Egypt - Demographic and Health Survey - 1998

Publication date: 1998

Egypt Demographic and Health Survey 1997 EI-Zanaty and Associates Cairo, Egypt Macro International Inc. Calverton, Maryland June 1998 The 1997 Interim Egypt Demographic and Health Survey (EIDHS-97) is part of the in~mational Demographic and Health Surveys project. Additional information about the EIDHS-97 may be obtained from: EI-Zanaty and Associates, 62 Mossadaq Street, Cairo, Egypt (Telephone: 20-2-349-6936; Telefax: 20-2-336-4120; and E-mail: edhs(~Jdsc.tov.e~,). Additional information about the worldwide DHS project may be obtained from: Macro International Inc., 11785 Beltsvine Drive, Calverton, MD 20705 (Telephone: 301-572-0200; Telefax: 301-572- 0999; and E~maih reports@macroint.com). Table of Contents List of Tables . 1 Introduction . 1 A. Survey Design and Implementation . I B. Coverage of the Sample . 3 C. Background Characteristics of Respondents . 3 2 Fert i l i ty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 A. Current Fertility . 7 B. Trends in Fertility . 8 3 Fami ly P lann ing Knowledge and Use . 11 A. Knowledge and Ever Use . 11 B. Levels and Trends in Current Use . 11 C. Differentials in Current Use . 13 D. Trends in Current Use by Background Characteristics . 14 4 Fami ly P lann ing Serv ices . 19 A. Sources of Family Planning Methods . 19 B. Cost of Family Planning Methods . 20 C. Information Received at Pharmacies . 21 D. Assessing Services at Clinical Providers . 22 5 Family Planning Communication . 25 A. Communication Channels . 25 B. Promotion of Gold Star Clinics . 26 6 Fert i l i ty Pre ferences and Unmet Need for Fami ly P lann ing . 29 A. Desire for Children . 29 B. Unmet Need for Family Planning . 29 7 Materna l Hea l th . 33 A. Antenatal Care . 33 B. Tetanus Toxoid Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 C. Overlap between Tetanus Toxoid and Antenatal Care Coverage . 33 D. Advice about ANC/FP . 34 E. Assistance at Delivery . 35 F. Differentials in Maternal Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 G. Trends in Maternal Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 8 Ch i ld Hea l th . 39 A. B. C. D. E. F. Vaccination Coverage . 39 Prevalence of Childhood Illnesses . 41 Treatment of Diarrhea . 42 Treatment of Respiratory Illnesses . 43 Nutritional Status of Children . 43 Infant and Child Mortality . 47 References . 51 Append ix A . 53 iv List of Tables Table number I. 1 Sample results . 3 1.2 Background characteristics of respondents . 4 2.1 Current fertility by residence . 7 2.2 Trends in fertility . 8 2.3 Trends in fertility by residence . 9 3.1 Knowledge and ever use of family planning methods . 11 3.2 Trends in current use of family planning methods . 12 3.3 Current use of family planning methods by residence . 13 3.4 Current use of family planning methods by selected demographic and social charactertistics . 14 3.5 Trends in current use of family planning methods by social and demographic characteristics . 15 4.1 Sources fur modern family planning methods . 19 4.2 Sources of family planning methods by residence, 1995 and 1997 . 20 4.3 Cost of the pill . 20 4.4 Cost of the IUD . 21 4.5 Cost of injectables . 21 4.6 User assessment of services at clinical providers by type of source . 22 5.1 Exposure to family planning rncssagcs . 25 5.2 Perceptions regarding Gold Star clinics . 26 6. I Fertility prefcrances . 29 6.2 Need fur family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 7.1 Antenatal care . 33 7.2 Tetanus toxoid coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7.3 Antenatal care and tetanus toxoid coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7.4 Assistance at delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 7.5 Mammal health indicators by background cbaractcTistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7.6 Trends in maternal health indicators . 37 8.1 Vaccinations by background characteristics . 40 8.2 Trends in vaccination coverage, Egypt 1988-1997 . 40 8.3 Prevalence of childhood illnesses by background characteristics . 41 8.4 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 8.5 Treatment of cough . 44 8.6 Nutritional status by demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 8.7 Nutritional status by socio-economic characteristics . 46 8.8 Trends in nutrition status of children . 47 8.9 Levels and trends in early childhood mortality . 48 8.10 Early childhood mortality by socio-economic characteristics . 48 8.11 Early childhood mortality by damographic cheractcristics . 49 V I Introduction The 1997 Egypt Interim Demographic and Health Survey (EIDHS-97) is the most recent in a series of national-level population and health surveys in Egypt.' The EIDHS-97 was carried out by E1-Zanaty and Associates. Macro International provided technical support for the survey through the Demographic and Health Surveys project, which is sponsored by the United States Agency for International Development (USAID) to assist counlries worldwide to obtain information on key population and health indicators. USAID/Cairo provided funding for the survey under the Population and Family Planning HI project. This report presents a summary of findings related to the principal topics in the survey. A. Survey. Design and Implementation Objectives of the Survey The EIDHS-97 was undertaken to provide information to measure progress toward the achievcmcnt of Government of Egypt and USAID goals in the population, health and nutrition sector. The EIDHS-97 was more limi~l in scope than earlier DHS surveys in Egypt, focusing on the collection of information on a number of key indicators. The survey also covered a smaller sample than earlier DHS surveys. Sample Design and Selection The sample for the EIDHS-97 was designed to provide estimates of population and health indicators including fertility and mortality rates for the country as a whole and for five major subdivisions (Urban Govcrnorates, urban Lower Egypt, rural Lower Egypt, urban Upper Egypt, and rural Upper Egypt). The Frontier Govemorates were excluded because they represent less than 2 percent of the total population. A systematic random sample of around 6,000 households was chosen for the EIDHS-97. In all areas except Assuit and Soulmg, the EIDHS-97 sample was drawn from the same sample points as the 1995 Demographic and Health Survey sample a, using the household listings that were prepared for the 1995 survey. Assuit and Souhag govemorates were oversampled in the 1995 survey because they were the sites for a special indepth study on the reasons for the non-use of conlraception. This study involved several rounds of follow-up interviews with respondents from these governorates in the 1995 survey. To avoid any effect that the revisits that were made to the sample segments in the indepth study might have on the outcome of the 1997 Interim Survey, a decision was made to select new segments in Assuit and Souhag. In each of these two governorates, therefore, the first stage of sample selection for the EIDHS-97 involved the selection of a subsample of 17 primary sampling units (PSUs) from the total number of PSUs in the 1995 EDHS sample. At the second stage, two new segments were chosen in each of the selected PSUs. A listing for all households living within each of the segments in the selected PSUs was then prepared and used for the final sample selection in the m i The EIDHS-97 is the fourth Demographic and Health Survey to be implernanted in Egypt; the earlier DHS surveys were conducted in 1988, 1992, and 1995. Other national-level sorveys for which results ere shovmin this report include the 1980 Egyptian Fertility Survey (EFS-80), the 1984 Egypt Contraceptive Prevalence Survey (ECPS-~,) and the 1991 Egypt Maternal and Child Health Sorvey (EMCHS-91). 2 For more information on the sample design for the 1995 EDHS, see EI-Zanaty et al., 1996. two governorates. In order to allow for the subregional estimates, the number of households selected from each gnvemorat¢ in the 1997 EIDHS is disproportionate to the size of the population in the gnvemorate. Thus, the EIDHS-97 sample is not self-weighting at the national level. Questionnaires Two questionnaires were used in the EIDHS-97: a household questionnaire and a woman's questionnaire. The household and woman questionnaires were based on the questionnaires used in the EDHS-88, the EDHS-92, and the EDHS-95 and on model survey instruments developed in the DHS program. However, because of the interim nature of the survey, the content of the 1997 questionnaires was more limited in scope than in the earlier surveys. The questionnaires were developed in English and translated into Arabic. A pretest of the household and woman questionnaires was conducted in October 1997. The household questionnaire was used to enumerate all usual members of and visitors to the selected households and to collect information on the socioeconomic status of the households. The first part of the household questionnaire collected information on the age, sex, marital status, educational attainment, and relationship to the household head of each household member or visitor. This information was used to identify the women who were eligible for the individual interview. It also provides basic demographic data for Egyptian households. In the second part of the household questionnaire, there were a limited number of questions on housing characteristics (e.g., the number of rooms, the flooring material, etc.) and on ownership of a variety of consumer goods. The individual questionnaire for women obtained information on the following topics: respondent's background characteristics, reproduction, contraceptive knowledge and use, fertility preferences and attitudes about family planning, pregnancy care and infant feeding practices, child immunization and health, marriage and husband's background, and height and weight of children an mothers. Data Collection and Processin~ Eight teams collected data for the EIDHS-97; each team consisted of four interviewers and field editor, and the team supervisor. The interviewers end editors were all females, while the supervisors were all males. One team was assigned for Cairo, and one team for Alexandria and Bebem. Each of the other teams was assigned to work in three governorates. The field staffwas trained during a four-week period in November 1997. The main fieldwork began on December 2rid, 1997. All interviews, callbacks, and reinterviews were completed by the first week of January 1998. Questionnaires were returned to the EIDHS survey office in Cairo for data processing. The office editing staff first checked that questionnaires for all selected households and eligible respondents had been received from the field staff. In addition, the few questions which had not been precoded (e.g., occupation) were coded at this time. The data were then entered and edited using microcomputers and the ISSA (Integrated System for Survey Analysis) soflware which was developed in the DHS program to facilitate processing of survey data. Office editing and data processing activities were initiated almost immediately aRer the beginning of fieldwork and were completed in late January 1998. 2 B. Coverage of the Sample Table 1.1 presents information on the results of the household and individual interviews. A total of 6,318 households were selected for the EIDHS-97 sample. Household interviews were completed for 6,067 households, which represents 99 percent of the sample households. As noted above, an eligible respondent was defined as an ever-married woman age 15-49 who was present in the household on the night before the interview. A U3tal of 5,615 eligible women were identified in the interviewed households in the EIDHS-97 sample. Of these women, 5,554 were successfully interviewed, with a response rate of 98.9 percent. Table l.I Percent distribution of households and eligible women by the result of the interview, and ~esponse rates, 1997 Egypt Demographic and Health Survey Urban Lower Egypt Upper E~/pt Result of interview Gover- and responserate Urban Rural notates Total Urban Rural Total Urban Rural Total Households (HH) Sampled 3,259 3,059 1,635 2,629 929 1,700 2,054 695 1,359 6,318 Found 3,142 3,000 1,573 2,556 892 1,664 2,013 677 1,336 6,142 Interviewed 3,087 2,980 1,537 2,531 878 1,653 1,999 672 1,327 6,067 HH response rata 98.2 99.3 97.7 99.0 98.4 99.3 99.3 99.3 99.3 98.8 Eligible women (EW) Identified 2,524 3,091 1,276 2,334 675 1,659 2,005 573 1,432 5,615 Interviewed 2,502 3,052 1,266 2,303 667 1,636 1,985 569 1,416 5,554 EW respease rate 99.1 98.7 99.2 98.7 98.8 98.6 99.0 99.3 98.9 98.9 C. Background Characteristics of Respondents Table 1.2 presents the distribution of ever-married women 15-49 interviewed in the EIDHS- 97 by selected background characteristics. Almost all of the respondents were married at the time of the interview, with 7 percent reporting that they were widowed or divorced. Considering the age distribution, 17 percent of the sample were under age 25, 35 percent were in the 25-34 age group, and 48 percent were over age 35. The age distribution of the EIDHS-97 reflects the fact that the age at first marriage has been steadily-increasing over time in Egypt. The majority of the EIDHS-97 respondents were from rural Egypt, with 30 percent residing in rural areas in Lower Egypt and 24 percent in rural areas in Upper Egypt. More than half of the urban residents--24 percent of the entire sample--were living in one of the four Urban Govnmorates. The educational attainment of EIDHS-97 respondents varied considerably. More than four in ten women in the sample had never attended school, 19 percent had had less than a primary education, 13 percent had completed the primary but not secondary level, and 26 percent had completed at least the secondary level. Table 1.2 Backt, round characteristics ofrcsl3ondents Percent distribution of ever-married women 15-49 by selected background characteristics, Egypt 1997 Number of women Background Weight~l Weighted Unweighted characteristics percent number number Marital status Currently manied 92.9 5,157 5,152 Widowed 5.3 295 304 Divorced 1.8 101 98 Age 15-19 4.2 232 234 20-24 13.0 719 71 l 25-29 17.0 947 944 30-34 18.2 1,012 999 35-39 18.6 1,032 1,000 40-44 15.7 870 888 45-49 13.4 742 778 Urban-rural residence Urban 45.8 2,546 2,502 Rural 54.2 3,008 3,052 Place of resldeace Urban Governorates 23.6 1,308 1,266 Lower Egypt 42.1 2,338 2,303 Urban 11.7 651 667 Rural 30.4 1,687 1,636 Upper Egypt 34.4 1,908 1,985 Urban 10.6 586 569 Rural 23.8 1,322 1,416 Educational level No education 43.0 2,388 2,422 Some primary ! 8.5 1,030 1,019 Prima~y completed/Some secondary 12.8 709 699 Sccondary completed/Higher 25.7 1,428 1,414 Total 100.0 5,554 5,554 4 Total Fertility Rates Egypt 1975-1997 5.3 4.9 1 9 ~ " ~ 4.4 4.1 YS 1984 3.9 3,6 S- 1 ~ 4 ~ 3.6 3. 3 1990-91 DIIS MCIIS 1992 1995 1997 DHS DHS IDHS 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Year At the time of the 1997 EIDHS, Egyptian women were having an average of 3.3 births---two births fewer than the average in the 1970s. Rural fertility has declined more rapidly than urban fertility; as a result, the urban- rural fertility gap narrowed from around two births in the mid-1980s to one birth in the mid-1990s. Trend in Total Fertility Rates by Urban-Rural Residence Egypt 1988-1997 5.4 4.9 Urban Rural I'tWD~(I~) btmDnS(im-~) [ B 1~ DHS (199~-9S) D 1997 IDHS ( t~ Total Fertility Rates by Place of Residence Egypt 1997 4.6 Urban Gevlrnorates Lowtr ~ Lower F4ypt Upper EgYPt Upper glUM Urban Rurtl Urlmn Rural The fertility rate among women from urban Upper Egypt is more than 20 percent higher than the rate among women from the Urban Governorates or urban Lower Egypt. Rural fertility also is higher in Upper Egypt than in Lower Egypt. 6 2 Fertility In the EIDHS-97, retrospective reproductive histories were obtained from all respondents. In collecting these histories, each woman was first asked about the number of sons and daughters living with her, the number living elsewhere and the numl:er who had died. She was then asked for a history of all her births, including the month and year in which each child was born, the child's name, sex and, if dead, the age at death, and, if alive, the current age and whether the child was living with the mother. The information on the age and/or date of birth of children is used to estimate current levels of fertility in Egypt. A. Current Fertility Table 2. I presents age-specific and total fertility rates for the three-year period before the survey according to the mother's residence at the time of the interview (i.e., for the approximate calendar period 1995-1997). The total fertility rate indicates that, if fertility rates were to remain constant at the level prevailing during the period 1995-1997, an Egyptian woman would bear 3.3 children during her lifetime. Table 2.1 Currant fertility by residence Age-specific fertility rates (per 1,000 women) and total fertility for the three years preceding the survey, Egypt 1997 Age Urban Urban Lower Egypt Gover- Rural notates Total Urban Rural Upper Egypt Total Urban Rural Total 15-19 23 73 20 36 14 45 91 29 113 52 20-24 139 223 126 190 140 207 225 177 247 186 25-29 165 209 147 187 182 187 222 187 240 189 30-34 132 139 129 108 104 109 175 164 180 135 35-39 58 74 55 61 61 62 80 64 91 65 40-44 12 24 12 16 10 19 28 18 33 18 45.49 4 5 4 3 2 3 9 I 1 8 5 Total 15-44 2.7 3.7 2.5 3.0 2.6 3.1 4.1 3.2 4.5 3.2 Total 15.49 2.7 3.7 2.5 3.0 2.6 3.2 4.2 3.3 4.6 3.3 Note: Rates are for the period 1-36 months preceding the survey. Rates for the age group 45.49 may be slightly biased due to truncation. Rural women are having more children than urban women. At current levels, rm'al women will have 3.7 births by the end of the childbearing period, one birth more than ~ women. A more detailed examination of the age-specific rates in Table 2.1 suggests that much of the overall urban-rural differential is the result of significantly higher fertility levels among rural women under age 30 compared to urban women in the same age group. For example, the age-specific fertility rate for rural women 15- 19 is three times the rate among urban women in the age group, and the mtc for rural women 20-24 is 60 percent higher than that for urban women in the same age group. Differences in fertility levels in the under 30 age group reflect both earlier ages at marriage and lower rates of adoption of contraception in rural compared to urban areas. By place of residence, fertility levels are lowest in the Urban Governorates, followed by Lower 7 Egypt. Upper Egypt, where the average woman is having slightly more than 4 live births, has the highest level. Within Upper Egypt, the urban-rural differential in fertility is fairly large; rural women in Upper Egypt are having an average of 4.5 births, more than one birth more than the rate among urban women in the region. In contrast, the fertility rate for rural Lower Egypt is 3.2 births. Urban women in Lower Egypt are giving birth at almost the same rate as women living in the Urban Govemorates. B. Trends in Fertility using data from earlier surveys as well as from the EIDHS-97, Table 2.2 shows the trend in fertility in Egypt since the late 1970s. Overall, fertility levels fell by 2 births, from 5.3 births at the time of the 1980 Egypt Fertility Survey to 3.3 births at the time of the EIDHS-97. Considering the decline in the age-specific rates, fertility fell at a faster pace among women age 30 and over than among younger women. Table 2.2 Trends in fertility Age-specific fartility rates (per 1,000 women) and total fertility rates, Egypt 1979-1997 Age EFS-80 ECPS-84 EDHS-88 EMCHS-91 EDHS-92 EDHS-95 EDHS-97 1979- 1983- 1986- 1990- 1990- 1993- 1995- 19801 19841 1988 ~ 199P 1992 = 19952 1997 = 15-19 78 73 72 73 63 61 52 20-24 256 205 220 207 208 200 186 25-29 280 265 243 235 222 210 189 30-34 239 223 182 158 155 140 135 35-39 139 151 118 97 89 81 65 40-44 53 42 41 41 43 27 18 45-49 12 13 6 14 6 7 5 Total 15-49 5.3 4.9 4.4 4.1 3.9 3.6 3.3 Rates are for the 12-month period preceding the survey. 2 Rates are for the 36-month period preceding the survey. Note: Rates for the age group 45-49 may be slightly biased due to truncation. Source: EFS-80 - Hallooda et aL, 1983, volume II, Table 4.16 ECPS-84 - unpublished results EDHS-88 - Sayed et aL, 1989, Table 3.2 EMCHS-91 - AbdeI-Azeem et al., 1993, Table 7.14 EDHS-92 - EI-Zanaty et al., 1993, Table 3.1 EDHS-95 - EI-Zanaty otal., 1996, Table 3. I The trend in fertility by residence is shown in Table 2.3 for the period between the 1988 EDHS and the 1997 EIDHS. Rural fertility declined more rapidly than urban fertility throughout this period. As a result, the gap between the rural and urban fertility rates decreased from almost 2 births in the mid-1980s to one birth at the time of the EIDHS-97. By place of residence, the decline in fertility during the period was greatest in Lower Egypt. In urban areas in that region, there was around a 30 percent decline in the total fertility rate between the 1988 EDHS and the 1997 EIDHS. This was a more rapid decline than that experienced in the Urban Governurates, where fertility fell by 17 percent or in urban Upper Egypt, where fertility decreased by 21 percent during the same period. Table 2.3 Trends in fertility by residence Total fertility ra~ by urban-rural residence end place of reaidence, Egypt 1986-1997 Residence EDHS-88 EMCHS-91 EDHS-92 EDHS-95 EDHS-97 1980- 1990- 1990- 1993- 1995- 19882 1991' 19922 19952 19972 U~an-~l r~dence Urban 3.5 3.3 2.9 3.0 2.7 Rural 5.4 5.6 4.9 4.2 3.7 Place of residence Urban Govemorates 3.0 2.9 2.7 2.8 2.5 Lower Egypt 4.5 U 3.7 3.2 3.0 Urban 3.8 3.5 2.8 2.7 2.6 Rural 4.7 4.9 4.1 3.5 3.2 Upper Egypt 5.4 U 5.2 4.7 4.2 Urban 4.2 3.9 3.6 3.8 3.3 Rural 6.2 6.7 6.0 5.2 4.6 Total 15-49 4.4 4.1 3.9 3.6 3.3 L Rates are for the 12-month period preceding the survey. 2 Rates arc for the 36-month period preceding the sun, cy. U-Unavailable Note: Rates for the age group 45-49 may be slightly biased due to truncation. Source: EDHS-88 - Sayed et at., 1989, Table 3. I EMCHS-91 - Abdel-Azeem et ai., 1993, Table 7.11 EDHS-92 - El-Zanaty et al., 1993, Table 3.1 EDHS-95 - El-Zaanty et at., 1996, Table 3.1 Fertility also fell at a somewhat faster pace in rural areas in Lower Egypt than in rural Upper Egypt. Among rural women in Lower Egypt, the total fertility rate decreased by 32 percent, from 4.7 births at the t ime o f the 1988 EDHS to 3.2 births at the time of the 1997 EIDHS. In rural Upper Egypt, fertility fell by 26 percent during the period from 6.2 births to the era'rent level of 4.6 births. 9 Current Use of Family Planning Egypt 1980-199/ All meelmd, f~ J " IUD • : ' - - - . - - : ' . : : . . . ,0 . . . . Z~-0 m. - - b -y , , 'D l ' " 1980 1984 1988 1990/91 1992 1995 1997 F'S CPS DHS MCFIS DI4S DI'L~ IDHS Contraceptive use has more than doubled in Egypt since 1980. Much of the growth is the result of increased.IUD use s!nce pill use has been dechnmg, and mjectables were introduced fairly recently. Contraceptive use rose steadily in rural areas between 1988 and 1997. In urban areas, growth was moderate during this period, with some evidence of a plateauing during the period between 1992 and 1995. Current Use by Urban-Rural Residence Egypt 19s8-1997 63 19m 1992 lggS 1997 19B 1991 tlP~J 1997 Urban Rural Current Use by Place of Residence Egypt 1997 67 66 igfl U rbln Lower Egypt Lower EllyPt Upper Etypt Upper gl[ypt Covemonltet Urbnn R in l Urbnn Rural In 1997, the contraceptive use rate in rural areas in Lower Egypt was 60 percent, higher than the rate in urban Upper Egypt and twice the rate in rural areas in Upper Egypt. 10 3 Family Planning Knowledge and Use The EIDHS-97 collected information on the knowledge and use of family planning. To obtain these data, respondents were first asked to name all of the methods that they had heard about. For methods not mentioned spontaneously, a description of the method was read, and the respondents were asked if they had heard of the method. For each method that they recognized, respondents were asked whether they had ever used the method and if they knew of a place where they could obtain the method. Finally, women were asked if they were currently using a method, and, if so, where they had obtained the method that they were using. A. Knowledge and Ever Use Table 3.1 Knowledge and ever use of family planning methods Percentage of currently married women 15-49 who know a family planning method and who have ever used a family planning method, by method, Egypt 1997 Percent Percent ever knowing truing Method method method Any method 99.7 75.8 Any modern method 99.6 73.7 Pill 99.5 43.0 IUD 99.4 56.1 lnjectables 97.3 11. I Norplant 72.2 0.4 Diaphragm, foam or jelly 34.8 2.1 Condom 49.2 6.6 Female sterilization 58. I 1.4 Male sterilization 9.6 -- Any traditional method 75.1 14.1 Periodic abstinence 31.1 3.3 Withdrawal 24.0 3.0 Prolonged breastfeoding 69.0 10.0 Other methods 7.5 0.8 Number of woman 5,157 5,157 The EIDHS-97 findings confirm that knowledge of family planning methods is almost universal among Egyptian women (Table 3.1). With regard to knowledge of specific methods, the EIDHS-97 results indicate that virtually all currently married women have heard about the pill, IUD, and injectables, more than 70 percent know about Norplant, and nearly 60 percent have heard of female sterilization. In contrast, recognition of male methods is less widespread; 49 percent of EIDHS-97 respondents know about the condom, 24 percent about withdrawal, and less than 10 percent about male sterilization. The EIDHS-97 found that 76 percent of enrrently married women in Egypt have had some experience in using family planning methods (Table 3.1). Almost all of the women who have ever used a method have used a modern contraceptive. Overall, 74 percent of currently married women have ever used a modem method while 14 percent have used a traditional method. Looking at ever use of specific methods, the IUD and the pill are the most widely adopted methods; 56 percent of married women have used the IUD at some time while 43 percent have ever used the pill. Around one in ten married women report ever use ofinjectables and of prolonged breastfeeding. B. Levels and Trends in Current Use Overall, 55 percent of currently married women were currently using a contraceptive method at the time of the EIDHS-97 (Table 3.2). With regard to the method mix, the IUD is the prinicipal method used by Egyptian couples to control their fertility. At the time of the EIDHS-97, 35 percent of married women---nearly two-thirds of all current users---were using an IUD. The pill, used by 10 percent of married women, is the second most popular method followed by injectables. 11 Table 3.2 Trands in current use of family planning methods Percent distribution of currently married women by the family planning method currently used, Egypt 1980-1997 EFS ECPS EDHS EMCHS EDHS EDHS EDHS Method 1980 1984 1988 1991 1992 1995 1997 Any method 24.2 30.3 37.8 47.6 47.1 47.9 54.5 Any modern method 22.8 28.7 35.4 Pill 16.6 16.5 15.3 IUD 4.1 8.4 15.7 lnjcctables 0.3 0A Not'plant Vaginal methods 0.3 0.7 0.4 Condom 1.1 1.3 2.4 Female sterilization 0.7 1.5 1.5 Male sterilization 0.0 0.0 44.3 15.9 24.1 44.8 45.5 51.8 12.9 10.4 10.2 27.9 30.0 34.6 0.5 2.4 3.9 0.0 0.0 0.1 0.4 0.1 0.2 2.0 1.4 1.5 I.I I.I 1.4 0.0 0.0 0.0 0.1 Any traditional method 1.4 1,6 2.4 3.3 2.3 2.4 2.7 Periodic abstinence 0.5 0.6 0.6 0.7 0.8 0.6 Withdrawal 0.4 0.3 0.5 0.7 0.5 0.4 Prolonged breastfeeding 0.6 1.1 0.9 1.0 1.5 Other methods 0.3 0.1 0.2 0.1 0.1 0.1 Not using 75.8 69.7 62.2 52.4 52.9 52.1 45.5 Totalpercent 100.0 100.0 100.0 100.0 100.0 100.0 I00.0 Number of women 8,012 9,158 8,221 8,406 9,153 13,710 5,157 Note: A dash (-) indicates that information on the method was not collected or reported. Source: EFS-80 - Unpublished results ECPS-84 -Sayed et al., 1985, Table 9.4 EDHS-88 - Sayod et al., 1989, Table 6.1 EMCHS-91 - Abdel-Azeera et al., 1993, Table 8.7 EDHS-92 - EI-Zanaty et al., 1993, Table 5.1 EDHS-95 - E1-Zanaty et al., 1996, Table 5.1 Table 3.2 presents the trend in the use of family planning between 1980 and 1997. The use rate rose quite rapidly in the 1980s. As a result, by 1992, 47 percent of married women were using family planning, almost twice the level reported in the 1980 Egypt Fertility Survey (24 percent). The pace of change in use rates then slowed substantially during the period 1992-1995, before accelerating again following the 1995 EDHS. Much o f the growth in use rates in Egypt has been a result of the increased use of the IUD. Overall, the proportion of married women who reported current use of the K ID rose from 4 percent in 1980 to 35 percent in 1997. The continued importance of inereases in the level of IUD use to the overall growth in family planning use in Egypt is evident in the pattern of growth in contraceptive use during the period between the 1995 and 1997 DHS surveys. There was an almost 5 percentage point increase in the use of the IUD between 1995 and 1997, which represented almost 70 percent of the total net gain in family planning use during this period. In contrast to the continuous increase in IUD, there was a steady decline in the use of the pill throughout the period between the 1980 EFS and the 1997 EIDHS. The slowing of the growth in the overall level of contraceptive use in Egypt during the first half of 1990s was owed, at least in part, to 12 the decline in the pill use rates. Between the 1988 and 1995 DHS surveys, the level of use of the pill decreased by around one-third. The decline in pill use appeared to have been arrested during the period between 1995 and 1997 Eli)I-IS, with 10 percent of married women reporting that they were using the pill at both points in time. The introduction of the injectable as a program method broadened the choice of family planning methods available to Egyptian women. Overall, use of injectables rose from less than one percent in 1992 to 4 percent at the time of the 1997 EIDHS. At least initially, injectable users may have been disportionately drawn from among women who were using the pill, cunlributing to the decline in pill use rates and the plateau'rag in the overall prevalence rate between the 1992 and 1995 EDHS surveys. Between the 1995 and 1997 surveys, however, increased use ofinjectables contributed significantly to the overall increase in use levels; more than one-fifth of the growth in family planning use between the 1995 and 1997 EDHS surveys was accounted for by increased use of injectables. C. Dif ferentials in Cur rent Use _Residence According to the EIDHS-97 results, there continue to be marked differences in the level of current use of family planning methods by residence within Egypt (Table 3.3). The current use rate among currently married women was 63 percent in urban areas compared to 47 percent in rural areas. Table 3.3 Current use of family olannint methods bv residance Percent disWibution of cunently married w~ 15-49 by the family planning method currently used, according to residence, Egypt 1997 Urban Lower Egypt Upper Egypt Gover- Method Urban Rural notates Total Urban Rural Total Urban Rural Total Any method 63.1 47.1 67.0 61.6 65.9 59.9 37.4 52.1 30.3 54.5 Any modern method 60.2 44.6 63.8 59.4 63.2 57.9 34.3 49.3 27. I 51.8 Pill 10.8 9.7 10.7 12.2 12.8 11.9 7.5 8.9 6.9 10.2 IUD 41.7 28.4 44.1 40.0 42.4 39.1 21.4 35.8 14.5 34.6 lnjectables 3.0 4.6 3.3 4.3 3.4 4.7 3.7 1.8 4.5 3.9 Norplant 0.1 0.0 0.2 0.1 0.0 0.1 0.0 0.1 0.0 0.1 Vaginal methods 0.2 0.1 0.4 0.1 0.0 0.2 0.1 0.0 0.1 0.2 Condom 2.7 0.5 3.2 1.2 2.3 0.8 0.7 1.8 0.2 1.5 Female sterilization 1.7 1.1 1.8 1.5 2.3 1.2 0.9 0.8 0.9 1.4 Male sterilization 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Any traditional method 3.0 2.6 3.2 2.2 2.7 2.1 3.1 2.8 3.2 2.7 Periodic abstinence 1.2 0.2 I.I 0.5 1.2 0.3 0.4 1.3 0.0 0.6 Withdrawal 0.5 0.4 0.5 0.5 0,6 0.5 0.2 0.3 0.2 0.4 Prolonged 1.1 1.9 1.3 1.1 0.8 I.I 2.3 1.2 2.9 1.5 Other methods 0. I 0.2 0.2 0.1 0.0 0.2 0.1 0.1 0.1 0.1 Not using 36.9 52.9 33.0 38.4 34.1 40.1 62.6 47.9 69.7 45.5 Total percent I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 Numberofwomen 2,386 2,771 1,199 2,187 614 1,572 1,771 573 1,198 5,157 13 By place of residence, use rates were considerably higher in the Urban Govemorates (67 percent) and Lower Egypt (62 percent) than in Upper Egypt (37 percent). The differential in current use rates between rural Lower Egypt and rural Upper Egypt is especially marked; 60 percent of currently married women in rural Lower Egypt were using a method at the time of the EIDHS-97 compared to 30 percent of married women in rural Upper Egypt. Demographic and Social Characteristics Differentials in current use by other selected social and demographic characteristics are presented in Table 3.4. Current use rises rapidly with age, reaching a peak (69 percent) in the 35-39 age group. Use rates also are related to family size. Few women use before having their first birth. After the in'st child, contraceptive use increases sharply with the number of living children, peaking at 68 percent among women with 3 children, after which it declines slightly. Current use levels are directly related to the educational level of the woman, increasing from 46 percent among women who never attended school to 65 percent among women who have completed the secondary level or higher. TJbk 3.4 Current me of family, plannin.~ methods by selected ~ ¢ and social characteristics Pt~'nt dism'bution of curl~fly mm'ded women 15-49 by contrac~ve method cmrent] y mad according to sek, cted demographic ta~ soCml ¢hantctmlsfiea, Egypt 1997 Pro- Pen- Any Any Feint J© Any ~ongod odic Ntmther Backgmuod met- rood- lnjec. Vagth Nor- Con- sterili- tradi- breast- ah~ti- Not Total of characte~fics hod ¢m Pill IUD Tables -als plant dora zafion fional feeding hence Other t~ing pet~nt women Age 13-19 21.4 18,0 3.1 12.9 1.5 0.0 0.0 0.5 0.0 3.4 3.4 0.0 0.0 78.6 1~.0 227 20-24 40,3 37.8 $,0 30.7 1.7 0,0 0.0 0.4 0.0 2,6 2.4 0.0 0.2 39.7 100.0 710 25-29 53.3 50,5 9.8 35.1 4.2 0.0 0.2 1.1 0.0 2.8 2.5 0.2 0.1 46.7 leO.0 916 3034 63.9 60.6 12.8 42.4 3.8 0.1 0.1 0.8 0.6 3.4 1.5 0.9 0.9 36.1 I(X).0 965 35-39 68.7 65.7 13.3 43,2 4.6 0.0 0.0 2.1 2.2 3.0 1.4 0.7 1.0 31.3 100.0 971 4044 61.0 58.2 12.2 33.8 6.4 0.3 0.0 3.0 2.4 2.9 0.4 1.8 0.7 39.0 leO.0 767 45,-49 39.4 38.4 7.8 21.0 2,3 0.7 0.4 2.2 4.0 1.0 0.1 0.3 0.6 60.6 100.0 602 Number of Ilvlalt ¢hBdren 0 0.7 0.7 0.3 0.0 0.0 0.0 O.0 0.4 0,0 0,0 0.0 0.0 0,0 99.3 100.0 633 I 38.8 36.3 5,3 29,1 0,8 0.0 0.2 0.5 0.1 2.5 2.0 0.2 0,3 61.2 100,0 615 2 61.9 59.2 9.6 44.7 2.0 0.4 0.0 2.1 0.3 2.8 1.3 1.5 0.0 38.1 100.0 1,017 3 67.6 64.6 12.3 44.6 3.4 0,0 0.0 2.4 2.0 3.0 1.4 0.6 0.7 32.4 100.0 1,053 4+ 60.2 57.0 13.0 33.3 6.7 0.2 0.2 1.3 2.2 3.2 1.9 0.4 0.9 39.8 100.0 2,038 Edtemgt~nn No education 45.6 42.7 9.7 26.0 4.6 0.1 0.2 0.6 1.5 3.0 2.1 0.1 0.7 54.4 109.0 2,147 Someprittatr/ 57,1 55.0 12,7 32.1 6.1 0.2 0.0 1.7 2,2 2.1 1,5 0.1 0.4 42.9 100.0 956 Pfitmry ¢omp./ Some~condary 58.4 56.7 10.0 39.8 3.6 0.0 0.0 2.8 0.4 1.7 0.9 0.6 0.2 41.6 100.0 677 seo=d~ COmp JHigher 64.7 61.4 9.4 47.0 1,3 0.3 0.1 2,2 1.0 3.4 0.9 1,9 0.6 35.3 leO.0 1,377 Total 54.5 51.8 10.2 34.6 3.9 0.2 0.1 1.5 1.4 2.7 1.5 0.6 0.5 45.5 ICO.0 3.157 D. Trends in Current Use by Background Characteristics Table 3.5 presents the trends in contraceptive use during the period between 1988 and 1997 by selected background characteristics of women for all methods and for the pill, IUD, and injectables. Looking at the entire period, all residential groups shared in the rise in use rates. However, the absolute change in use rates among rural women, especially those living in Lower Egypt, was greater than the change in the population as a whole. As a result, the urban-rural 14 Table 3.5 Trends in current use of family vlaonina methods by social and dernom'aohic characteristics Trends in the percentages of currcntly married women currendy using any contraceptive method and the pill, IUD, and injectable, by selected demngraphic andsocial character/stics, Egypt 1988-1997 Any method Pill IUD Injectables Background Characteristics 1988 1992 1995 1997 1988 1992 1995 1997 1988 1992 1995 1997 1988 1992 1995 1997 Urben-rural Urban 51.8 57.0 56.4 63.1 18.4 14.0 11.0 10.8 23.0 34.6 36.2 41.7 0.1 0.5 2.4 3.0 Rural 24.5 38.4 40.5 47.1 12.4 11.9 9.9 9.7 8.8 22.0 24.6 28.4 0.1 0.5 2.5 4.6 Place of residence UrbanGovemorates 56.0 59.1 58.1 67.0 16.9 12.5 8.4 10.7 26.8 36.8 40.2 44.1 0.1 0.3 2.2 3.3 LowerEgypt 41.2 53,5 55.4 61.6 19.2 15.1 12~6 12.2 16.2 32.6 34.7 40.0 0,1 0.5 2.8 4.3 Urban 54.5 60.3 59.1 65.9 24.2 17.3 14.3 12.8 21.2 36.3 34A 42.4 0.0 0.7 3.0 3A Rural 35.6 50.5 53.8 59.9 17.2 14.1 11.9 11.9 14.1 31.0 34.8 39.1 0.1 0.5 2.7 4.7 UpperEgypt 22.1 31.4 32.1 37.4 10.0 10.7 9.1 7.5 7.9 16.4 17.7 21.4 0.1 0.6 2.0 3.7 Urban 41.5 48.1 49.9 52.1 16.0 13.8 12.6 8.9 17.6 27,6 30.3 35.8 0.2 0.6 1.8 1.8 Rural 11.5 24.3 24.0 30.3 6.7 9.3 7.5 6.9 2.7 11.6 11.9 14.5 0.0 0.6 2.1 4.5 Age 15-19 5.5 13.3 16.1 21.4 3.5 4.1 3.2 3.1 1.7 8.4 11.3 12.9 0.0 0.0 I.I 1.5 20-24 24,3 29.7 33.2 40.3 10.8 6.8 6.6 5.0 10.7 21.2 21.7 30.7 0.0 0.2 2.1 1.7 25-29 37.1 46.0 47.6 53.3 14,9 13.3 9.8 9.8 17.7 29.3 33.1 35.1 0.0 0.2 2.2 4.2 30-34 46.8 58.8 58.1 63.9 19.2 16.2 13.3 12.8 20.2 36.7 37.3 42.4 0.2 0.5 3.2 3.8 35-39 52.8 59.6 60.7 68.7 23.2 18.2 13.8 13,5 21.2 34.0 37.2 43.2 0.1 0.8 3.2 4.6 40-44 47.5 55.5 58.8 61.0 15.5 14.0 12.5 12.2 18.5 28.9 34.4 33.8 0.3 1.1 2.5 6.4 45-49 23.4 34.5 33.3 39.4 8.6 7.9 7.6 7.8 6.6 14.9 16.2 21.0 0.0 0.5 1.2 2.3 Number of living children 0 0.7 0.5 1.2 0,7 0.1 0.3 0.5 0.3 0.4 0,2 0.5 0.0 0.0 0.0 0.0 0.0 1 23.1 31.6 31.6 38.8 7.6 6.7 4.7 5.5 11.4 22.4 23.3 29.1 0.0 0.0 0.9 0.8 2 43.4 52.5 53.9 61.9 14.7 12.7 8.9 9.6 20.5 34.3 38.9 44.7 0.0 0.0 1.6 2.0 3 47.8 59.3 65.4 67.6 19.9 17.1 13.7 12.3 19.6 34.8 40.3 44.6 0.0 0.5 3.8 3.4 4+ 44.4 54.3 53.9 60.2 17.1 15.8 13.9 13.0 17.1 30.0 30.6 33.3 0.2 1.0 3.2 6.7 Education Noeducafion 27.5 37.5 40.6 45.6 13.4 12.0 11.0 9.7 10.0 20.7 23.8 26.0 0.1 0.5 2.3 4.6 Some primary 42.5 53.5 50.5 57.1 20.3 17.6 12.2 12.7 16.3 29.4 30.2 32.1 0.1 0.5 3.1 6.1 Primary ¢omp./ Somesecondmy 52.3 56.1 51.2 58.4 15.6 13.7 10.1 10.0 23.9 34.0 32.8 39.8 0.0 0.6 2.3 3.6 Secondary comp./ Higher 53.2 58.0 56.5 64.7 13.8 9.8 8.3 9.4 27.1 40.0 39.0 47.0 0.1 0,4 2.0 1.3 Total 37.8 47.1 47.9 54.5 15.3 12.9 10.4 10.2 15.7 27.9 30.0 34.6 0.1 0.5 2.4 3.9 differential in use rates narrowed during the period. Considering the age patterns, an examination of the results in Table 3.5 indicates that increases in use rates were fairly uniform across age groups. There is no evidence of a trend toward the adoption of contraception immediately after marriage to postpone a first birth. Throughout the period, there was almost no use of family planning among women who had not begun childbearing. Much of the change in use rates over the past decade in Egypt was among women with less than a primary education. For example, between 1988 and 1997, use rates increased by 18 percentage points among women who never attended schonl (from 28 percent to 46 percent) and by 14 percentage points among women with less than a primary education (from 43 percent to 57 percent). Somewhat smaller increases were observed during the period among better educated 15 women. As a result, the differential in use rates across educational groups narrowed during the period. 16 Source for Family Planning Methods Egypt 1997 3% 6% In Egypt, family planning users are more likely to obtain their method from a private provider than from a public hospital or clinic. The percentage of IUD users getting the method from public sector sources increased between 1995 and 1997, especially in the Urban Governorates. Reliance on Public Sector Sources among IUD Users Egypt 1995-1997 45 49 i . 55 Total Urban Goveruorates IUD and Injectables: Median Cost in Pounds Egypt 1997 21.8 3.5 m m 7.4 On average, IUD users pay more than five times as much for the method at private providers as at public sector sources, and injectable users pay nearly twice as much. 18 4 Family Planning Services The EIDHS-97 obtained information on a number of aspects of the family planning service delivery including the source from which current users had obtained their method, the cost of obtaining services, and the extent of information provided to women obtaining family planning services from pharmacies or clinical sources. A. Sources of Family Planning Methods Data obtained from current users of modem methods about the source from which they had gotten their method is presented in Table 4.1. Overall, the EIDHS-97 findings indicate that users are more likely to obtain their method from a private than from a public sector source. Table 4.1 Sources for modem family planning methods Percent distribution of etm'ent users of modern family planning methods by the most recent source for their method, according to the method used, Egypt 1997 Injec- All Source Pill IUD tables me0mds Public sector 8.7 48.7 67.0 40.9 Miniswy of Health (MOH) 8.2 45.5 63.6 38.0 Urban heapitel 0.7 13.3 10.6 10.9 Urban health unit 1.7 15.3 14,5 11.7 Rural hospital 0.6 2.7 8.0 2.5 Rural health unit 4.5 7.8 25.2 8.1 Other MOH 0.7 6.4 5.2 4.8 Teaching hospital 0.2 0.8 2.1 1.0 HICCCCO 0.0 1.5 0.0 1.1 Other govenenental 0.3 0.9 1.2 0.7 Private sector 89.5 50.6 33.0 58.1 NGO/PVO clinics 0.6 8.2 7.4 6.2 EFPA 0.3 3.9 5.8 3.2 CSI 0.3 3.9 0.6 2.7 Other NGO/FVO 0.0 0.4 1.0 0.3 Mmque/ehurch health unit 0.2 3.6 0.0 2.5 Privat e hospitel/clniic 0.1 5.2 1.4 4.1 Private doctor 1.8 33.6 15.2 24.8 Pharmacy 86.6 0.0 7.5 20.3 Other vendor 0.3 0.0 1.5 0,2 Other 1.6 0.2 0.0 0.5 Other 0.0 0.2 0.0 0.1 Friends/relatives 1.6 0.0 0.0 0.3 Don't know 0.2 0.5 0.0 0.5 Total percent I00 100 100 100 Number of eaere 528 1,783 199 2,671 MOH - Minilmy of Health HIO - Heahh Iammaee OrllDiamio¢ CCO - Cemive Otto Orgaalmem NOO - ~agovemmeea mga lmeee PVO. Prlvate vo lmmy eqpmimem EFPA - Egypt Fmmly Phmm~ Alntoci~qa csa - ~ se~ie~ Xnwovmm* ~jm The majority of current users of the pill (87 percent) get their method at a pharmacy. Almost half of all IUD users had the method inserted at a public health facility, 39 percent at a private doctor or clinic, 8 percent at a facility operated by a nongov- ernmental or private voluntary organization (NGO/PVO), and 4 percent at a mosque or church- sponsored clinic. The principal providers of injectables are govern- ment health facilities (67 percent), private doctors or hospitaFclinics (17 percent), pharmacies (8 percent), and NGO/PVO facilities (7 percent). Table 4.2 takes into account residence in presenting the distribu- tion of IUD users by source. The table shows that the percentage of users reporting that the IUD was inserted at a public sector source at the time of the EIDHS-97 varied by region, from 42 percent in Upper Egypt to 55 percent in the Urban Governorates. Table 4.2 also shows the percentage of IUD users relying on public sector at the time of the EIDHS-97. A comparison of those pcrcentages with the EmHS-97 results indicates that there was an overall increase m the proportion of IUD users relying on public sector. The largest increases in the proportion 19 Table4.2 Sourees of family vlannin~t methods by residence, 1995 and 1997 Percent distribution of IUD users by the type of som'ce for the method at the time of the EIDHS-97 and the percentage of IUD users obtaining the method from public sector sources at the time of the EDHS-95, according to residence, Egypt 1995 and 1997 Method Urban Lower Egypt Upper Esypt Gover- Urban Rural notates Total Urban Rural Total Urban Rural Total EIDHS-97 Public sector 47.7 49.9 54.7 47.9 39.3 51.6 42.0 40.4 43,8 48.7 Private sector 51.8 49.1 45.2 50.9 59.4 47.3 57.4 58.8 55,8 50.6 NGO/PVO clinic 8.8 7.4 4.3 10.3 17.5 7.3 8.6 9.3 7,8 8.2 Private doctor/clinic/hosp. 38.2 39.7 34.7 38.8 39.6 38.5 44.6 45.2 44,0 38.8 Mosque/church clinic 4.8 2. I 6,2 1.7 2.3 1.5 4.2 4.3 4,1 3.6 Pharmacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other/Not sure 0.5 1.0 0.1 1.2 1.3 I. 1 0,6 0.8 0,4 0.7 Totalpercent I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 I00.0 Number of woman 995 788 529 875 260 614 379 205 174 1,783 EDHS-95 Public sector 42.8 46.7 46.5 44.4 37.4 47.3 42.1 39.9 44.5 44.5 NGO - Nongovernmental organization PVO - Private voluntary organization of users going to public sector providers for IUD services were observed in the Urban Governorates and rural Lower Egypt. B. Cost of Fmnily Planning Methods Table 4.3 C ~ Percent distribution of current users of the pill by the cost of a cycle, Egypt 1997 Cost of cycle Free 0.8 1-10 4.1 11-30 1.2 31-50 4.3 51-75 33.8 76-100 32.4 More than 100 piaatres 18.7 Total 100.0 Number 528 Median (in piastres) 95.1 Mean (in piastres) 94.5 The EIDHS-97 obtained informahon from current users on the cost of their method. Table 4.3 shows the percent distribution of pill users according to the amount that they paid for packet (cycle) of pills. The majority of users (66 percent) paid between 50 piasters and 1 pound for a cycle of pills. The median price paid per cycle was 95 piastzes. Table 4.4 shows that there is considerable vari- ability in the cost of IUD services. Relatively few K ID users received the method free (6 percent), but a significant proportion (33 percent) paid less then 5 pounds for the method. Most of the users paying less than 5 pounds relied on public sector sources, where the median cost o f an IUD was 3.5 pounds. In contrast, around 1 in 10 users obtaining the IUD from a private sector source paid less than 5 pounds or received the method free. The median amount paid for an IUD from private provider was 21.8 pounds. 20 Table 4.4. Cost of the IUD percent distribution of cunent users of the IUD by the cost of obtaining the method according to the type of source, Egypt 1997 Public Private health health Cost of method facility facility Total Free 7.8 5.1 6.4 < 3 30.6 2.4 15.8 3-4 32.3 3.1 16.9 5-6 14.7 4.0 9.1 7-8 5. I 2.4 3.6 9-10 3.6 6.6 5.2 11-15 2.3 15.4 9.2 16-20 1.6 16.3 9.3 21-30 1.3 15.8 9.0 31-50 0.7 18.9 10.3 > 50 0.2 8.7 4.6 Not sure 0.0 1.4 0.7 Total 100.0 100.0 100.0 Number 845 938 1,783 Median 3.5 21.8 10.2 Mean 4.9 28.0 16.4 Note: Privatc health facilities include private doctors, clinics or hospitals; NGO/PVO clinics; mosque or church clinics and other private sector providers, Table 4.5 Co~ of iniactables Percent distribution of corrsnt users of the injcctablcs by the cost of obtaining the method at the be~nning of the period of use,Egypt 1997 Public Private health health Cost of method facility facility Total Free 6.3 2.6 5.1 <3 5.0 2.0 4.0 3-4 68.9 27.3 55.1 5-6 11.7 11.0 I 1.4 7-8 5.6 20.3 10.5 9-10 0.6 14.5 5.2 > 10 0.8 21.2 7.9 Not sure 1. I 0.2 0.8 Total 100.0 100.0 100 Number 133 66 199 Median 3.8 7.4 4.2 Mean 6.4 8.7 7.2 Note: Private health facilities include private doctors, clinics or ho~pitels; NGO/PVO clinics; mosque or church clinics and other private sector providers. A similar pattern is observed in the case of injectable users (Table 4.5). The median amount paid by all injectable users was 4.2 pounds. Among users obtaining the method from public sector sources, the median amount paid was 3.8 pounds, around half the amount paid by users going to private sector providers (7.4 pounds). C. In fo rmat ion Rece ived at Pharmac ies Pharmacies are the primary source for the pill in Egypt, with nearly 9 in 10 current pill users obtaining the method from a pharmacy. Current pill users were asked a number of other questions about their experience in obtaining the method. First of all, previous studies have shown that women frequently do not go to the pharmacy to obtain the pill themselves, but instead rely on the husband or other family members to get the method. Therefore, pill users who reported the pharmacy as their source were asked if they themselves had actually obtained the method at the pharmacy. In addition, current users of the pill who reported a source other than a pharmacy were asked whether they had obtained the pill themselves from a pharmacy at any time during the cunent episode of use. Overall, 63 percent of pill users had themselves visited a pharmacy at some time during the cm'rent episode of use. These users were asked several questions about the information that they had received at the pharmacy (data not shown in table). Overall, relatively few women who had visited a pharmacy to obtain the pill reported receiving any information from the pharmacy staff. If they did receive reformation, they were most likely to have been shown how to use the pill (19 percent). One in 10 women who obtained the pill at a pharmacy reported that the possible side effects from the 21 method had been described to them, and 8 percent said that they had been told about other methods. D. Assessing Services at Clinical Providers Woman who reported that they had gone to a clinical provider to obtain their methods were asked a number o f questions to obtain information about the services that they received. Caution must be exercised in interpreting these findings since they are subject to a number o f potential sources of bias 3. Table 4.6 presents fmdings with regard to users' perspectives on the services that they had received. In general, users seem to be satisfied with most aspects o f the services that they are receiving from clinical providers; overall, 90 percent or more found their provider to be offering quick service, polite treatment, privacy during consultation, clean surroundings, and an affordable cost. Table 4.6 User assessment of service~ at clinical oroviders by type of suurce Percentage of currant users of modem methods obtairfmg their methods from a clinical source who said that they had received various components of sol'vices at the source by type of source, Egypt 1997 Public sector facility Privat© Other All NGO/ doctor/ Mosque Gold public public PVO clinic/ clinic/ Service indicator Star facility facilities clinic hospital church Total Quick service 92.8 88.7 89.2 91.3 93.5 83.4 90.9 Polite trcatmant 96.5 97.9 97.7 99.1 99.1 100.0 98.4 Information about methods 71.7 70.4 70.6 80.9 75.2 60.8 72.9 Information about side effects 62.8 64.4 64.2 71.4 72.7 57.2 67.9 Privacy during consultation 94.3 92.9 93.1 96.7 99.0 97.6 95.8 Clean surroundings 99.5 98.1 98.3 99.2 99.7 100.0 98.9 Affordable costs 99.2 97.8 97.9 97.5 94.0 94.2 96.2 Number ofuscn 145 1,009 1,154 177 925 73 2,329 NGO - Nongovernmental organization PVO - Private voluntary organization An area of greater concern regarding the services women are receiving from clinical providers is the information they are given about family planning methods. More than 1 in 4 users who obtained services from a clinical provider reported that the provider did not offer them information on any methods other than the one they adopted, One in 3 users reported that they were not given any information about side effects. Mosque and church clinics had the lowest proportion reporting that they had received information about other methods or about the possible side effects of the method that they had adopted. 3 One potential bias comes from difflenlties women may have in recalling aspects of the expedancos that they had at a provider, p~ticolm'ly if they have been using their method for an extended period of time. Respondents also may be unwilling to complain about the services that they had n~eived or m admit that the services had been too costly. The qucstiuns also do not capture the experiences of women who may not be using a method because of problems they experienced in obtaining services, 22 Exposure to Family Planning Messages By Residence Egypt 1997 98 97 97 92 I l a Urb#l Lower EIUTt 1.4wer g l l~t Upper glgypt Upper glypt Goveraofatel LTrbuu Rml Urban Rat,~ Family planning messages reach a broad audience in Egypt; the proportion of married women who had been exposed to a message recently ranges from 89 percent in rural Upper Egypt to 98 percent in the Urban Governorates. Nine in 10 married women have recently seen a family planning message on television, and nearly half have heard a radio broadcast about family planning. Main Channels of Information about Family Planning Egypt 1997 Televislom R,,dlo Poster l l l l i board Newspuper . . . . . . . ~i : ~ii ¸:.: " ~" ~: : ~ :~ :i: ~: . . . . . . ~ " :. : : ~i~iiil i:!:i: ::~ : : : : ~ : I m 3o 24 5 Family Planning Communication The EIDHS-97 obtained information on a number of aspects of women's exposure to family planning communication. Specifically, the survey obtained data on whether women had recently heard about family planning through various broadcast or print media. Questions also were included in the EIDHS-97 to ascertain whether women were familiar with Gold Star clinics. These clinics were promoted as part of the family planning Information, Education, and Communication (IE&C) efforts. A. Communication Channels Table 5.1 looks at the extent to which currently married women reported that they had recently seen or heard family planning messages through various communication channels. Overall, more than 90 percent of women had been exposed to family planning information through at least one print or broadcast medium. Almost two-thirds of the women had heard about family planning recently through more than one of the communication channels. Table 5.1 ~xpo~urc to family Dimming me~a2es Percentage of currently mamad women repm~in 8 that they had heard about family planning through various corranunication channels, EgYPt 1997 Cormnunication channel Urban Urb~ Lower EiV/pt Upper egypt Govef- Rural notates Total Urban Rural Total Urban Rural Total Television 95.7 84.1 97.0 90.1 94.9 88.2 83.6 93.7 78.8 89.5 Radio 57.1 41.0 63.4 49.9 54.2 48.3 36.5 47.2 31.4 48.5 Newspaper/magazine 34.7 13.5 34.7 23.8 38.2 18.2 15.0 30.9 7.4 23.3 Poster 38.8 22.3 33.0 31.9 46.0 26.3 25.5 43.2 17.1 30.0 Leaflet/brochure 23.8 10.9 22.4 19.0 30.9 14.4 10.4 19.2 6.3 16.9 Billboard/signboerd 33.3 18.1 30.2 27.9 39.0 23.5 18.3 33.6 11.0 25.1 Cormnanity meeting 6.5 4.2 5.5 6.1 9.2 4.9 4.0 5.5 3.2 5.2 Other 2.8 10.7 0.8 4.1 3.4 4.4 14.9 6.5 19.0 7.1 Any channel 97.6 91.1 98.2 93.8 97.2 92.4 91.7 96.8 89.3 94.1 More than one channel 73.6 54.1 75.7 62.7 73.2 58.6 55.1 69.4 48.3 63.1 Numberofwomen 2,386 2,771 1,199 2,187 614 1,572 1,771 573 1,198 5,157 Considering the variation by residence, the proportion of women who had been exposed to a family planning message through at least one communication channel was high in most areas, ranging from 89 percent in rural Upper Egypt to 98 percent in the Urban G-overnorates. There was greater variation by place of residence in the percentages of women exposed to family planning messages through more than one media. For example, fewer than half of womon in rural Upper Egypt reported that they had heard messages through more than one channel while three-fourths of women in the Urban Governorates had been exposed to messages through more than one communication channel. With regard to the coverage of specific communication channels, women were more likely to report hearing about family planning on television than through other communication channels. 25 Around 9 in 10 married women reported that they had seen a family planning message on television in the few months immediately prior to the survey. Among the other communication channels, women were most likely to report being exposed to a radio message (49 percent), followed by family planning posters (30 percent), billboards or signboards (25 percent), and newspaper/magazine articles (23 percent). B. Promotion of Gold Star Clinics The Ministry of Health and Population (MOH&P) adopted the Quality Improvement Program (QIP) as part of its efforts under the USAID-supported Systems Development Project (SDP) to improve the quality of family planning service delivery. QIP concentrates on introducing standards of service and monitoring the extent to which facilities are complying with these standards. It involves a rating system, whereby each health facility is assessed quarterly on their conformity to the QIP standards of service. Clinics scoring 100 points or more for two consecutive quarters are rewarded with a "Gold Star". Thus, a Gold Star is a mark of excellence. An on-going mass media campaign has been launched to inform the public of the meaning of the gold star and assure potential clients that they will obtain excellent services at clinics that display this symbol. Information collected in the EIDHS- 97 allows assessment of the extent to which women had heard about Gold Star clinics. Overall, 42 percent of currently married women were familiar with the Gold Star program. Women who had heard of the program were asked about what the "gold star" meant, Table 5.2 shows the proportion of women citing various characteristics as associated with the "gold star". Women were able to cite more than one characteristic. Women most often mentioned that the "gold star" meant that a facility offered information about methods (22 percent). Other characteristics which women associated with the gold star included polite treatment (19 percent), competent staff (16 percent), availability of services at any time (14 percent), suitable Table 5.2 Perceptions regarding Gold Star clinics Percentage of currently married women hearing about Gold Star clinics and, among women hearing about gold star, the percentages who identified Gold Star clinics with various aspects of service quality, Egypt 1997 Recognition of Gold Star program/ Characteristics associated with Gold Start Percentage having beard about Gold Star 42,0 Characteristics associated with Gold Star Facility clean 9.9 Staff competent 16,3 Service available at any time 13.7 Offer suitable method 14.1 Polite treatment 18.9 Information about methods 22.0 Offer method choice 5.8 Other 20.4 methods (14 percent), a clean facility (10 percent), and a choice of methods (6 percent). Although many women were aware of the Gold Star program, few users who had obtained their method at a public sector facility reported that the facility had a gold star. Overall, 13 percent of users reported they had obtained their method at a Gold Star clinic (data not shown in table). This may underestimate the coverage of Gold Star facilities since the program is fairly new and the gold star may not have been in place at the clinic when the user obtained her method. Users may also not have been aware of a facility's identification as a Gold Star unit since there is variation across clinics • in the prominence given to the display of the Gold Star. 26 Desire for Children Egypt 1997 "*" Wjntn , Wl ,q J !1% ~nsure when sNtber taler 1% 15% Around 8 in 10 married women in Egypt want no additional children or to delay the next birth for at least two years. The level of unmet need for family planning among married women varies from 11 percent in the Urban Governorates to 27 percent in rural Upper Egypt. Unrnet Need for Family Planning By Residence Egypt 1997 27 U~bau lower ]r4i)~ Lower g t~ Upper Egypt Upperlr4~pt GuverNrmlem UrMn RuJml Udma 1Ruuml 28 6 Fertility Preferences and Unmet Need for Family Planning Data on fertility preferences are important in assessing women's motivation to use family planning. To gain an insight into childbearing preferences, EIDHS-97 respondents were asked about whether they wanted to have another child and, if so, how soon. This information can be used to assess the extent to which women who are not using any contraceptive method are in need of family planning to achieve their childbearing goals. A. Desire for Children Table 6.1 summarizes the information on women's reproductive preferences. The majority of all married women express a desire to control future childbearing. Sixty-six percent either report that they do not want another child or are using female sterilization. Moreover, 15 percent who say that they want another child indicate that they want to wait at least two years before the birth of their next child. Table 6.1 Fertiliw preferences Percent dis~ibution of currently married women by desire for more children according to the number of living children, Egypt 1997 Number of living children plus current pregnancy Desire for more children 0 I 2 3 4 5 6+ Total Have another soon 91.8 24.7 9.1 2.8 1.8 2.5 1.1 11.6 Have another later 2.4 59.8 24.6 6.5 3.5 2.0 0.9 14.6 Wants, unsure timing 1.8 3.5 3.7 1.5 1.1 0.6 0.4 1.9 Undecided 0.1 2.8 4.7 3.9 2.0 1.5 1.7 2.8 Wants no more 1.0 7.9 56.3 81.1 87.8 87.5 83.8 64.6 Sterilized 0.0 0.1 0.3 1.9 1.0 2.3 3.5 1.4 Declared infecund 2.9 1.1 1.2 2.2 2.7 3.6 8.6 3.1 Total percent 100.0 100.0 100.0 100.0 100.0 I00.0 100.0 100.0 Number of women 309 620 1,039 1,095 834 527 733 5,157 The desire to delay childbearing is largely concentrated among women who have not started childbearing or have only one child. As expected, the proportion wanting no more children increases rapidly with the number of living children (including the current pregnancy). B. Unmet Need for Family Planning Data on fertility preferences can be combined with information on a woman's current contraceptive status to define a woman's need for family planning. Table 6.2 presents estimates of unmct need and met need for family planning and the total demand for family planning. Unmet need for family planning includes nonusers who are in need of family planning for spacing purposes, i.e., pregnant or amenorrbeic women whose pregnancy or last birth was mistimed as wen as other women who want to delay the next birth for two or more years or who are unsure when or if they want another birth. Unmet need for family planning also includes nonusers who are in need of family planning for limiting purposes, i.e., pregnant or amenorrheic women whose pregnancy or last birth 29 Table 6.2 Need for family planning services Percent distribution of cummtly married women 15-49 by need for family planning according to selected background characteristics, ESypt 1997 Background Cb~'ac~-'nsfics Age 15-19 20-24 25-29 3034 35-39 4O-44 45-49 Urban-rural Residence Urban Rural Place of residence Urban Govemorates Lowt~r Egypt Urban Rural Upper Egypt Urban Rural Educatinn No education Some prinmy Primary comp.l Some seconda~j Secondary comp./Higher Total Percen- Unmet need Met need (using) Fail Demand rage of Number dcwAnd of Space Lirmt Total Space Limit Total Space Limit Total Space Limit Total satisfied women 11.9 0.0 11.9 16.9 4.5 21.4 0.0 0.0 0.0 28.8 4.5 33.3 64.2 227 l~l-.1 3.6 16.8 25.5 14.8 40.3 0.4 0.0 0.4 39.0 18.5 57.5 70.9 710 8.9 9.9 18.8 17.5 35.8 53.3 0.1 0.0 0.1 26.5 45.7 72.2 74.0 916 5.9 11.4 17.3 10.5 53.5 63.9 0.2 0.4 0.6 16 .6 65.3 81.8 78.8 965 1.4 14.6 16.0 3.9 64.8 68.7 0.0 0.6 0.6 5.3 80.0 85.4 81.2 971 1.9 20.8 22.7 1.0 60.0 61.0 0.0 0.1 0.1 2.9 81.0 83.8 73.0 767 0.5 16,7 17.1 0.0 39.4 39.4 0.0 0.0 0.0 0.5 56.1 56.5 69.7 602 4.4 9.8 14.2 11.1 52.0 63.1 0.0 0.1 0.1 15 .6 61.9 77.5 81.6 2,386 6.7 14.2 20,9 9.4 37.7 47.1 0.2 0.3 0.5 16 .3 52.2 68.5 69.5 2,771 3.0 8.0 11.0 11.4 55.5 67.0 0,0 0.2 0.2 14.4 63.7 78.2 85.9 1,199 4.3 11.9 16.2 11.2 50.4 61.6 0,1 0,3 0A 15.6 62.6 78.2 79.3 2,187 3.9 11.5 15.4 10.0 55.9 65.9 0.1 0.0 0.1 14.0 67.4 81.4 81.1 614 4.4 12.1 16.5 11.7 48.3 59.9 0.1 0.4 0.5 16.2 60.8 77.0 78.5 1,572 9.1 15.3 24.3 8.1 29.2 37.4 0.2 0.1 0.3 17.4 44.7 62.1 60.8 1.771 7.9 11.8 19.7 11.7 40.4 52.1 0.0 0.2 0.2 19.6 52.4 71.9 72.7 573 9.6 17.0 26.6 6.4 23.9 30,3 0.3 0.1 0.4 16.4 41.0 57.3 53.7 1,198 6.5 16.5 23.0 5.3 40.4 45.6 0.0 0.2 0.3 11.8 57.1 68.9 66.6 2,147 4.8 13.8 18.6 6.7 50.3 57,1 0.2 0.4 0.6 11.8 64.5 76.3 75.6 956 5.5 8.8 14.2 13.0 45.5 58,4 0.2 0.2 0.4 18 .6 54.4 73.0 80.5 677 4.8 6.0 10.8 19.0 45.8 64.7 0.1 0.0 0.1 23.9 51.8 75.7 85.7 1,377 5.6 12.2 17.8 10.2 44.3 54.5 0.1 0.2 0.3 15.9 56.7 72.6 75.5 5,157 was not wanted as well as other women who want no more children. Menopausal and infectmd women are excluded from the unmet need category as are pregnant and amenorrheic women who became pregnant while using a method (these women are in need of better contraception). Met need for family planning includes women who are currently using family planning. The total demand for family planning represents the sum of the unmet and met need as well the proportions of pregnant and amenorrheic women who became pregnant while using a method. According to Table 6.2, the total unmet need for family planning is 18 percent. The majority of the unmet need is for limiting purposes. Similarly, the majority of the met need for family planning (contraceptive use) is for limiting purposes. Overall, the total demand for family planning comprises 73 percent of married women. Presently, 76 percent of that demand is being met. 30 Total Regular Antenatal Care by Urban-Rural Residence 19s~t997 Urb l t i I tS? . . . . . . . . . . . . . . IDH$ 00g}-gl} D I t tS DRS ( ln i - I~l ) • 1~9| DHS ( l I | | .~ l} I Urban women were much more likely than rural women to have regular antenatai care (at least four visits to a trained provider). Both regular antenatal care and medical assistance at delivery are more common among women l iving in rura l areas in Lower Egypt than in Upper Egypt. for ~ Arms F4D~ tg~ 24 mmmatal J mslstmmat information/Advice Received at Time of Tetanus Toxoid Injection Egypt t997 A~tmstsl ~ Family Plar, n~ Generally, women do not receive advice about other reproductive health services at the time they receive a tetanus toxoid injection. 32 7 Maternal Health Proper care during pregnancy and childbirth is important to the health of both the mother and her baby. To obtain data on these issues, the EIDHS-97 included questions on antenatal care, tetanus toxoid vaccination and the assistance received at delivery for each birth that a woman reported during the five-year period before the survey. A. Antenata l Care Antenatal care from a provider is important m order to monitor the pregnancy and reduce the risks for the mother and baby during pregnancy and at delivery. To be most effective, there should bc regular antenatal care throughout a pregnancy. In Egypt, it is recommended that all mothers see a trained provider at least four times during pregnancy. In the EIDHS-97, women were asked about whether they had received any antenatal care prior to delivery and, if so, who had provided the care. Overall, the EIDHS-97 found that antenatal care was received from a trained provider for 52 percent of the births during the five-year period before the survey (Table 7.1). Not all of these births received regular antenatal care, the mother reported that she had four or more antenatal care visits in only 32 percent of births. B. Tetanus Toxo id Vacc inat ions Tetanus toxoid injections are given during pregnancy in order to prevent neonatal tetanus, a frequent cause of infant deaths where sterile procedures are not observed in cutting the umbilical cord following delivery. Table 7.2 shows that mothers had received at least one tetanus toxoid injection during pregnancy in the case of 72 percent of birtha during the five-year period before the survey. Public sector facilities are responsible for providing the majority of tetanus toxoid injections. Overall, 64 percent of women who received a tetanus toxoid vaccination were given the injection at public sector facilities. Table 7.1. Antenatal care Percent distribution of births during the five- year period before the survey in which the mother received antenatal care by the type of provider from whom the care was received, and the type of facility at which the care was given, Egypt 1997 Antenatal care indicators •Do•tPo e of provider r 51.9 Trained nurse/midwife 0.1 Other/missing 0.3 No care 47.5 Type of facility Public sector 10.6 Private sector 39.8 Both 0.9 Other 1.1 No care 47.5 Number of antenatal care visits None 47.5 I 4.8 2 7.9 3 6.3 4 or more 31.8 Don't know 1.7 Total percent 100.0 Number of births 4,007 C. Overlap between Tetanus Toxoid and Antenatal Care Coverage Many women who received tetanus toxoid vaccinations during pregnancy did not report seeing a doctor for antenatal care. In some cases, women who had had antenatal care did not receive 33 Table 7.2 Tetanus toxoid coverage Percent distribution of births during the five- year period before the survey in which the mother received antenatal care by the number of tetanus toxoid injections received during the pregnancy and the type or facility proving the tetanus toxoid vaccinations, Egypt 1997 Antenatal care end tetanus toxoid Tetanus toxoid coverage None 27.1 One dose 31.8 Two doses 40.3 Not sure/missing 0.8 Type of facility Public sector 64.4 Private sector 3.1 Other 5.4 No vaccinations 27. I Total percent 100.0 Number of births 4,007 Table 7.3 Antenatal care and tetanus toxoid covera2e Percent dislribution of births during the five-yenr period before the survey by whether the mother received antenatal care end/or a tetanus toxoid injection, Egypt 1997 Antenatal care (ANC) and tetanus toxoid (TT) Both ANC and Tr injection (s) ANC only "IT injection(s) only Neither ANC nor 'I'r injection (s) 39.2 12.8 32.9 15.1 Total percent 100.0 Number of births 4,007 tetanus toxoid injections. Table 7.3 shows the overlap between antenatal care and tetanus coverage. Overall, mothers rci~rted receiving both tetanus toxoid vaccinations and other antenatal care in the case of 39 percent of the births in the five-year period before the survey. In 33 percent of the births, mothers had received tetanus toxoid vaccinations but had not seen a doctor for antenatal care. Mothers reported receiving antenatal care but no tetanus toxoid injections in the case 13 percent of the births. The proportion of births for which there was apparently no medical contact during pregnancy (i.e., neither tetanus toxoid injections nor antenatal care visits) was 15 percent. These results highlight the need for more eross-referrals between the various services in health clinics. D. Advice about ANC/FP In an effort to increase the proportion of Egyptian women receiving antenatal care, the Ministry of Health has instituted a program in which pregnant women who come to public sector facilities for tetanus toxoid vaccinations will be advised about the importance of antenatal care and given information about family planning. To provide a baseline figure for use in monitoring this program, mothers who received tetanus toxoid injections were asked whether they had been advised that they should go for antenatal care. They were also asked if someone had talked to them about family planning when they obtained their tetanus injection. The results show that the majority of women who went for tetanus toxoid vaccinations at public sector facilities did not receive advice about the need for antenatal care or family planning use (data not shown in table). Among those women who are given advice, they arc more likely m receive recommendations about the need for antenatal care (26 percent) than information about family planning (I 3 percent). 34 Table 7.4 Assistance at delivery Percent distribution of births during the five-year period before the survey by the type of provider assisting at delivery and the place where the mother delivered, Egypt 1997 Delivery assistance Type of provider Doctor 46.9 Trained nurse/midwife 9.5 Traditional birth attendant 38.1 Relative/other 3.8 No assistance 1.5 Don't know/missing 0.1 Type of facility Public sector 19.4 Privat~ sector 20.3 At home 59.7 Other 0.5 DK/missing 0. l Total percent 100.0 Number of births 4,007 E. Assistance at Delivery Other maternity care indicators obtained in the E]DHS-97 relate to circumstances at delivery including the person who assisted with the delivery and the place where the delivery occurred. Table 7.4 presents information on these indicators for births during the five-year period before the survey. A doctor or trained nurse/midwife assisted at the delivery of 56 percent of all births in the five-year period before the EIDHS- 97. Most of the remaining births were assisted by dayas (traditional birth attendants). The majority of deliveries took place at home. Among the deliveries in facilities, roughly half occurred in public sector facilities and half in private sector facilities. F. Differentials in Maternal Health Indicators Table 7.5 examines variations in maternity care indicators according to selected socio- economic and demographic background characteristics. Considering age patterns, women under age 20 arc less likely than older women to receive antenatal care or assistance at delivery from a Wained medical provider and to deliver in a medical facility. Tetanus toxoid vaccination coverage is, however, more common among younger than older women. There is a negative association between the birth order of the child and the maternal health indicators. For example, the proportion receiving regular antenatal care decreases from 43 percent among first births to women to 15 percent among births of order six or higher. Urban-rural residence and region are strongly associated with both antenatal care and assistance. Rural women, especially those living in Upper Egypt are less likely than urban women to receive care during pregnancy or assistance at delivery from trained medical providers. With regard to tetanus toxoid vaccinations, however, there is almost no differential in the proportions of births in which the mother received at least one injection. Regional differentials are also less marked with respect to tetanus toxoid coverage. G. Trends in Maternal Health Indicators Table 7.6 looks at the trends in key maternal health indicators during the period 1988-1997. The table suggests that there has been a very sharp increase in the proportions of women who receive 35 Table 7.5 Maternal health indicators by hacktround characteristics Percentage of births in the five-year period whose mothers received any antenatal care and regular antenatal care fi'om a trained medical provider and at least one tetanus toxoid vaccination and whose mothers were assisted at delivery by a medical provider and delivered in a medical facility, Egypt 1997 Assisted at Delivery Any Regular Tetanus by trained In Background antenatal antenatal toxoid medical medical characteristic care care injections provider facility Age under 20 46.8 21.7 77.1 48.4 33.3 20-34 53.1 33.2 73.4 57.7 40.6 35-49 49.9 31.8 57.0 55.1 39.4 Birth order 1 65.5 43.0 81.5 71.6 56.0 2-3 55.4 34.9 74.5 59.9 43.4 4-5 44.5 26.0 68.5 47.5 29.1 6 or more 34.0 15.0 57.5 36.9 20.2 Urban-rural residence Urban 70.8 53.1 70.1 76.9 63.8 Rural 40.1 18.1 73.5 43.2 24.2 Place of residence Urban Govemorates 74.0 58.2 67.6 82.3 71.5 Lower Egypt 53.2 31.2 76.4 60.3 41.0 Urban 75.2 55.1 71.3 79.3 67.1 Rural 46.5 24.0 78.0 54.5 33.1 Upper Egypt 41.3 20.6 70.2 41.3 24.4 Urban 61.9 43.0 73.2 66.2 48.3 Rural 33.8 12.4 69.1 32.3 15,7 Education No education 34.5 15.6 67.8 38.4 22,5 Some primary 49.2 25.6 71.2 50.0 33,0 Primary cutup./ Some secondary 59.2 37.7 79.1 63.1 48.7 Completed secondary/Higher 77.1 57.2 76.0 84.5 65.6 Total 52.0 31,8 72.1 56.4 39.7 Note: A woman is considered to have had regular antenatal care if she had 4 or more visits for care during the pregnancy tetanus toxoid injections during pregnancy. Improvements in other maternal health indicators were more gradual but steady during the period. The proportion of births in which the mother had regular antenatal care increased from 23 to 32 percent between 1992 and 1997. The decline in the total proportion of births in which the mother received any antenatal care is not a genuine trend but the result of changes in study procedures between the 1992 and 1995 surveys. The proportion of births attended by a doctor or trained nurse/midwife increased from 35 percent in 1988 to 56 percent in 1997. 36 Table 7.6 Trends in maternal hfalth indicators For births during the five-ye.~ period before the survey, the pexeentage whose mothers had at least one tetanus toxoid injection, antenatal care from a doctor or trained nurse-midwife, and four or more antenatal care visits and the percentage whose mothers essisted at delivery by a trained medical provider and delivered in a medical, Egypt 1988-1997 Maternal health indicator EDHS-88 EMCHS-91 EDHS-92 EDHS-95 EIDHS-97 Antenatal care Any 52.8 52.1 52.9 39.1 52.0 Regular U U 22.5 28.3 31,8 Tetanus toxoid injection I 1.4 42.5 57.3 69.5 72.1 Medical assistance at delivery 34.6 35.5 40.7 46.3 56.4 Delivered in medical facility 22.9 U 27.1 32.5 39.7 U -- unknown (not available) 37 Vaccination Coverage: Children Fully Immunized Egypt 1988-1997 79 83 1988 1992 1995 1997 The proportion ~pf young children who are fullv immunized has been increasing steadily in Egypu. Medical providers were consulted in nearly half the cases of diarrheal illness in children under age 5, and 4 in 10 children received some form of oral rt hydration therapy. Treatment of Diarrhea Egypt 1997 49 42 Consulted medical Used provider ORS/RHS Level of Stunting by Residence Egypt 1997 Udum L~r E I3~ l.,ewer EKypt Upper ESyPt Upper EID~ Gevernerates Urbma Raral Urbaa Rural The proportion of children whose growth is stunted, i.e., the child is too short for his age ranges from 18 in the Urban Cro,~en norates and urban Lower Egypt to 34 percent in rural Upper Egypt. 38 8 Child Health The EIDHS-97 obtained information on a number of key child health indicators, including immunization of young children and treatment practices when a child has diarrhea. A. Vaccination Coverage In the EIDHS-97, information on childhood immunizations was collected for all children born during the five-year period before the survey. In Egypt, immunizations are recorded on a child's birth record (certificate) or on a special health card'. For each child, mothers were asked whether they had the birth record or health card for the child and, if so, to show the document to the interviewer. When the mother was able to show the birth record or health card, the dates of vaccinations were copied from the document to the questionnaire. Ifa birth record or health card was not availablc (or a vaccination was not recorded), mothers were asked questions to determine whether the child had received each vaccine. The estimates of immunization coverage among children 12-23 months in Table 8.1 are based on the information taken from the birth record or health card and, for those whom no document was seen (or a vaccination not recorded), from the information provided by the mother. Mothers were able to provide birth records for 73 percent of the children. The World Health Organization guidelines for childhood immunizations call for all children to receive: a BCG vaccination against tuberculosis, three doses of the DPT vaccine to prevent diphtheria, pertussis and tetanus; three doses of polio vaccine; and a measles vaccination. Egypt has added the hepatitis vaccine to its child immunization program. However, although it is shown in the table, hepatitis immunizations are not taken into account in calculating the proportion of children who arc considered to be fully immunized. Thus, a child is considered to have had the full schedule of immunizations if they have received a BCG and measles vaccination and three doses of the DPT and polio vaccines. Levels and Differentials in Vaccination Coverafe Table 8.1 shows that, among Egyptian children 12-23 months, 83 percent are regarded as fully immunized. Only two percent had received no vaccinations. Looking at coverage levels for individual vaccines, the proportions of children who have received the BCG vaccination and three doses of DPT and polio vaccines exceed 90 percent. Almost 90 percent had also received the measles vaccine. Although coverage is somewhat lower than the levels for the other vaccines, 77 percent of children had received three doses of the hepatitis vaccine. Considering differentials in immunization coverage, there is no difference in the levels of immunization between boys and girls. By residence, however, there are clear differences. Urban children arc more likely to be immunized than rural children. Looking at place of residence, the percentage considered to be fully immunized was lowest in rural Upper Egypt, where 1 in 4 cl~ddren had not received all recommended vaccinations. 4 During earlier rounds of the DHS in Egypt, vaccination data usually were obtained only from the birth record. A new health card was introduced during the period shortly before the EIDHS-97. Therefore, the EIDHS-97 questionnaire was modified so that information from either document could be easily recorded. 39 Table 8.1 Vaccinations bv back~round characteristics Among children 12-23 months, the percentage who had vaccination records seen by the inte~iewer and the percentage who had received each vaccine (according to the vaccination record or the mother's report) by selected background char~tetistics, Egypt 1997 DPT Polio Hepatitis Fully Number Background Record Men- irraa~en, of Characteristics seen BCG 1 2 3 1 2 3 1 2 3 ales ised None children Stx Male 75.4 97.1 97.5 95.7 90.3 99.3 96.5 91,9 84,5 80.8 75.9 88.9 83.5 0.5 411 Female 69.1 94.6 96.6 93.1 88.7 97.3 95.5 90.7 86.0 82.9 77.6 90,0 82.1 2.7 351 Urban-rnral Urban 72.6 98.0 97.7 95.9 91.6 98.6 96.8 93.9 87.3 83.2 78.6 91.2 86.4 1.4 315 Rural 72.5 94.5 96.7 93.6 88.1 98.2 95.5 89.5 83.6 80.7 75.3 88.1 80.3 1.6 446 Place of retldence Urban Govemorates 67.6 97.9 96.2 95.9 92.7 98.0 96.7 95.7 86.0 83.9 78.0 89.9 86.7 2.0 153 LowerEgypt 76.5 96.9 98.8 95.4 90.9 99.5 96.2 91.0 9L0 87.5 81.6 93.4 84,7 0.5 295 Urban 81A 96.8 98.0 92.7 86.7 98.0 92.7 86.7 94.6 87.1 82.6 89.6 83.2 2.0 69 Rural 75.0 96.9 99.1 96.2 92.2 100.0 97.3 92.3 89.9 87.6 81.3 94.5 85,1 0.0 226 Upp~Egypt 71.1 94,1 96.0 93.0 86.8 97.5 95.5 89.6 79.2 75,3 71.5 85.4 79.3 2.3 314 Urban 74.3 99.1 100.0 98.1 93,4 100.0 100,0 96,3 83.9 79.2 76.7 94.5 88,3 0,0 94 Rural 69.8 91.9 94.3 90.8 83.9 96.4 93.5 86.7 77.2 73.7 69.2 81.5 75.4 3.3 220 Education Noeducatico 73,3 91.1 93.8 91,0 86.0 96.6 93.5 87.5 77.5 74.3 68.3 83.0 76,1 3.2 294 Some primary 72.4 97.8 97.7 95.9 91.4 98.8 97.8 94.8 89.4 87.9 82.7 88.0 83.4 1.2 125 Primary comp./ Sornesecoodacy 71,1 99.6 100.0 96.6 91.1 I00.0 98.0 92.6 88.9 82.9 80.2 98.6 90.8 0.0 105 Secondary comp,/Higher 72.2 99.2 99,7 97.2 92.3 99.7 97.3 93.7 90,7 87.2 82.3 93.9 87.4 0.3 237 Total 72.5 95.9 97,1 94.5 89.6 98.4 96.0 91.3 85.1 81.7 76.7 89.4 82.8 1.5 "761 Note: Children are fully iramuoized if they have received BCG, measles, and three doses of DPT and polio vaccines. Trends in Vaccination Covera~,e Table 8.2 shows vaccination coverage rates in Egypt during the period 1988-1997. The percentage of children 12-23 months who were fully immunized increased steadily during the period, from 54 percent in 1988 to 83 percent in 1997. The table also documents the rapid expansion in Table 8.2 Trends in vaccination coverage, Egypt 1988-1997 Among children 12-23 months, the percentage who had recetved specific vaccinations and the percentage fully immunized, Egypt 1988-1997 Specific vaccinations 1988 1992 1995 1997 BCG 70 90 95 96 DPT 3 66 76 83 90 Polio 3 66 79 84 91 Measles 76 82 89 89 Hepatitis HA NA 57 77 Fully immunized 54 67 79 83 Note: C'hildren ate fully immunized if they have received BCG, measles, and three doses of DPT and polio vaccines. Source: EDHS-88 and EDHS-92 - Sommeffelt and Piani, 1977, Table 7.1 EDHS-95 - El-Zanaty et al., 1996, Table 11.2 40 hepatitis coverage rates after the inclusion of the vaccine in the country's immunization program. B. Prevalence of Childhood Illnesses In the EIDHS-97, mothers of children under age five were asked if their children had had diarrhea during the two-week period before the survey. If the child had had diarrhea, the mother was asked about what she had done to treat the diarrhea. Mothers were also asked about the presence of fever and of the symptoms of acute respiratory infection (cough with short, rapid breathing) among children during the two-week period before the survey. If the child had symptoms of respiratory illness, the mother was asked about the actions taken to treat the illnesses. Since the prevalence o f diarrhea and acute respiratory illnesses varies seasonally, the results pertain only to the pattern during the period November-December, 1997 when the EIDHS interviewing took place. In assessing the information on the prevalence of these illnesses, it should be remembered that the mother's assessment is subjective. Table 8.3 presents information on the prevalence of childhood illnesses among young children. Overall, 15 percent of children under age five were reported to have had diarrhea in the Table 8.3 Prevalence of childhood illnesses by background changteri~cs Percentage of children under age five reported as having diarrhea, diarrhea with bloody stools, fever or a cough with short, rapid breathing during the two-week period before the survey, Egypt 1997 Dian'hea Cough with Number Background All with blood short, rapid of characteristic diarrhea in stools Fever breathing children Child's age < 6 months 18.4 0.0 33.0 28.3 376 6-11 months 27.9 0.7 52.5 42.6 335 12-23 months 23.4 1.9 42.8 34.4 761 24-35 months 13.8 2.6 45.1 32.7 759 36-47 months 9.4 1.0 41.4 27.7 774 48-59 months 5.9 0.8 37.8 32.4 776 Sex Male 17.0 1.3 42.3 34.0 1,982 Female 12.6 1.4 41.4 30.6 1,801 Urban-rural residence Urban 15.1 1.6 43.7 31.7 1,514 Rural 14.8 1.2 40.6 32.8 2,269 Place of residence Urban Govurnoratas 12.8 1.2 43.0 30.0 730 Lower Egypt 16.5 1.4 44.7 33.5 1,485 Urban 19.5 1.4 42.8 32.5 354 Rural 15.5 1.3 45.3 33.8 1,132 Upper Egypt 14.4 1.4 38.6 32.4 1,567 Urban 15.3 2.2 45.5 34.0 430 Rural 14.1 1.1 36.0 31.8 1,137 Education No education 16.7 2.1 40.7 33.2 1,590 Some primary 15.1 0.6 42.3 33.6 638 Primary eompJSome secondary 16.4 1,4 43.7 35.5 484 Secondary comp./Higher I 1.5 0.7 42.5 29. I 1,070 Total 14.9 1.3 41.9 32.4 3,783 41 two-week period before the survey, and 1 percent were reported as having bloody stools. As expected, diarrhea is more prevalent among children age 6-23 months. This pattern is believed to be associated with increased exposure to the illness as a result of both weaning and the greater mobility of the child as well as to the immature immune system of children in this age group. Table 8.3 also shows the prevalence of fever and of symptoms of acute respiratory infection (ARI) among young children. More than 40 percent of children reported to have had a fever during the two-week period before the survey, and 32 percent had had a cough with short, rapid breathing. Differentials in the prevalence of these illnesses are generally small. The peak prevalence for both illnesses is found among children 6-11 months old. C. T reatment o f D ia r rhea The EIDHS-97 included questions with regard to the actions mothers took to treat children who had had diarrhea. Table 8.4 presents the findings from these questions. The table shows that mothers sought advice from a medical provider in 49 percent of the cases. Among mothers reporting that medical advice was sought, the majority said that a private doctor was consulted. Table 8.4 Treatment ofdiarrbea Percentage of children under age five ill with diarrhea during the two-week period before the survey who received various treatments by selected background characteristics, Egypt 1997 Taken to health facility Oral rehydration therapy Either Home Number Background ORS ORS/ Increased Anti- lnjec- remedy/ Of characteristics Any Public Private Packets RHS RHS fluids biotics tion Other None children Sex Male 44,8 15.3 30.5 36.9 8.5 40.8 27.6 37.1 5.1 27.2 16.9 338 Female 55.3 18.6 37.5 40.7 6.6 44.1 26,8 40.4 6.5 16.4 18.8 226 Urban-rural Urban 44.3 16.7 27.8 33.4 8.8 38.3 30.6 40.0 3.1 21.2 18.1 228 Rural 52.2 16.6 37.0 41.9 7.0 44.8 25.0 37.4 7.4 23.9 17.4 336 Place of residence Urban Gov. 47.8 19.3 28.6 29.0 15.8 39.9 31.6 34.8 3.2 18.4 18.2 94 Lower Egypt 49.9 16.4 35.4 43.4 7.6 44.9 28.2 40.5 7.4 20.8 16.4 244 Urban 34.2 11.2 23.5 35.1 3.8 35.1 28.6 47.1 4.1 17.2 20.5 69 Rural 56.1 18.4 40.0 46.7 9.l 48.8 28.0 37.9 8.7 22.2 14.8 176 Upper Egypt 48.5 15.9 33.0 37.0 4.5 40.1 24.5 37.7 4.7 26.9 18.S 226 Urban 49.9 18.8 31.1 37.9 4,1 39.4 31.2 40.0 1.8 29.5 15.5 66 Rural 47.9 14.7 33.8 36.6 4.7 40.3 21.7 36.7 5.9 25.9 20.2 160 Education No education 46.9 19.8 27.2 42.1 8.3 47.1 30.4 31.8 5.8 23.1 16.8 265 Some prinmpy 48.0 14.5 35.8 3%4 7.7 42.3 21.3 42.0 10.5 14.0 20.2 96 Prir~ry completed/ Some secondary 46.1 17.4 28.7 34.5 7.5 37.6 26.3 38.3 0.4 22.7 20.3 79 Secondary comp./Higher 56.1 11.2 47.5 32.3 6.6 34.2 25.8 50.0 4.9 29.3 15.8 123 Total 49.0 16.7 33.3 38.4 7.7 42.1 27.3 38.4 5.6 22.8 17.7 564 Note: Oral rehydrafion therapy (OPT) includes solutions prepared from ORS packets and recormncndcd home fluids (RHF), e.g., sugar-salt solutions. Increased fluids includes increased frequency ofbreasffeeding. The administration of oral rehydration therapy (ORT) is a simple means of countering the effects of dehydration accompanying diarrhea. During ORT, the child is given a solution either prepared by mixing water with the salts in a commercially prepared rehydration packet (ORS) or by making a homemade solution using sugar, salt and water. Slightly more than 40 percent of the 42 children who had diarrhea were treated with oral rehydration therapy (either ORS packets or a homemade solution). ORS packets were used more often than homemade solutions. Children in the age group 6-23 months, where the prevalence of diarrhea was the highest, were also the most likely to have been treated with oral rehydration therapy. There is comparatively little variation by residence in the proportions of children treated with some form of ORT. Among the other common responses to diarrheal episodes was to increase the amount of fluids a child was given. Table 8.4 shows that 27 percent of mothers had given the children with diarrhea increased fluids (other than ORS or RHS solutions). Mothers also reported that children were frequently given antibiotics or home remedies to treat the diarrhea. Table 8.4 shows that there are relatively minor differences by gender in the tz'eatment practices mothers reported. Mothers were slightly more likely to seek medical advice for episodes of diarrhea among girls than among boys. Also, girls were more likely than boys to be U'eated with some form of ORTor with antibiotics. Considering the other differentials shown in Table 8.4, a medical provid~ was consulted more often for children living in rural areas and children whose mothers had completed secondary or higher level than for other children. Rural children also wcrc more likely than urban-children to have received some form of ORT. There was a negative association between the likelihood a child was given some form of ORT and the mother's level of education. D. Treatment of Respiratory Illnesses The EIDHS-97 also included questions with regard to whether medical advice was sought when a child had the symptoms of an acute respiratory infection. Table 8.5 shows that mothers sought advice from a medical provider in 67 percent of cases where the child had a cough with short, rapid breathing. As was the case with diarrheal illnesses, among motbers who sought medical advice, the majority reported that a private doctor was consulted. There was no significant difference by gender in the likelihood that medical advice would be sought when a child was ill. However, medical advice was less likely to be sought in the case of rural children than urban children and for children whose mothers were from Upper Egypt. The likelihood of seeking medical advice was also directly associated witk~the mother's educational level. E. Nutritional Status of Children Nutritional status is a primary determinant of a child's health and well-being. Both inadequate or unbalanced diets and chronic iUness arc associated with poor nutritional status among children. The 1997 EIDHS included the collection of anthropometric data which permit an assessment of the nuU'itional status of young children in Egypt. Measurement of Nutritional Status In order to assess nutritional status, measurements of height s and weight were obtained uring the survey for children of EIDHS respondents who were under age five. Using these anthropome~'ic 5 Although the term "height" is used, children younger than 24 months were measured lying on a measuring board, while standing height was measured for older children. Weight data were obtained using a digital scale with an accuracy of 100 grams. 43 Table 8.5 Tream~ent of cough Percentage of children under age five ill with cough with short rapid breathing during the two-week period before the survey who were taken to a health facility for treatment by selected background characteristics, Egypt 1997 Taken to health facility Number Background of characteristics Any Public Private children Sex Male 68.3 22.6 46.9 673 Female 66.0 20.1 46.6 552 Urban-rural residence Urban 75.0 24.3 52.5 481 Rural 62.2 19.6 43.0 745 Place of residence Urban Governorates 80.6 27.7 54.2 219 Lower Egypt 68.0 19.4 49.0 498 Urban 70.5 20.9 51.1 ll5 Rural 67.3 18.9 48.4 383 Upper Egypt 60.7 20.8 41.3 508 Urban 70.2 21.9 51.3 146 Rural 56.9 20.3 37.3 362 Education No education 61.5 24.3 38.7 528 Some primary 69.9 26.2 43.7 214 primary comp./Some secondary 69,9 19.9 50,5 172 Secondary comp./ Higher 73.7 14.4 60.5 311 Total 67.3 21.5 46.8 1,225 measurements as well as information on the ages of the children, three standard indices ofphy growth describing the nutritional status of children are consU'ucted: height-for-age weight-for-heighi weight-for-age Each index measures a somewhat different aspect of nutritional status. The height-for index provides an indicator of linear growth retardation and, thus, assesses the proportion of c~ who are stunted. Stunting of a child's growth may be the result of a failure to receive adequate nutrition over a long period of time or of the effects of recurrent or chronic illness. The weight-for- height index measures body mass in relation to body length and provides a measure of the proportion of children who arc wasted. Wasting is an outcome of a failure to receive adequate nutrition during the period immediately before the survey. It may bc the result of recent episodes of illness or acute food shortages. The weight-for-age index is a composite index of height-for-age and weight-for- height, and, thus, does not distinguish between the effects of acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be underweight because hc is wasted, stunted or both. As recommended by the World Health Organization (WHO), evaluation of nutritional status in this report is based on the comparison of the indices for the population of children in the survey 44 with those reported for a reference population of well-nourished children. Use of a reference population is based upon the finding that well-nourished children in all population groups follow similar growth patterns and, thus, exhibit similar distributions with respect t~ height and weight at given ages (Martorell and Habicht, 1986). One of the most commonly used reference populations, and the one used for this study, is the international reference population defmed by the U.S. National Center for Health Statistics (NCHS) and accepted by WHO and the U.S. Center for Disease Control (CDC). Children whose values on an index fall below nfmus two standard deviations (°2 SD) from the median for the reference popolation are considered as undernourished and those whose values fall below minus three standard deviations (-3 SD) from the reference population median are considered to be severely undernourished. In a well-nourished population, only 2.3 percent of children fall below minus two standard deviations for each of the three indices. Levels and Differentials in Nutrition Status Table 8.6 shows the percentage of children under age five who are classified as malnourished according to the height-for-age, weight-for-height, and weight-for-age indices by the child's age and Table 8.6 Nutritional staUm by demographic characteristics Percentage of children under five years of age who are classified as undernourished according to three anfluopomeUic indices of nutritionei status: height-for-age, weight-for-height, and welght-for-age, by selected demographic characteristics, Egypt 1997 Height-for-age Weight-for-halght Welght-for-age (stunting) (wastin$) (underweight) Percentage Percentage Percentage Percentage Percentage Percentage Number Demographic below below below below below below of characteristics -3 SD -2 SD I -3 SD -2 SD 1 -3 SD -2 SD 1 children Age <6 months 3.3 9,4 I.I 8.1 0.0 2.8 310 6-11 months 12.0 25.1 3.4 11.2 7A 20.2 286 12-23 months 13.7 31,0 2.2 6.6 4.2 16.4 666 24-35 months 13.0 25,5 1.6 4.6 3.3 12.7 675 36-47 months 9.5 27.3 1.8 5.5 1.5 11.2 692 48-59 months 7.2 22,9 , 1.2 4.8 1.4 7.0 699 Sex Male 10.2 25,6 1.7 6.2 3.1 12.4 1,735 Female 10.2 24.1 1.8 6.1 2.4 10.9 1,593 Birth order I 7.5 21,4 2.1 6.0 2.5 10.1 770 2-3 9.7 22.8 1.4 4.7 2.3 10.4 1,355 4-5 9.6 25.8 1.8 8.4 3.1 12.2 666 6+ 16.0 34,0 2.4 7.1 4.0 16.5 537 Birth Interval First bi~lh 7.4 21.1 2.1 5,9 2.4 10.0 781 <24 months 14.5 30.8 1.2 5.6 3.7 13.2 591 24-47 months 11.0 26.8 1.6 6.1 2.6 12.8 1,247 48+ months 8.2 20.7 2.3 6.9 2.5 10.3 709 All children 10.2 24.9 1.8 6.1 2.8 11.7 3,328 Note: Figures are for children born in the 0-59 mon~m preceding the survey. Each index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Children are classified as undernourished if their z-scores arc below minus two standard deviations (-2 SD) from the median of the reference population and as sevcre/y undernourished if their z-scores are below minus three standard deviations (-3 SD) flora the median of the reference population. I Includes children who are below-3 SD. 45 selected other demographic characteristics. Overall, one in 4 children in the age group are considered to be stunted or too short for their age end 6 percent are wasted, or too thin for their height. The proportion considered as underweight is 12 percent. The child's age is closely associated with nutrition status. Children under age 6 months are much less likely to be undernourished than older children. The highest level of stunting is found among children in the 12-23 month age group, while the highest proportions of children who are wasted or underweight are observed for children age 6-I I months. A child's gender is not closely associated with the likelihood that the child will be undernourished. However, the likelihood that a child will be undernourished generally rises with a child's birth order end declines as the length of the birth interval increases. Data on the nutrition status indicators are presented in Table 8.7 by residence end the educational level of the child's mother. Rural children, especially those living in Upper Egypt, are less well offthen urban children with regard to all of the indicators of nutritiun status. The level of stunting among rural children, for example, is 28 percent compared with 20 percent among urban children. Table 8.7 Nutritional states by socio-ecounmic characteristics Percentage of children under five years of age who are classified as undernourished accordio 8 to three anthrepometric indices of nutntional status: height-for-age, weight-for-beight, and weight-for-age, by selected socio-ecounmie characteristics, Egypt 1997 Helght-for-age Weight-for.height Weight-for-age (stunting) (wasting) (underweight) Percentage Percentage percentage Percentage Percentage Percentage Number Socio-ecounmic below below below below below below of characteristics -3 SD -2 SD 1 -3 SD -2 SD 1 -3 SD -2 SD 1 children Urban-rural residence Urban 7.4 20.0 1.9 5.5 1.9 9.5 1,344 Rural 12.1 28.2 1.7 6.5 3.4 13.1 1,984 Piece of residence Urban Governoretes 6.9 18.4 2.1 5.9 2. I 11.0 629 Lower Eg3~t 8.1 21.5 I.I 4.6 2.0 9.1 1,357 Urban 6.4 17.6 1.6 4.6 1.5 7.4 333 Rural 8.7 22.8 1.0 4.6 2.2 9.7 1.023 Upper Egypt 13.8 31.4 2.3 7.8 3.8 14.6 1,342 Urban 9.0 24.7 1.7 5.7 1.8 8.9 381 Rural 15.8 34.0 2.5 8.6 4.6 16.8 961 Education No education 13.4 30.1 2.0 6.8 3.7 14.4 1,390 Some primary 10.6 24.7 2.7 6.7 3.8 13.3 577 PrimarJ compJ some secondary 7.6 21.6 0.9 5.1 2.0 9.2 439 Secondary comp./ Higher 6.4 18.6 1.2 5.3 1.0 7.8 922 All children 10.2 24.9 1.8 6.1 2.8 I 1.7 3,328 Note: Figures are for children born in the 0-59 months preceding the $u~ey. Each index is exp~ in tenus of the number of standard deviation (SD) units from the median of the NCHS/~O international reference population. Children are classified as undernourished if their z-scores are below minus two standard deviations (-2 SD) from the median of the reference population and us sewrely undernourished if their z-santos are below minus three standard deviatiorLs (-3 SD) from the median of the reference population. 1 Includes children who are below -3 SD. 46 As expected, a child's nutrition status also is positively related to the mother's educational level. For example, the proportion of children who are stunted varies from 19 percent among children of mother's who have at least a secondary education to 30 percent among children whose rriothers never attended school. Trends in Nutrition Status Table 8.8 looks at recent trends in the nutritional status of children under age 5 in Egypt, using data from the 1992, 1995 and 1997 DHS surveys. The results indicate that levels of undemutrition have remained relatively stable during the current decade. Between 25 and 30 percent children were stunted at the time of each of the surveys, 3-6 percent were wasted, and 10-12 percent were considered to be underweight. Table 8.8 Trends in nutrition status of children Among children under age five, the percentage classified as undernourished according to height-for-age, weight-for-height, and weight-for-age by residence, Egypt 1992-1997 Height-for-age Weight-for-height Weight-for-a~e Residence 1992 1995 1997 1992 1995 1997 1992 1995 1997 Urban-rural residence Urban 20.0 22.8 20.0 3.4 4.7 5.5 7.1 9.9 9.5 Rural 29.6 34.4 22.8 3.4 4.5 6.5 11.6 14.1 13.1 Place of residence Urban Govemorates 16.8 18.4 18.4 4.5 5.4 5.9 7.7 9.1 I I .0 Lower Egypt 27.0 28.0 21.5 2.6 3.0 4.6 8.1 9.6 9.1 Urban 20.5 25.6 17.6 2.3 2.4 4.6 4.5 8.8 7.4 Rural 29.1 28.8 22.8 2.7 3.2 4.6 9.3 9.9 9.7 Upper Egypt 28.7 36.5 31.4 3.7 5.2 7.8 12.6 16.1 14.6 Urban 24.6 27.2 24.7 2.8 4.7 5.7 b.8 11.0 8.9 Rural 30.0 39.7 34.0 4.0 5.3 8.6 13.8 17.8 16.8 Total 26.0 29.8 24.9 3.4 4.6 6.1 9.9 12.5 11.7 Note: Figures ire for children born in the 0-59 months preceding the survey. Each index is expresaed in terrm of the number of sUmdard deviation (SD) units from the median of the NCHS/CDC/WHO international refe~cce population. Children are classified as undernourished if their z-scores are below miflus two standard deviations (-2 SD) from the median oftbe refet-vnce population. With regard to the patterns by residence, urban children were less likely to be stunted or underweight than rural children throughout the period. Children in the Urban Governorates exhibited the least evidence of undernutrition at all points in time, while children in rural Upper Egypt consistently had the highest levels of both acute and chronic tmdernutrition throughout the period. F. Infant and Child Mortality Trends in Early Childhood Mortality The maternal and child health indicators for which information was collected in the EIDHS- 97 all have an impact on the mortality of young children. Increased family planning use also contributes significantly to improving child survival by reducing the numbers of births in which there is an elevated risk of mortality for the child. 47 Data on children's birth dates, survivorship status and age at death obtained in the birth histories collected in the EIDHS-97 can be used to estimate the levels and trends in mortality among children under the age of five in Egypt. Table 8.9 presents the information on early childhood mortality for a 15-year period prior to the survey. The results suggest that mortality among young children has fallen steadily during the peiod since 1985. Overall, under-five mortality has fallen steadily from an estimated level of 126 deaths per 1,000 births during the period 1983-1987 to 65 deaths per 1,000 births during the five-year period immediately prior to the EIDHS-97. Table 8.9 Levels and uends in early childhood mortality Early childhood mortality rates for the five-year periods before the 1997 EIDHS Approximate calendar period Neonatal Post-neonatal Infant Childhood Under-five 1993-1997 29.3 23.0 52.3 13.3 64.9 1988-1992 35.3 35.8 71.1 21.0 90.6 1983-1987 46.5 42.0 88.6 41.2 126.2 Differentials in Ear ly Chi ldhood Mortal i ty Although there has been a steady decline in mortality levels among young children in Egypt, Tables 8.10 and 8.11 show that there remain significant differentials in mortality levels in the population. The mortality rates shown in these two tables are calculated for a ten-ve~ period before the survey because most subgroups were not sufficiently large to permit reliable estimation of five- year rates. Considering the relationship with socio-economic measures, Table 8.10 shows that mortality levels are higher in rural areas than in urban areas. Place of residence is also associated with Table 8.10 Eerie childhood mortality by socio-economic characteristics Early childhood mortality ra~ for the tan-year period preceding the survey by selected socio- economic charactcrlsfics Background characteristic Neonatal Post-neonatal Infant Childhood Under-five Urban-rural residence Urban 22.3 20.0 42.3 7.7 49.6 Rural 39.0 36.2 75.2 24.2 97.5 Place of r~ldence Urban Governoratas 18.7 9.8 28.4 4.9 33.2 Lower Egypt 30.3 22.5 52.9 12.7 64.9 Urban 23.8 19.5 43.4 8.3 51.3 Rural 32.4 23.5 55.9 14.3 69.4 Upper Egypt 40.5 45.6 86.1 28.3 111.9 Urban 26.8 36.4 63,8 12.0 75.0 Rural 45.6 49.0 94.6 34.7 126.1 Education No education 36.8 34.7 71.5 22.9 92,7 Some pnrnm7 32.5 37.0 69.6 21.8 89.9 Primary comp./Some sec. 32.1 28.2 60.3 12,1 71.7 Secondary comp./Higher 24.2 14.9 39.1 4.2 43.1 Total 32.4 29.7 62.1 17.4 78.4 48 mortality levels, with the highest levels observed in Upper Egypt, particularly in rural areas where the under.five mortality rate is 126. As expected, Table 8.10 also indicates that mortality levels arc negatively associated with the educational level of the mother. Table 8.11 shows that the mortality levels do not vary greatly with the sex of the child. However, the interval since the previous birth is strongly related to a child's survival chances. Mortality levels decline significantly as the interval since the previous birth increases. Mortality levels are also significantly greater for children of birth order six or higher and for births to woman under age 20. Table 8, I I Earn childhood mortality by demo~'anhic ¢hm'acter/stics Early childhood mortality rates for the ten-year period preceding the survey by selected demographic characteristics, Egypt 1997 Background charecteristic Neonatal Post-neonatal Infant Childhood Under-five Sex Male 38.0 25.0 63.0 16.3 78.3 Female 26.4 34.7 61.2 18.4 77.5 Mother's age at birth Less than 20 59.4 48.9 108.3 19. I 125.4 20-34 27.9 25.3 53.2 17.3 69.6 35 or more 30.9 37.9 68.9 14.9 82.7 Birth order I 34.2 23.3 57.5 8.1 65.1 2-3 24.6 27.3 51.9 13.6 64.9 4-5 37.7 27.6 65.3 24.6 88.2 6+ 41.4 55.3 96.6 29.6 123.4 Previous birth Interval Less than 2 years 56.9 63.9 120.8 41.7 157.5 2-3 years 20.8 19.7 40.5 10.7 50.7 4 years or more 21.2 8.7 29.9 8.3 38.0 49 References Abdel-Azeem, F., Farid, S., and Khalifa, A.M. 1993. Egypt Maternal and Child Health Survey. Central Agency for Public Mobilization and Statistics [Arab Republic of Egypt] and the Pan Arab Program for Child Development [Arab League]. EI-Zanaty, F., Hussein, Enas M., Shawky, Gihan A., Way, Ann and Kishor, Sunita. 1996. Egypt Demographic andHealth Survey 1995. Calverton, Maryland: National Population Council [Arab Republic of Egypt] and Macro International Inc. El-Zanaty, F. 1995. Contraceptive Use in Egypt: Trends and Determinants. In Perspectives on Fertility and Family Planning in Egypt, edited by M. Mahran, F. EI-Zanaty and A. Way. Calverton, Maryland: National Population Council [Arab Republic of Egypq and Macro International Inc. El-Zanaty, F., Sayed, H. A. A., Zaky, H. and Way, Ann. 1993. Egypt Demographic and Health Survey 1992. Calverton, Maryland: National Population Council [Arab Republic of Egypt] and Macro International Inc. HaUouda, A. M., Amin, S.Z., and Farid, S., editors. 1983. The Egyptian Fertility Survey. 4 vols. Cairo: Central Agency for Public Mobilization and Statistics. Martorell, R. and J.P. Habicht. 1986. Growth in early childhood in developing countries. InHuman growth: A comprehensive treatise, cd. F. Falkner and J. M. Tanner, Vol.3. New York: Plenum Press. 241-262. Sayed, H. A. A., EI-K_horazaty, M. N., and Way, A. A. 1985. Fertility and Family Planning in Egypt. Columbia, Maryland: Egypt National Population Council [Arab Republic of Egypt] and Westinghouse Public Applied Systems. Sayed, H. A. A., Osman, M., E1-Zunaty, F., and Way, Ann. 1989. Egypt Demographic andHealth Survey 1988. Columbia, Maryland: National Population Council [Arab Republic of Egypt] and Institute for Resource Development/Macro Systems, Inc. Sommerfelt, A. E. and Piani, A. L. 1997. Childhoodlmmunization: 1990-1994. DHS Comparative Studies No. 22. Calvertun, Maryland: Macro International Inc. 51 APPENDIX A ESTIMATES OF SAMPLING ERRORS The estimates from a sample survey are affected by two types of errors: (I) nonsampling errors, and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of eitber the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the EIDHS-97 to minimize this type of error, nonsampling errors are impossible to avoid and difficultto evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the EIDHS-97 is only one of many samples that could have bean selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or n~mus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the EIDHS- 97 sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the EIDHS-97 is the ISSA Sampling Error Module (ISSAS). This module used the Taylor linearization method of variance estimation for survey estimates that are means or proportions. The Jacknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method Ireats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variabley, and x represents the total number of cases in the group or subgroup under consideration. The variance ofr is computed using the formula given below, with the standard error being the square root of the variance: var(r) = x2 ~ zz~- - - tll mh in which z~ = Yhi ° r. xj~, and zh = Yh" r. xh 53 where h mh Yhi Xhi f represents the stratum which varies from I to H, is the total number of enumeration areas selected in the hth stratum, is the sum of the values of variabley in EA i in the h th stratum, is the sum of the number of cases in EA i in the h th stratum, and is the overall sampling fraction, which is so small that it is ignored. The Jacknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample, and calculates standard errors for these estimates using simple formulae. Each replication considers all but one of the clusters in the calculation of the estimates. Pseudo-independent replications are thus created. In the EIDHS-97, there were 934 non- empty clusters (2 dusters per PSU). Hence, 934 replications were created. The variance of a rate r is calculated as follows: 1 k vat(r) = - - E ( r, - r )2 k (k -1 ) ~-I in which r i f k r - ( k - l )ra) where r r(o and is the estimate computed from the full sample of 934 clusters, is the estimate computed from the reduced sample of 933 clusters (i th cluster excluded), k is the total number of clusters. In addition to the standard error, ISSAS computes the design effect (DEFT) for each estimate, which is defmed as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater thar 1.0 indicates the increase in the sampling error due to the use of a more complex and less stetisticall efficient design. ISSAS also computes the relative error and confidence limits for the estimates. Sampling errors for the EIDHS-97 are calculated for the country as a whole for selected variables considered to be of primary interest. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table A.I. Tables A.2 presents the value o the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, th design effect (DEFT), the relative standard error (SF-JR), and the 95 percent confidence limits (R~2SE), for each variable. The DEFT is considered undefined when the standard error for a simpl ramdom sample is zero. In general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions. For example, for the variable contraceptive use for currently married women age 15-49, the relative standard errors as a percent of the estimated mean is 1.9 percent. The confidence interval (e.g., as calculated for contraceptive use for currently married women age 15-49) can be interpreted as follows: the overall national sample proportion is 0.545 and its standard error is .01. Therefore, to obtain the 95 percent confidence limits, one adds and subWacts twice the standard error to the sample estimate, i.e. 0.545±2 (.01). There is a high probability (95 percent) that the true average proportion of contraceptive use for currently married women age 15 to 49 is between 0.525 and 0.566. 54 Table A. 1 List of variables selected for sampling error calculation, Egypt Interim DHS 1997 Variable name Estimate Base population No education Proportion Ever used any contraceptive method PropoRion Currently using any contraceptive method Proportion Currently using a modem method Proportion Currently using pill Proportion Currently using IUD Proportion Currently using injeetables Proportion Using public sector source Proportion Want no more children Proportion Want to delay at least 2 years Proportion Mothers received tetanus injection Proportion Mothers received medical care at delivery Proportion Fled diarrhea in last 2 weeks Proportion Treated with ORS packets Proportion Consulted medical personnel about diarrhea Proportion Having immunization record Proportion Received BCG vaccination Proportion Received DPT vaccination (3 doses) Proportion Received polio vaccination (3 doses) Proportion Received measles vaccination Proportion Received hepatitis vaccination 0 doses) Proportion Fully immunized Proportion Weight-for-height Proportion Height-for-age Propo~ion Weight-fur-age Proportion Total fertility rate (0-3 years) Rate Neonatal mortality rate (0-9 years) Rate Posmennatal mortality rate (0-9 years) Rate Infant mortality rate (0-9 years) Rate Child mortality rate (0-9 years) Rate Under-five mortality rate (0-9 years) Rate Ever-roamed women 15-49 Currently nmlried women 15.49 Currently married women 15.49 Currently married women 15-49 Cunently married women 15.49 Currently married women 15.49 Currently married women 15.49 Currently married women 15.49 Cunently married women 15.49 Currently married women 15.49 BiRhs in last 5 years Births in last 5 years Children 0-59 months Children under 5 with diarrhea in last 2 weeks Children under 5 with diarrhea in last 2 weeks Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 12-23 months Children 0-59 months Children 0-59 months Children 0-59 months Women-years of exposure to childbearing Number of births Number of births Number of births Number of births Number of births 55 Table A.2 Sampling errors - National sample, Egypt Interim Survey 1997 Confidence Number of cases limits Standard Design Relative Value error Unwalghted Weighted effect error Variable (It) (SE) (h') (WIN) (DEFT) (SE/R) R-2SE R+2SE No education 0.430 0.014 5,554 5,554 2 .034 0.031 0.403 0.457 Ever used any contraceptive method 0.758 0.010 5,152 5,157 1.605 0.013 0.739 0.777 Currantly using any contraceptive method 0.545 0.010 5,152 5,157 1.493 0.019 0.525 0.566 Currently using a modern method 0,518 0.010 5,152 5,157 1.466 0.020 0,497 0.538 Culrently using pill 0,102 0.005 5,152 5,157 1.183 0.049 0.092 0.112 Currently using IUD 0,346 0.010 5,152 5,157 1.443 0.028 0.327 0.365 Currantlyusinginjectables 0.039 0.003 5,152 5,157 1.234 0.086 0.032 0.045 Using public sector source 0.409 0.013 2,576 2,671 1.343 0.032 0.383 0.435 Want no more childron 0.646 0.008 5,152 5,157 1.160 0.012 0.631 0.662 Want to dclay at least 2 years 0.146 0.006 5,152 5,157 1.12g 0.038 0.135 0.157 Mothers received tetanus injection 0.721 0.011 3,971 4,007 1.270 0.015 0.700 0.743 Mothers received medical care at delivery 0.564 0.016 3,971 4,007 1.653 0.029 0.532 0.596 Had diarrhea in last 2 weeks 0.149 0.008 3,749 3,783 1.221 0.051 0.134 0.164 Treated with ORS packets 0.384 0.023 561 564 1.089 0.060 0.338 0.431 Consulted medical personnel about diarrhea 0.490 0.023 561 564 1.042 0.047 0.444 0.536 Having immunization record 0.725 0.020 742 761 1.226 0.028 0.685 0.765 Received BCG vaccination 0.959 0.008 742 761 1.056 0.008 0.944 0.975 Received DPT vaccination (3 doses) 0.896 0.013 742 761 1.111 0.014 0.870 0.921 Received polio vaccination (3 doses) 0.913 0.011 742 761 1.099 0.012 0.891 0.936 Received measles vaccination 0.894 0.013 742 761 1.155 0.015 0.867 0.921 Received hepatitis vaccination (3 doses) 0.767 0.019 742 761 1.177 0.024 0.730 0.804 Fullyinanunized 0.828 0.016 742 761 1.138 0.019 0.797 0.860 Weight-for-height 0.061 0.005 3,328 3,328 1.174 0.082 0.051 0.071 Height-for-age 0.249 0.010 3,328 3,328 1.240 0.039 0.229 0.268 Weight-for-age 0.117 0.007 3,328 3,328 1.183 0.059 0.103 0.130 Total fertility rate (0-3 years) 3.249 0.081 NA 159,308 1.171 0.025 3.088 3.410 Neonatal mortality rate (0.9 years) 32.395 2.533 8,297 8,362 1.149 0.078 27.329 37.461 Postneonatal mortality rate (0-9 years) 62.084 3.514 8,320 8,383 1.176 0.057 55.057 69.11 ] lnfant mortality rate (0.g yeats) 17.354 1.952 8,326 8,388 1.164 0.112 13.449 21.259 Child mortality rate (0-9 years) 78.360 4.089 8,351 8,412 1.212 0.052 70.183 86.538 Under-five mortality rate (0-9 years) 26.689 2.356 8,318 8,381 1.175 0.079 24.976 34.401 56 Front Matter Title Page Contact Information Table of Contents List of Tables Chapter 01 - Introduction Chapter 02 - Fertility Chapter 03 - Family Planning Knowledge and Use Chapter 04 - Family Planning Services Chapter 05 - Family Planning Communication Chapter 06 - Fertility Preferences and Unmet Need for Family Planning Chapter 07 - Maternal Health Chapter 08 - Child Health References Appendix A - Estimates of Sampling Errors

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