Egypt - Demographic and Health Survey - 1993

Publication date: 1993

Egypt Demographic and Health Survey 1992 National Population Council ~DHS Demograbhic and Health Surveys Macro International Inc. Egypt Demographic and Health Survey 1992 Fatma H. EI-Zanaty Hussein A. A. Sayed Hassan H. M. Zaky Ann A. Way National Population Council Cairo, Egypt Macro International inc, Calverton, Maryland USA November 1993 This report summarizes the findings of the 1992 Egypt Demographic and Health Survey (EDHS) conducted by the National Population Council. Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development (USAID). The EDHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information about the Egypt survey may be obtained from the National Population Council, P.O. Box 1036, Cairo, Egypt (Telephone 3638207; Fax 3639818; and Telex 94086 USRAH CAIRO). Additional information about the DHS program may be obtained by writing to: DHS, Macro International Inc., 11785 BeltsviUe Drive, Calverton, MD 20705 (Telephone 301-572-0200 and Fax 301- 572-0999). CONTENTS Page Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii Map of Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi CHAPTER 1 I.I 1.2 1.3 1.4 1.5 1.6 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Demographic and Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Socioeconomic Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Population Policy and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Health Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Objectives and Organization of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 CHAPTER 2 2.1 2.2 2.3 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Characteristics of the Household Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Household Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Background Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 CHAPTER 3 3.1 3.2 3.3 3.4 3.5 FERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Teenage Pregnancy and Motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 CHAPTER 4 4.1 4.2 4.3 4,4 4.5 KNOWLEDGE, ATTITUDES, AND EVER USE OF FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Knowledge of Family Planning Methods and Source . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Exposure to Family Planning Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Attitudinal Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Ever Use of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 First Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 iii CHAPTER 5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Page CURRENT USE OF FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Levels and Differentials in Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . 67 Trends in Current Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Trends in Current Use of Family Planning by Residence . . . . . . . . . . . . . . . . . . . . . . . 73 Reasons for Choosing Current Method of Family Planning . . . . . . . . . . . . . . . . . . . . 76 Problems with Current Method of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Sources for Modem Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Accessibil ity of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 CHAPTER 6 6.1 6.2 USE OFTHE PILL AND IUD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Pill Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 IUD Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 CHAPTER 7 7.1 7.2 7.3 7.4 7.5 NONUSE OF FAMILY PLANNING AND INTENTION TO USE . . . . . . . . . . . . . . 95 Discontinuation Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Reasons for Discontinuing Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Future U~ of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Reasons for Nonuse of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Preferred Methods of Family Planning among Nonusers . . . . . . . . . . . . . . . . . . . . . . . 99 CHAPTER 8 8.1 8.2 8.3 8A FERTIL ITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Desire for More Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Ideal and Actual Number of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Fertility Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 CHAPTER 9 9.1 9.2 9.3 9.4 9.5 9.6 PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . 111 Current Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Marital Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Marriage between Relatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Postpartum Amenorrhea, Abstinence and Insusceptibility . . . . . . . . . . . . . . . . . . . . . 117 Termination of Exposure to Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 CHAPTER 10 10.1 10.2 10.3 10.4 10.5 INFANT AND CHILD MORTAL ITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Assessment of Dala Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Levels and Trends in Infant and Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Socioeconomic Differentials in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Demographic Differentials in Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 iv CHAPTER 11 11.1 11.2 11.3 11.4 Page MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Nature of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Immunization of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Childhood Illness and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 CHAPTER 12 12.1 12.2 12.3 INFANT FEEDING AND MATERNAL AND CHILD NUTRIT ION . . . . . . . . . . . 149 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Nutritional Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Nutritional Status of Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 CHAPTER 13 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 13.9 13.10 13.11 HUSBANDS' SURVEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Husbands' Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Background Characteristics of Husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Comparison between Characteristics of Husbands and Wives . . . . . . . . . . . . . . . . . . 165 Knowledge o f Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Differentials in Knowledge and Use of Family Planning . . . . . . . . . . . . . . . . . . . . . . 171 Intention to Use Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Attitudes about Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Fertility Desires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Wife 's Status in the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Typical Family Expenditure and Wife 's Contribution to the Household Budget . . . . 185 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 APPENDIX A SURVEY STAFF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 APPENDIX B B.I B.2 B.3 B.4 B.5 SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Sample Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Sample Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Sample Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Results of Sample Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 APPENDIX C ESTIMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 APPENDIX D DATA QUAL ITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 APPENDIX E QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 V Table 1.1 Table 1.2 Table 2.1 Table 2.2 Table 2.3 Table 2.4.1 Table 2.4.2 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 TABLES Page Survey timetable, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Results of the household and individual interviews . . . . . . . . . . . . . . . . . . . . . . 13 Household population by age, residence and sex . . . . . . . . . . . . . . . . . . . . . . . 15 Population by age, 1988 and •992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Educational level of the male household population . . . . . . . . . . . . . . . . . . . . . 18 Educational level of the female household population . . . . . . . . . . . . . . . . . . . . 19 School enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Access to mass media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Trends in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Teenage pregnancy and motherhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 vii Table 3.11 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Children bom to teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Knowledge of family planning methods and source for methods . . . . . . . . . . . . 46 Trends in knowledge of family planning methods and source . . . . . . . . . . . . . . . 47 Knowledge of family planning methods and source for methods by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 First source of family planning information . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Sources influencing women to seek information about family planning . . . . . . . . 51 Exposure to family planning messages on radio and television . . . . . . . . . . . . . . 52 Exposure to family planning messages through print media/community meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Attitudes toward family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Belief that religion allows or forbids family planning . . . . . . . . . . . . . . . . . . . . 57 Approval of use of specific family planning methods . . . . . . . . . . . . . . . . . . . . 57 Ever use of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Trends in ever use of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . 59 Ever use of family planning methods by background characteristics . . . . . . . . . . 61 First method used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Source of first method used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Number of children at first use of family planning . . . . . . . . . . . . . . . . . . . . . . 65 Reproductive intentions at time of first use of family planning . . . . . . . . . . . . . . 66 Current use of family planning by residence . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Current use of family planning by method . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Trends in current use of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Trends in the family planning method mix . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Trends in current use of family planning by residence . . . . . . . . . . . . . . . . . . . . 74 Current use of family planning by govcmorate . . . . . . . . . . . . . . . . . . . . . . . . . 75 viii Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 5.11 Table 5.12 Table 5.13 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 6.9 Table 6.10 Table 6.11 Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 8.1 Page Reasons for choosing current method of family planning . . . . . . . . . . . . . . . . . . 77 Problems with current method of family planning . . . . . . . . . . . . . . . . . . . . . . . 78 Sources for modem family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Trends in the sources of family planning methods . . . . . . . . . . . . . . . . . . . . . . 81 Sources of family planning methods by residence . . . . . . . . . . . . . . . . . . . . . . . 82 Reasons for choosing current source of family planning methods . . . . . . . . . . . . 83 Time to source of supply for modem family planning methods . . . . . . . . . . . . . 84 Quality of pill usc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Action taken if forgot to take the pill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Use of social marketing brand pill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Cost of method for pill users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Amount willing to pay for pills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Cost of consultation for pill users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Information received at pharmacies about the pill . . . . . . . . . . . . . . . . . . . . . . . 90 Service delivery indicators for pill users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Cost of method for IUD users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Amount willing to pay lot 1UD insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Service delivery indicators for IUD users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Reasons for discontinuing usc of family planning . . . . . . . . . . . . . . . . . . . . . . . 96 Future use of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Reasons for not using family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Preferred method of family planning for future use . . . . . . . . . . . . . . . . . . . . . 100 Fertility prcfcrcnccs by number of l iving children . . . . . . . . . . . . . . . . . . . . . . 101 ix Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Table 8.7 Table 8.8 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Table 9.7 Table 9.8 Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Page Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Mean ideal number of children by background characteristics . . . . . . . . . . . . . 108 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Marital exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Consanguinity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Postpartum amenorrhea, abstinence and insusceptibility . . . . . . . . . . . . . . . . . . 117 Median duration of postpartum insusceptibility by background characteristics . . 119 Termination of exposure to the risk of pregnancy . . . . . . . . . . . . . . . . . . . . . . 120 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Trend in infant mortality, 195(I-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Infant and child mortality by background characteristics . . . . . . . . . . . . . . . . . 124 Infant and child mortality by demographic characteristics . . . . . . . . . . . . . . . . 126 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . . . . . . . . 131 Tetanus toxoid vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Table 11.5 Table 11.6 Table 11.7 Table 11.8 Table 11.9 Table 11.10 Table 11.11 Table 11.12 Table 11.13 Table 11.14 Table 12.1 Table 12.2 Table 12.3 Table 12.4 Table 12.5 Table 12.6 Table 12.7 Table 12.8 Table 13.1 Table 13.2 Table 13.3 Table 13.4 Table 13.5 Table 13.6 Page Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Characteristics of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Vaccinations by source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Vaccinations in the first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Prevalence and treatment of acute respiratory infection . . . . . . . . . . . . . . . . . . 142 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Knowledge and use of ORS packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Feeding practices during diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Breastfeeding and supplementation by age . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Median duration and I~'cquency of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . 154 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . 156 Nutritional status by socioeconomic characteristics . . . . . . . . . . . . . . . . . . . . . 157 Anthropometric indicators of maternal nutritional status . . . . . . . . . . . . . . . . . 159 Differentials in maternal anthropometric indicators . . . . . . . . . . . . . . . . . . . . . 160 Husbands' background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Husbands' level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Husbands' access to mass media by background characteristics . . . . . . . . . . . . 164 Couples' age difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Couples' level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Husbands' knowledge of family planning methods and source for methods . . . . 167 xi Table 13.7 Table 13.8 Table 13.9 Table 13.10 Table 13.11 Table 13.12 Table 13.13 Table 13.14 Table 13.15 Table 13.16 Table 13.17 Table 13.18 Table 13.19 Table 13.2(I Table 13.21 Table 13.22 Table 13.23 Table 13.24 Table 13.25 Table 13.26 Table 13.27 Table 13.28 Page Husbands' f i~t source of family planning information . . . . . . . . . . . . . . . . . . 168 Husbands' exposure to media messages about family planning . . . . . . . . . . . . . 169 Husbands' use of family planning methods . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Ever use of family planning among couples . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Current use of family planning among couples . . . . . . . . . . . . . . . . . . . . . . . . 171 Husbands' knowledge and use of family planning methods by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Husbands' future use of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Husbands' reasons for nonusc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Husbands' approval of family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Wives' perceptions of husband's approval of family planning . . . . . . . . . . . . . 175 Husbands' perceptions of wil~z's approval of family planning . . . . . . . . . . . . . . 176 Husbands' belief that religion allows or forbids family planning . . . . . . . . . . . 176 Husbands' approval of use of specific methods of family planning . . . . . . . . . . 177 Husbands' problems with spccific methods of family planning . . . . . . . . . . . . . 178 Husbands' objection to wi lt seeing male doctor . . . . . . . . . . . . . . . . . . . . . . . 179 Husbands' desire for more children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Husbands who want no more children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Husbands' ideal number of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Husbands' and wives' perceptions of main infiucncc on decision to have another child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Husbands' and wives' perceptions of wife's position,in family . . . . . . . . . . . . . 184 Husbands' and wives' opinions as to who should have the last word on household decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Husbands' and wives' belief that husband should have last word on household decisions, according to residence . . . . . . . . . . . . . . . . . . . . . . . . . . 185 xii Table 13.29 Table 13.30 Table B. 1 Table B.2 Table B.3.1 Table B.3.2 Table C. 1 Table C.2 Table C.3 Table C.4 Table C.5 Table C.6 Table C.7 Table C.8 Table C.9 Table C. 10 Table C.11 Table D. 1 Table D.2 Table D.3 Table D.4 Table D.5 Table D.6 Page Husbands' opinions as to the typical family expenditure . . . . . . . . . . . . . . . . . 186 Wives' contributions to the household budget . . . . . . . . . . . . . . . . . . . . . . . . 187 Distribution of target sample and number of primary sampling units (PSUs) by governorate and sector (urban-rural) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Primary sampling units by govemoratc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Sample implementation: Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Sample implementation: Husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 List of selected variables for sampling errors, Egypt 1992 . . . . . . . . . . . . . . . . 219 Sampling errors - Entire sample, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . . . . . 220 Sampling errors- Urban, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Sampling errors - Rural, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Sampling errors - Urban Govcrnorates, Egypt 1992 . . . . . . . . . . . . . . . . . . . . 223 Sampling errors - Total Lower Egypt, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . 224 Sampling errors - Urban Lower Egypt, Egypt 1992 . . . . . . . . . . . . . . . . . . . . 225 Sampling errors - Rural Lower Egypt, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . 226 Sampling errors - Total Upper Egypt, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . 227 Sampling errors - Urban Upper Egypt, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . 228 Sampling errors - Rural Upper Egypt, Egypt 1992 . . . . . . . . . . . . . . . . . . . . . 229 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Age distribution of eligible and intcrvicwed women . . . . . . . . . . . . . . . . . . . . 234 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Births by calendar year since birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 xiii Figure 1.1 Figure 1.2 Figure 1.3 Figure 1.4 Figure 2.1 Figure 2.2 Figure 2.3 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 3.6 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 5.1 Figure 5.2 Figure 5.3 Figure 5.4 FIGURES Page Trend in population size by sex, Egypt 1937-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Trend in crude birth rate, Egypt 1985-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Trend in crude death rate, Egypt 1985-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Organization of the 1992 EDHS staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Population pyramid of Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Median number of years of education by sex and age . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Percentage of ever-married women with no education, by place of residence . . . . . . . 26 Total fertility rates by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Age-specific fertility rates by urban-rural residence . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Total fertility rates, Egypt 1979-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Age-specific fertility rates for 5-year periods preceding the survey . . . . . . . . . . . . . . . 35 Percentage of women who gave birth before age 15 and before age 20, by age group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Percentage of teenagers who have begun childbearing, by place of residence . . . . . . . 43 Number of family planning methods known by place of residence . . . . . . . . . . . . . . . 49 Exposure to family planning broadcasts by place of residence . . . . . . . . . . . . . . . . . . . 53 Couple approval of family planning use from the wife's perspective by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Ever use of family planning, Egypt 1980-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 First family planning method used by level of education . . . . . . . . . . . . . . . . . . . . . . . 63 Current use of family planning methods, currently married women 15-49 . . . . . . . . . . 68 Current use of family planning methods by place of residence . . . . . . . . . . . . . . . . . . . 69 Current use of family planning methods, Egypt 1980-1992 . . . . . . . . . . . . . . . . . . . . . 72 Change in method mix, Egypt 1984-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 XV Figure 5.5 Figure 5.6 Figure 6.1 Figure 6.2 Figure 6.3 Figure 7.1 Figure 7.2 Figure 8.1 Figure 8.2 Figure 9.1 Figure 9.2 Figure 10.1 Figure 10.2 Figure 11.1 Figure 11.2 Figure 11.3 Figure 12.1 Figure 12.2 Figure 13.1 Figure 13.2 Figure 13.3 Figure 13.4 Page Current use of family planning methods by governoratc . . . . . . . . . . . . . . . . . . . . . . 76 Source for family planning methods, current users of modcm methods . . . . . . . . . . . . 80 Quality of pill use among current pill users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Pill brands used by current pill users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Service delivery indicators among ever users of the IUD . . . . . . . . . . . . . . . . . . . . . . . 94 Reasons for discontinuing use of family planning methods . . . . . . . . . . . . . . . . . . . . . 97 Preferred method among nonusers who intend to use in the future . . . . . . . . . . . . . . . 100 Fertility preferences, currently married women 15-49 . . . . . . . . . . . . . . . . . . . . . . . . 102 Percentage of currently married women who want no more childrcn by place of residence, 1988 and 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Median age at first marriage, all women 25-49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Percentage of births whose mothers arc amcnorrhcic or abstaining . . . . . . . . . . . . . . 118 Infant mortality, Egypt 1950-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Infant mortality by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Antenatal care indicators by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Delivery at health facility by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Percentage of children 12-23 months who arc fully vaccinated, by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Distribution of children by breastf~:cding status according to age . . . . . . . . . . . . . . . . 151 Median duration of breastfeeding, by place of residence . . . . . . . . . . . . . . . . . . . . . . 155 Percentage of husbands who have no education, by place of residence . . . . . . . . . . . 163 Comparison of levels o f education o f husbands and wives . . . . . . . . . . . . . . . . . . . . . 166 Percentage of husbands who disapprove of the use of family planning, by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Percentage of husbands who would object if wife visited a male doctor for family planning, by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 xvi Figure 13.5 Figure 13.6 Figure B. 1.1 Figure B.1.2 Figure B.1.3 Page Fertility preferences of husbands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Opinions of husbands and wives as to person with main influence on decision to have another child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Distribution of sampling points, Urban Govemorates, Egypt Demographic and Health Survey 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Distribution of sampling points, Lower Egypt, Egypt Demographic and Health Survey 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Distribution of sampling points, Upper Egypt, Egypt Dcmographic and Health Survey 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 xvii FOREWORD The 1992 Egypt Demographic and Health Survey (EDHS) is the most recent in a series of surveys carded out in Egypt to provide information on fertility and child mortality levels, family planing awareness, approval and use and basic indicators of maternal and child health. 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-relatcd information for mothers and their children. These data arc especially important for under- standing 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 more than 50 surveys implemented through the Demographic and Health Surveys program. A total of 22 months was spent in preparing and carrying out the various activities of the 1992 EDHS, including fieldwork, data processing, and analysis of the survey rcsults. The main findings from the EDHS are presented in this report. This report summarizes basic information on fertility levels, childbearing intentions, and contra- ceptive knowledge and use in Egypt. It also looks at key maternal and child health indicators including the extent to which mothers reccive trained medical care during pregnancy and at the time of delivery and, for young children, the extent of immunization coverage and the prevalcncc and treatment of diarrheal disease. The 1992 survey is the second Demographic and Health Survey to be conducted in Egypt; the first was carried out in 1988. The availability of data on a periodic basis provides analysts and policymakers with the relevant information to monitor trends. The challenge that remains is to use the information collected in the two rounds of the DHS as a basis for evaluating and modifying family planning and health service delivery in Egypt. Survey data are only truly useful when they are employed to improve the efficiency of population and health programs in Egypt. Finally, I would like to express my appreciation to the EDHS team on their devotion and sincere efforts to complete the planned activities and this basic analysis of the findings. Prof. Dr. Mahcr Mahran Minister of Population and Family Welfare xix ACKNOWLEDGMENTS The 1992 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. Preparations for the EDHS started in January 1992 under the supervision of the National Population Council (NPC). The Cairo Demographic Center (CDC) provided office space for the EDHS headquarters staff. Technical and financial assistance was provided by Macro Intemational Inc. through the international Demographic and Health Surveys (DHS) program. Funds from USAID/Cairo under the Population/Family Planning II Project financed the EDHS. I would like to express my gratitude to Dr. Maher Mahran, Minister of Population and Family Welfare. He provided strong and continuing support to the project and has shown great intcrcst in the survey results. Although it is not possible to acknowledge all of the individuals who contributed to the EDHS, I would like to especially acknowledge some individuals whose efforts were very important in completing the survey. Dr. Hussein A. A. Sayed, Senior Consultant, deserves my deepest gratitude for his valuable com- ments and advice during the various survey activities. My thanks and appreciation also are extended to Dr. Madany D. Mostafa, who served as a sampling consultant. Dr. Hassan H. M. Zaky, the EDHS Assistant Director, Dr. Gihan A. Shawky, Associate Director for Data Processing, and Dr. Enas M. Hussein, Associate Director for Sampling, were instrumental in the successful completion of the survey activities. Mr. Abdel Hakim M. Abdel Hakim, the Fieldwork Coordi- nator, ably supervised the field team. Dr. Rashad Hamed coordinated the successful data processing effort. Dr. Effat Fakher El-Din and Dr. Abdel Monem Darwesh were instrumental in carrying out the anthropometric training. My sincere gratitude and appreciation go to Dr. Ann Way who has worked closely with us on all phases of EDHS. Her spirit and devotion were instrumental throughout the survey and during the preparation of this report. My thanks also are extended to Dr. Alfredo Aliaga, for his advice and guidance in designing the sample. Mr. Trevor Croft deserves my deepest thanks for his assistance in data processing and tabulations required for this report. I gratefully acknowledge Dr. Carol Carpenter-Yaman, Director, and Mrs. Amani Selim, Project Management Specialist, Office of Population, USAID/Cairo, for their support and valuable input throughout the survey activities. xxi I am deeply indebted and grateful to all EDHS field and office staff. Without their participation and commitment, this project would have bccn impossible. Finally, 1 would like to express my appreciation for all the assistance received from the office staff and administrative and financial departments of the National Population Council during the survey. Dr. Fatma H. EI-Zanaty Technical Director 1992 Egypt Demographic and Health Survey xxii SUMMARY OF FINDINGS Fertility and Family Planning The results of the 1992 Egypt Demographic and Health Survey (EDHS) indicate that limility and family planning behavior in Egypt has changed dramatically since 198ll. The fertility rate has fallen to 3.9 births per woman from a level of more than 5 births in 1980. Virtually all couples know about lamily phm- ning, and around two-thirds have experience in using a method at some time. At the time of the survey, 47 percent of couples were using family planning to achieve their childbearing goals, which is almost double the level of current use reported in 1980 (24 percent). Almost all users employ modem methods, principally the IU D (28 percent) and the pill ( 13 percent). The shill in the method mix toward greater reliance on the IUD is one of the major trends observed when the EDHS results were compared with the findings of the 1980 Egypt Fertility Survey (EFS). In 1980, two of three users relied on the pill and only one in six employed the IUD. By 1992, almost three in five users relied on the IUD and only around one in four were using the pill. Both the public and private sectors play an important role in the provision of family planning services in Egypt. Current users of the pill obtain their supply largely from pharmacies, while users of the IUD are about equally divided between those obtaining services from private doctors or government facilities. The EDHS results indicate that family planning methods are easily accessible to users. Overall, 58 percent of current users of modem family planning methods live less than 30 minutes from the place where they obtained their method. Physical access to services also does not appear to be a major barrier to the adoption of family planning by nonusers. There is virtually no difference between the travel times to tamily planning sources reported by users and nonusers, and few nonusers cite reasons relating to physical access when asked why they do not intend to use family planning in the future. Cost also does not seem to be a major barrier to the use of family planning. Comparatively [cw users obtain their methods free of charge, and most indicate a willingness to pay more. Although pill users pay comparatively little for supplies (usually 50 piastres or less for a packet), more than three-quarters indicate a willingness to pay at least 1 Egyptian pound per packet and more than one-fifth arc willing to pay 5 pounds or more. IUD users, for whom the median cost of services is almost 8 Egyptian pounds, also indicate a willingness to pay more. Eight in ten IUD users would pay 10 pounds for the method, and one in two would be willing to pay 25 pounds or more. The results of the husbands' survey carried out as part of the EDHS confirm that husbands play a significant role in fertility and family planningdecisionmaking. Men are concerned about limiting family size and are supportive of family planning; three in five husbands say that they do not want more children and around eight in ten approve of the use of family planning. The age at which women first marry is another important determinant of fertility levels. The EDHS results suggest that there has been a steady increase over the past 20 years in the age at marriage in Egypt. The median age at marriage among women 25-29 (19.9 years), is 1.6 years higher than the median age among women 45-49. Although the EDHS findings show rapid progress in lowering fertility and increasing use of family planning, there remain a number of areas of concem. One is the large variation in fertility levels and use of family planning by residence. At current fertility levels, a rural woman may expect to have an average of 4.9 xxiii children, two children more than a woman residing in an urban area. Fertility rates are much higher in rural Upper Egypt (6.0 births per woman) than in rural Lower Egypt (4.1 births per woman). Marked differences in the level of family planning use by residence are also observed. Urban women are more likely to use family planning and to employ an IUD than rural women. The highest level of current use is found in the Urban Govemorates (59 percent) and the lowest in Upper Egypt (31 perecnt) The differential in use between rural Lower Egypt and rural Upper Egypt is particularly striking; 51 percent of married women in rural Lower Egypt are using family planning methods compared to 24 percent in rural Upper Egypt. A key concern for the Egyptian family planning program is the rate at which users discontinue use of contraception and the reasons for the discontinuations. The EDHS results show that almost three in ten users stop using within twelve months of starting. Six percent become pregnant unintentionally, 4 pcreent want to get pregnant, 13 percent stop because they experience side efli~cts or health problems, and 7 percent stop for other reasons. The one-year discontinuation rate lor the pill (42 percent) is three times the rate for the IUD (13 percent). Side effects and health conccms arc the major reasons for stopping usc of both the pill and the IUD. The EDHS results also suggest that many pill users are at incrcased risk of an unplanned pregnancy because they fail to lake the pilI correctly. For some, remembering to take the pill daily is a problem, while others believe that it is necessary to take the pill only when the husband is present in the household Other pill users do not have a pill packet available because they arc "resting" from the pill. Information collected in the EDHS on the interaction between providers find users at the time that the pill or the IUD was adopted indicates that providers in both the public and private sectors need to improve counseling for family planning clients. Increased follow-up is also ncedcd to reduce the rate of discon- tinuation. Despite the steady reduction in lcrtility levels, many couples arc having more children than they consider ideal. At current lertility levels, the average woman in Egypt has 1.2 births more than she wants. In rural Upper Egypt, actual tcrtility exceeds wanted fertility by 1.7 births. Many births are not only unwanted, but more than 60 percent carry higher than average risks of morbidity and mortality for thc mother and child because of the mother's age (under 18 or over 34), high birth order (3 or more) or a short Nrth interval (less than 24 months). The substantial unmet need for family planning in Egypt indicates that there is potential lor further increases in contraceptive use. One in five currently married women is considered to be in need el lamily planning. These are women who want no more children, or want to delay the next birth, but are not using fiunily planning. Maternal and Child Health The EDHS results document the rapid decline in infant and child mortality that has bccn taking place in Egypt. Estimates suggest that infant mortahty decreased by around half between 1972 and 1992. Nevertheless, in the five-year period preceding thc EDHS, 62 of 1,000 children died belore reaching their first birthday and 85 of 1,000 died before reaching age five. Mmlality levels fire higher in rural than in urban areas, and the highest levels are observed in rural Upper Egypt. The EDHS results suggest that spacing births can potentially reduce childhood mortality; a child born less than two years after an older sibling is three times as likely to dic bclore his fifth birthday as a child born xxiv after an interval of four or more years. Reducing the number of high parity births and births to young mothers would also contribute to a lowering of childhood mortality. The care that a mother receives during pregnancy and at the time of childbirth allccts the health and survival of both the mother and the child. The EDHS findings indicate that the majority of Egyptian mothers do not receive adequate antenatal care. For births in the five years preceding the survey, only 53 percent of the mothers reported receiving any antenatal care, and only 23 percent had four or more consultations with a medical provider during pregnancy (the minimum level of antenatal care considered acceptable). For three in five births, mothers received at least one tetanus toxoid injection during pregnancy. Although still low, the coverage rate for tetanus toxoid is more than five times the level reported in the 1988 EDHS. Almost three-quarters of births in the five years preceding the survey took place at home. Most were assisted by dayas (traditional birth attendants) or relatives and friends. Only two in livc births were assisted by doctors or nurses. One of the primary mechanisms for improving child survival is increasing the proportion o f children vaccinated against the major preventable childhood diseases. The EDHS results indicate that almost all young children receive at least some vaccinations; only 4 percent of children age 12-23 months have not had any immunizations. However, many children have not received the full primary course of iinmunizations; only two-thirds of young children arc fully immunized. Diarrheal disease and acute respiratory infections (ARI) arc among the leading causes uf infant and child deaths in Egypt. Thirteen percent of children under age five were reported to havc had diarrhea during the two week period belore the survey. Seven in ten mothers reported thai they did something to treat the diarrhea. Forty-five percent of children suffering from diarrhea were taken to a health facility lot advice or treatment, and 43 percent of children received some lorm of oral mhydration therapy (ORT) (i.e., a solunon made from an oral mhydration salt (ORS) packet, a recommended home fluid (sugar-salt-water solution), or increased fluids). Only 29 percent of mothers of children with diarrhea reported that ORS packets were used in preparing the solution used to treat the diarrhea. However, virtually all mothers nf young children know about these packets. Overall, seven in ten mothers of children under age live havc used ORS packets in treating diarrhea at some time. Eight percent of children under age five were reported to have experienced cough and rapid breathing (symptoms of acute respiratory infection (ARI)) during the two weeks belore the survey. Six in ten of these children were taken to a health facility lot advice or treatment. Only one in five children with AR[ symptoms was given nothing to treat the illness. Undemutrition contributes to child deaths. The EDHS lbund that 24 percent of Egyptian children were stunted or short in relation to their age, as compared to an international reference population. Stunting reflects the long-term effects of poor diet and may also be the outcome of chronic illness. Three percent of the children are wasled or thin for their age. Wasting is the result of acute undemutrition over a short period of time and may be an outcome of sudden, severe illness. One in eleven children are underweight for their age. Bmasffeeding practices and the timing of the introduction of supplemental leeds arc important determinants of the health and nutritional status of inl)nts and young children. Almost all young children in Egypt are breastlizd for some period of time. The median duration of breastlceding (19.1 months) is moderately long. However, supplemental leeds and liquids arc introduced cmnparatively early, the median duration lor which a child receives breast milk only is 1.8 months. Nearly one in live bmastfcd children less than eight months of age was given a bottle with a nipple on the day before the interview. XXV Egypt MEDITERRANEAN SEA 5 2,3 24. 2.5 26 t8 19 / 20 RED SEA 22 URBAN GOVERNORATES 1 Cairo 2 Alexandria 3 Port Said 4 Suez LOWER EGYPT 5 Damietta 6 Dakahlia 7 Sharkia 8 Kalyubia 9 Kafr El-Sheikh 10 Gharbia 11 Menoufia 12 Behera 13 Ismallia UPPER EGYPT 14 Giza 15 Beni Suef 16 Fayoum 17 Menya 18 Assiut 19 Souhag 20 Qena 21 Aswan FRONTIER GOVERNORATES 22 New Valley 23 Matrouh 24 North S,nal 25 South Sinai 26 Red Sea xxvi CHAPTER 1 INTRODUCTION 1.1 Geography Egypt is situated at the northeast comer of the African continent. The total area of Egypt covers approximately one million square kilometers; however, only 6 percent of this area is inhabited (Central Agency for Population Mobilization and Statistics (CAPMAS), 1993b). Administratively, Egypt is divided into 26 govemorates. Four of these govemorates are totally urban (Cairo, Alexandria, Port-Said and Suez). Nine govemorates are found in the Nile Delta (Lower Egypt), which extends from Cairo to the Mediterranean Sea, and eight are located in the Nile Valley (Upper Egypt). An additional five frontier govemorates are found on Egypt's western and eastern boundaries (see map). Each govemorate is divided administratively into smaller units (kism/shiakha in urban areas and markaz/villages in rural areas). 1.2 Demographic and Health Indicators Population Size, Density and Distribution On the first of July, 1993, the population of Egypt was estimated to be 56,984 ~ million, with a sex ratio of around 104.3 (CAPMAS, 1993a). This figure represents an increase of around 9 million from the reported de facto population in the 1986 Census. Figure 1.1 shows that, since 1937, the population has more than tripled in size, increasing from only around 16 million to 57 million in 1993. Projections indicate that, by the year 2025, the population will exceed 90 million; at that point Egypt will rank 17th among the world's most populous countries (United Nations, 1991). Currently, the majority of Egypt's population lives in rural areas. However, the urban population has been growing rapidly; in 1990, it represented 47 percent of the total population, compared to 44 percent at the time of the 1986 Census data and 37 percent in 1960 (UNDP, 199t). If the urban growth continues at its current rate, Egypt will be mostly urban by the year 2025, with only around 25 percent of its Fx)pulation living in rural areas. For Egypt as a whole, the population density averages 1,035 persons per square kilometer of inhabited area. The average density varies widely by govemorate, fluctuating from a low of 22 persons per squareki lometerinSueztoahighof31,699inCairo(CAPMAS, 1993b). Within Egypt's metropolitan areas, some areas are extremely crowded. For example, a number of kisms in Cairo have population densities of more than 100,000 persons per square kilometer, and population density reaches its maximum in a kism in Alexandria, where the density is 128,000 per square kilometer. Fertility According to information from the vital registration system (which was established in Egypt in 1912), fertility levels generally have been high in Egypt for the past 50 years, decreasing only gradually between the early 1930s and the mid-1980s, when the decline accelerated. Over this period, the crude birth rate (CBR) 1Excludes 2,579 million who were living abroad. M~lhon Figure 1.1 Trend in Population Size by Sex, Egypt 1937-1992 60 50 37 40 31 30 26 ~ l 20 16 1 u 1937 1947 1960 1966 1976 Source CAPMAS, 1993b 1986 1993 fell from a level of 50 births per thousand population to 34.5 births per thousand population in 1973, when it began to rise again) Figure 1.2 shows that, since 1985, the decline in fertility has been continuous, with the CBR failing below 30 per thousand in 1992 (CAPMAS, 1993b). As a result of the past high fertility, the age structure of the Egyptian population is very young, with around 40 percent of the population under 15 years of age in 1993. Mortality Mortality levels started their serious decline after the World War II, with the crude death rate (CDR) dropping from around 30 deaths per thousand population to about 15 deaths per thousand during the sixties. As shown in Figure 1.3, the CDR continued to decline from 9.4 deaths per thousand in the mid- 1980s to 7.4 per thousand in 1992 (CAPMAS, 1993b). Infant and child mortality represent the majority of all deaths, and these rates still are considered high in Egypt. However, there is evidence that they have declined sharply during the period since World War II. The estimated infant mortality rate for the period 1985-90 was about 65 per thousand live births. The IMR is expected to continue to decline to a level less than 40 per thousand by the year 2000-2005 (United Nations, 1991). 2The decline has been attributed to various factors, including the effects of the war and of delays in marriage. However, recent studies suggest that structural changes in the age distribution, resulting from the changes in fertility and mortality conditions during the period 1930-1950, were also responsible for the trend (Bucht and EI-Badry, 1986). Births per 1,000 40 0_ 38 0 36 0 34 0 32 0 30 0 28 0 Figure 1.2 Trend in Crude Birth Rate Egypt 1985-1992 38 7 379 375 31 5 1985 1986 1987 1988 1989 1992 Source CAPMAS, 1993b Deaths per 1,000 95 Figure 1,3 Trend in Crude Death Rate Egypt 1985-1992 9O 85 8O 75 70 1985 81 r i i ~ I 1986 1987 1988 1989 1990 Source CAPMAS. 1993b 1992 The impact of mortality decline was reflected on the increased expectation of life at birth. It reached around 60.3 years in 1990, compared to 46.1 years in 1960 (UNDP, 1991). In conjunction with the declines in both the fertility and mortality rates, the health status of the Egyptian population has improved in response to govemmental eflons. The government increased the proportion of the total budget expended on health from 2.4 percent in 1980 to 2.8 percent in 1991 (World Bank, 1993). As a result, the population per physician declined from 1,900 in 1970 to 1,320 in 1990, and the population per nurse also decreased from 2,320 to 490 during the same period. 1.3 Socioeconomic Indicators The Egyptian economy has been experiencing drastic changes during thc last several decades. It was characterized by a centralist approach in the ill'ties and sixties, when the market was mainly dominated by the public sector. In the seventies, the "open-door" policy shaped the decade. Since the eighties, the government has been adopting an economic liberalization program that gives the private sector a greater share in the economic market. Economic reform has achieved tangiblc results in rostoring both cxternal and internal economic equilibria. In the fiscal year 1991/92, the Gross Domcstic Product (GDP) reacbed 125,485 million Egyptian pounds (L.E.) (Central Bank, 1993). This figure rcprescnts an avcrage annual increase of 3.9 percent over the GDP at the time that the second five-year plan period started in 1986/87 (at constant 1986/87 prices). The inflation rate (based on the consumer price index) decreased drastically in 1991/92 to 9.7 percent, compared to 20.7 percent in 1991//91. The drop in the inflation rate is reflected in the stabilization of the exchange rate at 3.3 L.E. to the dollar for the past two years. As a result, the demand lor the Egyptian pound increased, and savings dcposits in Egyptian pounds rose. As for the state budget of 1991/92, the deficit was lcss than half the 1990/91 budget deficit. As a result, the ratio of deficit to the GDP fell to 5.2 percent. With respect to the external transactions, the surplus in the balance of payments showed a substantial increase, reaching U.S. $3.8 billion during 1991/92. This is compared with a surplus of U.S. $1.4 billion recorded for the first time in the previous year (Central Bank, 1993). The leading earners of foreign currency in the economy are workers' remittances, tourism revenues, Suez Canal dues, and oil exports. Although the economic indicators show that the economy is improving, Egypt is ranked at the lower end of the human development index (UNDP, 1991). However, a number of key human development indicators have improved ovcr time. Among these improvments are: Primary enrollment rates in schools have jumped from 75 percent in 1970 to 98 percent in 1990, while for the secondary stage, the rate increased from 35 percent to 82 percent for the same period. In addition, the primary pupil/teacher ratio declined from 38 to 25 pupils/teacher. Female education has improved. Illiteracy among women age 10 and over decreased from 71 percent in 1976 to 63 percent in 1986, according to the 1976 and 1986 population censuses. Female enrollment rates increased dramatically, from 57 percent in 1970 to 90 percent in 1990 for the primary stage. For secondary education, the rate also increased, from 23 percent to 71 percent. 4 The investment allocation for education has increased. The share in total investment during the period 1982/83-1986/87 was 1.8 percent, while the same sham was 2.3 percent for the five-year period 1987/88-1991/92. The Gross National Product per capita has doubled during the last 20 years to reach US $610 in 1991 (World Bank, 1993). 1.4 Population Policy and Programs The population problem in Egypt has three interrelated dimensions; namely, high rates of population growth, unbalanced population distribution, and human resource constraints including illiteracy that affect the productivity of the labor force. Efforts to raise awareness and discussions about the sensitivity and complexity of the population problem began in Egypt in the 1930s. A "National Committee for Population Matters" was established by the govemment in 1953 (one year after the revolution) to examine the population situation and identify the best course of action that should be followed by the government. Egypt has had three formal population policies; the first national policy was introduced in 1973 and was followed by an implementation plan for the period 1973-1982 and the second population policy issued in 1980. Following the national population conference that was held in March 1984 under the chairmanship of the President of Egypt, the National Population Council (NPC) was established, and the third National Population Policy was adopted in 1986. The 1986 population policy m cognized seven principles necessary for the achievement of its basic objectives. These principles include: 1) Each family has the right to decide on the appropriate number of childm n to have and to obtain information about the means to enable them to achieve their decision within the framework of religion, Egypt's civilization and the values of its society; 2) the avoidance of the use of abortion or sterilization as a means of family planning; 3) recognition of the citizen's right to migrate and to move from place to place within Egypt or abroad; 4) adoption of a positive incentive system based on increased awareness of the role of the individual and the community and the avoidance of any methods of coercion, negative incentives or punitive methods; 5) educational, cultural and health development of the individuals to help them to become a source of productive energy; 6) local government bodies am considem d the base for implementation of all programs; and 7) encouragement of voluntary efforts and community participation in the solution of the problem. Targets for key indicators relating to population growth am set by the Egyptian government. The target-setting process significantly improved over the years, especially with the availability of basic population and family planning data, which has served as the basis for periodically updating the targets since the 1986 policy was adopted. In 1991, the NPC introduced a population strategy with targets for the rate of natural incm ase, crude birth rate, total fertility rates, and contraceptive pm valence (National Population Council, 1991). The targets are as follows: The crude birth rate is to bc reduced to 27 per thousand in the year 1997 and 26 per thousand in 2002. The rate of natural increase in the years 1997 and 2002 will bc reduced to 2.0 percent and 1.9 percent, respectively. The total fertility rate will be reduced to 3.5 in 1997 and 3.1 in 2002. Current contraceptive prevalence will increase to 55 percent and 59 percent in the year 1997 and 2002, respectively. In sum, Egypt, which was one of the first countries to adopt formal population policies and objectives, has already achieved a demographic breakthrough as a result of changes in key demographic variables. The success of this process is reflected in the evaluation of the population program's performancc during the 1980s. According to a review of the performance of family planning programs in 98 countries, the Egyptian program was categorized in 1989 as at the top of the moderate group, which represents a significant improvement over previous program performance which was described as weak (Mauldin and Ross, 1991). 1.5 Health Policies and Programs Health for all by the year 2000 is the main health objective of the Egyptian Government. The Ministry of Health (MOH) has long given high priority to implementing this objectivc, developing a national system of health facilities providing scrvices at all levels (central, governoratc and local). The MOH is especially concerned with increasing the coverage of the health care system, especially in rural areas, emphasizing preventive care and children's immunization. Primary health care for all, and especially maternal and child health care, havc recently gained significant additional momentum from the Egyptian Government. The Egyptian health policy emphasizes: Provision of health services lor all, with adherence to social justice and more attention to upgrading medical care suitable to the individual's income levcl; Reduction of mortality and morbidity; Improved health care quality; Increased coverage of child immunization programs; Expansion of the national health care financial system and introduction and/or development of other types of health insurance; Development of the cost-recovery system and a greater role for the priw~tc sector; Provision of health education and health messages and studies relating to health economics; Continual upgrading of the health information system; Review and modification of health legislation on a periodic basis to cope with social changes; and Improved management of the health services system. 1.6 Object ives and Organ izat ion of the Survey The 1992 Egypt Demographic and Health Survey (EDHS) is the latest in a scrics of national-level population and health surveys in Egypt) It was implemented under the supervision of the National Popu- lation Council (NPC) with financial support from the United States Agency for International Development (USAID). Macro International Inc. provided technical assistance for the survcy through thc international Demographic and Health Surveys program. 3In addition to the first EDHS conducted in 1988 (Sayed et al., 1989), these surveys include the 1979-1980 Egypt Fertility Survey (EFS) (Hallouda et al., 1983), the 1980 and 1984 Contraceptive Prevalence Surveys (ECPS) (Khalifa et al., 1982 and Sayed et al., 1985) and the 1991 Egypt Maternal and Child Health Survey (EMCHS) (Abdel-Azeem et al., 1993). Survey Objectives The primary objective of the EDHS is to provide data on fertility and mortality, family planning, and maternal and child health. The survey obtained detailed information on these issues from a sample of ever- married women in the reproductive ages. In addition, a subsample of husbands was interviewcd in an effort to obtain information on their fertility preferences and the role which they play in family planning decisionmaking. The EDHS information is intended to assist policymakers and administrators to evaluate cxisting programs and to design new strategies for improving family planning and health services in Egypt. A secondary objective is to enhance the capabilities of institutions in Egypt to collect, process and analyze population and health data so as to facilitate the implementation of future surveys of this type. Organization and Timetable Figure 1.4 presents the organizational structure of the 1992 EDHS staff. A list of the staff involved in each phase of the EDHS is included in Appendix A. A detailed timetable is shown in Table 1.1. The organization, training and supervision of the staff participating at the various stages of the survey arc described below. Figure 1,4 Organization of the 1992 EDHS Staff CoRsul[ants ] Tec hnlca4 1 Director I Asslslanl Director I Associate Directors r Da~ao P[dlCet~s;n g I I Data P[ocesslng Staff Office and Admlnls[raWe/ Financial Staff ] Fieldwork Coordinator I l ont ] Interwew~ng Staff Relntervlewln9 Statf Table 1.1 Survey timetable~ Egypt 1992 Activity Starting Date Duration Development of the sample design Quick-count operation Recruitment and training of listing staff Listing and refisting Sample selection Questionnaire design Preparation of training manuals and other documents Printing the pretest materials Pretest Finalization of qucstaonnaires Recruitment of field staff Printing survey materials Training of field staff Fieldwork Remterviews Office editing Data entry Computer editing Preliminary report Detailed tabulations Final report preparation January 1992 1 month May 1992 3 months August 1992 3 weeks September 1992 1 month October 1992 2 weeks April 1992 I month May 1992 3 months May 1992 2 weeks May 1992 2 weeks August 1992 I month September 1992 I month September 1992 1 month October 1992 4 weeks November 1992 2 months December 1992 5 weeks November 1992 3 months November 1992 3 months December 1992 3 months M~ch 1993 2 weeks Aprd 1993 I month July 1993 4 months Sample Design The 1992 Egypt Demographic and Health Survey covered over 11,000 households, which were scattered in 21 governorates. One of the key concerns in the design of the sample was the need 1o provide reliable estimates of fertility levels and contraceptive use for Egypt as a whole, and for urban and rural areas separately. Other domains for which reliable estimates were desired included the Urban Govemorates, Upper Egypt, and Lower Egypt. In addition, estimates of key indicators for the women's sample were needed at governorate level. In order to allow for the govemorate-level estimates, the number of households selected from each governorate is disproportionate to the size of the population in the governorate; thus, the EDHS sample is not self-weighting at the national level. The 1992 EDHS sample was 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 these primary 8 sampling units (PSUs) was based on 1986 census data, which were provided by the Central Agency for Public Mobilization and Statistics (CAPMAS). During the first stage selection, 377 PSUs were sampled (169 in urban areas and 208 in rural areas). The second stage of selection involved several steps. First, maps were obtained for each shiakha and village that had been selected at the first stage and divided into a number of roughly equal-sized parts. One of the pans was then selected from each PSU. In both urban and rural PSUs, a quick-count operation was carried out in the field to provide the information which was used to divide the selected pan into a number of segments of roughly equal size. Two segments from urban areas and one segmcnt from rural areas were then chosen as the secondary sampling units. After the secondary sampling units (SSUs) were selected, a household listing was obtained for each SSU. Using the household listing, a systematic random sample of households was chosen for the EDHS. A subsample of one-third of the households in every segment was selected for the husband survey. All ever- married women 15-49 who were present in the household on the night before the interview were eligible for the survey. The husbands' sample covered men who were currently married to eligible women. A more detailed description of the sample design is included in Appendix B. Sampling errors for key variables are presented in Appendix C. Sample Implementation Two different field operations were conducted during the sample implementation phase of the 1992 EDHS. A quick count for the PSUs selected in shiakhas/towns and villages was the first field operation. The objective of the quick count was to obtain an estimate of the number of households in the part to serve as the measure of size for the second stage selection. Experience in the 1988 EDHS, in which a quick-count operation was carried out in only the urban PSUs, indicated that there was frequently significant variation between the target and the actual number of households in rural areas. This variation was largely due to the imprecision in assigning measures of size in some rural PSUs, which involved measuring the residential area on a map, many of which were out of date. Therefore, it was decided to carry out a quick count in both urban and rural areas. Prior to the quick-count operation, maps were obtained for each shiakha or town selected for the urban sample and for villages included in the rural sample that had more than 20,000 population. These maps were divided into approximately equal-sized parts, and one part was randomly selected for the quick-count operation. For villages with less than 20,000 population, the quick count was carried out for the entire village. It should be noted that the quick count for a rural area covered both the main village and all associated hamlets. The one-week training course held prior to the quick-count field operation included both classroom instruction and practical training in shiakhas and villages not covered in the survey. The quick-count operation, which covered all 377 PSUs, was carried out between mid-May and mid-July 1993. A group of 52 field staff participated in the quick-count operation. The staff was divided into 15 teams, each composed of one supervisor, one cartographer and one counter. As a quality control measure, 10 percent of the parts were selected, and a second count obtained. If the difference between the first and second counts was within 2 percent, the first count was accepted; otherwise, another visit was made to the field to resolve the discrepancy between the two counts. There were only a few cases in which a third visit was required. The second field operation during the sample implementation phase involved a complete listing of all of the households living in the 546 segments chosen during the second stage of the sample selection. Prior to the household listing, 38 listing staff attended a one-week training course, which involved both classroom lectures and field practice. After the training, 11 listing teams were formed. Each team consisted of a supervisor and two listers. The listing operation started on September 10th and was completed by mid-October. Segments were relisted when the hum ber of household in the listing differed markedly from that expected based on the quick- count figures. Questionnaire Development and Pretest The 1992 EDHS involved three types of questionnaires: a household questionnaire, an individual questionnaire for women, and an individual questionnaire for husbands. These questionnaires were based on the model survey instruments developed for the international Demographic and Health Surveys program. In particular, the household and women's questionnaires were built on the DHS model "A" questionnaire for high contraceptive prcvalcnce countries. Additional questions on a number of topics not covercd in the DHS model questionnaire were included in both the household and individual questionnaires. The questionnaires were pretested in May 1992, following a two-week training course Ior supcrvisors and interviewers. Two supervisors, two field editors and ten 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 questionnaires is included in Appendix E. The household questionnaire obtained a listing of all usual household members and visitors and identified those present in thc household during the night beforc 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. Finally, the household questionnaire also included questions on characteristics of the physical and social environment of the houschold (e.g., availability of electricity, source of drinking water, household possessions, ctc.), which are assumed to be related to the health and socioeconomic status of the household. The individual questionnaire for women was administered to all ever-married women age 15-49. It obtained information on the following topics: Background characteristics Reproduction Knowledge and use of family planning Other issues relating to contraception Fertility preferences Maternal care and breastfeeding Immunization and health Marriage Husband's background, residence and women's work The women's questionnaire included a monthly calendar, which was used to record fertility, contraceptive use, marriage, spousal absence, migration, and employment histories for a nearly six-year period beginning in January 1987. In addition, the interviewing teams measured the height and weight of all children who were bom since January 1987 and of their mothers. 10 The husbands' questionnaire was administered to all men who were currently married to an eligible woman in the households included in the husbands' survey subsample. The husbands' questionnaire was similar but shorter than the women's questionnaire. It included questions relating to background characteristics, lifetime childbearing, fertility preferences, knowledge, use and attitudes toward family planning, and the status of women. Data Collection Activities Staff Recruitment. Candidates for the positions of interviewer and field editor were idcnti fled in two ways. First, advertisements in newspapers attracted a number of applicants. Second, the Ministry of Social Affairs (MOSA) nominated a number of its female personnel, who were working to ful fill 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. All candidates for the interviewer and field editor positions were recent university graduates. Another basic qualification was a willingness to work in any ofthc govemoratcs covcrcd 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 cxperiencc and to ensure that all trainees had a similar background. However, previous survey experience was a basic quail fication for the candidates for the positions of supervisor and assistant supervisor. Training Materials. A variety of materials were developed for use in training personnel involved in the fieldwork. A lengthy interviewer's manual giving general guidelines to follow in conducting an interview, as well as specific instructions for asking particular questions in the qucstionnairc, was prepared and given to all field staff. In addition, a chart to convert months from the Islamic calendar to the Gregorian calendar was designed for the 74 months before the EDHS and distributed to all field workers. 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 team supervisors. SupervisorandInterviewerTraining. Interviewer training for the 1992 EDHS data collcction began in the first week of October 1992. Seventeen supervisors, 14 assistant supervisors, plus 97 interviewers participated in the training program. A special training program for supervisors and assistant supervisors was conducted during a three-day period prior to the main fieldwork training. 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 training program. The training program, which was held in Cairo for four weeks, included: general lectures related to family planning and public health; specific sessions with visual aids on how to fill out the questionnaire; opportunities for role playing and mock interviews; four days of field practice in areas not covcrcd in the survey; and five quizzes. Trainees who failed to show interest in the survey, did not attcnd the training program on a regular basis, or failed the first three tests were disquali fled immediately. The training was originally planned for three wceks, but because of disruptions due to the October 12 earthquake, the training program was extended for an additional week. 11 At the beginning of the third week of the training, a preliminary list was compiled of the 20 trainees who had performed best during both the classroom and field exercises. Those trainees were further examined in order to select 12 field editors. A special training session was held for the field editors following their selection. About 45 trainees plus all assistant supervisors were selected tot anthropometric training. This training included both classroom lectures and practice measurement in a nursery sehooh At the end of the program, the 36 best trainees were selected to serve as measurers during the EDHS fieldwork. At the end of the training course, 63 of the 97 candidates originally recruited for the interviewer training were selected to work as field editors, interviewers and measure~ in the EDHS fieldwork. Fieldwork. Fieldwork for the survey including initial interviews, callbacks, and reinterviews began on November 7, 1992 and was completed on February 8, 1993. A total of 91 staff, including one fieldwork coordinator, one assistant fieldwork coordinator, 13 supervisors, 13 assistant supervisors, 12 field editors and 51 interviewers were responsible for the data collection. All supervisors and assistant supervisors were male, while field editors and interviewers were female. The field staff was divided into 12 teams; each team had a supervisor, assistant supervisor, a field editor and four or five interviewers. Usually two of the interviewers in the team and the field editor plus the assistant supervisor were specially trained to collect the height and weight measurements. During the fieldwork, each team worked in two govemorates, except Cairo and lsmailia. At the beginning of the fieldwork, visits were made to all of the areas in which earthquake damagc had occurred in order to check and, if neccssary, update the original household listings. Listings were checked in Cairo, Giza, Kalyubia, Fayoum, Menya, Bcni Suef and Ismailia. Only a few segmcnts had experienced significant damage, and, even in those segments, 70 percent or more of tile houscholds listed initially were found at their original addrcsscs. Thus, the earthquake did not adversely affect the EDHS sample. After the initial fieldwork was completed, a random sample of up to 10 percent of the interviews were reinterviewed as a quality control measure. In the reinterview, a shorter version of the questionnaires was used. 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 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 serious errors lbund 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 bc detected and corrected at the entry stage, 12 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 eight IBM-compatible microcomputers to process the EDHS questionnaires. During the machine entry 20 percent of each segment was reentered for verification. One of the computers was assigned for this process. Working six days per week in two shifts, the data entry personnel completed the machine entry and editing of the data in three months. Coverage of the Sample Table 1.2 summarizes the results of the household and individual interviews. A total of 11,304 households were selected; of these households, 10,760 were successfully interviewed. As noted, an eligible respondent for the women's survey was defined as an ever-married women between the age of 15 and 49 years present in the household on the night before the interview. A total of 9,978 eligible respondents were identified, and of these women, 9,864 (99 percent) were interviewed. A total of 3,027 men were identified as eligible for the husbands' survey, i.e, they were resident in a household selected for the husband subsample and married to a woman between the ages of 15 and 49. Of the eligible men, 2,466 were sucessfully interviewed (82 percent). Table 1,2 Results of the household and individual interviews Number of households and eligible women and husbands and response rates by urban-rural residence and place of residence, Egypt 1992 Place of residence Urban Lower Egypt Upper Egypt Interview Gover- results Urban Rural notates Total Urban Rural Total Urban Rural Total Households sampled Households found Households interviewed Household response rate Eligible women Eligible women interviewed Eligible woman response rate Eligible husbands Eligible husbands interviewed Eligible husband response rate 6082 5222 3243 4215 1551 2664 3846 1299 2559 11304 5874 5076 3132 4121 1506 2615 3697 1236 2461 10950 5726 5034 3039 4067 1481 2586 3654 1206 2448 10760 97.5 99.2 97.0 98.7 98.3 98.9 98.8 97.6 99.5 98.3 4725 5253 2517 3864 1215 2649 3597 993 2604 9978 4673 5191 2487 3812 1200 2612 3565 986 2579 9864 98.9 98.8 98.8 98.7 98.8 98.6 99.1 99.3 99.0 98.9 1426 1601 773 1175 360 815 1079 293 786 3027 1196 1270 664 947 295 652 855 237 618 2466 83.9 79.3 85.9 80.6 81.9 80.0 79.2 80.9 78.6 81.5 13 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS This chapter describes the general characteristics of the sample population, including age and sex composition, residence, education, housing facilities, household possessions and exposure to mass media. The highlighted factors are those that influence nuptiality, fertility, and contraceptive behavior, as well as maternal care and child morbidity and mortality. 2.1 Characteristics of the Household Population The 1992 EDHS questionnaire included two questions distinguishing between the dejure (persons who are usual residents in the selected household) and the de facto (persons who spent the nigh1 before the interview in the household) populations. This report uses the de facto definition, unless stated othcrwise. Age and Sex Table 2.1 and Figure 2.1 show the distribution of the de facto household population by five-year age groups? according to sex and urban-rural residence. The sex ratio for the population as a whole is 98.5 Table 2.1 Household population by age T residence and sex Percent distribution of the de facto household population by five-year age groups, according to urban rural residence and sex, Egypt 1992 Urban Rural Total Age group Male Female Total Male Female Total Male Female Total 04 12.1 11.4 11.7 16.9 15.3 16.1 14.7 13.5 14.1 5-9 13.0 12.8 12.9 15.8 15.2 15.5 14 5 14.1 14.3 I0-14 13.1 12.5 12.8 14.3 13.2 13.7 13.7 12.8 13.3 15 19 10.4 100 10.2 11.3 10.7 11.0 10.9 10.4 10.6 20-24 7.6 8.7 8.2 6.6 7.8 7.2 7.0 8.2 7.6 25-29 7 5 8.4 7.9 6.5 7.5 7.0 7.0 7.9 7.4 30-34 7.1 7.3 7 2 5.5 6.0 5.7 6.2 6.6 6.4 35-39 5.8 6.8 6 3 4.8 5.2 5.0 5.3 5.9 5.6 40-44 5.9 5.5 5.7 4.0 4.4 4.2 4.9 4.9 4.9 45-49 4.3 4.3 4.3 3.4 3.3 3.4 3.8 3.8 3.8 50-54 3.2 3.5 3.4 2.6 2.9 2.8 2.9 3.2 3.0 55-59 3.1 2 8 2.9 2.5 2.4 2.4 2.8 2.6 2.7 60-64 2.4 2.7 2.5 2.2 2.5 2.4 2.3 2.6 2.4 65-69 2.0 1.5 1.8 1.6 1.6 1.6 1.8 1.5 1.7 7(I-74 1 3 1.1 1.2 1.0 1.2 1.1 1.1 1.1 1.1 75-79 0.6 0.3 (I.4 0.4 0.3 0.3 0.5 0.3 0.4 80 + 11.5 0.5 0.5 0.6 0.6 0.6 0 5 0.6 0.5 Total 100.0 100.0 100 0 100.0 100.0 100.0 100.0 100.0 100.0 Number 13517 13650 27167 15771 16095 31866 29288 29745 59033 1Single-year age distributions are presented in Appendix D, which reviews the quahty of the EDHS data. 15 Age 80+ 75 7.( 70 7~ 65 69 60 64 55 59 50 54 45 49 40 44 35 39 30 34 25-29 20 24 1519 10 14 59 O4 20 Figure 2,1 Population Pyramid of Egypt Male ~ I Female 15 10 5 0 5 10 15 20 Percent EDHS 1992 males for every 100 females. The age pattern is typical of a country with relatively high fertility in the recent past, i.e., a much greater concentration of the population in younger than older age groups. The urban age distribution has a narrower base (i.e, is less concentrated at the younger ages) and a broader spread than the rural distribution; the diffcrcnces in the age distributions lor the two groups are a result of the lower fertility and mortality levels in urban arcas comparcd to rural arcas. Table 2.2 presents the distributions of the dc facto household populations by broad age groups for the 1988 and 1992 DHS surveys. The distributions are nearly identi- cal. Dependency ratios also are shown. The age depend- ency ratio is the ratio of non-productive persons (persons age 0 to 14 and age 65 and over) to persons age 15 to 64. The dependency ratio indicates that, in Egypt, for every person in the productive age groups, there arc 0.8 persons under age 15 or over age 64. Household Size and Composition Table 2.2 Population by age~ 1988 and 1992 Percent dxstnbutxon of the tx)pulation by broad age group. 1988 EDHS and 1992 EDHS 1988 1992 Age group EDHS EDHS Less than 15 41.2 41.7 15-64 55.0 54.6 65+ 3.8 3 7 Household characteristics affect the social and eco- Total 100.0 100.0 nomic well-being of the members of the household. Large I)ependency ratio 81.8 83.2 household size may be associated with crowding, which can lead to unfavorable health conditions. Houschold hcad- ship is another important indicator of household welfare. Households headed by females, usually have limited financial resources. Finally, the data on household composition provide the basis for an analysis of relationship structure, distinguishing nuclear from cxlendcd households. 16 Information on the size and composi- tion of sampled households is shown in Table 2.3. Unlike the two earlier tables, Table 2.3 is based on de jure members, i.e., usual resi- dents. Of all households covered, 12 percent are headed by women. There is almost no dif- ference between urban and rural areas in the percentage of female-headed households. There are, on average, 5.6 persons in an Egyptian household. Only one in eight households includes 2 or less persons, and one in five has 8 or more persons. Urban households are considerably smaller, on aver- age, than rural households (4.9 persons and 6.5 persons, respectively). Many rural house- holds are quite large. For example, around one in three rural households has 8 or more persons compared to only one in nine urban households. Taking account of adult household members age 15 and over only, the large ma- jority of households are composed of two re- lated adults of the opposite sex or of three or more related adults. Single adult households are relatively rare, comprising only 6 percent of all households. In rural areas, there are al- most twice as many households with three or more related adults as households with two related adults (61 percent and 32 percent, re- spectively). In urban areas, households arc more evenly divided between these two types. Only 1 percent of households include foster children, i.e., children under the age of 15 who live in households in which neither their natural mother nor their natural father is resident. Education of the Household Population Table 2,3 Household composition Percent distribution of households by sex of head of household, household size, and relationship structure, and percentage of households with foster children, according to urban-rural residence, Egypt 1992 Characteristic Urban Rural Total Household headship Male 87.4 89.1 88.2 Female 12.6 111.9 11.8 Total 100.0 100.0 100.0 Number of usual members l 5.2 37 44 2 10.3 6.6 8.5 3 12.1 7 9 10 1 4 18.6 11.1 15.0 5 18.6 12.3 15 6 6 14.7 13.6 14.2 7 9.2 12.6 10.8 8 5,3 I0 1 7.6 9+ 5.9 22.1 13.6 Total 100.0 100,0 l(XhO Mean size 4.9 6.5 5 6 Relationship structure One adult 6 1 5.1 5.6 Two related adults' Of opposite sex 42.3 32.2 37.5 Of same sex 1.7 1 5 1.6 Three or more related adults 49.2 611.8 54.7 Other 0.6 0.3 11.4 Total Households with foster children 100.0 1011.11 100.0 12 12 1.2 Number of households 5651 51/19 10760 Note: Table is based on de Jure members, Le,, ususal residents. Foster children are those under age 15 living in households with neither their mother nor their father present. Education has been identified in the literature as an important variable affecting demographic and health behavior. Higher education is usually associated with use of family planning methods and better health practices. The education system in Egypt has evolved over a long period of time. There have been many changes, especially in the number of years of compulsory schooling. Currently, basic education is compulsory for the first 8 years, starting at age six. A further three-year period, known as the secondary 17 stage, is not compulsory. Although many students pay to attend private schools, particularly in urban areas, public education at all levels including universities is free. Tables 2.4.1 and 2.4.2 present data on the educational composition of the population age five and over obtained from the EDHS household questionnaire. The results highlight the gap in educational attainment that exists between men and women in Egypt. Overall, 78 percent of men have attended school compared to only 59 percent of women. The median number of years of schooling for males (5.3 years) is more than twice the median number for females (2.3 years). The improvements that have occurred in public education in recent decades can be examined by looking at the changes in the educational indicators across successive age cohorts (see Tables 2.4.1 and 2.4.2). Both sexes show a rapidly increasing level of education although females continued to lag behind males until recently. For example, the median number of years of schooling for men in the 25-29 age group is 11.5 years compared to 4.0 years for women in the same cohort. In younger cohorts, the sex differentials arc narrower; the gap in the median number of years of schooling is less than four years for the 20-24 age group and less than one year for those under age 20 (sec Figure 2.2). Table 2.4.1 Educational level of the male bousehoJd population Percent distribution of the de facto male household population age five and over by highest level education attended, according to selected background characteristics, Egypt 1992 of Prunary Completed Number Median Background Sonic through secondary/ of number characteristic None prtmary secondary higher Mtssmg Total persons of years Age group 5-9 28,4 71 4 0.1 00 0,0 100.0 4249 I 1 10-14 5.8 42.2 51,9 0.1 0,0 100,0 4025 6,1 15-19 78 127 657 13,8 0.0 1000 3194 9,5 20-24 11 0 11,5 20,4 56.9 0 1 100,0 2(k53 12,2 25 29 14 7 20 5 16,0 48.7 0 1 10011 2036 11 5 31) 34 169 23.// 163 43.7 0 1 1000 1822 8.9 35-39 223 24,7 172 35.8 0.0 1000 1546 6.4 4044 28.9 22,2 17.9 309 0.0 100.0 1430 5.9 4549 365 2011 17.7 259 0.0 1000 1128 52 50-54 42 3 20.8 17 3 19.0 0.5 100,11 846 3.5 55-59 48 9 23.1 I 1.3 16 7 0.0 100.0 810 I 0 60-64 56 1 25 5 9.1 9 4 0.0 100.0 680 0 0 65+ 68,6 15 8 8.2 7 5 0,0 100.0 1165 0 0 Urban-rural residence Urban 15.0 29 0 27.6 28 4 0,0 100 0 11886 6 7 Rural 29 4 33 7 23 4 13,5 0 (I 100 0 131 I0 4 0 ]>lace of residence Urban Governorates 13.6 284 29.1 28.9 00 1000 6130 6.9 Lower Egypt 22.9 32.6 25.8 18.6 0,0 1000 10474 5 2 Urban 14.7 3113 277 27.3 00 1000 3130 6.6 Rural 26 5 33 6 25.0 14.9 0 0 100,0 7344 4.5 Upper Egypt 28.6 32 2 22 3 16.9 0 I 100,0 8392 4.2 Urban 18 5 28 9 24.1 28 4 0.1 l 1)0 (I 2626 6.4 Rural 33 2 33 7 21 4 11.7 0 0 100 0 5765 3.2 Total 22 5 31 4 25 4 20 6 0.0 1 (R) 0 24995 5 3 18 Table 2.4.2 Educational level of the female household population Percent distribution of the de facto female household population age five and over by highest level of education attended, according to selected background characteristics, Egypt 1992 Primary Completed Number Median Background Some through secondary] o[ number characteristic None primary secondary higher Missing Total persons of years Age group 5-9 37.6 62.4 0.0 0.0 00 11~) 11 4199 09 10-14 16.0 35.9 48.1 0.0 0.0 100.0 3819 5.4 15-19 23.6 11.0 51.6 13.7 0.0 100.0 30911 8.9 20-24 33.9 I 1.7 12.7 41 7 0.0 100 0 2445 8 4 25-29 40,8 18.8 10.0 30 5 0.0 100 0 2355 4.0 30-34 42.1 24 2 8.5 25.2 0.0 100.0 1956 3.1 35-39 464 25.1 10.1 18.4 0.0 100.0 1768 2.3 40-44 53.6 22.9 10,9 12.5 0.1 100.0 1457 0,0 45-49 59.1 20.7 I 1,8 8.4 0.0 100 0 1131 011 50-54 65 6 22.4 6.0 6.0 0.0 100.0 948 0.0 55-59 70.7 21.3 4.0 3.9 0 2 100.0 759 0 0 60-64 76.6 17.0 4 5 1 8 t) 0 It)0 t) 763 t) 0 65+ 88.1 8,0 2 3 I 4 0 3 100 0 1040 0 0 Urban-rural residence Urban 26.0 29.2 23 2 21.6 0.0 100 0 12(~16 5 0 Rural 53,7 26.4 14,3 5.6 00 1000 13638 00 Place of resJdence Urban Governorates 23.9 27.9 24.8 23.4 0 0 100.0 6089 5.7 Lower Egypt 40.2 29 8 18.8 11.2 0.0 100.0 111773 2.2 Urban 26.3 31.5 22.0 20.1 0.0 1 (X).tl 3173 4 6 Rural 46,0 29.1 17.4 7 4 01) 100 0 76(X) 1 0 Upper Egypt 52 7 25.1 13.8 8.4 0.0 100.0 8872 0.0 Urban 30.0 29.4 21.2 19.4 0.0 100.0 2834 4.2 Rural 63 3 23.1 10.4 3.2 0 0 100 0 6038 0 0 Total 40.7 27.7 18.5 131 00 1000 25733 23 There is a notable difference in educational attainment between urban and rural residents. The median number of years of schooling for urban men is 6.7 years, almost 3 years more than for rural men. The differential is even greater for females. On average, urban women have spent 5 years in school compared to less than 1 year among rural women. By place of residence, the Urban Govornorates show the highest medians and rural Upper Egypt the lowest medians for both females and males. The low level of educational attainment of women in rural Upper Egypt is particularly striking. For example, while around half of women in rural Lower Egypt have attended school, only about one-third of women in rural Upper Egypt have gone to school. School Enrollment Table 2.5 presents the percentage of the household population 6-24 years of age who are enrolled in school. Around eight in ten children age 6-15 are enrolled in school. Enrollment after age 15 drops substantially; only 43 percent of the population age 16-20 are attending school and, among those in their early twenties, only 11 percent are still in school. School enrollment rates are higher for urban than rural residents, particularly among those age 16 and over. 19 Figure 2.2 Median Number of Years of Education by Sex and Age M~d,.lrl ye,lrc of F,du, 311c/q 14 12 18 5-9 ~0 ]4 15 19 2c%24 25 29 30 34 35-39 40 4,1 45 49 50 54 ~ 5.a f)ll ('}4 Age : bHS 1992 Table 2.5 School enrollment Percentage of the de facto household population age 6-24 years enrolled m school, by age group, sex, and urban rural residence, Egypt 1992 Male Female Total Age group Urban Rural Total Urban Rural Total Urb~m Rural Total 6-10 92.5 86.0 88.7 92,0 68.1 78.2 92.2 77.0 83.5 11 15 83.6 73.6 77.9 84.0 56.1 68.3 83.8 65.1 73.3 6 15 88.1 80.0 83.5 88.2 62.5 73.6 88 2 71.4 78.6 16-21/ 58 3 43.8 511.4 53.4 23.3 36.7 55 8 33.3 43.5 21-24 19.4 10 4 15.0 12.9 2.4 7.7 16.0 6 1 11.1 In the population as a whole, males are more likely than females to be enrolled in school in all age groups, with the differential being greatest for the 16-20 age group. Sex differentials in school enrollment are less noticeable for urban residcnts than for rural residents. 20 2.2 Household Environment The EDHS household questionnaire obtained information on basic housing characteristics and household possessions. These data contribute to an understanding of the economic status of the household and environmental conditions in which the EDHS respondents live. Housing Characteristics Table 2.6 presents the distribution of households by selected housing characteristics. Availability of electricity, source of drinking water, type of sanitation facilities, type of flooring material, and persons per sleeping mom are aspects of the household environment that relate to the socio-economic level of the household and may have important influences on the health status of household members, especially children. Overall, more than 90 percent of households in Egypt have electricity. Rural households are somewhat less likely to have electricity in all or part of their dwelling than are urban households (88 percent and 98 percent, respectively). By place of residence, the percentage of bouseholds with electricity varies from 83 percent in rural Upper Egypt to 99 pei'cent in the Urban Govemorates. Both access to safe drinking water and adequate sanitation facilities are important determinants of health conditions. In Egypt, four-fifths of all households have access to piped water, primarily in their residence, although 10 percent rely on a public tap. Most of the remaining households use well water; less than 5 percent obtain drinking water from the Nile, canals or other sources. In urban areas, virtually all households have piped water, but in mraI areas, only 61 percent of households have access to piped water. By place of residence, piped water is universally available to households in the Urban Govemorates. Households in Lower Egypt arc somewhat more likely to have access to piped water than those in Upper Egypt (76 percent and 69 percent, respectively). Households in rural Upper Egypt are the least likely to report use of piped water for drinking; only 56 percent have piped water, and about a third of these households obtain water from a public tap. Table 2.6 also presents inlormation on sanitation facilities. Overall, only 27 percent of households have modem flush toilets, 47 percent have traditional toilets, mainly with bucket flush, and 9 percent have no facilities. Among urban households, the variation in the percentage without toilet facilities is small, from less than 1 percent in the Urban Govemoratcs to 5 percent in urban areas in Upper Egypt. However, households in rural Upper Egypt are flvc times more likely than households in mral Lower Egypt to have no toilet facilities (32 percent and 6 percent, respectively). Regarding types of flooring material, one in two households live in dwellings having cement tile floors, 15 percent have cement floors, and threc in tcn have earttVsand floors. Earth/sand floors are more common in rural areas (60 percent), especially rural Upper Egypt (75 percent), than in other areas. Rural households are also more likely to have cement rather than cement tile floors. Cement tiles are the most common flooring material in urban dwellings, especially in the Urban Govcmorates (80 percent). It should be noted that the percentage of households in urban Upper Egypt living in dwellings with earth/sand floors is 16 percent, more than twice that in urban Lower Egypt (6 percent). Information on the number of rooms that a household used for sleeping was collected in order to provide a measure of crowding. Table 2.6 reveals that 50 percent of households had one or two persons per sleeping room, and a third had three to four persons per sleeping room. The overall mean is 3 persons per sleeping room. Urban households appear to be somewhat less crowded than rural households; the mean number of persons per slecping room is 2.7 in urban areas compared to 3.4 in rural areas. By place 21 Table 2.6 Housing characteristics Percent distribution of households with eligible women by housing characlerislics, according to urba~l-rural residence and place of residence. Egypt 1992 Characteristic Urban Rural Urban Lower Egypt Upper Egypt Gover- norates Total Urban Rural Total Urban Rural Total Electricity Yes, in all 97.4 83.4 98.2 92.3 97.9 89.2 82.9 94.9 76.2 90.7 Yes, in part 1.0 4.5 0.6 2.3 1.1 2.9 4.8 1.9 6.5 2.7 No 1.6 12.1 1.2 5.4 1.0 7.8 12.3 3.2 17 3 6.6 Total 100.0 IO0.O lO0+O 100.0 100,0 100.0 100.0 100.0 100,o 100.0 Source of drinking water Piped water 96.9 61.1 99.3 76.3 97.9 64.8 68.7 911.4 56.6 79.9 Piped into residence 91.8 44.9 95,2 65.7 94.2 50.6 53.6 81.7 38.0 69.6 Public tap 5.1 16.2 4.1 10.6 3.7 14.3 15.1 8.7 18.6 11/.4 Well water 1,9 30.4 0.3 17.2 0.8 26.0 25.5 6.9 35.8 15.4 Well in residence 1.4 16.0 0.2 9.1 0.7 13.6 14 1 5.3 19.11 8.4 Public well 0.5 14,4 0.1 8.1 0 1 12 4 11.4 1.7 16.8 7 1 Nile/canal 0.1 5.5 0.1 4 6 0,0 7.(I 2.4 0.2 3.7 2.7 Other 1.1 3.0 0.3 1.9 1.3 2.2 3.4 2.5 3.9 2.0 Total 100.0 1 (~1.0 100.0 100.0 100.0 I i)0,0 100.1) 1 iX).0 100 0 100.0 Sanitation facility Modem flush toilet 46.3 5.7 57.6 16.7 35.1 6.9 14.9 34.1 4.2 27.0 Traditional w/tank flush 3.7 1,5 3.4 2.3 3.7 1.5 2.6 4.5 1.4 2.7 Traditional w/bucket flush 44.7 50.2 36.6 61.9 57.8 64.1 38.4 47.5 33.3 47.3 Pit toilet/latrine 3.6 24.3 2.0 14.2 1.9 21/.8 21 7 9.3 28.6 13.4 Barrel/tank 0.1 0,3 0.0 0.5 0.3 0.6 0.0 0.1 0.0 0.2 No facility 1.6 17.9 0.5 4.4 1.1 6 1 22.4 4.5 32 3 9.3 Other 00 0.1 0.0 0.0 0.0 0,1 0.1 0.0 0.2 0.1 Missing 0.0 0.0 0.0 0.0 0.1 0.0 0 0 0.1) 0.0 0.0 Total 100.0 100.0 100,0 100,0 100.0 100.0 11)00 100,(i 100.0 100,0 Flooring Earth/sand 5.7 60.1 1.0 33.4 5.8 48 1 53.7 16,2 74 6 31.5 Parquet/polished wood 1.9 0.1 1.9 0.9 2.2 0.2 0.6 1.5 11.1 1.0 Ceramic tiles 0.5 0.1 0.5 0.2 0.5 0.0 0 3 0.5 0.2 0.3 Cement tiles 75.8 18.4 79.8 41.0 73 3 23.8 32.4 69.5 11.7 48.5 Cement 9.6 20.9 8.6 21.8 I 1.8 27.2 l 1.8 9.4 13.2 15.0 Wall-to-wall carpet 4.7 0.3 5.7 1.9 4.5 0.5 I).9 2.5 0.1 2.6 VinyI 1.8 0.1 23 0.7 1.7 0.1 I).2 0.6 0.11 1.0 Other 0.1 0.1 0.1 0.0 0.1 0.0 11.1 I).0 0.1 0.1 Missing 0.1 0.0 0.2 0.0 0.0 0 0 0.0 0.0 ii 0 0.1 Total 100.0 100.0 100.0 100.0 100.0 1000 I110.0 1 (it).() 100.0 100.11 Persons per sleeping room 1-2 59.9 39.3 60.1 49.8 62.7 42.9 42.5 56.2 34.9 50.1 3-4 31.3 43.9 31.1 39,7 29.8 45./) 39.4 33 4 42.7 37.3 5-6 6.3 12.2 6.4 8.3 5.5 9.7 12.2 6.8 15 2 9.1 7 + 2.5 4.6 2.3 2.2 2.0 2.4 5.9 3 5 7.2 3.5 100.0 100.0 100.0 100.1) 3.4 2.7 3.0 2.6 5109 2879 4299 1492 Total 100.0 Mean persons per room 2.7 Number of households 5651 ] 00 0 100. 0 ] 00 .0 100 (,I 100. 0 3.1 3 3 2.9 3.6 3.0 2806 3582 12811 2302 10760 22 of residence, the mean varies from a low of 2.7 in the Urban Govemorates to a high of 3.6 in rural Upper Egypt. The latter mean is significantly greater than the mean for rural Lower Egypt (3.1), suggesting that rural households in Upper Egypt experience greater crowding than those in Lower Egypt. Household Durable Goods and Other Property Table 2.7 provides information on household ownership of major durable goods and other property. With regard to durable goods, around eight in ten households in Egypt own a television, seven in ten own a washing machine, and more than half own a radio, a cooking stove and a refrigerator. There are striking differences between urban and rural areas in the percentage of households possessing various durable goods. For example, only two-thirds of rural households own a television compared to 96 percent of urban households. The largest urban-rural differential is observed in the case of cooking stoves; 83 percent of urban households have stoves, compared to only 27 percent of rural households. Households in rural Upper Egypt are the least likely to possess any of the durable goods (with the exception an electric fan). Table 2.7 Household durable goods Percent distribution of households possessing various household effects, means of transportation, property and farm animals/implements, according to urban-rural residence and place of residence, Egypt 1992 Characteristic Urban Urban Lower Egypt Upper Egypt Gover- Rural norates Total Urban Rural Total Urban Rural Total Household effects Radio 72.0 50.7 76.8 61.7 68.5 58 1 50.1 65 1 41 7 61.9 Television 95.6 67.5 99.5 81.8 93.4 75.6 68.9 89.2 57.5 82.2 Video 10.6 0.9 14.1 2.9 6.6 0.9 3.2 7.3 0.9 6.0 Electric fan 64.7 30.4 68.1 37.5 56.4 27.5 45.7 66.9 33.9 48.4 Cooking stove 82.7 27.4 90.6 51.5 78.1 37.3 35.1 70.4 15.4 56.5 Water heater 41.3 5.5 50.0 15.0 31.9 6.1 14.9 33.0 4.8 24.3 Refrigerator 78.2 29.5 84.3 44.8 71.9 30.4 43.8 71.7 28.4 55.1 Washing machine 86.6 52.3 89.8 73.7 87.6 66.3 50.4 78.0 35.2 7(I.3 Sewing machine 25.0 10.9 26.0 17.1 24.8 12.9 13.5 22.7 8.5 18.3 Means of transportation Bicycle 12.4 13.3 8.2 14.2 14.3 14.1 14.9 19.4 12.4 12.8 Car/mormcycle 9.4 3.1 11.4 4.1 5.4 3.4 5.1 9.4 2.8 6.4 Bus/minivan/other vehicle 2.2 2,0 2.0 2.4 2.3 2.5 1.9 2.6 1.5 2.1 Property Residential/commercial bldg. 9.6 6.1 7.6 8.0 12.0 5.9 8.0 11.1 6.3 7.9 Farm/other land 6.3 38.9 3.4 29.2 10.1 39.4 27.6 8.0 38.4 21.8 Farm animals/implements Livestock/poultry 10.4 61.6 3.3 47.5 18.7 62.8 44.6 16.8 60.1 34.7 Farm implements 1.0 6.0 0.3 5.3 2.4 6.8 3.6 0.8 5.1 3.4 Number of households 5651 5109 2879 4299 1492 2806 3582 1280 2302 10760 With respect to ownership of a means of transportation, only 13 percent of households own a bicycle, and 6 percent or less report owning a car or motorcycle or other vehicle (bus, minivan, etc.). Urban households are more likely to own a car or motorcycle than rural households. 23 The EDHS also collected information on ownership of residential and commercial buildings and of farms or other land. Overall, only one in thirteen households in Egypt own residential or commercial property, and only one in five own a farm or other land. As ex- pected, rural households have an advantage with respect to the ownership of a farm or other land and urban households are some- what more likely to own residential/commer- cial buildings. Among rural households, how- ever, only two in five own any land, and only one in ten urban households own residential or commercial property. Finally, the EDHS collected informa- tion on the possession of livestock and poul- try and of mechanized farm equipment (e.g., a tractor), Overall, 35 percent of all house- holds in Egypt own livestock or poultry. The labor intensive nature of farming is evident in the fact that only 3 percent own mechanized farm equipment. Rural households are more likely to report ownership of these items than urban households. Six in ten rural households own livestock or poultry, and 6 percent own mechanized farm equipment. 2.3 Background Characteristics of Survey Respondents General Characteristics Table 2.8 presents the distribution of the respondents to the women's questionnaire by selected background characteristics, in- cluding age, marital status, residence, educa- tion, religion and employment status. The questionnaire was administered to ever-mar- ried women age 15-49. Of the ever-marricd women in the sample, 93 percent are cur- rently married, 5 percent are widowed and 2 percent are divorced. Table 2.8 Background characteristics of respondents Percent distribution of ever-married women by selected background characteristics, Egypt 1992 Number of women Background Weighted Un- characteristic percent Weighted weighted Marital status Married 92.8 9153 9148 Widowed 5.2 510 508 Divorced 2.0 201 208 Age group 15-19 4.3 423 437 20-24 13.8 1362 1384 25-29 20.4 2013 1993 30-34 18.6 1838 1819 35-39 17.3 1709 1721 40-44 14.3 1411 1404 45-49 11.2 l 108 l 106 Urban-rural residence Urban 46.6 4596 4673 Rural 53.4 5268 5191 Place of residence Urban Governorates 23 9 2357 2487 Lower Egypt 41.2 4067 3812 Urban 12.3 1210 120(/ Rural 29.(I 2857 2612 Upper Egypt 34.9 3440 3565 Urban 10.4 1029 986 Rural 24.4 2411 2579 Education No education 48.4 4771 4638 Some primary 21.1 2078 2096 Primary through secondary 11.1 1093 1160 Completed secondary/hxgher 19.5 1922 1970 Work status Working for cash 14.8 1464 1447 Not working for cash 85 2 8400 8417 Religion Muslim 94.5 9317 9320 Christian 5.5 547 544 All women 100.0 9864 9864 Two questions were used in the individual questionnaire to ascertain the age of respondents: "In what month and year were you born?" and "How old were you at your last birthday?" Interviewers were trained to probe in those situations where respondents did not know their age or date of birth; and, as a last resort, interviewers were instructed to record their best estimate of the respondent's age. The five-year age distribution for respondents is shown in Table 2.8. The percentages in the 15-19 and 20-24 age groups are smaller than the percentages in the 25-29 group; this reflects the fact that the EDHS interviewed an ever-married sample and that there has been a trend toward delaying marriage in Egypt. This trend is described in detail in Chapter 9. 24 At the time of the survey, the majority of respondents were living in rural areas, while 47 percent lived in urban areas. By place of residence, 41 percent resided in Lower Egypt, 35 percent in Upper Egypt, and 24 percent in one of the four Urban Governorates. Table 2.8 shows the distribution of the respondents according to the level of education attained. Almost one in two respondents has never attended school, around 21 percent attended but did not complete the primary level, 11 percent completed the primary level and/or some secondary, and 20 percent completed the secondary or higher level. Table 2.8 also examines the extent to which respondents reported that they were working at a job for which they were paid in cash. Such employment is assumed to compete with childbearing and child- rearing. Only one in seven respondents is working at a job for which she is paid cash. Nearly all of the respondents are Moslems. Only 6 percent are Christian. Differentials in Education Table 2.9 gives an overview of the relationship between the level of education and other back- ground characteristics. The relationship between age and education is not uniform. The proportion of respondents with no education exhibits a U-shaped curve with age. The higher proportion of women who Table 2.9 Levelofeducation Percent distribution of ever married women by highest level of education attended, according to selected background characteristics, Egypt 1992 Level of education Primary Completed Number Background Some through secondary/ of characteristic None primary secondary higher Total women Age group 15-19 53.3 16,7 24.4 5.6 100.0 423 20-24 48.1 14.8 12.4 24.7 100.0 1362 25-29 44.1 19.4 9.7 26.9 I00.0 2013 30-34 42.4 24.3 8.6 24.7 100.0 1838 35-39 46.8 25,1 10.3 17.8 100.0 1709 40-44 54.0 22.5 11.2 12.3 100.0 1411 45-49 59.7 20.0 12.2 8.1 100.0 1108 Urban-rural residence Urban 29,5 22.8 15.8 31.8 100.0 4596 Rural 64.8 19.5 6.9 8.7 100.0 5268 Place of residence Urban Govemorates 27.2 22.4 17.1 33.4 100.0 2357 Lower Egypt 51.3 21.3 10.6 16.8 100.0 4067 Urban 30.0 24.1 16.9 28.9 100.0 1210 Rural 60 3 20.2 7.9 11.6 I00.0 2857 Upper Egypt 59 4 19.8 7.6 13.2 100.0 3440 Urban 34.4 22.3 11.7 31.6 100.0 1029 Rural 70.1 18.8 5.8 5.3 IO0.O 2411 Work status Working for cash 21.2 10.0 4.6 64.2 100.0 1464 Not working for cash 53.1 23.0 12.2 11,7 100.0 8400 Total 48.4 21.1 11.1 19.5 100.0 9864 25 never attended school in the 15-19 and 20-24 age groups than in the 25-29 group should not be interpreted as a decline in educational attainment among young females. Since only ever-married women were interviewed, the respondents in the 15-19 and 20-24 age groups include a disproportionate share of women who married early and, thus, were likely to have lower educational levels than women in the age cohort as a whole. The level of education varies greatly according to residence. Nearly two-thirds of rural women never attended school compared to 30 percent of urban women, and more than three times as many urban women as rural women have completed the secondary level (32 percent and 9 percent, respectively). By place of residence, the percentage who have never attended school is somewhat greater among women living in urban areas in Lower Egypt (30 percent) and Upper Egypt (34 percent) than among women in the Urban Govemorates (27 percent). Among rural women, the regional differences arc greater, 70 percent of women in rural Upper Egypt have never attended school compared to 60 percent in rural Lower Egypt (see Figure 2.3). As expected, working for cash is associated with higher educational atlainment. The percentage of working women with at least some secondary education is 64 percent compared to only 12 percent among women who are not working. Figure 2,3 Percentage of Ever-Married Women with No Education, by Place of Residence Percenl 80 60 40 20 / 0 ~ Urban Total Urban Rural Total Urban Rural Governorates Lower Egypt Upper Egypl EDHSt992 Access to Media Women were asked if they usually read a newspaper at least once a week and the number of hours that they listened to the radio and television each day. This information is important because it provides an indication of the level of exposure of women to the mass media, which are used to convey family 26 planning and health messages to the population. Table 2.10 shows that 25 percent of ever-married women read a newspaper at least once a week, 82 percent watch television daily and 67 percent listen to the radio daily. The relationship between age and exposure to mass media is not strong; however, the youngest and the oldest age groups are the least likely to be exposed to either print or broadcast media. Reflecting lower literacy levels, rural women are much less likely to report that they read a newspaper weekly. They also are less likely to be exposed to television or radio on a daily basis. By place of residence, women residing in the Urban Govemorates are more likely to have been exposed to media than their counterparts in Lower Egypt and Upper Egypt. Women in rural Upper Egypt are the group that is least exposed to any of the mass media. As expected, there is a positive association between exposure to mass media and level of education, particularly with regard to exposure to print media. Concerning work status, women who are working for cash are more likely to be exposed to the various media than women who do not work. This probably is due at least in part to the association between education and employment discussed earlier. Table 2.10 Access to mass medna Percentage of ever-married women who usually read a newspaper once a week, watch television daily, or listen to the radio daily, by selected background characteristics, Egypt 1992 Read Watch Listen to Number Background newspaper television radio of characteristic weekly daily daily women Age group 15-19 12.6 80.0 62.6 423 20-24 24.7 81.8 68.1 1362 25 29 29.1 84.6 70.0 2013 30-34 28.0 82.9 66.0 1838 35-39 23.7 81.7 65.7 1709 40-44 21.7 82.1 65.1 1411 45-49 19.1 80.1 63.9 1108 Urban-rural residence Urban 41.5 91.0 77.1 4596 Rural 9.7 74.8 57.4 5268 Place of residence Urban Governorates 45.7 92.7 82,1 2357 Lower Egypt 19.7 85.7 70.4 4067 Urban 38.7 93.5 77.3 1210 Rural 11.7 82.4 67,5 2857 Upper Egypt 15 6 71.2 51.3 3440 Urban 34.9 84. [ 65.3 I029 Rural 7.3 65.7 45.3 2411 Education No education 0 4 73.3 54.7 4771 Some primary 12.7 85.6 68.4 2078 Primary through secondary 52.8 93.5 79,6 1093 Completed secondary/higher 8(I.8 95.0 86.6 1922 Work status Working for cash 59.6 87.5 76.1 1464 Not working fur cash 18.4 81.4 64.9 8400 Total 24.5 82.3 66.5 9864 27 CHAPTER 3 FERTILITY The fertility measures presented in this chapter are based on the retrospective reproductive histories of women age 15-49 interviewed in the Egypt DHS survey (EDHS). In collecting these histories, each woman was asked the number of sons and daughters living with her, the number living elsewhere, and the number who had died. She was then asked for a history of all her births, including the month and year each child was born, name, sex, and if dead, the age at death, and if alive, the current age and whether the child was living with the mother. Based on this information, measures of current fertility and cumulative fertility are examined. 3.1 Current Fertility Measures of Current Fertility The level of current fertility is the most important topic in this report because of its direct relevance to population policies and programs. Several measures of current fertility, including age-specific fertility rates, the total fertility rate, the general fertility rate, and the crude birth rate are presented in Table 3.1 for the three-year period preceding the survey, a period covering principally the calendar years 1990-1992. The three-year period was chosen for calculation of these rates (rather than a shorter or longer period) as a compromise between three criteria: to provide the most current information, to reduce sampling error, and to avoid problems of the displacement of births. Age-specific fertility rates are useful in order to understand the age pattern of fertility. Numerators of age-specific fertility rates are calculated by isolating live births which occurred in the 1-36 months preceding the survey (determined from the date of interview and date of birth of the child), and classifying them by the age (in five-year age groups) of the mother at the time of birth (determined from the date of birth of mother). The denominators of these rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. Although information on fertility was obtained only for ever-married women, the age-specific rates are presented for all women (regardless of marital status); data from the household questionnaire on the age structure of the population of never-married women is used to calculate the all-women rates. This procedure assumes that women who have never been married have had no children. The total fertility rate (TFR) shown for women 15-49 and women 15-44 is a useful means of examining the overall level of fertility. The TFR is calculated by summing the age-specific fertility rates. It can be interpreted as the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed rates. ~The distribution of all children by calendar year of birth shows a slight deficit of b~rths in calendar year 1987 and an excess of births in calendar year 1986 (see Table D.4). The apparent transference of births out of 1987 was greater for dead children than for living children. This pattern has been noted in other DHS surveys; it is believed to be the result of transference of births by interviewers out of the period for which the health and calendar data were collected (January 1987 through the date of the survey). 29 Table 3.1 Current fertility Age-specific arid cumulative fertility rates and the crude birth rate for the three years preceding the survey, by urban- rural residence and place of residence, Egypt 1992 Urban Lower Egypt Upper Egypt Gover- Age group Urban Rural notates Total Urban Rural Total Urban Rural Total 15-19 28 89 24 54 23 64 98 42 122 63 20-24 145 269 121 222 164 247 258 179 295 208 25-29 188 256 188 215 171 235 259 205 287 222 30-34 130 180 121 133 123 137 208 160 231 155 35-39 64 117 56 77 60 85 135 89 161 89 40-44 26 61 26 37 19 45 66 37 82 43 45-49 2 10 2 5 0 7 11 3 15 6 TFR 15-44 2.9t 4.86 2.68 3.69 2.80 4.07 5.12 3.56 5.89 3.90 TFR 15-49 2.92 4.91 2.69 3.72 2.80 4,10 5,18 3,58 5,97 3.93 GFR 98 169 92 128 96 141 177 117 205 136 CBR 23,3 35.0 21.9 28.4 22.8 30.7 36.2 27.1 40.l 29.7 Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. TFR: Total fertility rate expressed per woman GFR: General fertility rate (births divided by number of women 15 44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population The general fertility rate (GFR) represents the annual number of births in a population per 1,000 women age 15-44. The crude birth rate (CBR) is the annual number of births in a population per 1,000 persons. Both these measures are estimated using the birth history data for the three-year period before the survey and the age-sex distribution of the household population. Fertility Levels Current fertility estimates are presented in Table 3.1 for Egypt as a whole and for major geographic areas. The total fertility rate indicates that, if fertility rates were to remain constant at the level prevailing during the period 1990-92, an Egyptian woman would bear 3.9 children during her lifetime. In rural areas, the TFR is 4.9 births per woman, two children higher than the rate for urban areas (2.9 births per woman). Considering the variation by place of residence, the TFR for the Urban Govemorates (2.7 births) is one child lower than the rate for Lower Egypt (3.7 births) and more than two children lower than the level for Upper Egypt (5.1 births). Of particular note is the much higher fertility in rural Upper Egypt than in rural Lower Egypt (see Figure 3.1). Women in rural Upper Egypt are having an average of six births, almost two births more than women living in rural areas in Lower Egypt. There is also a significant but much smaller differential in the urban fertility rates between the two regions. According to the EDHS results, the crude birth rate for the period 1990-92 was 29.7 births per 1,000 persons, and the general fertility rate for the same period was 136 births per 1,000 women. Residential differentials in these fertility measures exhibit a pattern similar to the differentials in the TFR, with the lowest levels observed in urban areas, particularly the Urban Govemorates, and the highest levels found for rural Upper Egypt. 30 Figure 3,1 Total Fertility Rates by Place of Residence BirThs per woman 6] 41 37 / Total Urban Rural Urban To~al Urban Rural Governorates Lower Egypl Upper Egypl EDHS1992 Age Pattern of Fertility The age pattern of fertility indicates that Egyptian women have children early in the childbearing period. At the current age-specific rates shown in Table 3.1, an Egyptian woman will have given birth to 1.4 children---more than one-quarter of her lifetime births--by age 25 and to 2.5 births--more than 6(I percent of her lifetime births~by age 30. The age pattern of fertility varies somewhat by residence, with the peak childbearing years coming somewhat later among urban women compared to rural women. As Figure 3.2 shows, urban age-specific fertility rates are highest in the 25-29 age group (188 births per 1,000 women), followed closely by the rate for the 20-24 group (145 births per 1,000 women). Rural fertility rates peak among women 20-24 (269 births per 1,000 women), followed closely by the rate for women 25-29 (256 births per 1,000 women). The results in Table 3.1 and Figure 3.1 also show that fertility levels among teenagers and women age 35 and over are substantially higher in rural areas than in urban areas. For example, at current levels, only one in thirty-five urban women 15-19 would give birth annually compared to around one in eleven rural women. Age-specific rates among women age 35 and over are twice as high in rural as in urban areas. The urban-rural differentials in fertility for these groups are particularly significant since women 15-19 and age 35 and over have been shown to have the highest risks of pregnancy-related morbidity and mortality. 31 300 Figure 3.2 Age-specific Fertility Rates by Urban-rural Residence Births per 1 000 women 25O 20O 1 5O 100 50 0 15-19 20 24 25-29 30 34 35-39 40 44 45-49 Age EDHS1992 Fertility Trends and Differentials Table 3.2 presents current total fertility rates and the mean number of children ever bom (CEB) to women age 40-49 (completed fertility) for major subgroups of the population. Although vulnerable to understatement of parity by older women, comparisons of completed fertility among women aged 40 or more with the total fertility rate provide an indication of the direction and the magnitude of fertility change in Egypt during the past 20-25 years. Overall, the results in Table 3.2 suggest that there has been a decline of more than 30 percent in fertility levels in Egypt during this period. The substantial residential differentials in current fertility described above are also evident in the completed fertility measures. The fertility decline implied by a comparison of the TFR with completed fertility has been relatively faster in the Urban Govemorates and Lower Egypt than in Upper Egypt. Differentials by education and work status are notable. The level of fertility is negatively associated with educational attainment. Women who completed secondary school or higher have the lowest level of current fertility (2.9 births per woman) while those with no education have the highest level (5.0 births per woman). Moreover, there is a difference of almost one child between the TFR for women with some primary education and the TFR for women who completed the primary level but not the secondary level. Lower fertility has apparently characterized women with a secondary or higher education Ior some time; the TFR for the three-year period before the survey is virtually identical to the mean number of children ever born to women 40-49. 32 Table 3.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey and mean number of children ever born to women age 40-49, by selected background character- istics, Egypt 1992 Mean number of children Total ever bom Background fer tihty to women characteristic rate I age 40-49 Residence Urban 2.91 4.66 Rural 4.91 6.84 Region Urban Govemorates 2.69 4.44 Lower Egypt 3.70 5.81 Urban 2.80 4.64 Rural 4.10 6.37 Upper Egypt 5.17 6.72 Urban 3.58 5.29 Rural 5.97 7.46 Education No education 5.03 6.45 Some primary 3.98 5.73 Primary through secondary 3.03 4.60 Completed secondary/higher 2.91 2.91 Work status Working for cash 2.90 4.05 Not working for cash 4.1(/ 5.98 Total 3 93 5.71 IWomen age 15-49 years Current fertility levels arc lower among women working for cash than among those who are not working for cash. Working women have also clearly been at the forefront of the transition to lower fertility for a long period of time; completed fertility among working women 40-49 is nearly two children lower than the completed fertility among women who were not working for cash. Table 3.3 examines the trend in fertility in Egypt by comparing the results of the EDHS with those of earlier surveys. Fertility levels in Egypt have steadily declined, from 5.3 births per woman in the late 1970s to 4.4 births for the period 1988-91, 4.1 births for the period 1990-91 and 3.9 births for the period 1990-92 (see Figure 3.3). 33 Table 3.3 Trends in fertility Age-specific fertihty rates (per 1,000 women) and total fertdity rate, Egypt 1979-1992 EFS ECPS EDHS EMCHS EDHS 1979- 1983- 1986- I990- i990 Agegroup 19801 19841 19882 19911 19922 15-19 78 73 72 73 63 20-24 256 205 220 207 208 25-29 280 265 243 235 222 30-34 239 223 182 158 155 35 39 139 151 118 97 89 40-44 53 42 41 41 43 45-49 12 13 6 14 6 TFR 15-49 5.28 4.85 4.41 4.13 3.93 TFR 15-44 5 22 4.79 4.38 4.06 3.91) tRates are R,r the 12-month period preceding the survey 2Rates are for the 36-month perkxl preceding the survey Source: EFS - Hallouda et al., 1983, Volume I1, Table 4.16 1984 ECF'S - Unpublished results 1988 EDHS - Sayed et al., 1989, Table 3 2 EMCHS - AbdeI-Azeem et al, 1993, Table 7.14 B~rths per woman Figure 3.3 Total Fertility Rates Egypt 1979-1992 1979 1980 1983 1984 1986 1988 1990 19!)1 1990 1992 34 Finally, further evidence of the decline in fertility is found in Table 3.4, which pmsenLs age-specific fertility rates for successive five- year periods, using data from the respondents' birth histories. The age-specific schedule of rates is progressively truncated 2 as the time before the survey increases. The results in Table 3.4 and Figure 3.4 confirm that fertility has fallen substanti',dly among all age groups, with the most rapid decline occurring in the 15-19 age group. Overall, the cumulative fertility rate for women 15-30 decreased by 27 percent, from 3.6 births per women during the period 15-19 years before the survey to 2.6 births per women in the five-year period preceding the EDHS. The decline clearly gained momentum during the ten-year period immediately before the survey. Table 3.4 Age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, by mother's age, Egypt 1992 Number of years preceding the survey Mother's age 0 4 5 9 10-14 15-19 15-19 69 112 124 135 20-24 224 258 287 278 25-29 231 271 292 308 30-34 170 208 245 [243] 35-39 102 134 [1641 40-44 45 [49] 45-49 151 Note: Age-specific fertility rates are per 1,000 women. Estimates enclosed in brackets are truncated. Figure 3.4 Age-specific Fertility Rates for 5-year Periods Preceding the Survey Births per 1,000 women 350 30O 25O 2O0 150 100 ~ I 5O 0 15 19 i i i i i 20 24 25-29 30-34 35-39 40-44 45-49 Age EDHS1992 2The rates are truncated because they do not include the fertility experience of women who were m the childbearing ages daring the period for which the rates are calculated but who were age 50 or older at the time of the EDHS and, thus, not interviewed in the EDHS. 35 Table 3.5 presents fertility rates forever-married women by duration since first marriage for five-year periods preceding the survey. These rates are similar to the ones presented in Table 3.4 and are subject to similar problems of truncation. Declines are observed in the rates for all marriage durations, with the declines being greater at longer marriage durations. For example, during the ten-year period before the survey, fertility rates declined by only 4 percent among the women married less than five years compared to 33 percent among women married 20-24 years. Table 3.5 Fertility by marHal duration Fertility rates fi~r ever-married women by duration since first marriage in years, for five-year periods preceding the survey, Egypt 1992 M arri age duration at birth Number of years preceding the survey 0-4 5-9 10-14 15-19 <4 363 378 386 386 5-9 249 301 331 346 10-14 18(1 231 267 303 15-19 127 165 233 12441 20-24 75 112 [2081 25-29 38 [731 Note: Fertility rates are per 1,000 women. Estimates enclosed zn brackets are truncated. 3.2 Children Ever Born and Living The distribution of women by the number of children ever bom is presented in Table 3.6 for all women 3 and for currently married women. In the EDHS questionnaire, the total number of children ever born was ascertained by a sequence of questions designed to maximize recall. Lifetime fertility reflects the accumulation of births over the past 30 years and, therefore, its relevance to the current situation is limited. However, the information is useful in looking at how average family size varies across age groups and lbr estimating the level of primary infertility. The results for currently married women in Table 3.6 differ markedly from those for the sample as a whole. These differences are due to the large number of women, particularly in the younger age groups, who have not yet married. Differences at older ages are minimal and generally retlect the impact of marital dissolution. 3Data from the household questionnaire on the age structure of the population of never-married women is used to calculate the all-women distribution. This procedure assumes that women who have never been married have had no children. 36 According to Table 3.6, an Egyptian woman has an average of 2.7 births. Out of that number, 2.3 children are still alive, indicating that mortality claimed 15 percent of the children ever born to each woman. Cumulative fertility is very low among women 15-19; it increases by one birth or more for each five-year age group, among women under age 40. Women 45-49 years of age, who are approaching the end of their childbearing period, have had an average of 6 births. Reflecting the high levels of fertility prevailing during the 30-year period when these women were having their children, around one in eight has had 10 or more births. The data also indicate that primary sterility is very low in Egypt. The percent childless among women nearing the end of the reproductive period, age 45-49, is only 4 percent. Table 3.6 Children ever born and living Percent distribution of all women and of currently married women by number of children ever born (CEB) and mean number ever born and living, according to five-year age groups, Egypt 1992 Number of children ever born (CF, B) Number Mean no. Mean no, Age of of of living group 0 1 2 3 4 5 6 7 8 9 10+ Total women CEB children ALL. WOMEN 15-19 92,5 5.8 1.4 03 0.0 0.0 0.0 00 0.0 00 0.0 100.0 3037 0.09 0.09 20-24 54.2 18 .3 14.3 8.5 3.5 0.9 0.2 0 0 0.0 0.0 0.0 100.0 2405 0.93 0.84 I5-29 20.9 12,4 20.2 19.0 15 4 6.5 3.4 1.6 0.3 0.2 0.1 100.0 2324 2.41 2.15 30-34 9.6 5.9 15.2 17.6 16.4 14.2 9 2 6,6 2.8 1.5 0.9 100.0 1933 3.72 3.25 35-39 5.7 2.8 10,0 15.8 15.4 14.2 12 1 10,1 6,7 3.6 3.6 100.0 1754 4.71 4.00 40-44 5.7 3.6 7.4 11.1 12,2 117 12.2 I1,0 80 65 10.6 1000 1444 5,48 4.52 45-49 4.3 2.4 6.0 8.3 10,2 I 1 9 14 .4 11.9 I0 3 7 2 13 0 100.0 I 119 6,01 4.73 Total 35.8 8.2 10.7 10.9 94 7.1 5.8 4.5 2.9 I 9 27 ltX) 11 14015 2.73 231 CURRENTLY MARRIED WOMEN 15-19 45.9 41.9 10.1 2.0 Ol O0 00 0.0 O0 00 0,0 I00.0 415 (168 0.64 20-24 18.6 32.1 25.5 15.4 6.3 I 7 0 4 11,11 0.0 0.0 0.0 100.0 1324 I 65 1.49 15-29 8.2 13.7 23.6 22,0 18.2 7 7 4.0 1.9 (1.4 0.2 111 100 0 1956 2 81 2 52 30-34 4.6 5.7 15.6 18,8 17 6 15 1 9.6 7.2 3.0 1.7 1.11 100 0 1743 3 97 3 46 35-39 2.9 1.9 9.7 16.2 15.8 14 8 12 9 10.7 7.3 3,8 3.9 100.0 1582 4.95 4.21 40-44 2.5 2.8 7.0 11 5 13.11 11.7 13 I 11,3 8.5 7.1 11,5 100.0 1231 5,78 4.80 45-49 3.0 1.3 5.7 82 101 11,5 13 ,7 122 I I3 83 14,7 100.0 902 6.31 5.01 Tclal 8.5 11.4 15.3 15 8 13.6 10.0 8 1 6 3 4.2 2.8 3.9 100.0 9153 3.88 3.31 3.3 Birth Intervals There is a considerable body of research to indicate that short birth intervals are deleterious to the health of babies. This is particularly true for babies born at intervals of less than 24 months. Table 3.7 shows the percent distribution of births in the five years preceding the EDHS by the number of months since the previous birth. These findings indicate that women favor long birth intervals since around 69 percent of all children are born at least two years after their siblings. Moreover, more than one in three births is bom after an interval of 3 years, and almost one in five is born after 4 years or longer. The ovcrall median birth interval is around 30 months. 37 Table 3.7 Birth intervals Percent distribution of births in the five years preceding the survey by number of months since previous birth, according to demographic and socioeconomic charactertstics, Egypt 1992 Number of months since prewous birth Characteristic 7-17 18-23 24-35 36-47 48+ Me&an number of months ~g/ l ) ber s ince (If previou~ Total btrths blah Age of mother 15-19 29.6 32.3 34.0 4.1 0.0 100.0 59 22.8 20-29 20.2 18 7 36.3 15.9 8 9 1011 0 3180 26.5 30-39 10.8 14.0 33.1 16.8 25 4 100 0 2937 33.{) 40 + 6.6 10.1 24.0 17.9 41.4 100.0 679 41.4 Birth order 2-3 18.8 17.9 32.4 16.3 14.6 100.0 3047 28.0 4-6 12.4 13.6 34.2 16.2 23 5 100.0 2538 31.6 7 + 10.5 15.8 35.5 16.9 21.2 100.0 1271 31.3 Sex of pr ior b i r th Male 13.9 15.9 33.8 16 2 2/).3 100.0 3414 30.4 Female 16.11 16.0 33 6 16.6 17 9 100 0 3442 29.4 Survival of prior birth Living 13 3 15.5 34.6 16 8 19.8 1 (XI 0 6124 3116 Dead 28 8 19,9 25.5 12.8 12.9 100.0 731 24 4 Urban- rura l residence Urban 14.1 12.9 29.4 17.0 26.7 100.0 2397 33.1 Rural 15 4 17 6 36.0 16.11 15.1 100,0 4458 28.9 Place of r~ ldence Urban Governorates I 0,9 12.0 29.9 17 6 29.6 100,0 1157 34 8 Lower Egypt 15 2 15 7 31 9 17,1 20.0 100.0 26511 3/I.6 Urban 15.7 1 I 0 27 3 19 7 26.3 100.0 584 34.5 Rural 15.1 17.1 33 2 16.4 18 2 100 0 21166 29.9 Upper Egypt 16.2 17 6 36.6 15.2 14 3 T00 0 3048 28.3 Urban 18.3 16 1 30.2 13.7 21 8 1000 656 29.4 Rural 15 6 18.0 38.4 15,7 12,3 100.0 2392 28.2 Education No education 14.6 17.2 34.8 15.9 17.5 100.0 3790 29.4 Some primary 12.2 15 0 33.7 16.4 22 7 100 0 1495 31.5 Primary through secondary 16.3 14 9 28.3 17.9 22 7 100 0 572 31.6 Completed secondary/higher 19 3 13 3 32.3 17.4 17 7 100 0 999 29.8 Work status Working for cash 14 3 13 3 32 1 18 5 21.8 II111.11 8411 31.8 Not wor~ng for cash 15.0 16 3 33 9 16 1 18 7 100 t) 6015 29 7 Total 14.9 15.9 33.7 16.4 19.1 100.0 6855 29.9 Note. First-order births are excluded. The interval for multiple births ts the number of months since the preceding pregnancy that ended in a live birth. 38 Regional differentials in the length of the birth interval are evident in Table 3.7. In urban areas, especially in the Urban Govemorates and in Lower Egypt, almost three in four births are born 24 months or longer after the previous birth. The median birth interval in urban areas is 33 months, more than 4 months longer than the rural median. Even in rural areas, however, two in three births are born 2 years or longer after the preceding birth. Younger women have shorter birth intervals than older women. The median birth interval for women 15-19 (23 months) is below the minimum safe interval. Among older mothers, the median interval gradually increases with the age of the mother from 27 months among women 20-29 to 41 months among women age 40 and older. The median birth interval increases slightly with birth order and is one month longer in the case of male than female births. As expected, intervals following a child who died are shorter (24 months) than those following living children (30 months). Surprisingly, the length of the birth interval does not vary greatly with the mother's educational or her work status. 3.4 Age at First Birth The age at which childbearing begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. In many countries, postponement of first births, reflecting an increase in the age at marriage, has contributed greatly to overall fertility decline. The proportion of women who become mothers before the age of 20 also is a measure of the magnitude of adolescent fertility, which is a major health and social concern in many countries. Table 3.8 presents the distribution of Egyptian women by age at first birth, according to their current age. For women 25 years and over, the median age at first birth is presented in the last column of the table. The results show that the proportion of women having births before age 20 decreases with the age of the mother (see Figure 3.5). Among women 45-49, for example, nearly one in two became mothers before the age of 20, one in four gave birth before age 18, and 6 percent gave birth before age 15. Among women in the 25-29 cohort, in contrast, only around one-third had given birth before age 20, one in five gave birth before age 18 and 3 percent gave birth before age 15. Table 3.8 Age at first birth Percent distribution of women 1549 by age at first birth, according to current age, Egypt 1992 Current age Women Median with Age at first birth Number age at no of first births <15 15-17 18-19 20-21 22-24 25+ Total women birth 15-19 92.5 0.4 4.5 2.6 NA NA NA 100.0 3037 a 20-24 54.2 2.2 12.3 14.2 11.8 5.4 NA 100.0 2405 a 25-29 20.9 3.4 16.6 17.0 15.6 17.8 8.9 100.0 2324 21.7 30-34 9.6 3.3 18.2 18.9 17.0 16.4 16.5 100.0 1933 21.0 35-39 5.7 4.0 15.0 19.9 1%8 17.2 20.5 100.0 1754 21.2 40-44 5.7 5.5 17.7 16 9 16.6 16.5 21 2 100.0 1444 21.0 45-49 4.3 6.2 20.4 19.5 15.5 16.9 17.1 100.0 1119 20.5 NA = Not applicable aLess than 50 percent of the women in age group x to x+# have had a birth by age x 39 60 50 40 30 20 10 0 Figure 3.5 Percentage of Women Who Gave Birth before Age 15 and before Age 20 by Age Group Percen[ 20-24 25-29 30-34 Age 35 3 @ 40-44 45-49 EDHS 1992 The median age at first birth increases across age cohorts, from 20.5 years among women 45-49 years of age to 21.7 years among women 25-29. Thcse changes parallel the increases in the median age at first marriage that took place during this period (see Chapter 9). Table 3.9 compares the median age at entry into motherhood for diftizmnt subgroups of the population and examines the trend across age cohorts for these groups. The measures are presented only for women 25- 29 years to ensure that half of the women have already had a birth. Residential and educational difli~rentials arc in the expected direction. The median age at first birth is highest in urban areas (22.8 years), particularly the Urban Govcrnora/es (23.1 yea~). In rural areas, the median age at first births is more than one year higher in Lower Egypt than in Upper Egypt (20.4 years and 19.3 years, respectively). The median age at first birth is inversely associated with the level of education, ranging from 19.7 years among women with no education to 21.8 years among those who completed primary or some secondary schooling. 40 Table 3.9 Median age at first birth Median age at first birth among women age 25-49 years, by current age and selected background characterisucs, Egypt 1992 Current age Background Ages characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Urban-rural residence Urban 23.8 22.8 22.6 22.6 21.4 22 8 Rural 20.3 19.7 20.0 19.9 19.6 19.9 Place of residence Urban Govemorates 23.8 23.5 23.2 22.8 21.6 23.1 Lower Egypt 21.6 20.6 21.1 20.8 20.2 20.9 Urban 24.2 (22.0) 22.7 21 9 20.9 22.6 Rural 20.9 20.1 20.4 20.4 19.8 20.4 Upper Egypt 2(I.3 20.1 20.2 19.9 19.7 20.1 Urban 23.3 (22.3) 21.6 22.4 21 1 22.2 Rural 19.4 19.0 19.6 18.9 19 4 19.3 Education No education 19.5 19.3 19.8 19.9 19.8 19 7 Some primary 20.7 (20.0) 20.7 20.5 19.7 2/I.4 Primary through secondary 21.4 (21.4) 21.8 22.7 21.8 21.8 Completed secondary/higher a 25.9 26.8 26.3 25.8 a Work status Working for cash Not working for cash Total a 25.2 25.3 25.7 24.(} a 21.1 20.3 20.5 20 5 20.1 2(I.5 21.7 21.0 21.2 21.0 20.5 21.2 Note: Medians in parentheses are based on 25-49 women. The medians for the 15 19 cohort and the 20-24 cohort could not be determined because half of the women have rtot yet had a birth. aMedians were not calculated for these cohorts because less than 51) percent of women in the age group x to x+4 have had a birth by age x. 3.5 Teenage Pregnancy and Motherhood Table 3.10 shows the percentage of women age 15-19 who are mothers or pregnant with their first child. This statistic is of major social and health concern because of its association with highcr morbidity and mortality for both mothers and their children. In addition, teenage pregnancy has a substantial limiting effect on the educational opportunities of young mothers. The overall level of teenage childbearing is 10 pcrecnt, of which 8 percent have already given birth and 2 percent are pregnant with their first child. Among those teens who have given birth, two-thirds had their first child before age 18 (see Table 3.8). 41 Table 3.10 Teenage pregnancy and motherhood Percentage of women 15-19 who are mothers or pregnant with their first child, by seleczed background characteristics, Egypt 1992 Percentage who are: Percentage who have Pregnant begun Number Background with fkst child- of characteristic Mothers child bearing women Age 15 0.4 0.8 1.2 707 16 1.2 2.6 3.9 695 17 5.0 1.1 6.1 671 18 10.2 2.6 12.8 697 19 17.1 3.7 20.8 654 Urban-rural residence Urban 3.8 1.3 5.1 1304 Rural 10 5 3.4 13.9 1691 Place of residence Urban Governorates 3.8 1.2 5.0 561 Lower Egypt 5.7 2.5 8.3 1346 Urban 3.4 1.4 4.8 346 Rural 6.5 2.9 9.4 1002 Upper Egypt 12.3 3.2 15.5 1047 Urban 4.6 1.6 6.1 352 Rural 16.1 4.0 20.1 701) Educathm No education 16.5 5.0 21.4 710 Some primary 10.5 4.4 14.9 344 Primary through secondary 4.2 0.9 5.1 1589 Completed secondary/higher 1.9 2.0 3.9 425 Work status Working for cash 4.1 0.0 4.1 97 Not working for cash 7.6 2.5 10.1 2942 Total 7.5 2.4 9.9 3037 Significant residential differences in the level of teenage childbearing are observed in the EDHS results. The level in rural areas (14 percent) is almost three times the level in urban areas (5 percent). By place of residence, the percentage varies from only 5 percent in Urban Governorates to 20 percent in rural Upper Egypt (see Figure 3.6). The level of teenage fertility is also strongly associated with education and work status. The lowest levels are observed for women who completed secondary school or higher (4 percent) and those who are working (4 percent). The inverse relationship between education level and teenage fertility is very evident. Women with no education and those who drop out before completing the primary level show the highest levels of teenage childbearing (21 percent and 15 percent, respectively). 42 Figure 3,6 Percentage of Teenagers Who Have Begun Childbearing by Place of Residence Percent Urban Total Urban Rural Total Urban Govemorates Lower Egypt Upper Egypt Rural EDHS1992 Table 3.11 shows the distribution of teenagers according to the number of children ever bom. Generally, teenagers who have given birth have had only one child. Only one in five teenage mothers has had two or more births. As expected, the likelihood that a teenager will have given birth increases with age, peaking at 22 percent among those 19 years of age. The likelihood that a teenage mother will have had more than one birth also increases with age, reaching a level of 30 percent among nineteen-year-olds. Table 3.11 Children born to teenagers Percent distribution of women 15-19 by number of children ever born (CEB), Egypt 1992 Age 0 1 2+ Number of Mean children ever born number Number of of Total CEB women 15 99.6 0.4 0.0 100.0 0 00 690 16 98.7 1.3 0.0 100.0 0.01 643 17 94.5 4.9 0.6 100.0 0.06 608 18 87.9 9.9 2.1 100.0 0.15 586 19 78.1 15.2 6.7 100.0 0 30 509 Total 92.5 5.8 1.7 100.0 0.09 3037 43 CHAPTER 4 KNOWLEDGE, ATTITUDES, AND EVER USE OF FAMILY PLANNING Knowledge of family planning methods and places to obtain them are crucial elements in the decision of whether and which methods to use. A positive attitude about family planning is an additional prerequisite to use. Data collected in the EDHS on knowledge of methods and sources, the channels through which Egyptian women receive information about family planning, and attitudes about the use of family planning methods are presented in this chapter. The chapter also looks at the level of ever use of family planning and, for ever users, the circumstances surrounding the first use of family planning, including the first method used, the source that provided this method, and the motivation for using (i.e., to space or limit). 4.1 Knowledge of Family Planning Methods and Source The level of knowledge of family planning methods was measured in two ways: . Respondents were first asked an open-ended question about which contraceptive methods they had heard of. All methods named in response to this question were recorded as spontaneously recognized (unprompted knowledge). . When a respondent failed to mention any of the methods listed in the questionnaire, the interviewer would describe the method and ask if the respondent had heard about it. All methods recognized by the respondent after the method was described were recorded as known after probing (prompted knowledge). Inform ation on knowledge was collected for eight modem methods (the pill, I UD,injection, Norplant, vaginal methods (foam, jelly, cream, sponge or diaphragm), the condom, female sterilization, and male sterilization), and three traditional methods (periodic abstinence, withdrawal, and prolonged breast feeding). In addition, provision was made in the questionnaire to record any other methods named spontaneously by respondents. In this analysis, only the overall levels of knowledge are presented, i.e, respondents are classified as knowing a method regardless of whether they recognized it spontaneously or after hearing it described. Thus, knowledge of a family planning method in the 1992 EDHS as in all other DHS surveys is defined simply as having heard of a method. No questions were asked to elicit depth of knowledge, such as how a specific method is used. Table 4.1 indicates that knowledge of at least one method is practically universal among ever-married women. Moreover, virtually all women who recognized at least one method were familiar with a modem method. Among modem methods, the pill (99 percent) and IUD (99 percent) are the most widely known methods, followed by injection (81 percent). The proportion of ever-married women knowing about female sterilization is 70 percent, and 54 percent know about the condom. The least recognized modem method, male sterilization, was known by only 13 percent of ever-married women. The percentage of women who recognized Norplant (46 percent) seems high, particularly since Norplant was not approved for general use IEgypt and Jordan are the only two DHS countries that included prolonged breastfeeding in the list of family planning methods on which respondents were prompted. 45 Table 4.1 Knowledge of family planning methods and source for methods Percentage of ever-married women and currently married women who know specific family planning methods and who know a source (for information or services), by specific methods, Egypt 1992 Know method Know a source Ever- Currently Ever- Currently Family planning married married married married method women women women women Any method 99.5 99.6 92.0 92.9 Any modern method 99.4 99.5 92.0 92.9 Modern method Pill 99.3 99.4 89.5 90.4 IUD 98.7 98.9 86.4 87.5 Injecnon 81.1 81.8 59.2 60.1 Norplant 46.0 47.3 29.5 30.3 Diaphragm/foam/jelly 36.8 37.5 29.4 30.0 Condom 53.7 55.0 45.7 46.9 Female sterilization 70,(I 70.6 59.9 60.6 Male sterilization 12.5 12,8 9.5 9.7 Any traditional method 77.0 77.6 19.7 20.2 Periodic abstinence 31.2 32.0 19.7 20.2 Withdrawal 27.6 28.4 NA NA Prolonged breast feeding 71.8 72.3 NA NA Other traditional methods 2.4 2.5 NA NA Number of women 9864 9153 9864 9153 NA - Not apphcable at the time of the survey. However, there was considerable press coverage of Norplant during the period immediately prior to EDHS, which may help to explain the relatively high level of recognition of the method. Traditional methods are less likely to be recognized than modem methods (77 percent and 99 percent, respectively). The most widely known 'traditional method is prolonged breastfeeding, which is recognized by 72 percent of women. With respect to knowledge of a source for modem methods, most womcn (92 percent) are aware of a place where they can obtain family planning services. There is some variation in knowledge of source by method: ever-married women are most likely to know about a source for the pill (90 percent) and IUD (86 percent) and least likely to know about male sterilization (10 percent) and vaginal methods (29 percent). 46 Trends in Knowledge of Methods and Sources Using information from three earlier surveys as well as the 1992 EDHS, 2 Table 4.2 shows the upward trend in the level of contraceptive knowledge during the 1980s. Overall, the percentage of ever- married women knowing any method increased from 90 percent in 1980 to almost 100 percent in 1992. Considering individual methods, the largest increase is observed in the knowledge of injection; only 16 percent had heard about injection in 1980 compared to 81 percent in 1992. There also has been a significant increase in knowledge in the case of the condom, vaginal methods, female sterilization, and the IUD. The smallest increase is in pill knowledge, which was already high in 1980 (89 percent). Table 4.2 Trends in knowledge of family planning methods and source Percentage of ever-married women who know specific family planning methods and who know a source (for family planning information or services), Egypt, 1992 EDHS, 1988 EDHS, 1984 ECPS and 1980 EFS Know method Know source Family planning EDHS EDHS ECPS EFS EDHS EDHS method 1992 1988 1984 1980 1992 1988 Any meth~ 99.5 98.(I 85.4 89.7 92 0 95.2 Any rn~lern method 99.4 97.8 85.2 92.0 95.2 M(~lern method Pill 99.3 97.4 84.9 89.4 89.5 93.9 IUD 98.7 93.3 74.9 69.6 86.4 87.2 Injection 81.1 60.5 35.3 15.6 59.2 47.9 Vaginal methods 36.8 39.6 27.8 13.8 29.4 36.6 Condom 53.7 43.3 21.5 25.9 45.7 40.2 Female sterilization 7/I.0 53.5 20.5 42.5 59 9 50.2 Male sterilization 12.5 9.6 5.3 6.0 9 5 8.4 Any traditional method 77.0 67.3 30.0 NA 19.7 20.0 Safe period 31 2 22.1 11.3 14.0 19 7 20.0 Withdrawal 27.6 13.4 6.9 9.8 NA NA Prolonged breastfeeding 71.8 64.8 24.7 NA NA NA Other traditional methods 2.4 4.6 1.3 NA NA NA Number of women 9864 8911 10013 8788 9864 8911 Source: Sayed eta[., 1988, Table 4.1 - = Not available NA -- Not applicable 2Differences in the probing techniques used in the four surveys may have some effect on the observed trends. In all of the surveys, the respondent was first asked to name all of the methods about which she had heard, and the interviewer then probed to find out whether the respondent recognized methods that she had not spontaneously mentioned. In the ECPS, the interviewer used only the name when probing whale, in the EFS and the EDHS, both the name of the method and a brief description were used. 47 Table 4.2 also shows the change in the proportion knowing a source between 1988 and 1992. 3 Comparing the 1992 data, there has been a small decrease in the proportion of women reporting knowledge of a source both for any method and for any modem method. This change is largely attributable to decreases in the proportions reporting knowledge of a source for the pill and vaginal methods. Source knowledge increased for most other methods, including injection, condom, female sterilization, and male sterilization. Differentials in Knowledge of Methods and Sources Table 4.3 presents the percentage of currently married women who know any method of contraception and any modem method and the percentage who know a source of a modem method by back- Table 4.3 Knowledge of famtly planning methods and source for methods by background characteristics Percentage of currently married women who know any family planning method and any modern method and who know a source (for family planning information or services), and the mean number of methods and modem methods known, by selected background characteristics, Egypt 1992 Mean Mean Know a Know no. of Know a no of source for Number Background any methods modem modern modem of characteristic method known method methods method women Age 15-19 98.2 4.9 97.9 4.1 82 8 415 20-24 99 6 5.8 99.6 4 6 91 4 1324 25-29 99.7 6.5 99.7 5 1 93.6 1956 30 34 100.0 6.8 99.9 5.3 95 5 1743 35-39 99.6 6.5 99.6 5.1 94.1 1582 40-44 99.4 6.7 99.4 5.3 93.3 1231 45-49 99 4 6.3 99.3 4 9 90.5 902 Urban- rura l residence Urban 99.8 7.3 99.8 5.6 97.9 4281 Rural 99.4 5.6 99.3 4.5 88.5 4873 Place of residence Urban Governorates 99.9 7.5 99.9 5.7 98 7 2201 Lower F.gypt 100.0 6.5 100.0 5.1 97 6 3746 Urban 100.0 7.1 100.0 5.5 99.1 1120 Rural 101,1.0 6.2 100 0 4.9 97.0 2626 Upper Egypt 99.0 5.5 98.8 4.5 83.4 3207 Urban 99.5 6.9 99.5 5.4 94.7 960 Rural 98.7 4.9 98 5 4 1 78.6 2247 Education No educauon 99.3 5.4 99.1 4 4 87.7 4363 Some primary 99.8 6.3 99,8 5 1 95.2 1913 Primary through secondary 100.0 7.1 100.0 5,5 98 1 1010 Completed secondary/hngher 11111.0 8 3 100.0 6.1 99.7 1867 Work status Working for cash 100.0 7.9 99.9 5.9 98,1 1317 Not working for cash 99.5 6.1 99 5 4.9 92,0 7836 Total 99.6 6.4 99.5 5 0 92 9 9153 3The 1988 EDHS differed somewhat from the 1992 EDHS in the manner in which the information on knowledge of source was obtained. In 1988 EDHS, a woman who reported knowing about a method was asked where would she go to obtain the method ff she wanted to use it, while in the 1992 EDHS, the question was: Do you know where a person could go to get (Method)? 48 ground characteristics. Because knowledge of any family planning method orany modem method is almost universal in Egypt, the table also includes the mean number of methods known and the mean number of modem methods known. Differentials in the proportions knowing any method, any modem method and a source for a modem method are generally minimal. Of most significance is the fact that nearly one-fifth of women living in rural areas in Upper Egypt who know about at least one modem method are not able to name a place where a person can obtain a method. There are significant differences in the mean number of methods known across the subgroups shown in Table 4.3. By age, there is a difference of almost two methods in the mean number of methods known between women in the 15-19 age group, where the mean is lowest (4.9 methods) and the 30-34 age group, where the mean is highest (6.8 methods). A marked difference in the mean number of methods known is evident between urban and rural areas (7.3 methods and 5.6 methods, respectively). Women from rural Upper Egypt are particularly limited in the number of methods that they recognize; the mean number of the methods known among women from rural Upper Egypt is 4.9 compared to 6.2 methods for women in rural Lower Egypt (Figure 4.1). Figure 4,1 Number of Family Planning Methods Known by Place of Residence Mean number 10 6 0 Urban Total Urban Rural Total Urban Governorates Lower Egypt Upper Egypt Rural EDHS1992 Education level clearly is related to the number of methods recognized by a woman; the mean number of methods known varies from 5.4 among women with no education to 8.3 among womcn with at least a secondary education. There is a nearly two-method difference between the mean for women who are not working for cash and the women who are working for cash (6.1 methods and 7.9 methods, respectively). 49 4.2 Exposure to Family Planning Information Activities to inform and educate couples about use of contraception are one of the major components of the Egyptian family planning program. The EDHS obtained information on a number of aspects of women's exposure to family planning information, including the first source from which information was obtained, recent exposure to family planning messages broadcast on radio and television and of articles on family planning in newspapers or magazines, and attendance at community meetings in which family plan- ning or Egypt's population problem were discussed. First Source of Family Planning Information The data on the first source of information about family planning is very useful to understand the avenues through which women are initially exposed to the concept of family planning. Table 4.4 shows the distribution of ever-married women by the source from which they first heard about family planning according to residence. Television clearly serves as the primary source of information for the majority of women; 70 percent of women mentioned that they first heard about family planning on television. Friends and relatives (other than the husband) were the tint source for family planning information lor 22 percent ofthe women. Relatively small percentages mentioned other sources, including the radio (1 percent), the raiyda or other family planning outreach workers (2 percent), or public/private health personnel (2 percent). Table 4.4 First source of family p lanning information Percent distribution of ever married women by source from which they first heard atx~ut family p lannmg, according to urban-rural residence and place of residence, Egypt 1992 Urban Lower Egypt Upper Egypt First Gover- source Urban Rural norates Total Urban Rural Total Urban Rural Total Televxslon 76.4 65.0 78.9 73.7 79.5 71.3 60.3 67.0 57 5 70.3 Radio 1.0 1.2 1.1 1.1 0.6 1.3 1.1 1.2 1 0 1.1 Pnnt media 0.8 0.1 0.8 0.4 0.7 0.2 0.3 0.9 0.0 0.4 Spouse 0.2 0.3 0.2 0.3 0 2 0.3 0.3 0.2 0.3 0.3 Fnends/relativ es 167 26.0 159 19.9 136 22.6 277 22,4 300 21.7 Government doctor/chmc 1 6 1.1 1.2 1.1 1.5 0.9 1.7 2 6 1.4 1.3 Private doctor]clime 0 8 0 2 0.5 0.4 1.0 0 2 0.5 1 0 0.3 0.5 Rmyda]other family planmng worker 1.3 3 4 1.1 2.1 1.1 2 5 3.7 2 1 4 4 2 4 Commumty acuvlty 0.3 0.3 0.1 0.3 0.5 0,2 0.4 0.6 0 3 0,3 Other 0.9 1.7 0.2 0.7 1.4 0 5 2.7 1.9 3.1 1 3 Never heard about family planmng 0.0 0.9 0.0 0 1 0.0 0.2 1,2 0 I 1 7 0 5 Total 100.0 1000 100.0 100.0 100.0 100.0 100.0 1000 100.0 100.0 Number 4596 5268 2357 4067 1210 2857 3440 1029 2411 9864 The preeminence of television as the first source of family planning information is observed in all areas. However, rural women, particularly those living in Upper Egypt were somewhat less likely to hear about family planning for the first time on television and somewhat more likely to hear for the first time from friends or relatives than other women. 50 Sources Influencing Women to Seek Family Planning Information The EDHS collected information about specific sources or events that women perceived as influencing them to seek more information about family planning. Table 4.5 summarizes this information by residence for ever-married women knowing about family planning. Again, TV spots and friends or relatives are the main influences on a woman's decision to seek more information about family planning (51 percent and 44 percent, respectively). Between 10 and 15 percent of women mention private doctors/clinics, government doctors/clinics and raiydas or family planning workers as influencing them to seek information about family planning. Only around 3 percent mentioned community activities (e.g., meetings). Table 4.5 Sources influencing women to seek information about family planning Percentage of ever-married women knowing about family planning who indicated various sources influenced them to seek information about family planning, according to urban-rural residence and place of residence, Egypt 1992 Sources influencing Urban Lower l'gypt Upper Egypt information- Gover- seeking behavior Urban Rural norates Total Urban Rural Total Urban Rural Total TV spots 54.2 48.4 51.9 56.9 60.8 55.2 43.7 51.4 40.4 51.1 Friends/relatives 44.3 44.0 45.3 51.0 49.9 51.5 35.3 35.3 35.3 44.2 Government doctor/clinic 14.2 9.3 18.9 12.1 11.9 12.2 6.0 6.3 5.9 11 6 Private doctor/clinic 18.2 10.2 20.5 14.0 18.0 12.4 9.3 13.1 7.7 13.9 Raiyda/other family planning worker 8.8 11.3 9.2 10.5 9.0 11.2 10.2 7.5 11.4 10.1 Community activity 2.6 2.6 1.9 3.1 3.7 2.8 2.4 2.8 2.3 2.6 Other 31.2 22.8 32.1 26.0 29.4 24.6 23.9 31.3 20.7 26.7 Number of women 4596 5268 2357 4067 1210 2857 3440 11129 2411 9864 Exposure to Messages through Radio and Television Table 4.6 presents the percentage of ever-married women who had heard a messagc about family planning on broadcast media (radio or television) during the month prior to the interview. As might be expected given the wider coverage of television (see Chapter 2), family planning messages broadcast on the television are more successful in reaching an audience than radio messages. Almost three in four women saw a message on television in the month before the survey compared to only one in five women who had listened to a family planning message on the radio. Moreover, virtually all women who had listened to a radio message about family planning also had seen a television message. Around one-quarter of women reported that they had not listened to a radio message nor seen a television message. Recent exposure to family planning messages through broadcast media varies by residence. Rural women are less likely to have seen or listened to a message than urban women (65 percent and 86 percent, respectively). By place of residence, the proportion who had been exposed to a family planning message during the month before the interview varied from a high of 89 percent in the Urban Govemorates to 61 percent in Upper Egypt. Almost half (46 percen0 of the women in rural Upper Egypt had not seen or listened to a family planning message compared to one-quarter of the women in rural Lower Egypt (see Figure 4.2). 51 Table 4,6 Exposure to family planning messages on radio and television Percent distribution of ever-married women by whether they have heard a family planning message on radio or on television in the month preceding the survey, according to selected background characteristxcs, Egypt 1992 Heard family planning message on radio or on television Number Background Radio Television of characteristic Neither only only |]oth Missing Total women Age 15 19 28.9 0.8 53.7 16.5 0.0 100.0 423 20-24 25.5 1.1 53.7 19.7 0.1 100.0 1362 25-29 23.4 0.7 53.0 22.8 0.1 100.0 2013 30-34 23.0 1.1 55.4 20.5 0.1 100.0 1838 35-39 24.8 1.6 53.4 20.2 0.0 100 0 17139 40 44 27.0 0.7 53.7 18.4 13.2 100.0 1411 45-49 28.8 0 8 50.1 20.3 0 0 liX) 0 11118 Urban-rural residence Urban 14.2 13.8 59.3 25 7 0.1 100.0 4596 Rural 34.8 1.2 48.3 15.6 O.l 100.0 5268 Place of residence Urban Govemorates 11.5 0.9 63.0 24.6 0.1) 100.0 2357 Lower Egypt 21.7 1 2 52.3 24.8 () 0 100.0 4067 Urban 13.0 0.5 57.2 29.2 0.0 100.0 1210 Rural 25.4 1.5 50.2 22.9 0.0 100.0 2857 Upper Egypt 38.7 0.9 48.1 12.1 0.2 100.0 3440 Urban 21.6 1.1 53.2 23.8 0.3 100.0 11329 Rural 46.0 0.8 46.(3 7.1 O.l 100.13 2411 Education No education 35.7 1.1 51.6 11.5 0.1 100.0 4771 Some primary 23.6 1.3 53.2 21 8 0.1 100.0 2(378 Primary through secondary 11.6 0.6 59.2 28.6 0.0 I0(1 0 1093 Completed secondary/higher 8.7 0 7 54.7 35.9 0,1 10(h(3 1922 Work status Working for cash 18.1 0.7 53.4 27.8 0.1 100.0 1464 Not working for cash 26.5 1.1 53.4 19.0 0.1 100 0 8401/ Use of contraception Current user 16.2 1.0 58.4 24.3 11 1 100.0 4310 Past user 23.5 1.3 52.7 22.4 0. l I00 0 2064 Never user 37.4 0.8 47.6 14.1 0.1 l(X) O 3490 Total 25.2 1.0 53.4 2(3.3 0.1 11KI.O 9864 52 Figure 4,2 Exposure to Family Planning Broadcasts by Place of Residence Percent 1oo l 8O 60 : 40 :_Ll i L Urban Total Urban Rural Go'~emolales m Total Urban Rural Lower Egypt Upper Egypt EDHS 1992 Exposure to family planning messages varies directly with a woman's educational level. Women who work for cash also were somewhat more likely to report recent exposure to a family planning message than other women. Finally, women who were current users of family planning were more likely to report that they had seen or heard a message about family planning recently than were past users or never users. It is not clear whether the relationship between exposure to family planning messages and user status is causal or not. Because they are practicing family planning, current users may simply be more aware of messages on the topic than other women. Exposure to Mes~ges through Print Media/Community Meetings Women were asked if they had read an article about family planning in a newspaper or magazine during the month before the interview. They also were asked if they had attended a community meeting at which family planning or population problems were discussed during the past year. Responses to these questions are presented in Table 4.7. Few women receive information about family planning through newspapers or magazines. Overall, only about one in twenty women said that they had read an article about family planning; this represents about 14 percent of all women who were literate (data not shown in table). Only a small minority (one in seventeen women) also report attending a community meeting at which family planning or Egypt's population problems were discussed. As expected, women in rural areas, especially in Upper Egypt, were less likely to have read articles on family planning than other women. Exposure to family planning information through community meetings was more common among urban than rural women and rural women in Upper Egypt were the least likely to report attendance at such meetings. 53 Higher educational attainment and work in the cash economy were associated with exposure to family planning messages through newspapers or magazines or at com- munity meetings. There is also a small but definite relationship between exposure to in- formation through print media and communi- ty meetings and experience with the use of family planning methods. 4.3 Attitudinal Indicators After acquiring knowledge, the next step in family planning adoption is to have a positive attitude about the use of contracep- tive methods. Attitudinal data were collected by asking women in the sample whether, in general, they themselves approved of a cou- ple using family planning and what they thought was their husband's opinion on the subject. In addition, respondents were asked about their attitude regarding the use of spe- cific methods including the pill, IUD, con- dom, female sterilization, male sterilization and withdrawal. Attitudes about Use of Family Planning Methods Table 4.8 shows the level of approval of family planning among currently married non-sterilized women who know at least one contraceptive method according to back- ground characteristics. The table also looks at the extent to which these women say their attitude parallels that of their husband. 4 Over 90 percent of non-sterilized married women approve of the use of family plan- ning, and only 5 percent disapprove. Most of the women also believe that their husband approves. Overall, according to the woman, three of four couples approve of the use of family planning. Among couples in which the wife reports differences of opinion, the husband--and not the wife--is more often Table 4.7 Exposure to family planning messages through print media/community meetings Percentage of ever married women who read an artxcle about family planning m a newspaper or magazine during the month before the interview, and the percentage who attended a community meeting at which famJly planning/Egypz's population problem was discussed during the past year. according to selected background characteristics. Egypt 1992 Read article Number Background on family Attended of characterisuc planning meeting women Age 15-19 3 6 4.0 423 20-24 5.3 5.0 1362 25 -29 6.1 7.0 2013 30 34 6.9 8.0 1838 35 -39 5.8 7.0 1709 40-44 5.0 5.t) 141 I 45-49 4.3 5 0 1108 Urban-rural residence Urban 9 1 9.0 4596 Rural 2 6 4.0 5268 Place of residence Urban Govemorates 8.8 10.0 2357 Lower Egypt 5 2 4.0 4067 Urban 10 2 6.0 1210 Rural 3.1 4.0 2857 Upper Egypt 3.9 6.0 3440 Urban 8.6 9.0 1029 Rural 2.0 4.0 2411 Education No education 0.2 3.0 4771 Some primary 2 I 4,0 2078 Primary through secondary 9.1 7.11 1093 Completed secondary/higher 20.8 17.0 1922 Work status Working for cash 17.5 17.0 1464 Not working for cash 3.6 4 0 8400 Contraceptive u~ Current user 7.6 8,0 4310 Past user 5.4 6.0 2064 Never user 3.3 4.0 3490 Total 5.6 6.0 9864 reported to disapprove of family planning. Only 5 percent of women disapprove of family planning use while 13 percent of husbands are perceived by their wives to disapprove. 4See Chapter 13 for a comparison with the husbands' actual attitudes. 54 Table 4.8 Attitudes toward family planning Percent distribution of currently married, non-sterilized women who know of a family planning method by their attitude toward family planning, and their perception of their husband's attitude, according to selected background characteristics, Egypt 1992 Woman approves Woman disapproves Husband Husband's Husband's Number Background Both dis- auitude Husband attitude Both of cbaracteristtc approve approves unknown approves unknown disapprove Other Total women Age 15-19 65.5 6.4 12.4 1.3 1.8 6.5 6.1 1000 408 20-24 72.6 12.0 6.5 1.3 0.6 3.3 3.7 100.0 1319 25-29 76.9 10.8 4.6 1.2 0.6 2.5 3.4 100.0 1948 30-34 77.5 11.1 4.2 1.1 0.4 2.5 3.2 100.0 1730 35-39 79.8 8.6 3.4 1.1 0.4 3.0 3.8 100.0 1552 40-44 79.I 8.6 3.6 1.2 1.0 2.8 3.7 100.0 1192 45-49 73.1 7.7 7.3 1.0 1.1 3.7 6.1 100.0 865 Urban.rural residence Urban 83.3 8.6 3.2 0.8 0.1 1.7 2.2 100.0 4220 Rural 70.1 11.0 6.8 1.4 1.1 4.2 5,3 1000 4794 Place of residence Urban Governorates 85.4 6.8 2.7 1.0 0.0 1.9 2.1 100.0 2168 Lower Egypt 79.9 10.0 5.2 0.9 0.3 1.3 2.4 100.0 3691 Urban 83.0 10.5 3.4 0.2 0.2 0.8 2.1) 100.0 1104 Rural 78.5 9.8 6.0 1.3 0.3 1.5 2.6 lO0.0 2587 Upper Egypt 65.8 11.8 6.6 1.5 1.6 5.8 6.8 100.0 3155 Urban 78.9 10.3 4.0 1.1 0.5 2.5 2.8 100.0 948 Rural 60.2 12.5 7.7 1.6 2.1 7.2 8.6 100.0 2207 Level of education No education 69.9 10.6 7.0 1.2 1.2 4.2 5.9 100.0 4270 Some primary 78.7 9,9 4.7 1.2 0.4 2.4 2.7 1 fgl.0 1892 Primary through secondary 82.5 9.1 2.8 0.5 0.0 2.4 2.6 100.0 994 Completed secondary/higher 85.2 8.5 2.2 1.5 0.1 1.2 1.1 100.0 1858 Work status Working for cash 75.1 10.0 5.5 1.1 0.7 3.3 4.2 100.0 7709 Not working for cash 83.3 9.1 2.4 1.4 0.4 1.1 2.3 100.0 1305 Contraceptive use Current user 89.1 7.4 1.6 0.8 0.0 0.3 0 8 100.0 4207 past user 80.2 105 3.8 1.6 0.2 1.5 2.2 100.0 1815 Never user 55.9 13.0 10.8 1.4 1.9 7.8 9.3 100.0 2992 Total 76.3 9.9 5.1 1.2 0.7 3.0 3.9 100.0 9014 The likelihood that a woman will report that both her husband and she approve of family planning increases with age, reaching a peak of 80 percent among women 35-39 before declining to 73 percent among older women. The level of approval varies between urban and rural areas; 83 percent of couples are reported by the woman to approve of the use of family planning compared to 70 percent in rural areas (see Figure 4.3). Among rural women, there are marked differences by place of residence in the proportion who report that both they and their husbands approve of the use of family planning; 79 percent of women in rural Lower Egypt say both they and their husbands approve compared to only 60 percent among women in rural Upper Egypt (see Figure 4.3). In rural Upper Egypt, women are almost twice as likely to say that their husbands disapprove of family planning as they are to say that they themselves disapprove (20 percent and 11 percent, respectively). 55 Figure 4,3 Couple Approval of Family Planning Use from the Wife's Perspective by Place of Residence Percenl 8O L__ 6O 4O 2O i 0' ~ ~ Urban [oral Urban Rural Total Urban Rural Governo~ates Lower Egypt Upper Egypt EDHS 1992 Approval of family planning is positively related to educational level, and it is somewhat more common among working women than among other women. Significantly, women who have never used family planning are likely to be more conservative in their attitudes than other women. Among never users, only 56 percent report that both they and their husbands approve of family planning compared to 80 percent of women who used in the past and 89 percent of current users. Religion and Use of Family Planning Women also were asked about whether they thought that religion allows or Iorbids the use of family planning. Around three in four women believe that there are no religious prohibitions against family planning, and only 15 percent thought that religion definitely forbids the use of family planning (see Table 4.9). The proportion of women believing that religion allows the use of family planning varies by residence. Women in rural Lower Egypt are the most likely to say religion allows the use of family planning and women in rural Upper Egypt were the least likely to think that family planning use was allowed by religion (80 percent and 69 percent, respectively). 56 Table 4.9 Belief that religion allows or forbids family planning Percent distribution of ever-married women according to whether they believe religion allows or forbids family planning by urban-rural residence and place of residence, Egypt 1992 Urban Lower F, gyp~ Upper Egypt Rehgion's Gover- position Urban Rural notates Total Urban Rural Total Urban Rural Total Allows 78.6 74.9 77.9 79.9 79.9 81).0 71.8 78.6 68.9 76.6 Forbids 15.8 14.7 16.5 14.6 15.6 14.2 15.2 14.7 154 15.2 Don't know 5.6 10.4 5.6 5.5 4.6 5.9 13.1 6.7 15 8 8.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1000 100.0 1000 Number 4596 5268 2357 4067 1210 2857 3440 11129 241 I 9864 Attitudes about Use of Specific Family Planning Methods Currently married women were asked if they agree or disagree with the use of specific family planning methods; the responses to the question are shown in Table 4.10. As expected, the level of approval was highest in the case of the IUD (79 percent), followed by pills (77 percent). The method mix among users in Egypt is still heavily dominated by these two methods. As for other methods, the proportions expressing approval are much lower; condom (22 percent), female sterilization (17 percent), withdrawal (8 percent) and male sterilization (2 percent). Table 4.10 Approval of use of specific family planning methods Percent distribution of currently married women by approval of the use of specific family planning methods, Egypt 1992 Approves of use of method Don't know/ Does Family planning undecided/ not know method Yes No missing method Total Pill 76.9 17.9 4.6 0 6 100.0 IUD 78.7 15.2 5.0 1 I 100.0 Female sterilization 16.8 49.1 4 7 29.4 100.0 Condom 21.6 25.9 7.5 45.0 100.0 Male sterilization 2.2 9.3 1.2 87.2 I00.0 Withdrawal 8.1 16.6 3.7 71 6 1110.0 4.4 Ever Use of Family Planning Methods The 1992 EDHS collected data on the level of ever use of family planning methods. A number of issues relating to method adoption including the first method used and the service provider also were investigated. 57 Levels and Trends in Ever Use The EDHS findings indicate that 65 percent of ever-married women and 67 percent of currently married women have used a family planning method at some time (see Table 4.11). Virtually all women who have ever used a method have experience with modem methods. The pill is the most widely adopted modem method among currently married women (45 percent), followed closely by the IUD (42 percent). Only 8 percent have tried the condom and less than 5 percent have ever used any other modem method (injection, vaginal methods, and female sterilization). The level of ever use of traditional methods is low in Egypt (10 percent). Table 4.11 Ever use of family planning Percentage of ever-married women and of currently married women who have ever used any family planning method, by specif ic method and age, Egypt 1992 Any Dia- Female Ma]e Pen- Proloaged modem phragm/ sterL sten- Any odlc breast- Number Any meth- lnjec- Nor- foam/ lit, a- hza- trad. absu- With- feed- of Age method od Pill IUD tion plant Jelly Condom uon tlon method hence flrawal mg Other women EVER-MARRIED WOMEN 15-19 19.8 18.5 9.7 11.3 0.5 0.0 0.3 1 1 0.0 00 1.4 0.0 0.0 1.3 0.0 423 20-24 43.7 41.6 220 28.2 0.5 0.0 0.4 1 8 0.0 00 4.3 (1.7 1.4 2.4 0.2 1362 25-29 65.6 63.7 38.1 42 8 1.9 0.1 1.7 5.6 0.1 0.0 7.11 2.2 1.6 3.9 0.2 2013 30-34 76.0 74.0 51.9 50.2 3.3 0.3 3.2 7.9 0.7 0.0 102 3.6 2.4 5.5 0.5 1838 35-39 74.7 73.3 54.3 46.7 4.0 0.1 4.3 10.2 1 4 0.0 10 6 4.1) 3.9 5.1 0.2 1709 40-44 70.9 69.2 54.7 40.7 4.8 0.0 7.8 12.0 2.4 0.0 144 5.1 3.7 7.4 1.0 1411 45-49 63.3 62.1 52.2 29.7 3.3 0.4 6.2 9.5 3 2 0.1 14.1 6.5 3 9 6.9 0.9 1108 Total 64.6 62.9 44.0 39.7 2.9 0.1 3.6 7.5 1.1 0.11 9.5 3 4 2.6 4 9 0.4 9864 CURRENTLY MARRIED WOMEN 15-19 20.2 18.8 9.9 11.5 0.5 0.0 0.4 1.2 0.0 0.0 1 4 0.0 0.0 1.4 0.0 415 20-24 44.8 42.6 22.5 29.0 0.6 0.0 0.4 1.8 0.0 0.0 4.4 0.7 1.5 2.5 0.2 1324 25-29 66.7 64.8 38.7 43.8 2.0 0.1 1.7 5.8 0.1 0.0 7 2 2.3 I 7 4.0 0.2 1956 30-34 78.0 76.1 53.1 51.9 3.5 0.3 3.4 8.2 0.8 0.0 111.4 3,7 2 4 5.6 11.5 1743 35-39 77.9 76.4 56.4 49.2 4.2 0.1 4.4 10.8 1.5 0.0 11.1 4.1 40 5.5 0,3 1582 40-44 75.4 73.8 580 44.1 5.3 0.0 8.2 13.5 2.6 0.0 15.7 5.6 42 7.8 1.1 1231 45-49 68.7 67.5 56.5 33~2 3.9 0.5 7.0 11.1 3.6 0.2 15.7 7.5 4.5 7.6 1.1 902 Total 66.9 65.1 45.2 41 7 3.0 0.2 3.7 7.9 1.1 0.0 9.8 3 5 2.7 5.1 0.5 9153 Across age groups, the highest level of ever use is observed for currently married women 30-39 (78 percent) and the lowest level for women 15-19 (20 percent). Women age 30 and older are more likely to have had experience using the pill while, among younger women, experience with the IUD is more common than experience with the pill. Older women also are more likely than younger women to have ever used a tra- ditional method. 58 A comparison of the 1992 EDHS findings with the results of earlier surveys is presented in Table 4.12. The level of ever use among ever-married women increased by around 8 percentage points between the 1980 and 1984 (from 40 percent to 48 percent) and then increased again by almost I0 percentage points between 1984 and 1988. By 1992, the level of ever use had reached 65 percent. Table 4.12 Trends in ever use of family planning methods Percentage of ever-married women 15-49 who have ever used a family planning method by specific methods, Egypt, 1992 EDHS, 1991 EMCHS, 1988 EDHS, 1984 ECPS and 1980 EFS Ever used method Family planning EDHS EMCHS EDHS ECPS EFS method 1992 1991 a 1988 1984 b 1980 c Any metht~l 64.6 63.2 57.4 48.2 39.8 Any modern method 62.9 59.8 55.9 46.7 38.9 Modern method Pill 44.0 44.7 46.0 41.0 35.8 IUD 39.7 32,3 25.6 14.8 8.7 Injection 2.9 2.3 1. I 0.5 Vaginal methods 3.6 5.3 3.9 1.2 Condom 7.5 8.6 3.4 5.0 Female sterilization 1.1 1.5 1.4 0.7 Male sterilization 0.0 0.0 0.0 O. 1 Any traditional method 9.5 11.4 5.3 Safe period 3.4 3.7 1.4 2.7 Withdrawal 2.6 2.4 1.0 2.3 Prolonged breastfeeding 4.9 6.5 3.1 Other traditional methods 0,4 0.8 0.5 Number of women 9864 9073 8911 10013 8788 aAbdeI-Azeem, F. et al., 1993, Table 8.3 bSayed et al., 1989, Tables 5.2 CHallouda et al., 1983, Volume IV, Table 4.3.1-1. By method, the greatest increase was registered for the IUD. In 1992, 40 percent of ever-married women had ever used the IUD, compared to 26 percent in 1988, 15 percent in 1984 and 9 percent in 1980 (see Figure 4.4). In the case of the pill, the level of ever use increased by almost 10 percentage points between 1980 and 1988; however, between 1988 and 1992, there was a small decline (2 percentage points) in the proportion of women who have ever used the pill. These results are consistent with the trend in the method mix among current users over the same period (see Chapter 5). 59 70 60 50 40 30 20 10 0 Pe,cent Figure 4.4 Ever Use of Family P4anning, Egypt 1980-1992 Any method Pqll IUD EDHS1992 Differentials in Ever Use of Family Planning Methods Table 4.13 looks at di ffercnccs among subgroups in the overall proportions of ever-married women who have ever used family planning and in both the distribution of ever use~ by the number of methods ever used and the mean number of methods ever used. The table shows that older women are not only m ore likely to have used a method some time but they also are more likely to have had experience with a greater number of methods than younger women. For example, less than 10 percent of women age 30 and younger report that they have ever used three or more methods compared to around 25 percent of women 40-49. Considering other differentials, a woman is more likely to have used a family phmning method if she lives in urban areas, i f she has at least some primary education, or if she is working for cash. Womcn in these categories also are generally more likely to have experience with more than one method (see Table 4.13). 60 Table 4.13 Ever use of family planning methods by background characteristics Among ever-married women, percentage who have ever used a family planning method and, among ever-users, percent distribution by number of methods used and mean number of methods used, according to selected background characteristics, Egypt 1992 Number of Ever methods ever used Mean Number Background used any number of characteristic method l 2 3+ Total used women Age 15-19 19,8 80.1 16.4 3.5 100.0 1.2 423 20-24 43.7 72.7 23.7 3.6 100.0 1.3 1362 25-29 65.6 61.2 30.4 8.4 100.0 1.5 2013 30-34 76.0 49.2 37.1 13.6 100.0 1.7 1838 35-39 74.7 46.6 36.4 17.0 100.0 1.8 1709 40-44 70.9 41.6 33.5 25.0 100.0 2.0 1411 45-49 63.3 45.2 30.8 24.0 100.0 1.9 1108 Urban-rural residence Urban 76.3 46.8 34.0 19.2 100.0 1.8 4596 Rural 54.5 58.6 31.4 10.0 100.0 1.6 5268 Place of residence Urban Goveraorates 78.0 45.3 35.2 19.5 100.0 1.9 2357 Lower Egypt 70.6 52.9 33.5 13.6 100.0 1.7 4067 Urban 79.2 47.4 34.3 18.2 100.0 1.8 1210 Rural 67.0 55.6 33.1 11.3 100.0 1.6 2857 Upper Egypt 48.4 58.3 29.0 12.7 100.0 1.6 3440 Urban 68.9 49.9 30.3 19.8 100.0 1.8 1029 Rural 39.7 64.6 28.0 7.5 100.0 1.5 2411 Level of education No education 54.8 58.0 31.3 10.7 100.0 1.6 4771 Some primary 71.8 48.5 36.1 15.4 100.0 1.7 2078 Primary through secondary 74.3 43.7 33.2 23.1 100.0 1.9 1093 Completed secondary/higher 75.7 50.0 31.9 18.1 100.0 1.8 1922 Work status Working for cash 74.2 48.1 32.9 19.0 100.0 1.8 1464 Not working for cash 63.0 52.9 32.8 14.3 100.0 1.7 8400 Total 64.6 52.1 32.8 15.1 100.0 1.7 9864 4.5 First Use of Family Planning 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 enable an examination of cohort changes in the timing of adoption in order to identify any trend toward earlier adoption of more effective methods. 61 First Method Used Overall, for the majority of Egyptian women, experience with contraception begins with adoption of the pill. Table 4.14 shows that, among ever-users almost 60 percent started family planning by using the pill, while 31 percent chose the IUD for their first method, 5 percent adopted other modem methods and 6 percent began contraception with a traditional method. Younger women (age 15-24) are somewhat more likely to have begun family planning with the IUD. This may reflect the increasing popularity of the IUD in the method mix during the period when younger women first began to use family planning (see Chapter 5). Table 4,14 First method used Percent distribution of ever-users by first method used, according Io selected background characteristics, Egypt 1992 First method used Other Number Background modem Traditional of characteristic Pill IUD method I method 2 Total women Age 15-19 42.4 45.4 5,2 6,9 100.0 84 20-24 43.1 45.1 3,0 8.8 100.0 595 25-29 48.9 38.9 5.2 7.0 100.0 1319 30-34 56.3 33.9 4.0 5.8 100,0 1397 35-39 63.6 26.4 5.6 4.5 100.0 1277 40-44 68.3 20.9 5.9 4.9 100.0 1000 45-49 74.4 15.3 4.7 5.6 100.0 702 Urban-rural residence Urban 57.0 33.5 5.0 4.6 100.0 3505 Rural 60.8 27.0 4.7 7.6 100.0 2869 Place of residence Urban Govemorates 53.4 36.9 5.1 4.6 100.0 1837 Lower Egypt 58.3 30.6 4.2 6,9 100,0 2871 Urban 61.3 30.3 4.7 3,7 100.0 958 Rural 56.9 30.8 3.9 8,5 100.0 1913 Upper Egypt 65.1 23.4 5.8 5.8 100.0 1665 Urban 60,4 28.9 4.9 5.9 100.0 709 Rural 68.5 19.3 6.4 5.8 100.0 956 Education No education 63.5 26.0 4.5 6,0 100,0 2616 Some primary 66,6 24.9 3.9 4,6 100.0 1492 Primary through secondary 60.1 30.6 4.9 4,4 100.0 812 Completed secondary/higher 41.2 44.4 6.4 8.1 100.0 1454 Work status Working for cash 50.3 37,0 6.1 6.6 100.0 1086 Not working for cash 60.4 29.2 4.6 5.8 100.0 5288 Total 58.7 30.5 4.9 5.9 100.0 6374 1Includes injection, vaginal methods (diaphragm/foam/jelly). condom, female sterilization, and male sterilization. 2Includes periodic abstinence, withdrawal, prolonged breastfeeding and other folk methods. 62 Rural users are somewhat more likely than urban users to have started family planning use with the pill (61 percent and 57 percent, respectively) and less likely to have initiated use with IUD (27 percent and 34 percent, respectively). Rural women from Upper Egypt stand out as least likely to have begun family planning use by adopting the IUD; only 19 percent of ever-users in rural Upper Egypt adopted the IUD as their first method compared to 31 percent of ever-users in rural Lower Egypt. A woman's educational level is closely associated with the method selected when family planning use begins. Highly educated women begin use with the IUD more often than other women (see Figure 4.5). Table 4.14 also shows that women in paid employment are somewhat more likely than other women to adopt the IUD as their first method. Percenl Figure 4,5 First Family Planning Method Used by Level of Education 8O 4O ii'ii~ /i '"--"--1 I ~ i 20 i o ~ ~ No education Some primary Pnmary thru secondary Completed secondary/higher EDHS1992 Source for the First Method The 1992 EDHS collected detailed information (name, location and address) of the source from which ever-users first obtained a method. These data are tabulated according to the type of source in Table 4.15. Private sector sources (private hospitals/clinics, private doctors, clinics operated by the Egyptian Family Planning Association (EFPA), the Clinical Services Improvement (CSI) project, and other private voluntary organizations, mosque and church health units, and pharmacies) are clearly the major sources to whom women tum when they first adopt contraception. Two-thirds of ever-users obtained family planning services for the first time from a private sector source, mainly pharmacies. Government health facilities were the source for first methods for one-third of ever-users. 63 Table 4.15 Source of first method used Percent distribution of ever users by source of first method used, according to selected background characteristics, Egypt 1992 First methcxl used Other modem Source Pill IUD method I Total Public ~ctor 23.2 45.0 19.5 30.1 Urban hospital 1.7 10.6 12.6 5.1 Urban health unit 9,2 19.4 3 0 12.2 Rural hospital 1,2 3.6 1.4 2.0 Rural health unit 9.2 6.8 1 3 8.1) Other MOH 0.9 0 5 l).5 0.7 Teaching hospital 0.2 1.4 0.8 t).6 Health insurance organization 0.0 1.t) t).() l).3 Curative care organi/ation 0.7 1.5 0.l) 0.9 Other government 0,1 0.2 0 0 O. 1 Private sector 74 4 54.2 72.4 67.7 Medical private sector 74.0 54.2 72.4 67.5 EFPA 0.4 2.1 0.0 0.9 CSI 0.9 5.4 2.5 2.5 Other PVO 0.5 1.3 0 0 (I.8 Mosque health unit O.1 3.8 00 1.3 Church health unit 0.1 0.2 0.0 O.1 Private hospital/clinic 0,3 3.8 O 8 1.5 Private doctor 2.1 36.5 9.3 13.6 Pharmacy 69 5 1.1 59.8 46.8 Other private sector 0.4 0.0 O.I) 0.3 Other vendor 0.4 0.0 /hO 0 3 Other 1,9 0.7 5.4 1.7 Friends/Relauves 1,3 0.1 2.11 0.9 Other 0.4 0.6 0.5 0.5 Husband bought 0.3 O.II 3.0 0 3 Don't know 0.5 0.11 2.2 0.4 Total 100.0 100.11 100.0 100.0 Number of women 3740 1946 3(/9 5996 MOH = Ministry of Health EFPA = Egyptian Family Planning Association CSI - Clinical Services Improvement project PVO = Private voluntary organization 2Includes injection, vaginal methods (diaphragm/foam/jelly), condom, female steriliTation and male sterilization 64 The source used initially by ever-users varies according to the method selected (see Table 4.15). Ever-users who chose the pill as their first method, generally relied on pharmacies for their supply, followed by public sector providers, especially urban and rural health units (70 percent and 23 percent, respectively). Among women who initiated use with the IUD, 54 perc

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