addition to being available at these sources, IUDs can be purchased at pharmacies at a subsidized rate for later insertion by a physician. Nearly 20 percent of women knowing about the IUD would buy the IUD from a pharmacy if they wanted to use it. Government hospitals and private physicians are the main service providers women report for female and male 55 Table 4.4 Percent Distr ibut ion of Ever-married Women Knowing a Contraceptive Method by the Source Where the Woman Would Go to Obtain the Method, According to Method, Egypt DHS, 1988 SteriLization Injec- Vagin- Safe Source P i t t IUD tion als Condom Female MaLe Period Government FP Clinic 5.0 r.2 2.3 1.8 0.9 0.7 0.5 2.6 Government MCH Center 2.4 4.1 1.1 0.4 0.3 0.2 0.0 1.0 Government Hospital 5.6 17.5 7.3 1.4 0.8 50.2 38.2 1.5 Home De[ ivered 0.4 0.1 0.2 0.3 0.3 0.0 0.0 0.0 Private FP Cl inic 0.3 0.6 0.1 0.1 0.0 0.1 0.3 0.4 Private Doctor/Clinic 1.8 45.2 22.1 3.1 1.7 41.3 47.1 36.4 Pharmacy 80.0 17.8 45.1 85.2 88.5 1.3 1.1 0.3 Relatives, Friends and Other 0.9 0.9 0.8 0.2 0.4 0.1 0.9 46.3 Nowhere 0.0 0.0 0.2 0.0 0.0 0.1 0.2 1.7 Don't Know 3.6 6.4 20.5 7.2 6.4 5.6 10.9 6.1 Missing 0.1 0.1 0.3 0.3 0.7 0.5 0.8 3.6 Total Percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of Wonlen 8,084 8,313 5,392 3,532 3,856 4,767 853 1,972 sterilization. Relatives and friends (46 percent) and private doctors (36 percent) are the primary sources from which women would seek advice about using the safe period. In summary, private sector providers are perceived to be the principal providers for contraceptive methods. The pharmacy is the most frequently cited source for the pill and other methods requiring resupply (condom, vaginal methods and injection), and many women would purchase the IUD at a pharmacy. Private doctors are most often named as the source for the IUD. Only a minority of women would rely on government facilities for any methods except sterilization, which is not widely available or used in Egypt. Acceptability of Methods Table 4.5 shows the problems women associated with specific contraceptive methods. For most methods except the pill and the ]UD, the majority of respondents either do not consider the method to have any problems or report that they do not know about any problems. The proportion indicating that there are no problems with the method ranges from 11 percent in the case of injection to 48 percent in the case of prolonged breastfeeding, while the proportion claiming not to know about any problems varies from 10 percent for prolonged breastfeeding to 62 percent for injection. Respondents falling into the "don't know" category may not be familiar enough with the methods (e.g., injection) to be able to specify problems or they may be embarrassed to discuss problems with using some methods (e.g., the condom). Therefore, the large proportions of women answering that they do not know about any problems with a method 56 Tabte 4.5 Percent Distribution of Ever-~arrind Women Knowing a Contraceptive Nethod by the Nain Probtem Perceived in Using the Nethod, According to Nethod, Egypt DHS, 1988 Steri l izat ion Safe Protonged Injec- Vagin- con- Per- With- Breast- Pitt IUO t im ets dom Femate Kate iod drawer feeding Hain Problem NO Probtem 18.0 20.8 11.2 13.2 18.5 25.0 13.5 26.2 25.8 48.0 Husband Disapproves 0.1 0.2 0.1 0.4 13.1 1.2 11.7 2.6 16.3 0.0 Other Retative Disapproves 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.1 0.0 0.1 Retigious Prohibitions 0.3 0.1 0.2 0.3 0.5 11,2 13.3 0.3 0.7 0.2 side Effects for Woman 59.2 39.9 18.4 13.5 2.5 6.7 1.3 0.6 1.4 4.1 Side Effects for Chitd 1.0 0.0 0.1 0.1 0.1 0.0 0.0 0.2 0.0 1.0 Hethod Irreversible 0.1 0.1 1.3 0.1 0.0 15.5 12.0 0.0 0.0 0.0 Diff icutt to Obtain 0.0 0.0 1.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 Not Effective 1.2 8.7 3.8 16.2 12.6 0.9 0.4 43.6 16.5 33.9 Costs Too Huch 0.0 0.1 0.1 0.0 0.0 0.3 0.1 0.0 0.0 0.0 Inconvenient to Use 0.7 1.4 0.6 1.3 2.9 1.3 2.4 2.2 4.2 1.0 Other 0.7 1.7 1.1 1.2 2.1 1.8 2.7 1.6 4.4 0.7 Don't Know 16.6 27.0 61.8 53.1 47.0 35.5 41.8 21.9 29.9 10.4 Hissing 0.1 0.1 0.3 0.4 0.5 0.5 0.5 0.9 0.8 0.6 Total Percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of Women 8,684 8,313 5,392 3,532 3,856 4,767 853 1,972 1,192 5,7?3 should not be interpreted as evidence that the method is "without problems" for women. Lack of adequate information about a method, including both its advantages and disadvantages, may in itself be the greatest barrier to the method's use. Among those women citing problems with methods, side effects (for the woman) tend to be the chief concern. In the case of the pill, six in ten women consider such side effects to be the main problem, while four in ten women are concerned about side effects in using the IUD. Side effects are also associated with the injection and vaginal methods, although by considerably smaller proportions of women. Ineffectiveness is the principal problem for the safe period and prolonged breastfeeding and, to a lesser extent, the condom, vaginal methods, withdrawal and the IUD. Irreversibility of the method and religious prohibitions are cited by 10 to 15 percent of women as the main problems associated with female sterilization and male sterilization. For the latter method and the condom, similar proportions of women point to husband's disapproval as an obstacle to use. Other potential problems, including cost or difficulties in obtaining or using methods, are mentioned by very few women. In conclusion, the findings in Table 4.5 suggest that the major potential barrier to use of contraceptive methods for most Egyptian women are method side effects, and such side effects are primarily associated with use of the pill and the IUD. To some extent, these results may simply reflect greater familiarity with the pill and the IUD on the part 57 of women and consequently, greater awareness of the possibility that side effects can occur with these methods. However, the results suggest that concerns about side effects are a significant obstacle to use of these methods, which must be addressed in educational campaigns and through improved followup of women adopting these methods. 4.2 ATI ' ITUDINAL INDICATORS A positive attitude toward family planning is another basic prerequisite for contraceptive use. Attitudinal data were collected by asking women in the sample whether they approved of family planning use and, if they were married, whether their husbands approved or not. The extent to which wives and husbands discuss family planning use was investigated, on the assumption that more frequent discussion might predispose the couple to use. Finally, information was obtained on attitudes toward the timing of the first use of family planning in order to better understand at what stage in childbearing women believe contraceptive use should be initiated. In addition, the issue of whether Egyptian women consider female sterilization to be an acceptable contraceptive method was explored. Approval of Family Planning Use Table 4.6 shows the overall level of approval of family planning among currently married women who know at least one contraceptive method. The table also looks at the extent to which these women say that their attitude parallels that of their husband. Although the husband's actual attitude toward family planning may differ from what the wife reports, a wife's perceptions concerning his attitude are important since they will help to shape her decisions with regard to the use of family planning. According to wives, the majority of couples approve of the use of family planning; in only one in five couples does either or both Table 4.6 Percent Distr ibut ion of Currently Narried Women Knowing a Contraceptive Nethocl by the Wife's Att itude Toward Contraceptive Use and the Wife's Perception about the Husband's Att i tude, Egypt DHS, 1988 Wife's and Husband,s Att itude Percent Wife Approves 86.6 Husband Approves 70.7 Husband Disapproves 9.4 Husband's Att itude Not Known 6.5 Wife Disapproves 7.2 Husband Approves 0.8 Husband Disapproves 4.8 Husbandls Att itude Not Known 1.6 Wife Not Sure 6.2 Husband Approves 0.4 Husband DisapprOves 2.0 Husband's Att itude Not Known 3.7 Total 100.0 Nua~r of W~n 8,082 spouses disapprove. In the case of most of these couples, it is the husband and not the wife who is seen as disapproving of family planning; onl)/ seven percent of women disapprove of family planning compared with 16 percent of husbands. 58 Discussion of Family Planning with Husband While husband-wife discussion of family planning is not a necessary precondition for adoption of a method, evidence of such discussion is an indication of interest in the subject on the part of the couple, which is presumed to precede use. Table 4.7 shows one in three women knowing a contraceptive has never talked about family planning with her husband. Among those who have discussed the subject, 60 percent talked to their husband at least once in the 12 months before the survey, and around half of these women report having had at least four conversations with their husband during the period. Table 4 .7 Percent Distr ibut ion of Currently NarriedWomen Knowing a Contraceptive Nethnd by Frequency of Discussion about Family Planning with Husband, Egypt DHS, 1988 Frequency of Family Planning Discussion Percent Discussed in Past Year 40.9 Once 8.5 2-3 Times 12.1 4 or Hore Times 20.3 Ever Discussed, Not in Past Year 26.5 Never Discussed 32.4 No information 0.2 Total 100,0 Number of Women 8,082 Initiation of Family Planning Use Although the majority of married women knowing about a contraceptive method approve of the use of family planning, EDHS results indicate that there is little support for family planning use during the early stages of childbearing. None of the women advocate using a contraceptive method prior to the birth of the first child, and only a small fraction (10 percent) think a couple should begin using family planning after one child (Table 4.8). However, almost 60 percent of the women approve of the use of family planning when a couple has two or three children, and only 11 percent feel contraceptive use should be started only after a couple has had four or more children. Table 4.8 Percent Distr ibut ion of Currently Harried Worsen Knowing a Contraceptive Hethed by the Number of Children a Wonlan Should Have Before Using Contraception and the Hean Number of Children a Wotnan Should Have Before Using Cootraception, Egypt DHS, 1988 Humber of Children Percent None O.O 1 Chi ld 10.3 2 Chi ldren 34.9 3 Chi ldren 24.6 4 Chi ldren 8.7 5 on Hore Children 1.9 Not Sure 9.9 Should Not Use 7.4 Hissing 2.2 Total 100.0 Number of Women 8,082 Bean NLmdoer of Ch i ldren( I ) 2.5 (1) CaLculated only for women giving numeric responses (N = 6,502) 59 Attitude About Use of Sterilization In order to collect data on attitudes toward sterilization as a method for limiting births, EDHS respondents were asked: "If a couple has had the number of children that they want, do you think that it is acceptable for women to have an operation to prevent her from becoming pregnant again if her husband agrees?" Overall, women are fairly evenly divided on this issue; among women knowing at least one contraceptive method, 47 percent of the women knowing about family planning consider sterilization acceptable or sometimes acceptable, 44 percent feel it is unacceptable to have such an operation, and nine percent are unsure about their attitude. Differentials in the Attitudinal Indicators The EDHS results presented above indicate that the majority of wives and husbands approve of the use of family planning. Among almost one-fifth of couples, however, one (usually the husband) or both spouses disapprove of a couple using contraception. Couples talk about family planning, with only one in three women saying that she had never discussed family planning with her husband. Although there is widespread discussion and approval of family planning among couples, most Egyptian women do not consider it appropriate for a couple to begin using family planning until they have had at least two children. Thus, contraceptive methods are considered largely as a means to limit births once a couple has achieved a desired number of children, and there is little apparent demand for using family planning to space wanted second births. With regard to the use of female sterilization when a couple has achieved their desired family size, women seem to be equally divided between those who consider it acceptable and those who do not. Table 4.9 looks at differences in these attitudinal indicators across population subgroups. In general, rural women (and their husbands), women from Upper Egypt, women who never attended school, and those who are not working tend to be more conservative in their attitudes than other women. Women from rural Upper Egypt stand out as much more likely than other women to express negative feelings about family planning use. Much of the disapproval of family planning is, in fact, concentrated among women from rural Upper Egypt (Figure 4.2). For example, almost one in five women knowing a contraceptive method in this region disapproves of a couple using family planning, nearly three times the level of disapproval recorded for women in other residential categories. More than one in four women in rural Upper Egypt believes that her husband disapproves of family planning; this is more than twice the level of husband disapproval reported by women from rural Lower Egypt. There is little discussion about family planning among couples from rural Upper Egypt; only one in three married women has ever talked about the subject with her husband, and only one in four has had a recent conversation with her husband about family planning. The more conservative attitudes of women from rural Upper Egypt are also reflected in their opinion as to the time when a couple should initiate family planning use. 60 Table 4.9 Att i tudinal Indicators for Currently Married women Knowing s Contraceptive Method by Selected Backgrota~d Characteristics, Eg~!~t 0H$, 19~ Wife-Husband Mean Number Have Talked of Children Disal~oroves of About Family Any COL~Ote Using Contrscedtion PLanning Should Have Ster i I i - Before Using zation Nun/vet Background Wife Husband Within Contracep- Accep- of Characterist ic Both Only Only Ever Year t ion(1) table Women Age 15-19 7.8 3.3 12.2 ~.0 34.4 2.4 40.6 403 20-24 5.7 2.2 13.7 61.0 47.9 2.4 39.0 1,345 25-29 4.0 2.4 12.9 ~.0 51.2 2.4 39.0 1,592 30-34 4.1 1.7 11.0 75.5 48.4 2.5 41.6 1,451 35-39 3.9 2.7 9.7 74.7 39.9 2.6 42.0 1,454 40-44 5.1 2.4 9.9 68.0 29.8 2.6 44.6 1,020 45-49 6.3 3.3 10.1 57.3 15.0 2.6 41.9 817 Urban-Rural Residence Urban 2.3 1.0 9.6 80.2 44.5 2.3 44.6 3,984 Rural 7.4 3.9 13.2 55.0 37.4 2.8 48.6 4,098 Place of Residence Urban Governorates 1.9 0.8 9.4 82.5 40.6 2.2 43.3 1,992 Lower Egypt 2.6 1.8 10.1 73.1 48.0 2.5 49.1 3,202 Urban 0.7 0.6 8.6 82.2 53.1 2.3 43.0 949 Rural 3.3 2.4 10.6 69.3 45.8 2.6 51.6 2,253 Ul~oer Egypt 9.4 4.3 14.3 50.8 33.3 2.8 46.1 2 ,~ Urban 4.4 1.6 10.8 74.0 44.2 2.5 48.4 1,043 Rural 12.3 5.8 16.4 37.7 27.2 3.1 44.8 1,845 Education Level No Education 7.8 3.7 13.4 54.6 32.7 2.7 47.0 3,990 Less than Primary 2.9 2.2 11.7 72.9 44.2 2.5 55.8 1,876 Primary through SecocxJary 1.5 0.5 9.0 83.8 49.3 2.3 47.1 802 Completed Secondary/Higher 0.9 0.5 7.0 87.2 54.9 2.0 33.0 1,414 Work Status Working for Cash 1.9 0.9 9.4 82.1 47.0 2.1 36.5 984 Working, Rot Paid in Cash 4.3 2.8 12.8 59.1 35.3 2.7 58.4 650 Not Workit~3 5.3 2.6 11.6 ~. I 40.5 2.5 48.5 6,448 Interested in Work 2.9 1.5 10.0 73.3 47.6 2.4 55.3 1,938 Not Interestc~d in Work 6.4 3.1 12.3 63.0 37.5 2.6 43.4 4,510 Total 4.8 2.4 11.4 67.4 40.9 2.5 46.6 8,082 (I) Catcutats~d only for women giving numeric responses The mean preferred family size before use is initiated is 3.1 children among these women compared to 2.6 children for women from rural areas in Lower Egypt. Somewhat surprisingly, women from rural Upper Egypt are not more negative than women from urban areas regarding the acceptability of sterilization, although they are less likely to think sterilization is acceptable than women from rural Lower Egypt. 61 Figure 4.2 Percent of Wives and Husbands Disapproving of Family Planning by Place of Residence Percent of CMW* Who Know a Contracept ive Method 40 30 20 10 0 :i : :: i i i'::i iiii iii:,i ~i Urban Governorates Lower Egypt Lower Egypt Upper Egypt Upper Egypt Urban Rural Urban Rural RESIDENCE Wife and Husband • Currently married women Wife Only ~ Husband Only I Egypt DHS 1988 4.3 EXPOSURE TO MASS MEDIA AND FAMILY PLANNING MESSAGES Activities designed to inform and educate couples about the use of contraception are a major component of the Egyptian family planning program. To help design and evaluate one aspect of these activities, the EDHS obtained information on the overall coverage of broadcast (radio and television) media and the exposure of women to family planning messages through those media. Table 4.10 suggests that television has wider coverage of the female population than does radio; three in four currently married women say that they watch television every day, while only around one in two say that they listen to the radio daily. As might be expected given the wider coverage of television, family planning messages broadcast on the television are more successful in reaching an audience than radio messages; fewer than one in three women listened to a family planning message on the radio in the month before the survey compared to two in three women who reported seeing a message on television. Exposure to family planning messages varies according to age, residence, educational level and work status. Of concern is the more limited exposure to family planning messages reported for rural women, particularly those from Upper Egypt, than for other groups. For example, only 54 percent of rural women had watched a television broadcast about family planning in the month before the survey compared to 84 percent of urban 62 Table 4.10 Among Currently Married Women, Percent Watching Television or Listening to the Radio Daily and Percent Exposed to a Family Planning Message on the Television or Redio During the Month Before the Survey, by Selected Background Characteristics, Egypt DBS, 1988 Usually Exposed to Family Listens Usually Planning Message on: Number Background to Watches of Characteristic Radio Television Radio Television Women Age 15-19 53.6 68.5 24.9 59.9 416 20-24 59.2 75.0 35.0 68.7 1,369 25-29 57.5 77.4 35.1 70.4 1,607 30-34 56.7 78.5 33.3 73.5 1,473 35-39 53.6 73.9 30.7 68.9 1,470 40-44 51.3 76.5 30.9 67.7 1,042 45-49 51.5 71.8 27.6 62.3 844 Urban-Rural Residence Urban 66.2 86.7 41.8 84.3 4,006 Rural 45.0 64.7 23.0 53.9 4,215 Place of Residence Urban Governorates 66.3 89.1 40.2 86.5 1,996 Lower Egypt 53.0 73.8 34.8 65.7 3,230 Urban 67.5 85.8 49.7 83.8 952 Rural 46.9 68.8 28.6 58.1 2,278 Upper Egypt 50.6 68.1 23.9 60.1 2 ,~5 Urban (#+.8 82.9 37.8 80.8 1,058 Rural 42.8 60.0 16.4 48.9 1,937 Education Level No Education 44.4 65.6 22.4 55.8 4,105 Less than Primary 56.1 79.0 32.5 72.5 1,895 Primary through Secondary 69.2 89.6 44.7 85.9 804 Completed Secondary/Higher 78.3 91.2 52.9 91.2 1,417 Work Status Working for Cash 68.7 85.3 43.8 83.7 985 Working, Rot Paid in Cash 40.8 65.4 18.0 51.4 657 Not Working 54.8 74.9 31.8 68.2 6,579 Interested in Work 60.1 80.5 36.8 73.0 1,960 Rot Interested in Work 52.5 72.6 29.7 66.1 4,619 Total 55.3 75.4 32.2 68.7 8,221 women. Among women in rural areas in Upper Egypt, less than 50 percent had seen a family planning message on television (Figure 4.3). Much, but not all, of the more limited exposure to family planning messages m rural areas may be due to the fact that women from these areas are much less likely than women from other areas to report watching television or listening to the radio on a daily basis (Figure 4.4). Only 65 percent of rural women report that they watch television every day compared to nearly 90 percent of urban women. Among those watching television 63 100 Figure 4.3 . . . . Exposure to Family Planning Broadcasts by Place of Residence Percent of Currently Married Women 80 60 40 20 0 Urban Lower Egypt Lower Egypt Upper Egypt Upper Egypt Governorate8 Urban Rural Urban Rural RESIDENCE I Saw on TV ~ Heard on Radio / I Egypt DHS 1988 Figure 4.4 Exposure to Broadcast Media by Place of Residence Percent of Currently Married Women Urban Governorate8 Lower Egypt Lower Egypt Upper Egypt Upper Egypt Urban Rural Urban Rural RESIDENCE I Watch TV ~ Listen to Radio I I Egypt DHS 1988 64 regularly~ 83 percent of rural women had seen a family planning message compared to 97 percent of urban women. Thus, it seems likely that as coverage of the rural population by television expands, differentials in exposure to family planning messages will narrow. However, it is clear that alternate means of informing and educating rural women who are not regularly exposed to media messages on family planning must be considered, especially to reach rural women in Upper Egypt. 65 Chapter 5 EVER USE OF FAMILY PLANNING The EDHS collected information on the level of ever use of family planning and on patterns of method adoption including the first method used, the provider from which the first method used was obtained and the motivation for adopting family planning at the time of first use (i.e., to limit or space). Roles of the husband and wife in deciding to use family planning are also investigated. Finally, information on reasons for discontinuing use was obtained in order to provide insights into factors which lead women to stop using after they have adopted a method. 5.1 EVER USE OF FAMILY PLANNING Levels and Trends The EDHS findings indicate that 57 percent of ever-married women (60 percent of currently married women) have used a contraceptive method at some time (Table 5.1). Overall, modern methods are much more frequently adopted than traditional methods; 56 percent of ever-married women have used a modern method, while only 11 percent have used a traditional method. The pill is the most widely adopted modern method. Around one-half of ever-married women have used the pill, compared with only one in four who have used the IUD and fewer than one in ten have tried the condom. Five percent or less report ever use of other modern methods (injection, vaginal methods and female sterilization). Prolonged breastfeeding, the most widely adopted traditional method, has been used by only six percent of ever-married women. Across age groups, the highest level of ever use is observed for women 35-39 (70 percent), and the lowest level is recorded for women 15-19 (12 percent). In every age cohort, the pill is the most frequently adopted method. Older women are, however, more likely than younger women to have experience with other modern methods, particularly the IUD. Older women are also more likely than younger women to have used traditional methods. Comparing EDHS with ECPS findings, the level of ever use has increased by almost 20 percent, from 48 percent in 1984 to the present rate of 57 percent (Table 5.2). By method, the greatest increase over the period was registered for the IUD. One in four ever-married women had used the IUD at the time of the EDHS compared to fewer than one in six women in 1984 (Figure 5.1). The absolute increase in the percent ever using the pill was only about half that observed for the IUD. 67 O0 Table 5.1 Percent of Ever-married Women and Current ly Married Women Who Have Ever Used a Contraceptive Method by Nethod, According to Age, Egypt DHS, 1988 Any Pro- An), S ter i l i za t ion Tredi- Safe With- longed Nunloer Any Modern ln jec- Vagi- Con- t iona l Peri- draw- Breast- of Age Methed Method P i l l 1~ t ion hatS dom Female Male Methed ed at feeding Other ~o~ Ever-married Women 15-19 11.8 11.3 8.6 3.2 0.0 0.0 0.9 0.0 0.0 0.8 0.3 0.0 0.5 0.0 42Z 20-24 38.4 36.3 26.9 14.7 0.9 1.0 4.1 0.1 0.0 6.1 1.2 1.1 4.5 0.0 1,417 25-29 57.8 56.0 42.2 27.2 2.3 4.1 8.0 0.4 0.0 10.1 3.3 2.6 5.1 0.6 1,669 30-34 67.8 66.0 53.3 32.9 3.4 7.5 11.9 0.8 0.0 13.2 5.2 3.0 7.5 0.6 1,557 35-39 70.2 69.4 59.2 33.0 3.2 7.4 11.2 1.9 0.0 14.6 5.2 3.2 8.1 1.3 1,605 40-44 65.8 ~.5 56.9 30.0 3.3 7.7 11.6 4.1 0.0 14.8 5.1 3.0 8.3 1.5 1,207 45-49 56.0 54.6 48.7 19.7 1.4 5.5 6.5 3.5 0.2 13.6 3.4 2.1 8.2 1.7 1,0:54 Total 57.4 55.9 46.0 25.6 2.3 5.3 8.6 1.5 0.0 11.4 3.7 2.4 6.5 0.8 8,911 Current ly Married women Total 59.5 58.0 47.5 27.0 2.5 5.6 9.1 1.5 0.0 11.9 4.0 2.6 6.7 0.8 8,221 15-19 12.0 11.5 8.7 3.2 0.0 0.0 0.9 0.0 0.0 0.8 0.3 0.0 0.5 0.0 416 20-24 39.2 37.2 27.6 15.2 1.0 1.1 4.2 0.1 0.0 6.2 1.2 1.1 4.6 0.0 1,369 25-29 59.1 57.4 43.1 28.1 2.4 4.2 8.2 0.4 0.0 10.4 3.3 2.6 5.3 0.6 1,007 30-34 70.0 68.3 55.1 34.3 3.6 7.8 12.3 0.8 0.0 13.8 5.4 3.1 7.8 0.6 1,473 35-39 73.1 ~.3 61.9 34.8 3.5 8.0 12.0 1.9 0.0 15.5 5.7 3.5 8.4 1.4 I, 4"/'0 40-44 70.0 68;7 60.5 32.7 3.6 8.5 13.1 4.4 0.0 15.9 5.8 3.4 8.5 1.7 1,042 45-49 61.1 59.8 53.1 22.6 1.5 6.3 7.7 3.8 0.2 14.8 4.1 2.5 9.0 1.5 844 Table 5.2 Percent of Ever-married Women Who Have Ever Used a Contraceptive Method by Method, Egypt DHS, 1988, and CPS, 1984 Method ~ EDHS ECPS 1988 1984(1) Any Method 57,4 48.2 'Any Modern Method 55.9 46.7 Pi t t 46.0 41.0 IUO 25.6 14.8 Injection 2.3 1.1 VagLnet Methods 5.3 3.9 Cond~n 8~6 3.4 Female Ster i l i zat ion 1.5 1.4 Male Ster i l i zat ion 0.0 0.0 Any Traditional Method 11.4 5.3 Safe Period 3.7 1.4 Withdrawal 2.4, 1.0 Prolonged Breastfeeding 6.5 3.1 Other Methods 0.8 0.5 Number of Women 8,911 10,013 (1) Sayed et at . , 1985, Table 8 . ] Figure 5.1 Ever Use of Contraception by Method, 1984 and 1988 Percent of Ever-married Women 60 40 20 Any Pill Modern Method METHOD l m1984 ~1988 IUD Egypt OHS 1988 69 Differentials in Ever Use An Egyptian woman is most likely to have used a family planning method if she lives in an urban area, especially one of the Urban Governorates, has had some secondary education or is employed at a job for which she is paid in cash. The differentials in ever- use between these women and their rural, less educated, non-employed counterparts are presented in Table 5.3. Not only are urban women, educated women and women holding Table 5.3 Amor~;; Ever-married Wo~en, Percent Who Have Ever Used a Contraceptive Method ancl, Among Ever-users, Percent D is t r ibut ion by Nu~iDer of Hetheds Used and Mean Hur~ber of Metheds Usecl, According to Selected Background Character ist ics , Egypt DHS, 1988 Ever-~ers: Percent Ever Using Hurt/oar of Netheds Used Any Family Nean Number gackgrour~ PLanning 3 or Total Ncmber of Character ist ic Method 1 2 More Percent Used Women Age 15-19 11.8 85.8 14.2 O.O 100.0 1.1 422 20-24 38.4 67.9 24.2 7.9 100.0 1.4 1,417 25-29 57.8 55.5 30.4 14.2 100.0 1.7 1,669 30-34 67.8 47.2 31.9 20.9 100.0 1.9 1,557 35-39 70.3 46.4 30.7 22.9 100.0 1.9 1,605 40-44 65.9 39.3 35.9 24.9 100.0 2.0 1,207 45-49 56.1 49.0 32.3 18.7 100.0 1.8 1,034 Urban-Rural Residence Urban 75.2 42.5 33.3 24.3 100.0 2.0 4,305 Rural 40.8 63.3 27.2 9.6 100.0 1.5 4,606 Place of Residence Urban governorates 79.6 37.1 34.2 28.7 100.0 2.1 2,141 Lower Egypt 61.4 55.8 30.9 13.3 100.0 1.6 3,505 Urban 76.8 49.1 32.7 18.2 100.0 1.8 1,019 Rural 55.1 59.6 29.9 10.5 100.0 1.5 2 ,4~ Upper Egypt 38.6 58.0 26.9 15.1 100.0 1.6 3,265 Urban 65.4 47.7 31.8 20.5 100.0 1.8 1,145 Rural 24.1 ?3.2 19.8 7.0 100.0 1.4 2,120 Education Level No Education 45.3 58.7 29.9 11.4 100.0 1.6 4,531 Less than Primary 64.9 51.7 31.6 16.7 100.0 1.7 2,058 Primary through Secoc~clary 74.6 36.8 36.0 27.2 100.0 2.1 859 COalpleted Secondary/Higher 74.0 40.0 29.4 30.6 100.0 2.1 1,463 Work Status Working for Cash 71.9 40.1 30.5 L:~.3 100.0 2.1 1,109 gorking, Not Paid in Cash 51.7 60.3 30.3 9.4 100.0 1.5 694 got Working 55.7 51.2 31.2 17.6 100.0 1.8 7,108 Interestecl in Work 60.8 49.5 29.2 21.3 100.0 1.8 2,155 Not Interested in Work 53.5 52.1 32.2 15.8 100.0 1.7 4,953 Total 57.4 50.1 31.0 18.9 100.0 1.8 8,911 70 80 60 Figure 5.2 Ever Use of Contraception by Place of Residence Percent of Ever-married Women 40 20 Urban Governorates Urban Lower Egypt Lower Egypt Upper Egypt Upper Egypt Rural Urban Rural RESIDENCE ~m One Method ~ Two or More Methods j Egypt DHS 1988 jobs more likely to have tried a contraceptive method, but those who are ever-users are more likely than other women to have experience with more than one method. For example, more than one-half of urban women have tried two or more methods compared to only one in three rural women. Variations by place of residence are also striking (Figure 5.2). While almost two-thirds of ever-users living in the Urban Governorates have used at least two methods, only one-quarter of ever-users from rural Upper Egypt have tried more than one method. 5.2 FIRST USE OF CONTRACEPTION The Egypt DHS included questions on the first method ever used, the timing of the adoption of the method and the source from which the method was obtained. These data provide useful insights into the motivation women have when they first begin using contraception. They also enable an examination of cohort changes in the timing of adoption in order to identify any trend toward earlier adoption of more effective methods. First Method Used For most women, family planning experience begins with adoption of the pill. Table 5.4 shows that, among ever-users, 70 percent started practicing family planning by 71 Table 5.4 Percent Distribution of Ever-users by First Nethod Used, According to Selected Background Characteristics, Egypt OHS, 1988 Number 8ackground other Tradi- Totat of Ever- Characterist ic Pitt iUD Nodern tionat Percent users Age 15-19 65.3 24.9 5.3 4.4 100.0 50 20-24 62.9 22.4 7.1 7.7 100.0 544 25-29 64.0 23.3 8.2 4.5 100.0 964 30-34 68.1 19.8 6.9 5.1 100.0 1,055 35-39 74.5 16.0 4.5 5.0 100.0 1,128 40-44 77.7 12.5 5.9 3.9 100,0 795 45-49 75.6 11.7 5.1 7.5 100.0 580 Urban-Rural Residence Urban 66.7 20.6 6.6 6.1 100,0 3,235 Rural 77.0 13.3 5.7 4.0 100,0 1,881 Place of Residence Urban Governorates 62.2 22.7 6.8 8.2 100,0 1,704 LOWer Egypt 75.3 15.4 5.2 4.0 100.0 2,153 Urban 74.6 15.7 5.8 3.9 100,0 782 Rural 75.8 15.3 4.8 4.1 100,0 1,371 Upper Egypt 73.4 15.6 7.4 3.7 100,0 1,259 Urban 68.7 20.8 7,0 5.6 100.0 749 Rural 80.4 7.9 7,9 5.9 100.0 510 Education Level NO Education 75.6 14.7 4,3 5.4 100.0 2,055 Less than Primary 75.9 15.2 4,6 4.3 100.0 1,336 Primary through Secondary 70.8 19.5 5,1 4.6 100.0 640 completed Secondary/Higher 53.9 26.2 12.8 7.0 100.0 1,083 Work Status Working for Cash 60.9 23.6 9,6 5.9 100.0 797 Working, Not Paid in Cash 71.3 17.1 3,9 7.7 100.0 359 Not Working 72.4 16.8 5.8 5.0 100.0 3,960 Interested in Work 71.2 16.8 6.6 5.3 100.0 1,311 Not Interested in Work 72.9 16.8 5.4 4.8 100.0 2,649 Total 70.5 17.9 6.3 5.3 100.0 5,116 using the pill, while 18 percent chose the IUD for their first method, six percent first adopted other modern methods and five percent began contracepting with a traditional method. Although the majority of ever-users in all subgroups report that the first method adopted was the pill, younger users are somewhat more likely to have begun family planning use with the IUD than older women (Figure 5.3). This may reflect the increasing popularity of the IUD as a method in recent periods when younger women first began to use contraception (see Chapter 6). Rural users are somewhat more likely than urban users to have started family planning use with the pill (77 percent vs. 67 percent) and less likely to have initiated use 72 100 80 60 40 20 0 Figure 5.3 First Contraceptive Method Used by Current Age Percent of Women Who Ever Used Contraception 15-19 20-24 25-29 30-34 35-39 40-44 45-49 AGE [ "P i l l ~ IUD ~ Other Modern ~Tradit ional i Egypt DHS 1988 with the IUD (13 percent vs. 21 percent). Rural women from Upper Egypt stand out as least likely to have begun family planning use by adopting the IUD. Only eight percent of ever-users in rural Upper Egypt adopted the IUD as their first method compared to 15 percent of ever-users in rural Lower Egypt. A woman's educational level is closely associated with the method she adopts when she begins using. Although the majority of women in every educational category began use with the pill, the more highly educated the woman the more likely she is to chose the IUD or some other modern method as her first method. Table 5.4 also shows that women in paid employment are somewhat more likely than other women to adopt the IUD as the first method. Source for the First Method The source from which ever-users first obtained a method is examined in Table 5.5. Private sector sources (pharmacy and private doctor) are clearly the major providers of the first method. For two in three ever-users, the pharmacy was the source for the first method used, and, for one in ten, private doctors provided the first method that the woman used. Government facilities (FP clinics, MCH centers and hospitals) were the source for the first method for one in four ever-users. The service provider used initially by ever-users varies according to the method the user first adopted (Table 5.5). Ever-users adopting the pill as the first method generally 73 relied on pharmacies for their supply, with government facilities the second most widely used source (75 percent and 22 percent, respec- tively). Among those initiating use with the IUD, 46 percent reported the IUD was inserted by a private doctor, while public sector providers were the source for most of the remaining IUD users (42 percent). Around 10 percent of IUD users reported obtaining the IUD at a pharmacy prior to insertion. Number of Children at First Use of Contraception Table 5.5 Percent Distribution of Ever-users of Modern Methods by the Source for the Method First Used, Egypt DHS, 1988 Any Source for Other Modern First Method Pi l l IUD Modern Method Government Faci l i ty( I ) 22.2 41.9 10.8 23.6 Private Doctor/Clinic 1.4 46.2 6.4 10.2 Pharmacy 75.5 9.5 79.5 63.3 Other 2.7 2.2 3.0 2.6 Not Sure 0.3 0.2 0.3 0.3 Total Percent 100.0 100.0 100.0 100.0 Number of Ever-users 3,606 916 321 4,843 (1) Includes FP c l in i c , MC½ center and hospital Table 5.6 shows the percent distribution of ever-married women by the number of living children at the time of first use of contraception and the woman's current age. The results indicate that Egyptian women are adopting contraception at a fairly early stage in the family building process although almost none begin to use immediately after marriage in order to delay the first birth. Overall, one-third of all ever-users (20 percent of ever- married women) began using family planning when they had one child, and an additional one-quarter (13 percent of ever-married women) started when they had only two children. Clearly, there has been a downward trend over time in the parity at which women first Table 5.6 Percent Distribution of Ever-married Women by Number of Living Children at Time of First Use of Contraception, According to Current Age, Egypt DHS, 1988 Number of Living Children Number Never 5 or Total of Age Used None 1 2 3 4 More Percent Women 15-19 88.2 1.3 8.9 1.6 0.0 0.0 0.0 100.0 422 20-24 61.6 1.1 23.8 10.7 2.3 0.5 0.0 100.0 1,417 25-29 42.2 1.9 25.4 16.4 8.4 4.0 1.6 100.0 1,669 30-34 32.2 1.8 26.4 17.3 9.7 7.1 5.5 100.0 1,557 35-39 29.7 1.3 19.0 14.8 12.1 9.5 13.6 100.0 1,605 40-44 34.2 1.0 13.5 13.0 11.3 10.7 16.3 100.0 1,207 45-49 44.0 0.7 7.7 8.9 11.1 9.4 18.3 100.0 1,036 Total 42.6 1.4 19.7 13.3 8.6 6.3 8.1 100.0 8,911 74 Table 5.7 Percent Distribution of Ever-users by Number of Living Children st Time of First Use of Contraception, According to Selected Rackgro~Jnd Characteristics, Egypt DHS, 1988 Background Characteristic Number of LivirH| Children N~r of 5 or Total Mean Ever- No~ 1 2 3 4 More Percent Number users Urban-Rural Residence Urban 3.1 42.5 24.6 13.3 8.1 8.4 100.0 2.1 3,235 Rural 1.1 20.2 20.9 18.0 15.9 23.8 100.0 3.3 1,881 Place of Residence Urban Governorates 3.7 45.9 23.7 13.1 6.8 6.8 100.0 2.0 1,704 Lower Egypt 1.5 28.9 23.0 17.0 13.0 16.6 100.0 2.8 2,153 Urban 1.9 42.4 26.1 14.3 8.1 7.2 100.0 2.1 782 Rural 1.2 21.3 21.2 10.5 15.8 21.9 100.0 3.2 1,371 Upper Egypt 2.2 27.9 22.9 14.2 13.2 19.4 100.0 2.9 1,259 Urban 3.1 35.2 24.8 12.7 11.2 13.0 100.0 2.4 749 Rural 0.9 17.3 20.1 16.6 16.2 28.8 100.0 3.5 510 Education Level NO Education 1.2 18.5 21.7 18.1 15.5 24.9 100.0 3.3 2,057 Less than Primary 1.4 29.1 25.1 18.0 13.8 12.7 100.0 2.6 1,336 Primary through Secor~tary 1.4 44.5 26.3 16.5 6.4 4.8 100.0 2.0 640 Completed Secondary/Higher 6.4 64.9 21.9 4.6 1.7 0.4 100.0 1.3 1,083 Work Status Working for Cash 4.7 55.8 24.0 6.4 5.5 3.7 100.0 1.7 797 Working, Not Paid in Cash 2.2 17.1 17.3 16.8 16.8 29.7 100.0 3.5 359 Mot Working 1.9 31.6 23.6 16 .6 11 .5 14.7 100.0 2.6 3,960 Interested in Work 2.7 38.1 23.1 15.8 10.4 9.8 100.0 2.3 1,311 Rot Interested in Work 1.6 28.4 23.8 17.0 12.1 17.1 100.0 2.8 2,649 Total 2.4 34.4 23.2 15.0 11.0 14.0 100.0 2.5 5,116 adopt family planning, with younger users initiating use at lower parities than older women. Among ever-users, the proportion adopting when they had one child increased from less than 14 percent among women 45-49 to 44 percent among ever-users 25-29. Table 5.7 presents differentials in the number of living children at time of first use of contraception. Urban ever-users begin using at much lower parities than rural ever- users; for example, nearly 43 percent of urban ever-users initiated contraceptive use when they had only one child, compared with only 20 percent of rural ever-users. Education exhibits an inverse association with the timing of first use. Reproductive Intention at First Use of Contraception The EDHS questionnaire also obtained information on a woman's childbearing intentions at the time contraception was first used in order to investigate the extent of interest in limiting or spacing births. Overall, ever-users are divided almost equally into 75 Table 5.8 Percent Distr ibut ion of Ever-users by Reproductive Intent ion at Time of F irst Use of Contraception, According to Number of Living Children at Time of First Use of Contraception, Egypt OHS, 1988 Number of Living Children Reproductive 5 or Intention gone 1 2 3 4 Hore Total Wanted Child Later 89.4 86.7 47.6 26.0 13.6 4.2 48.9 Did not Want Child 9.7 13.1 51.9 74.8 86.2 95.5 50.8 Other 0.0 0.2 0.7 0.0 0.0 0.3 0.3 Hissing 0.9 0.0 0.0 O.O O.O 0.0 O.O Total Percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of Ever-users 122 1,757 1,188 768 563 718 5,116 those who began using to delay the next birth and those who initiated use because they wanted no more children. Table 5.8 shows that nearly 90 percent of ever-users who began using before they had two children were interested in spacing the next birth. Ever- users initiating use when they had two children are divided between limiters and spacers, while the majority of ever-users starting contraceptive use at parity three or higher want to limit births (Figure 5.4). 100 80 60 40 20 0 Figure 5.4 Reproductive Intention at the Time of First Use of Contraception by Number of Living Children at the Time of First Use Percent of Women Who Ever Used Cont racept ion None 1 2 3 4 NUMBER OF L IV ING CHILDREN m Wanted to Space ~ Wanted to L imi t 5 i Egypt DHS 1988 76 Table 5.9 shows that there is little relationship between the method ever- users adopt and their motivation for using a method. Although the pill is more appropriate for spacing than for limiting (because of the need for resupply), ever- users adopting the pill as the first method are as likely as ever-users adopting the IUD to say that they wanted to limit when they first began using. To some extent, this Table 5.9 Percent Distribution of Ever-users by Reproductive Intention at Time of First Use of Contraception, According to Method First Used, Egypt DHS, 1988 Any Reproductive Other Trodi- Modern Intention P i l l l~ Modern t ionat Method Wanted Child Later 46.8 48.4 53.9 72.1 48.9 Did not Want Child 53.0 50.8 45.4 27.9 50.8 Other 0.2 0.7 0.3 0.0 0.3 Hissing 0.0 0.1 0.3 0.0 0.0 Total Percent 100.0 100.0 100.0 100.0 100.0 Number of Ever-users 3,606 916 321 273 5,116 simply reflects the past dominance of the pill in the method mix among users in Egypt; a woman adopting a method in the past, no matter what her motivation, was likely to have begun use with the pill. Ever-users initiating use with traditional methods usually are intending to space rather than limit births. 5.3 FAMILY PI.,ANNING DECISION-MAKING Another area of investigation in the EDHS was the nature of the process of making the decision to use family planning. To obtain information on this topic, ever-users were asked if they had talked about using family planning with their husband before deciding to use and whether they felt that the use of family planning for the first time was mainly their idea, their husband's idea or a joint decision. Women were also asked whether they had talked about using family planning with other persons beside their husband before making the decision to use. Similar questions were asked about the choice of the method first adopted. The responses to these questions provide insights into the perceptions of ever-users as to the persons influencing the decision to use family planning. The results are, however, subject to recall problems, particularly among older ever-users who may have made the decision to adopt family planning years before the EDHS interview. Ever-users may also tend to provide responses that are in keeping with cultural norms (e.g., with respect to the husband's role) rather than reflecting the actual process of decision-making. These problems must be kept in mind in considering the information on family planning decision-making presented below. Decision to Use Family Planning Table 5.10 summarizes the information concerning the persons whom ever-users reported that they consulted prior to the decision to adopt family planning and on the role 77 Table 5.10 Among Ever-users, Percent Discussing Decision to Use Family PLanning With the Husband, a Female Relat ive or a Doctor, and Percent Reporting the Decision to Use Was Mainly the Wife's idea, the Husbandas Idea or a Joint Decision, According to Selected Background Character ist ics, Egypt DHS, 1988 Persons Consulted Main Decisionmaker Female Number Background Hus- Rela- Doc- HUS- of Ever- Character is t ic band t

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