Egypt - Demographic and Health Survey - 2004

Publication date: 2004

Egypt Interim Demographic and Health Survey 2003 EGYPT INTERIM DEMOGRAPHIC AND HEALTH SURVEY 2003 Fatma EI-Zanaty Ann A. Way January 2004 *t i Ministry of Health and Population El-Zanaty and Associates National Population Council ORC Macro Additional "information about the 2003 EIDHS may be obtained from the National Population Council, P.O. Box 1036, Cairo Egypt (Telephone: 5240425 or 5240505; Fax: 5240219). Additional information about the Measure DHS+ project may be obtained from ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (Telephone: 301-572-0200; Fax: 301-572-0999). Recommended citation: E1-Zanaty, Fatma and Ann A.Way. 2004. 2003 Egypt Interim Demographic and Health Survey. Cairo Egypt: Ministry of Health and Population [Egypt], National Population Council, E1-Zanaty and Associates, and ORC Macro. TABLE OF CONTENTS CHAPTER 1 INTRODUCTION . 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Background . 1 Survey Design and Implementation . 1 Survey Coverage . 3 Household Socio-economic Characteristics . 3 Household Wealth . i . 10 School Attendance . 11 Background Characteristics of EIDHS Respondents . 13 Exposure to Mass Media . 14 CHAPTER 2 FERT IL ITY . 15 2.1 2.2 2.3 2.4 • 2.5 Current Fertility . 15 Trends in Fertility . 16 Proximate Determinants of Fertility . 18 Fertility Preferences . 23 Premarital Examination: Knowledge and Practice . 27 CHAPTER3 FAMILY PLANNING . 29 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Knowledge and Ever Use of Family Planning . 29 Level and Differentials in Current Use of Family Planning . 30 Trends in Current Use of Family Planning . 34 Need for Family Planning . 36 Intention to Use Family Planning in the Future . 38 Contact of Nonusers with Family Planning Providers . 39 Exposure to Family Planning Messages . 41 Perceptions and Attitudes about Family Planning Use . 42 CHAPTER 4 FAMILY PLANNING SERVICES . 45 4.1 4.2 4.3 4.4 4.5 Source of Family Planning Methods . 45 IUD Use . 47 Pill Use . 48 Injectable Use . 49 Service Assessment Indicators . 50 CHAPTER 5 MATERNAL HEALTH . 53 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Pregnancy Care . 53 Content of Pregnancy Care . 57 Perceptions about ANC Coverage . 59 Exposure to Safe Pregnancy Messages . 60 Delivery Care . 62 Postnatal Care . 62 Trends in Maternal Health Indicators . 69 Table of Contents [ iii CHAPTER 6 CHILD HEALTH AND NUTRIT IONAL STATUS OF CHILDREN AND WOMEN . 71 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Immunizations . 7 I Diarrhea . 73 Acute Respiratory Infection . 75 Breastfeeding and Supplementation . 77 Nutritional Status of Children . 81 Nutritional Status of Women . 83 Micronutrient Supplementation . 85 CHAPTER 7 EARLY CHILDHOOD MORTAL ITY . 89 7.1 7.2 7.3 7.4 7.5 Levels of Early Childhood Mortality . 89 Trends in Early Childhood Mortality . 89 Socio-Economic Differentials . 90 Demographic Differentials . 91 High-Risk Fertility Behavior . 91 CHAPTER 8 KNOWLEDGE OF A IDS, HEPAT IT IS C, AND SAFE IN JECT ION PRACTICES . 95 8.1 8.2 8.3 Knowledge of AIDS . 95 Knowledge of Hepatitis C . 98 Knowledge of Safe Injection Practices . 101 CHAPTER 9 FEMALE C IRCUMCIS ION . 105 9.1 9.2 9.3 9.4 Prevalence of Female Circumcision . 105 Support for Female Circumcision . 106 Communication about Female Circumcision . 108 Beliefs about Circumcision . 109 REFERENCES . 111 APPENDIX A SAMPL ING ERRORS . 113 APPENDIX B 2003 EGYPT INTERIM DEMOGRAPHIC AND HEALTH SURVEY QUEST IONNAIRES . 115 iv [ Table c)f Contents LIST OF TABLES AND FIGURES CHAPTER 1 INTRODUCTION . 1 Table I. 1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 1.6 Table 1.7 Table 1.8 Table 1.9 Table 1.10 Table 1.11 Sample results . 3 Housing type and tenure . 4 Housing characteristics . 5 Drinking water facilities . 6 Sanitation facilities . 8 Hand-washing materials . 9 Household possessions . 10 Wealth index . 11 School attendance . 12 Background characteristics of respondents . 13 Exposure to mass media . 14 CHAPTER 2 FERT IL ITY . 15 Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 2.5 Table 2.6 Table 2.7 Table 2.8 Table 2.9 Table 2.10 Table 2.11 Table 2.12 Table 2.13 Table 2.14 Current fertility . 15 Trends in fertility . 16 Trends in fertility by residence . 17 Age at first marriage . 18 Median age at first marriage by background characteristics . 19 Age at first birth . 20 Median age at first birth by background characteristics . 20 Birth intervals . 21 Teenage pregnancy and motherhood . 22 Fertility preferences by number of l iving children . 23 Ideal number of children . 24 Mean ideal number of children by background characteristics . 25 Wanted fertility rates . 26 Premarital examination . 27 Figure 2.1 Trends in fertility by residence . 17 Figure 2.2 Total fertility rates and wanted fertility rates by wealth level . 26 CHAPTER 3 FAMILY PLANNING . 29 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 Table 3.11 Family planning knowledge and ever use . 29 Current use of family planning methods by residence . 3 I Current use of family planning methods by background characteristics . 33 Trends in current use of family planning . 34 Trends in current use of family planning by residence . 35 Trends in current use of family planning by socio-economic characteristics . 36 Need for family planning . 37 Future use of family planning . 38 Reasons for not using family planning . 39 Preferred family planning method . 39 Contact of nonusers with family planning workers and health facilities . 40 List of Tables and Figures ] v Table 3.12 Table 3.13 Table 3.14 Table 3.15 Exposure to family planning messages . 41 Most recent source of family planning information . 42 Opinion about extent and trend in family planning use . 43 Timing of use of family planning by newly married couples . 44 Figure 3.1 Current use of modem family planning methods by place of residence . 31 CHAPTER 4 FAMILY PLANNING SERVICES . 45 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Source for modem family planning methods . 45 Trends in source for modem family planning methods by residence . 46 Cost of method for IUD users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Amount users are will ing to pay for IUD insertion . 48 Brand of pill used . 48 Cost of method for pill users . 49 Amount users are will ing to pay for the pill . 49 Cost of method for injectable users . 50 Amount users are will ing to pay for injectables . 50 Service assessment indicators for clinical providers . 51 Figure 4.1 Trend in percentages of users obtaining IUD and all modem methods from public sector providers . 47 CHAPTER 5 MATERNAL HEALTH . 53 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 5.11 Table 5.12 Table 5.13 Table 5.14 Antenatal care . 53 Tetanus toxoid coverage . 54 Medical care other than visit for antenatal care or tetanus toxoid injection during pregnancy . 55 Care during pregnancy . 56 Content of pregnancy care . 58 Perceived coverage of antenatal care . 59 Coverage of safe pregnancy messages . 61 Delivery characteristics . 62 Medically-assisted deliveries by background characteristics . 63 Postnatal care for mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Postnatal care for mother by background characteristics . 65 Postnatal care for child . 66 Postnatal care for child by background characteristics . 68 Trends in maternal health indicators . 69 Figure 5.1 Antenatal care by place of residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 CHAPTER 6 CHILD HEALTH AND NUTRIT IONAL STATUS OF CHILDREN AND WOMEN . 71 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Vaccinations by background characteristics . 72 Prevalence and treatment of diarrhea . 74 Prevalence ant treatment of acute respiratory disease . 76 Initial breastfeeding . 78 vi [ L i s to fTab lesandF igures Table 6.5 Table 6.6 Table 6.7 Table 6.8 Table 6.9 Table 6.10 Table 6.1 I Table 6.12 Breastfeeding status . 79 Median duration and frequency of breastfeeding . 80 Nutritional status of children . 82 Trends in nutritional status of children . 83 Nutritional status of women by background characteristic . 84 Vitamin A supplementation among postpartum mothers . 85 Vitamin A supplementation among children 12-23 months . 86 Iodized salt . 87 CHAPTER 7 EARLY CHILDHOOD MORTAL ITY . 89 Table 7. I Table 7.2 Table 7.3 Table 7.4 Table 7.5 Early childhood mortality rates . 89 Trends in early childhood mortality in Egypt, 1965-2003 . 90 Early childhood mortality by socio-economic characteristics . 91 Early childhood mortality by demographic characteristics . 9i High-risk fertility behavior . 92 CHAPTER 8 KNOWLEDGE OF AIDS, HEPAT IT IS C, AND SAFE IN JECTION PRACTICES . 95 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Knowledge of AIDS . 96 Knowledge of ways a person can contract AIDS . 97 Knowledge of hepatitis C . 99 Knowledge of ways a person can contract hepatitis C . 100 Knowledge about safe injection practices . 101 Safe injection practices . 102 CHAPTER 9 FEMALE C IRCUMCIS ION . 105 Table 9. i Table 9.2 Table 9.3 Table 9.4 Prevalence of female circumcision . 106 Attitude about continuation of female circumcision . 107 Communication about female circumcision . 108 Beliefs about female circumcision . 110 APPENDIX A SAMPL ING ERRORS . 113 Table A. 1 Sampling errors for selected variables: National sample, 2003 Egypt Interim Demographic and Health Survey . 114 List of Tables and Figures I vii 1 INTRODUCTION 1.1 Background The 2003 Egypt Interim Demographic and Health Survey (2003 EIDHS) is the most recent of seven DHS surveys to be undertaken in Egypt. ~ The 2003 EIDHS was conducted under the auspices of the Ministry of Health and Population and the National Population Council. ORC Macro provided technical support for the survey through the MEASURE DHS+ project. USAID/Egypt provided funding for the survey under its bilateral population and health projects. This interim survey was undertaken to provide the information needed to track changes in major family planning, health and nutrition. This report presents the principal findings of the 2003 EIDHS. 1.2 Survey Design and Implementation Sample Design and Selection The sample for the 2003 EIDHS 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 Governorates, urban Lower Egypt, rural Lower Egypt, urban Upper Egypt, and rural Upper Egypt). In addition to the base sample, Menya govemorate and slum areas in Greater Cairo were oversampled in order to provide separate estimates for the USAID programs targeting these areas. The findings for Menya governorate and for the slum areas in Greater Cairo are presented in separate reports. The Frontier Governorates, which represent less than 2 percent of the total population, were excluded from the survey. A systematic random sample of more than 10,000 households was chosen for the main 2003 EIDHS sample (including the oversampling of Menya); in addition, around 4,000 households from the slum areas in Greater Cairo were chosen for the survey. The households were drawn from among those found in the 490 primary sampling units (PSU) selected for the 2003 EIDHS; 466 PSUs came from the original 2000 EDHS sample, 24 additional PSUs were selected in Menya, and 50 PSUs were selected from slum areas in Greater Cairo. In the process of selecting the 2000 EDHS sample, each of the PSUs was divided into parts. The number of parts selected for inclusion in the sample varied according to PSU size; in large PSUs (i.e., PSUs with 20,000 population or more), two parts were chosen for the sample while only one part was chosen in smaller PSUs. In new PSUs selected for the 2003 EIDHS, a similar procedure was used to select parts. In all PSUs selected for the main EIDHS sample, two segments were selected from each part. Thus, a total of 980 segments were selected for the main survey. An additional 90 segments were drawn in slum areas, for a grand total of 1,070 segments. In planning for the 2003 EIDHS, it was decided to obtain new household listings for all PSUs rather than employing the listings from the 2000 EDHS. Thus, a household listing operation was carried out in the segments chosen for the 2003 EIDHS prior to the main fieldwork. Using these listings, a systematic random sample of households was selected within each segment for the survey. JEarlier flail-scale DHS surveys were conducted in 1988, 1992, 1995 and 2000. In addition, interim DHS surveys were conducted in 1997 and 1998. Other national-level surveys for which results are shown in this report include the Egyptian Fertility Survey (1980 EFS), the 1984 Egypt Contraceptive Prevalence Survey (I 984 ECPS), and the 1991 Egypt Maternal and Child Health Survey (1991 EMCHS). Introduction [ 1 In order to allow for sub-regional estimates, the final number of households selected from each governorate in the 2003 EIDHS is disproportionate to the size of the population in the governorate. Thus, the 2003 E1DHS sample is not self-weighting at the national level. Questionnaires In order to collect information needed, two questionnaires were developed: a household questionnaire and a woman's questionnaire. The 2003 EIDHS household and woman questionnaires are similar to the questionnaires used in the 2000 EDHS in terms of the broad topics for which information is collected. However, a number of questions in the 2000 EDHS questionnaires were dropped from the 2003 survey instruments, and some questions were added to the 2003 EIDHS questionnaires in order to investigate new topics. Overall, the EIDHS questionnaires are more focused and limited in scope than the 2000 EDHS questionnaires. The EIDHS household questionnaire collected information on the names and characteristics (age, marital status, education, work, etc.) of all household members and on housing and household possessions. Height and weight measures also were obtained for eligible women and children. The EIDHS woman's questionnaire included questions on background characteristics of respondents (age, education, work, etc.). The questionnaire also collected information about reproduction, contraceptive knowledge and use, fertility preferences and attitudes towards family planning use, maternal health care including pregnancy care, infant feeding practices, child immunization and health, female circumcision, and husbands' background. In addition, new questions were added relating to knowledge about HIV/AIDS, Hepatitis C, and safe injection practices. Finally, the questionnaire contained a monthly calendar in which information was recorded on marital status, pregnancies and births, contraceptive use and discontinuation, and breastfeeding and postpartum amenorrhea. The calendar covered a 66-month period including the month in which the survey interview took place. A training manual for interviewers was prepared including general guidelines to follow in conducting an interview, as well as specific instructions for administering the EIDHS questionnaire. Data Collection Field staff were trained for four weeks during April and early May. Twelve teams collected data for the 2003 EIDHS. Each team consisted of four interviewers, one field editor, one assistant supervisor, and one supervisor. The field editor and the assistant supervisor were responsible for the height and weight measurements. All of the interviewers and field editors were females, and the assistant supervisor and supervisors were males. Two teams were assigned to work in Cairo, and the other teams were assigned to work in one to three governorates. The data collection started on May 9 th. Re-interviews and call backs started as soon as the first team completed the data collection. All call backs and re-interviews were completed by June 28 th Data Processing and Editing The data processing staff including coders, office editors and data entry personnel, attended the interviewer training program in order to become familiar with the questionnaires. Completed questionnaires were sent from the field to the office for registration and limited manual coding. Data were entered using microcomputers and the Integrated System for Survey Analysis (ISSA), a software package developed in the DHS program to facilitate processing of the survey data. Twelve computers were used for data entry. Verification was carried out for 100 percent of the questionnaires. A 2 [ Introduction consistency program was prepared to assure the quality and accuracy of the data. The data entry, verification and consistency checking, which overlapped with the field activities, took around three months to complete. 1.3 Survey Coverage Table 1.1 presents the results of the fieldwork for the main 2003 EIDHS sample (excluding slum areas) for both the household and individual interviews. The table shows that, out of 10,417 households selected for the 2003 EIDHS, 10,204 were found and 10,089 were successfully interviewed. This represents a household response rate of 99 percent. A total of 9,217 women were identified in those households as eligible for the individual interviews. Questionnaires were completed for 9,159 women, which represents a response rate of 99 percent. Table 1.1 Sample results Distribution of households (HH) and eligible women (EW) by the result of the interview, and response rates, according to urban- l~aral and place of residence, Egypt 2003 Interim Demographic and Health Survey Place of residence Urban Lower Egypt Upper Egypt Gover- Interview results Urban Rural norates Total Urban Rural Total Urban Rural Total Dwellings sampled 4,849 5,568 2,097 3,443 1,259 2,184 4,877 1,493 3,384 10,417 Households found 4,700 5,504 2,034 3,373 1,221 2,152 4,797 1,445 3,352 10,204 Households interviewed 4,611 5,478 2,000 3,310 1,177 2,133 4,779 1,434 3,345 10,089 HH response rate 98. I 99.5 98.3 98.1 96.4 99. I 99.6 99.2 99.8 98.9 Eligible women 3,630 5,587 1,482 3,147 950 2,197 4,588 1,198 3,390 9,217 EW interviewed 3,596 5,563 1,473 3,105 929 2,176 4,581 1,194 3,387 9,159 EW response rate 99.1 99.6 99.4 98.7 97.8 99.0 99.8 99.7 99.9 99.4 1.4 Household Socio-economic Characteristics In the following section, a profile of the characteristics of the households selected for the EIDHS sample is presented. Information on housing characteristics, housing facilities, and household possessions are highlighted. Housing TVDe Table 1.2 presents the housing type and tenure for the interviewed households. The majority of households in urban areas live in apartments (83 percent), whereas in rural areas the majority live in a free-standing house (71 percent). Nine in 10 rural households own their dwelling, with slight variations among regions. Ownership is less common in urban areas, particularly in the Urban Governorates, where 41 percent own or jointly own their dwellings. Households not owning their dwelling were asked about the possibility of being evicted. As shown in Table 1.2, the great majority of these households (90 percent) are not concerned about the possibility of eviction. Urban households were slightly more likely than rural households to report that there is no possibility of being evicted (90 percent and 87 percent, respectively). Housing Characteristics Table 1.3 presents the distribution of households by selected housing characteristics including electricity, type of cooking fuel, flooring, and the number of rooms. Overall, 99 percent of households have electricity. Differentials in the availability of electricity by residence are small, ranging from 96 Introduction [ 3 percent of households in rural Upper Egypt to nearly 100 percent of households in the Urban Governorates and urban Lower Egypt. Looking at the cost of electricity, 35 percent of households pay L.E.20 or more monthly for electricity, 20 percent pay L.E. 15-19, 24 percent pay L.E. 10-14, and 18 percent pay less than L.E. l 0. Possibly reflecting higher electrical usage, urban households pay higher amounts for electricity than rural households. Table 1.2 Housing type and tenure Percent distribution of households by housing type and tenure, according to urban-rural residence and place of residence, Egypt 2003 Place ofresidcncc Urban Lowcr Egypt Upper E~3ypt Housing type Gover- and tenure Urban Rural noratcs Tota l Urban Rural Total Urban Rural Total Type of dwelling Apartment 82.9 26.8 92.2 50.3 81.2 34.2 35.7 67.8 17.4 54.8 Free standing house 14.7 71.1 4.9 48.2 16.8 64.4 61.6 302 796 42.9 Other 2.4 2.1 2.9 1.6 1.9 1.4 2.6 2. I 30 22 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 10031 100.0 100.1) 100.0 Number of households 5,047 5,042 2,319 4,259 1,451 2,808 3,51 I 1,278 2,233 10.089 Dwelling owned/rented Owned/Owned jointly 52.0 90.7 40.8 80.1 61.3 89.9 80.9 61.9 91.8 71.4 Rented 43.7 4.3 55.1 14.4 33.0 4.8 15.0 35.1 3.6 24.0 Other 4.3 5.0 4.1 5.5 5.7 5.3 4.0 3.1 4.6 4.6 Total percent 100.0 100.0 10031 100.0 100.0 I/gh0 100.0 100.0 100.0 100.0 Number of households 5,047 5,042 2.319 4,259 1,451 2,808 3,51 I 1,278 2,233 10.089 Possibility of eviction Very likely 2.9 3.3 2.4 3.6 4.0 2.8 3.4 3.1 4.1 3.0 Somewhat Likely 1.5 2.9 1.8 1.5 0.8 3.0 1.9 1.6 2.8 1.7 Not very likely 2.4 4.4 2.2 2.5 2.8 1.9 4.1 2.4 8.4 2.7 No possibility of eviction 90.2 86.9 91.5 89.6 89.3 90.0 862 87.8 819 897 Don't know/missing 3.0 2.5 2.2 2.8 3. I 2.3 4.4 5. I 2.7 2.9 Total percent 100.0 1110.0 100.0 100.0 100.0 100.0 100.0 100.0 I00.0 100.0 Number of households 2,42l 467 1,373 846 562 285 669 487 182 2,888 The majority of households in both urban areas (98 percent) and rural areas (88 percent) usc LPG/natural gas as a cooking fuel. Use of kerosene is most common in rural Upper Egypt, where 20 percent of households use this type of fuel. With regard to flooring, more than half of households live in dwellings with cement tile floor, 19 percent report cement floors, and 15 percent have earth/sand floors. There are substantial differences in the flooring materials between urban and rural dwellings. Slightly more than one-quarter of rural households have a sand or earth floor compared with 3 percent among urban households. On the other hand, around three-quarters of urban households have a cement tile floor compared with 38 percent of rural households. With regard to the number of rooms, Table 1.3 shows that 10 percent of households have one or two rooms, and 69 percent have three to four rooms. The overall mean number of rooms per household is 3.8, and the mean number of persons per room is 1.4. 4 i Introduction Table 1.3 Housing characteristics Percent distribution of households by housing characteristics, according to urban-rural residence and place of residence, Egypt 2003 Place of residence Urban Lower Egypt Upper Egypt Gover- Housingcharacteristic Urban Rural notates Total Urban Rural Total Urban Rural Total Electricity Yes 99.7 97.8 99.9 99.2 99.7 98.9 97.5 99.5 96.3 98.8 No 0.2 2.2 0.1 0.8 0.3 1.1 2.5 0.4 3.7 1.2 Totalpercent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Average monthly electricity cost Free 0.3 0.2 0.3 0.1 0.1 0.0 0.3 0.4 0.3 0.2 1-9 LE 13.5 21.4 14.1 17.9 15.1 19.4 18.9 10.6 23.9 17.4 10-14 LE 21.3 26.9 18.9 27.1 25.6 27.9 23.9 20.9 25.6 24.l 15-19 LE 19.8 20.9 20.3 20.8 18.4 22.1 19.8 20.5 19.3 20.3 20+ LE 43.0 27.6 44.5 31.3 38.2 27.7 34.2 45.5 27.6 35.4 Don't know/missing 2.2 3.1 2.0 2.8 2.7 2.9 2.9 2.1 3.3 2.6 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.4 0.3 0.8 0.2 0.2 0.2 0.3 0.0 0.5 0.4 LPG, natural gas 97.5 87.6 97.6 96.8 98.5 95.9 84.1 96.2 77.2 92.6 Kerosene 1.9 10.8 1.4 2.8 1.2 3.6 14.0 3.6 20.0 6.4 Charcoal 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.0 Firewood/straw/dung 0.0 0 9 0.0 0.0 0.0 0.1 1.3 0.0 2.1 0.5 Other 0.1 0.1 0.1 0.1 0.0 0.2 0.1 0.0 0.1 0.1 Missing 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 Totalpercent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Flooring Ceramic/marble tiles 14.1 2.5 19.1 5.0 8.4 3.2 5.2 11.6 1.5 8.3 Cement tiles 72.1 37.7 71.2 54.7 75.8 43.8 44.5 69.7 30.1 55.0 Cement 6.5 32.4 3.7 30.3 10.5 40.5 16.7 7.2 22.2 19.4 Wall-to-wall carpet 1.9 0.8 1.5 1.6 2.6 1.1 0.9 1.9 0.4 1.3 Vinyl 0.4 0.0 0.3 0.2 0.5 0.0 02 0.6 0.0 0.2 Parquet/polished wood 1.9 0. I 2.8 0.5 1.3 0.1 0.3 0.7 0.0 1.0 Wood planks 0.1 0.1 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 Earth/sand 2.8 26.3 1.0 7.6 0.9 1 ] 31.9 8.2 45.5 14.5 Other 0.0 0.1 0.1 0.1 0.0 0.1 0.1 0.0 0.2 0.1 Missing 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.1 0.0 0.0 Totalpercent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of rooms 1-2 9.0 10.1 10.3 6.0 6.8 5.6 13.4 9.3 15.8 9.6 3-4 76.3 61.8 74.4 67.7 78.9 61.9 67.2 76.9 61.7 69.1 5+ 14.4 28.0 15.3 26.3 14.0 32.6 19.1 13.4 22.3 21.2 Missing/DK 0.2 0.1 0.1 0.1 0.2 0.0 0.3 0.4 0.2 0.1 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Mean rooms per household 3.6 4.0 3.6 4.0 3.7 4.2 3.7 3.6 3.8 3.8 Mean persons per room 1.3 1.5 1.3 1.3 1.3 1.4 1.6 1.4 1.8 1.4 Numberofhouseholds 5,047 5,042 2,319 4,259 1,451 2,808 3,511 1,278 2,233 10,089 Drinking Water Information on the source of water that households use for drinking and on storage practices employed for drinking are presented in Table 1.4. As the table shows, more than eight in ten Egyptian households have access to piped water, mainly within their dwelling. Introduction [ 5 Urban households haxe almost universal access to sate drinking w'ater; 99 percent report they have piped water in their residence, and most of the remaining households obtain water fiom a public tap. Alnong rural households, these proportions are markedly lower; 74 percent have access to piped water, and 6 percent drink water from public taps. Among the remaining rural households, almost all report they obtain drinking water from covered wells. I ab le l 4 Drinkin~ water flicilities Percent distiibution of b(~uscbolds by drinking watei lacility, according to urban rural residence and place ofresidence, Egypt 2003 Place ofresidence Urban IowerEgypt Upper Egypt Gover [)linking wiacrl~lcilitios Urban Rula/ Iloratcs Total Urban Rural Iotal lYrban Rural Total Source of dr ink ing ~ater Piped into residence/plot Pubbc tap (?pen well Co~eicd well Nile/canals Other I oral percent Numbc~ l hne to ~ater source Water witbbl 15 minutes %% ater supply interrupted Daily/a/most daily Few times per week Less b cquently Not interrupted I)on't know/udssing Total pm cent Numbm Water stored Yes No Don't know!nnissing I oral pclcent Number Storage containers co~ered All covered Y, om~+ co~ trod None cox eied Nol able to observe/mi>sing 7 oral percent N kllllbor Type of storage container Wide nloutb N~lrrOx~ lUOutb Botb types Missing Total perceiU NumbeI 98.6 736 993 832 98.7 752 80.8 97 1 7/.5 86.1 1.2 64 05 30 12 3.9 7.0 23 96 3.8 0 I 1.3 0.1 07 0 0 I 1 1.0 0.2 1 5 0.7 02 16.0 0. l 11.6 0.1 175 92 1) 4 142 8.1 00 0.0 0.0 0.0 00 00 00 00 01 0.0 00 2.7 0.1 1.5 0.0 23 2{I O0 3.1 1.3 /00 0 1000 100.0 100.0 100.0 100 0 1000 100.0 100.0 100.0 5,047 5,(/42 2,319 4,259 1.451 2,808 3.5l / 1,278 2,233 10,089 996 94.7 997 97.2 997 959 95.4 99.2 93.3 97 1 95 10.5 11.9 91) 78 9.6 10.0 7.2 11.6 100 15.0 17.4 13.5 179 181 178 159 14.1 16.9 16.2 8.8 6.8 9.2 10.0 128 8.6 41 34 45 78 66 2 6%0 64.8 62.8 60.9 637 69.6 749 66.6 65.6 115 04 0.6 0.4 0.5 0.3 0.4 04 0.4 0.5 100.0 /000 100.0 100.0 100.0 100.0 1000 100.0 100.0 I00.0 5.047 5.042 2,319 4,259 1,451 2,808 3.51/ 1,278 2.233 10,089 22.7 39.2 2 /3 314 25.8 343 36.8 21.8 45.4 30 9 772 607 78.6 685 742 636 63.1 78.0 54.6 690 0 1 0.0 0 1 0.0 00 0.1 0.1 0.3 0.0 0 I 1000 1000 100.0 100.0 I000 1000 I000 tO00 IO00 I00.0 5.047 ";.042 2.319 4.259 1,451 2.808 3,511 1,278 2,233 10.089 893 75.2 89.6 786 889 746 787 892 75.8 80.4 8.5 209 87 16.7 71 20.4 189 99 213 16.3 1.6 35 1 0 39 30 4.3 2.2 06 27 2.8 07 0.5 0.7 0.8 I0 07 0.2 03 02 06 IOOf) I000 1000 1000 1000 1000 I00.0 1000 100.0 100.0 1,145 1.977 493 1,338 374 964 1.29/ 278 1,013 3,122 282 46.5 18.0 416 388 427 46.1 320 51).0 398 44 5 343 43.3 43.1 490 40 8 309 40.7 28.2 38.1 273 19.1 38.7 15.2 122 163 230 27.3 21.8 221 0.0 0 I 0.0 O. ] O0 02 Od) 1) 0 0.0 0.0 100.0 1000 1000 1000 1000 100.0 100.0 100(/ 100.0 1000 [, lg7 1.968 48 c) 1,328 370 957 1,288 277 1.011 3,105 With regard to access to source of drinking water, 97 percent of households can fetch water within 15 minutes. 6 I ll~fl'°dz~cli°~7 Households were also asked about interruptions in the water supply. Sixty-six percent of households reported that the water supply is never interrupted while 10 percent of the households mentioned that water supply is interrupted daily. Drinking water that is stored may become contaminated if the storage container is not clean or covered. Table 1.4 presents data on the extent to which water for drinking purposes is stored and on the containers used for storage. Overall, 31 percent of households store drinking water and, among these households, 80 percent use covered containers to store the water. Forty percent of households use wide mouth containers, 38 percent use narrow mouth containers, and 22 percent use both. Households in rural areas are more likely to store water than households in urban areas; this is particularly the case among households in rural Upper Egypt where 45 percent of households store water. In the majority of both urban and rural households where water is stored, the containers are covered; however, around one-quarter of rural households and 10 percent of urban households had some containers that were not covered. Sanitation Facilities Two in 5 households have a modem flush toilet, with significant differences by residence (Table 1.5). For example, 68 percent of urban households have a modem flush toilet compared with only 13 percent among rural households. Eighty percent of households in the Urban Govemorates have a modem flush toilet compared to 8 percent among rural households in Upper Egypt. The type of drainage system varies by residence. The majority of urban households are connected to public sewers, especially in the Urban Governorates, where 97 percent are on public sewers. Among rural households, almost half have a septic system. Households in rural Upper Egypt are more likely to have Bayars than any other drainage system (46 percent). More than three-quarters of the households had no problems with the drainage system. Problems with the drainage system are more common in the Urban Governorates and in Lower Egypt than in Upper Egypt. Information also was collected about whether the toilet facilities were shared with other households. Only four percent of households share their toilet facility with other households. There are slight variations by place of residence, with rural Upper Egypt having the highest percentage (8 percent) of households sharing their toilet facility. The condition of the toilet was observed by interviewers. In 90 percent of the toilets observed, no fecal matter was present. Fecal matter was observed in the toilet area more often in rural households than urban households (10 percent and 4 percent, respectively). Rural Upper Egypt had the largest proportion of households (12 percent) where fecal matter was observed. Interviewers also asked to see the place where household members washed their hands. Household members are much more likely to wash their hands regularly after using the toilet if the place for hand washing is adjacent to the toilet. Nearly all urban households had a place for hand washing and, in 91 percent of these households, the place used for hand washing was adjacent to the toilet facility. In contrast, 40 percent of rural households either did not have a place for hand washing (22 percent) or the place used for hand washing was not adjacent to the toilet facility (18 percent). Introduction I 7 Table 1.5 Sanitation facil it ies Percent distribution of households by sanitation facilities, according to urban rural residence and place of residence. Egypt 2003 Sanilation fl~cilities Urban [)lace of residence Urban Lower Egypt Upper Egypt Gover Rural norates [ora l Urban Rural 9ota] Urban Rural Tolal Toilet facility Modern flush toilet 678 1331 80.2 32.5 62.t) 172 238 523) 7 7 4P.4 TJadit ionalwith tank flush 1 0 20 0.5 2 3 15 2.7 1 2 1.6 1.0 I 5 Traditgmal with bucket flush 30~ 789 19.3 637 360 77.9 67 2 44.6 80.1 54,7 Pit Ioilct/latrine 0.4 3.5 0.1 I .I 0 2 1 5 42 I 2 53) 1 9 No [hcili ly/bush (12 27 00 0.5 03 116 q6 0 6 5.3 1 5 Total percent 1000 I000 1000 100.0 1000 1000 10(h0 100.0 1003) 100.0 Number 5.047 5.042 2,319 4.259 1,451 2.808 3.51 I 1,278 2,233 10.089 Drainage system Public sewer 846 21.7 966 538 900 351 23.7 564 4 / 530 Vauh (Bayara) 82 25.1 19 62 09 90 394 278 463 165 Septicsyslcm 69 48.9 14 377 87 528 328 14.7 437 276 Pipe to canal 02 1.5 0 1 ] 6 04 2 ~ 0 3 0 1 ([.4 08 Pipe to groundwater 0 1 0.2 0.0 02 00 ()~ 1) 2 03 02 02 Emptied (11o connection) 02 2.5 0.0 0 4 0.1 05 3 5 07 5.2 I 3 Other 00 0 1 0.0 00 0.0 0.1 0 I 00 0.2 0 0 Total percent 100.0 1000 100.0 1000 10(I.0 100.0 1000 100 0 100.0 1000 Number 5,036 4.907 2,319 4,238 1,447 2.791 3,386 1.270 2.116 9,942 Problems with drainage system 8"cs 25.8 22.4 348 32.7 362 324 150 218 130 230 No 73.6 77.2 62 9 66.9 638 67 1 84 6 778 866 766 Don't know/missing 05 0.4 23 04 00 0~ 04 0 4 ft.4 04 Total percent 1000 100.0 100.0 1000 1000 1000 1000 1000 1000 1000 Number 766 3.713 78 1.94(I 144 1.796 2,4(H 945 1.917 4.479 Toilet facility shared Toilet not shared 97.3 95 1 966 97.0 98.1 97t 943 977 923 962 Toilet shared with: 1 household 0.7 1.2 06 (18 1.0 0.7 1.4 04 19 10 2 households 09 1.9 I 1 1 0 06 1.2 2.1 [) 8 2 8 1.4 3+ households I 0 17 15 05 03 07 23 10 3J) 1.5 Not sure/missing (10 00 0 1 00 0dl 0 1 00 00 P3) 00 [ oral percent 1000 100.0 1000 1000 1000 1000 1000 1000 1000 1000 Number 5,036 4.907 2,319 4,238 1,447 2,791 3,386 1,270 2,116 9,942 Condition of toilet facility Condition observed Fecal matter prcscm 36 95 2.6 6 8 4.6 8,0 8.9 4 4 I [.6 6.5 No l~cal matter present 94 2 858 95.5 91(I 935 89,6 85.3 927 808 90.1 Not determined I (I 37 04 1.0 117 I I 47 2.3 6 1 "~ I Not observed/missing I .I 1 4 I 5 1 3 1 2 1,3 I I 00 1.6 1.3 Total percent 1000 100.0 100.0 1000 1000 100,0 100.0 1000 100.0 100.9 Numbel 5,036 4,907 2,319 4,238 1,447 2.79I 3.386 1.27(I 2,1 t6 9.942 Place for hand ~ashing Place observed Same area/adjacent to toilet 90.5 594 92 7 782 918 71.2 592 850 44.5 749 Area not near toilet 5.3 17.5 3 7 9.5 5 1 I 1,8 187 8.4 24.6 I 1 4 No toilet ihcil ity 0. I 0.4 0 0 0.2 0.2 02 05 0.0 0.7 fl,2 Not able to observe 08 0.5 1 2 (I.6 (1.5 0.6 0 4 0.4 0.3 0.6 None/missing 34 22.2 2.4 II 6 2.5 16.2 21.2 62 298 12.8 9otal percent 100.0 I ()(I.0 100.0 100.0 1000 1000 100.0 100.0 100.0 1000 Number 5,047 5,042 2,319 4,259 1,451 2,8fl8 3,511 1,278 2,233 10,089 Disposal of kitchen waste/trash Collected b'om home 51.6 17.7 51(~ 317 499 223 270 ~36 118 346 Collected li'om container in street 268 3,2 392 88 190 36 6.6 13.4 2 7 150 Dtunped into street/empty plot 17.6 31.2 83 26.1/ 26.6 257 330 24.4 38(1 244 Dumped into canal/drainage 13 19.1 04 164 2.1 23.9 9 2 2.2 13.1 10.2 Burned 2.(I 211 03 135 2.4 19.2 166 46 23.4 leg Fed to animals/ 0 3 5 3 D.I 2.6 (/ I 3.8 4.9 1.0 7 1 2 8 Otber/don't know 0.3 25 0 / 1.0 0.1 1 4 2 8 08 3.8 1 4 Total percent 100.0 1000 100.(} 1000 1000 100.0 100(} 100.0 1(10.0 100 0 Number 5,047 5,042 2,319 4,259 1,451 2,808 3,511 1,278 2,233 10,089 8 I Introduction With regard to disposal of kitchen waste and trash, 52 percent of urban households have their waste collected from home compared to 18 percent of rural households. Dumping waste in the street, an empty plot, or into a drainage canal or ditch is a common practice among rural households (50 percent) while around 20 percent of rural households burn their trash. Hand-wash ing Mater ia ls Interviewers observed the hand-washing area to determine the presence of the following items: water/tap, soap, basin, and towel or cloth. Table 1.6 shows that 40 percent of all households had all the hand-washing materials present. Looking at the specific items, water or a tap was available in the hand washing area for 85 percent of households, 71 percent had soap or ash, and 79 percent had a basin. The item most likely to be lacking was a towel or cloth, which less than half the households had. Urban households were more than twice as likely to have all the items as rural (56 percent and 24 percent, respectively). Table 1.6 also shows considerable variation in the presence of hand-washing materials by place of residence. Households in urban Lower Egypt (61 percent) most often had all of the items while households in rural Upper Egypt households (11 percent) were least likely to have them. Table 1.6 Hand-washing materials Percentage of households with hand-washing materials by urban-rural residence and place of residence, Egypt 2003 Water or Soap/ Towel/ All Residence tap ash Basin cloth items Total Urban-rural residence Urban 94.7 85.4 93.5 57.5 56.0 5,047 Rural 75.9 56.7 64.5 25. I 24 1 5,042 Place of residence Urban Governorates 94. I 85.3 95.2 61.3 59. I 2,319 Lower Egypt 86.8 74. I 77.9 44.8 43.5 4,259 Urban 96.8 88.5 93.8 62.4 61.3 1.451 Rural 81.7 66.7 69.6 35.7 34.3 2,808 Upper Egypt 77.7 57.9 69.8 23.9 23.3 3.511 Urban 93.3 82.0 90.3 45.2 44.3 1.27S Rural 687 44.1 58.1 I 1.7 113 2,233 Total 85.3 71.1 79.0 41.3 40.1 10,089 Househo ld Possessions Table 1.7 provides information on household ownership of durable goods and other possessions. More than nine in ten households own a television, and around 80 percent have a washing machine (other than automatic). Around 47 percent of households have a telephone, and 17 percent have a mobile phone. Urban households are more likely to have most household effects than rural households. For example, more than 60 percent of urban households have a telephone compared with 30 percent of rural households, and 92 percent of urban households own a refrigerator compared with 67 percent of rural households. Ownership of various household possessions also varies by place of residence, with highest rates of ownership among households in the Urban Governorates and the lowest ownership in among households in rural Upper Egypt. Table 1.7 also includes information on household ownership of means of transportation. Overall, nine percent of households own a car, with the highest rate of ownership in the Urban Governorate (19 Introduction I 9 percent) and the lowest rate in rural Upper Egypt (3 percent). Rates of ownership of bicycles vary from 5 percent in the Urban Governorates to 27 percent in rural Lower Egypt. Table 1.7 Household possessions Percentage of households possessing various household effects, means of transportation, property and farm animals, according to urban-rural residence and place of residence, E~ypt 2003 Place of residence Urban Lower Egypt Upper Egypt Gover- Possession Urban Rural norates Total Urban Rural Total Urban Rural Total Household effects Radio 90.6 77.8 92.5 84.3 89.9 81.4 78.5 87.7 73.2 84.2 Television 96.2 89.2 95.9 93.9 96.6 92.4 S9.1 96.1 85.1 92.7 Video 27.6 4.9 34.7 9.7 17.9 5.4 12.1 25.8 4.2 16.3 Satellite dish 12.5 2.7 16.8 4.8 8.4 2.9 4.9 9.2 2.4 7.6 Telephone 63.9 29.8 70.9 39.4 53.7 32.11 40.0 62.7 27.0 46.8 Mobile telephone 28.4 5.9 35.7 12.3 21.7 7.5 10.8 22.8 4.0 17.2 Personal home computer 13.4 0.9 18.0 3.2 7.6 0.8 4.8 11.5 0.9 7.1 Electric fan 92.6 81.9 91.8 85.2 91.5 82.(/ 86.7 95.2 81.8 87.2 Air conditioner 7.6 0.4 I 1.2 1.0 2.3 0.4 2.9 7.0 0.5 4.0 Water heater 65.8 18.8 73.2 35.8 59.4 23.6 29.9 59.7 12.9 42.3 Refrigerator 91.7 67.2 93.6 78.8 90.1 72.9 70.9 90.0 60.0 79.4 Freezer 6.3 1.0 9.5 1.8 3.4 1.0 1.9 3.7 0.9 3.6 Automatic washing machine 33.5 4.1 41.6 11.0 23.7 4.4 13.2 29.9 3.6 18.8 Other washing machine 78.6 81.1 76.3 88.8 85.7 90.4 71.3 74.5 69.4 79.9 Gas/electric stove 84.2 64.7 86.8 74.1 78.4 71.9 66.6 85.9 55.6 74.4 Dishwasher 2.5 0.1 4.4 0.3 0.6 (hi 0.4 1.1 0.0 1.3 Sewing machine 10.7 6.0 11.7 8.4 1 I. I 7.1 6.0 8.2 4.7 8.3 Means of transportation Bicycle 12.5 24.7 4.8 24.3 18.7 27.2 20.8 19.4 21.5 18.6 Motorcycle/scooter 1.7 2.4 1.2 2.8 2.3 3.1 1.6 1.9 1.5 2.0 Car/van/truck 14.1 4.2 18.6 6.3 9.1 4.9 6.4 11.6 3.4 9.2 Property Farm/other land 6.0 38.5 3.7 28.5 8.7 38.8 26.9 7.2 38. I 22.2 Farm animals Livestock/poultry 12.5 66.5 4.0 48.3 17.7 64.1 52.2 21.9 69.5 39.5 None of the above 0.6 1.7 0.5 0.5 0.3 0.6 2.3 1.0 3.0 I.I Number of households 5,047 5,042 2,319 4,259 1,451 2,808 3,511 1,278 2,233 10,089 As for land ownership, rural households own land more than urban households (39 percent and 6 percent, respectively). Land ownership varies markedly by place of residence; only four percent of households in the Urban Governorates own [and compared to slightly less than 40 percent in rural Upper and Lower Egypt. A similar pattern is observed for ownership of farm animals. 1.5 Household Wealth The wealth index 2 uses information on household assets to derive a measure of the standard of living of households. Wealth index values were calculated as follows: • The value one was ass igned i f the asset ex isted in the household, and the value zero i f the asset did not exist. Assets that are not d ichotomous were g iven their actual values. 2The wealth index used here is a proxy for long-tern1 economic status of the household. The index has been compared against both po',erty rates and gross domestic product pcr capita for India, and against expenditure data from household surveys in Nepal, Pakistan and Indonesia (Filmer and Pritchet0 1998, 2001) and Guatemala (Rutstein 1999). The evidence from those studies suggests that the assets index is highly comparable to conventionally measured consumption expenditures 10 I Introduction • The unweighted mean and standard deviation of each asset was calculated. • Factor analysis was used to obtain a weight for each asset reflecting the ability of the asset to differentiate between the non-poor and the poor. These weights are called factor scores. • Standardized household asset scores were calculated and summed for all the assets. • Households were ranked according to the standardized scores, and the appropriate quintile cut- off points were defined. Table 1.8 presents the distribution of households according to the wealth index. The table shows that a much larger proportion of households in urban areas than in rural areas fall in the highest wealth index group (44 percent and 6 percent, respectively). In turn, rural households are much more likely than urban households to be in the lowest wealth index group (31 percent and 4 percent, respectively). Table 1.8 Wealth index Percent distribution of households by poverty level, according to urban-rural residence and place of residence, Egypt 2003 Wealth index Urban Urban Lower Egypt Upper Egypt Gover- Rural notates Total Urban Rural Total Urban Rural Total First (lowest) quintile 4.1 31.2 2.9 15.7 3.4 22.1 29.8 7.2 42.7 17.7 Second quintile 6.6 27.0 3.8 22.3 8.4 29.5 18.8 9.7 24.0 16.8 Middle quintile 14.7 23.2 9.9 23.8 19.4 26.1 19.0 18.0 19.6 18.9 Fourth quintile 30.3 12.9 29.9 21.9 34.7 15.4 15.8 26.2 9.8 21.6 Fifth (highest) quintile 44.3 5.6 53.6 16.2 34.2 7.0 16.6 39.0 3.9 25.0 Total percent 100.0 I00.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,047 5,042 2,319 4,259 1,451 2,808 3,511 1,278 2,233 10,089 Households in rural Upper Egypt are generally poorer than households in other areas, while households from Urban Governorates are wealthier than other areas. For example, 43 percent of households in rural Upper Egypt fall in the lowest wealth index group, while more than half of the households from Urban Governorates fall in the highest wealth index group. 1.6 School Attendance Table 1.9 presents data on the school attendance for the year 2002-2003 for the household population age 6-24. The results in Table 1.9 indicate that 84 percent of children age 6-10 were attending school while the level was 87 percent among those aged 11-15. 3 School attendance decreases rapidly in the higher age groups. Fifty-two percent of individuals in the age group 16-20 were enrolled in school, while only 13 percent in the age group 21-24 were enrolled in the year 2002-2003. ~Attendance may be lower for the age group 6-10 than that of the 11-15 group because a number of the children who were age 6 at the time that the EIDHS interviews, which took place primarily May 2003, had not reached their sixth birthday in time to be eligible to enroll in school in the year 2002-2003. Introduction [ 11 Table 1.9 School attendance Percentage of the de-facto household population age 6-24 years who were attending school during the 2002-2003 school year by sex and age group, according to urban-rural residence and place of residence, Egypt 2003 Place ofresidence Urban Lower Egypt Upper Egypt Gove~ Age group Urban Rural norates Total Urban Rural Total Urban Rural Total MALE 6-10 86.4 83.2 87.8 86.5 86.1 86.7 81.1 84.7 79.8 84.5 11-15 92.2 89.7 91.8 90.7 92.2 90.1 902 92.6 89.2 90.7 6-15 89.4 86.5 89.8 88.7 80.4 88.4 85.8 88.9 84.6 87.7 16-20 65.3 51.9 64.1 57.0 66.0 53.5 55.2 66.3 50.2 57.5 21-24 22.3 12.2 23.9 15.0 20.8 13.1 14.2 21.0 11.2 16.5 FEMALE 6-10 87.9 80.0 90.6 87.2 88.0 86.8 76.1 83.9 72.8 83.2 11-15 92.8 77.7 92.3 9(/.I 94.9 88.2 735) 91.4 67.6 83.5 6-15 90.3 78.8 91.5 88.6 91.5 87.5 75.0 87.7 70.0 83.4 16-20 60.2 36.4 58.5 49.3 64.6 43.6 37.4 58.7 28.1 46.3 21-24 15.7 5.0 17.5 9.0 17.2 5.9 6.3 11.2 3.9 9.7 TOTAL 6-10 87.1 81.7 89.2 86.8 87.1 86.7 78.8 84.3 76.5 83.9 I I-15 92.5 83.8 92.0 90.4 93.5 89.2 82.3 92. I 78.5 87.2 6-15 89.9 82.8 90.6 88.7 90.4 88.0 80.6 88.3 77.6 85.6 Urban-rural differentials in school attendance are quite evident, particularly in the older age groups. For example, more than 60 percent those in the 16-20 age group in urban areas are attending school compared to 44 percent in rural areas. The Urban Goveruorates and urban Lower Egypt generally have higher school attendance levels than urban Upper Egypt. Similarly, school attendance levels are higher in rural Lower Egypt then in rural Upper Egypt in all age categories. Gender differentials in school attendance favor males. The gap between male and female school attendance which is quite small (1 percentage point) in the 6-10 age group becomes increasingly more evident at older ages. For example, looking at the 16-20 age group, 58 percent of males are attending school compared with only 46 percent among females. Looking at the relationship between gender and residence, gender differences in school attendance levels are less evident among urban children than rural children, especially in the younger age cohorts. Rural Upper Egypt generally has the largest gender differentials in school attendance. For example, among children 6-10 years, 80 percent of boys were attending school compared to 73 percent of girls. The gap widens in the older age groups, with 89 percent of boys 11-15 years in school compared to 68 percent of girls. In contrast, in rural Lower Egypt, school attendance rates are virtually identical for boys and girls 6-10 years, and the gender gap in the 1 1-1 5 age group is quite small (2 percentage points). 12 I Introduction 1.7 Background Characteristics of EIDHS Respondents Table 1.10 presents the distribution of inter- viewed women in the 2003 EIDHS by back- ground characteristics, including marital status, age, education, occupation, place of residence and wealth index. Overall, 92 per- cent of interviewed women are currently married, while 5 percent are widowed and 3 percent were either divorced or separated. Reflecting the effects of the increasing age at first marriage, few women fall in the age group 15-19 (4 percent). Women in the other age groups are fairly equally distributed with the largest proportion found in the age group 25-29 (20 percent) and the smallest proportion in 45-49 group (14 percent). Fifty-seven percent of the 2003 EIDHS re- spondents live in rural areas, while 43 per- cent are urban residents. Looking at place of residence, 18 percent of women reside in the Urban Governorates, 45 percent live in Lower Egypt, and 37 percent live in Upper Egypt. The table shows the educational level of women as well. Overall, 38 percent of women never attended school, 13 percent attended school but did not complete the primary level, 14 percent completed prima/-y school or had some secondary education, and 36 percent completed the secondary level or higher. The low educational level is reflected in the high illiteracy rate; 44 percent of the women could not read at all. Table 1.10 also shows that comparatively few women are working in occupations for which they are paid in cash. Overall, 84 per- cent of women are not working or are not paid in cash for work they do. As expected given the manner in which the wealth index is constructed, women are fairly evenly distributed across the wealth quintiles. Twenty-one percent of women fall in the highest quintile, while 19 percent fall in the lowest quintile. Table 1.10 Background characteristics of respondents Percent distribution of ever married women age 15o49 by selected background characteristics, Egypt 2003 Number of women Background Weighted Un- characteristic percent Weighted weighted Current marital status Married 92.2 8,445 8,430 Widowed 4.8 442 447 Divorced 2.2 205 216 Separated 0.7 67 66 Age 15-19 3.7 343 402 20-24 15.0 1,372 1,453 25-29 19.5 1,782 1,733 30-34 15.4 1,415 1,419 35-39 17.3 1,588 1,574 40-44 15.1 1,380 1,332 45-49 14.0 1,279 1,246 Urban-rural residence Urban 42.7 3,908 3,596 Rural 57.3 5,251 5,563 Place of residence Urban Governorates 18.2 1,666 1,473 Lower Egypt 44.8 4,105 3,105 Urban 12.9 l,I 81 929 Rural 31.9 2,924 2,176 Upper Egypt 37.0 3,388 4,581 Urban I 1.6 1,061 1,194 Rural 25.4 2,327 3,387 Education No education 37.7 3,452 3,681 Some primary 12.7 1,167 1,176 Primary comp./some secondary 13.9 1,270 1,203 Secondary comp./higher 35.7 3,270 3,099 Literacy Cannot read at all 43.9 4,016 4,250 Able to read only parts of sentence 7.5 685 677 Able to read whole sentence 3.3 304 291 Preparatory/higher education 45.3 4,146 3,934 Missing 0.1 7 7 Work status Working for cash 15.9 1,455 1,443 Not working for cash 84.1 7,701 7,714 Missing 0 3 2 Wealth index Lowest quintile 18.6 1,699 2,184 Second quintile 19.3 1,769 1,787 Middle quintile 20.5 1,874 1,759 Fourth quintile 21.2 1,937 1,753 Highest quintile 20.5 1,879 1,676 Total 100.0 9,159 9,159 Introduction I 13 1.8 Exposure to Mass Media The 2003 EIDHS collected information on the exposure of women to various mass media including television, radio, and print (i.e., magazines and newspapers). These data, which are presented in Table 1.11, are important for designing family planning and health media campaigns. As noted in previous surveys, television has the widest coverage of the three media, with 93 percent of women watching TV weekly. Around two-thirds of women listen to the radio weekly and 21 percent read newspaper/magazines weekly. Sixteen percent are exposed to all of the three media on a weekly basis. Five percent of women are not regularly exposed to any media. Urban women are more likely to be exposed to the different media than women in rural areas. Exposure to the different media increases directly with a woman's educational levels and with the household's socio-economic status as assessed through the wealth index. Table 1.11 Exposure to mass media Percentage of ever-married women age 15-49 who watch television weekly, listen to radio weekly, read newspapers/ magazines weekly by selected background characteristics, Egypt 2003 Read Watch Listen to magazine/ Number Background TV radio newspaper All lhree No media of characteristic weekly weekly weekly media exposure women Age 15-19 92.9 60.2 10.0 7.6 4.4 343 20-24 93.9 64.6 17.0 12.9 3 9 1,372 25-29 94.4 66.9 20.6 15.3 3.7 1,782 30-34 94.2 66.7 25.5 19.7 3.6 1,415 35-39 93. I 61.5 23.4 19.0 5.0 1,588 40-44 90.6 63.5 23.8 18.9 6.7 1,380 45 49 90.4 57.5 16.8 13.0 6.6 1,279 Urban-rural residence Urban 95.9 69.8 35.0 26.5 1.9 3,908 Rural 90.7 58.9 10.4 8.5 7.0 5,25 I Place of residence Urban Governorates 95.0 67.8 37.5 26.8 1.9 1.666 Lower Egypt 93.2 67.0 17.7 14.3 4.4 4,105 Urban 95.6 72.6 31.0 24.7 2. I I,I 81 Rural 92.3 64.8 12.4 10. I 5.3 2,924 Upper Egypt 91A 57.2 16.5 13.2 6.9 3,388 Urban 97.4 69.6 35.4 27.9 1.7 1,06 I Rural 88.6 51.5 7.8 6.5 9.2 2,327 Education No education 87.3 49.2 0.8 0.6 9.9 3,452 Some primary 92.9 60.2 4.2 3.4 4.7 I,I 67 Primary complete/some secondary 95.4 72.2 20.2 14.4 1.7 1,270 Secondary complete/higher 97.8 76.4 48.3 37.9 0.7 3,270 Work status Working lbr cash 93.7 69.7 48.8 38.0 4.2 1.455 Not working for cash 92.7 62.4 15,6 12.1 4.9 7.701 Wealth index Lowest quintile 77. I 39.5 2. I 1.5 18. I 1,699 Second quintile 94.8 60.3 6.2 5.0 3.3 1,769 Middle quintile 95.6 67.5 13.2 10.5 2.6 1,874 Fourth quintile 97.0 73.2 26.0 20.5 0.9 1.937 Highest quintile 98.4 743 543) 41.3 0.6 1.879 Total 92.9 63.5 20.9 16.2 4.8 9,159 14 I Introduction 2 FERTILITY The chapter reviews information on fertility behavior and attitudes from the 2003 EIDHS that is useful in monitoring the progress and evaluating the impact of the population program in Egypt. Levels, patterns, and trends in current fertility are presented first. The chapter then looks at data on the age at first marriage, the age at which women initiate childbearing, and the length of interval between births. Finally, the chapter considers women's fertility preferences and assesses the level of wanted fertility. 2.1 Current Fertility To collect data on fertility patterns, each E1DHS respondent was asked a series of questions on the number of her sons and daughters living with her, the number living elsewhere, and the number who died. Then, a complete history of all of the woman's births was obtained, including the name, sex, month and year of birth, age, and survival status for each of the births. Finally, information was collected on whether currently married women were pregnant at the time of the survey. Table 2.1 presents several measures of current fertility derived from the retrospective birth history data obtained in the EIDHS including the total fertility rate, age-specific fertility rates, general fertility rate, and crude birth rate. The total fertility rate (TFR) indicates that, if fertility rates were to remain constant at the level prevailing during the three-year period before the 2003 EIDHS (approximately May 2000-April 2003), an Egyptian woman would bear 3.2 children during her lifetime. In rural areas, the TFR is 3.6 births per woman, one birth higher than the rate in urban areas (2.6 births per woman). Much of the overall urban-rural differential is due to the significantly higher fertility levels among rural women under age 30 compared to urban women in the same ages. For example, the age- specific fertility rate for rural women 15-19 is almost twice the rate among urban women in the same age group, and the rate of rural women 20-24 is around 60 percent higher than the rate for urban women in the same age group. Table 2.1 Current fertility Age-specific and total fertility rates and the general fertility and crude birth rates for the three years preceding the survey, by urban-rural residence, Egypt 2003 Place ofresidence Urban Lower E~pt Upper Egypt Mother's age Gover- at birth Urban Rural norates Total Urban Rural Total Urban Rural Total Age-specific rates 15-19 31 58 25 40 23 45 66 44 75 47 20-24 136 224 109 195 154 211 215 161 242 185 25-29 167 209 160 198 189 202 197 154 218 190 30-34 126 129 103 111 137 100 162 153 167 128 35-39 51 71 49 47 46 47 88 60 103 62 40-44 10 27 8 20 14 24 23 9 31 19 45-49 2 9 0 6 4 6 10 4 14 6 Fertility rates TFR 15-49 2.6 3.6 2.2 3.l 2.8 3.2 3.8 2.9 4.3 3.2 TFR 15-44 2.6 3.6 2.2 3.1 2.8 3.2 3.8 2.9 4.2 3.2 GFR 87 126 77 107 90 112 128 95 144 I09 CBR 21.7 29.8 19.1 26.6 23.5 27.8 29.6 23.7 32.3 26.3 Note: Rates are for the period 1-36 months preceding the survey (approximately May 2000 April 2003). TFR-Total fertility rate expressed per woman GFR General fertility rate (births divided by number &women 15-44 and expressed per 1,000 women) CBR-Crude birth rate (births divided by total population and expressed per 1,0001 Fertility I 15 Looking at the differentials across the place of residence categories, the highest fertility rate is found in rural Upper Egypt (4.3 births per woman). The TFR for rural Lower Egypt (3.2 births per woman) is more than one birth lower than the rural Upper Egypt rate. Unlike the situation in rural areas, there is almost no difference in the fertility level between urban Lower Egypt and urban Upper Egypt (2.8 births and 2.9 births, respectively). The Urban Govemorates have the lowest TFR (2.2 births per woman), more than two births lower than the rate in rural Upper Egypt. Estimates of the general fertility rate and crude birth rate also are included in Table 2.1. For the period 2000-2003, the general fertility rate was 109 births per thousand women, and the crude birth rate was 26.3 per thousand population. Striking differences are apparent by residence in both the general fertility rate and crude birth rate. For example, the general fertility rate GFR is highest in rural Upper Egypt (144 births per thousand women), close to double the G FR in the Urban Goveruorates (77 births per thousand women). A similar pattern is observed for the crude birth rate; the CBR is 32.3 births per thousand population in rural Upper Egypt compared to 19.1 births per thousand population in the Urban Governorates. 2.2 Trends in Fertility Using data from earlier surveys as well as 2003 EIDHS, Table 2.2 shows the trend in fertility since the late 1970s. Overall, as seen in Figure 2.1, fertility levels fell by more than two births during the period, from 5.3 births at the time of the 1980 Egyptian Fertility Survey to 3.2 births at the time of the 2003 EIDHS. The pace of decline was faster in the 1980g than in the 1990s. Considering the decline in the age-specific rates, Table 2.2 shows that fertility fell at a relatively faster pace among women age 30 and over and among those under 20 years of age than among other women. Table 2,2 Trends in i%rtiliw Age-specific fertility rates (per 1,000 women) and total fertility rates for women 15-49, Egypt 1979-2003 EFS ECPS EDHS- EMCHS EDHS EDHS EIDHS EIDHS EDHS EIDHS 1980 1984 1988 1991 L992 1995 1997 1998 2000 2003 1979- 1983 1986- 1990- 1990- 1993- 1995- 1996- 1997- 2000- Age I9801 19841 19882 19911 1992 ~ 19952 19972 19982 20002 20032 15-19 78 73 72 73 63 61 52 64 51 47 20-24 256 205 220 207 21)8 200 L86 192 196 [85 25-29 280 265 243 235 222 211) 189 194 208 190 30-34 239 223 182 158 155 140 [35 135 147 128 35-39 139 151 118 97 89 81 65 73 75 62 40-44 • 53 42 41 41 43 27 18 22 24 19 45 49 12 13 6 14 6 7 5 I 4 6 TFR 15-49 5.3 4.9 4.4 4.1 3.9 3.6 3.3 3.4 3.5 3.2 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 lbr rates L 979 2000: EI-Zanaty and Way, 2001, Table 4.3 Table 2.3 shows trends in fertility by residence for the period between 1988 EDHS and the 2003 EIDHS. The large decline in rural fertility helped to reduce the gap between the urban and rural fertility rates, from almost two births in the mid-1980s to only one birth in 2003 (Figure 2.1). Considering place of residence, Table 2.3 shows that the decline in fertility during the past two decades was greatest in rural Upper Egypt. Between the 1988 EDHS and 2003 EIDHS, for example, the TFR declined by two births in rural Upper Egypt, a much more rapid decline than that experienced in rural Lower Egypt in the same period. Fertility also fell at a somewhat faster pace in urban areas in Upper Egypt than in urban Lower Egypt. The TFR in urban Upper Egypt dropped by 1.3 births, from a 1 6 I Fertility level of 4.2 births at the time of 1988 EDHS to 2.9 births at the time of the 2003 EIDHS. In comparison, the TFR declined by one birth in urban Lower Egypt and by 0.7 births in Urban Governorates during the same period. Figure 2.1 Trends in Fertility by Residence r 1987 1990 1991 1994 1996 1997 1998 2001 I " Urban " " " Rura l - - - -Tota l I I I Table 2 3 Trends in fertility by residence Total fertility rates by urban-rural residence and place of residence, Egypt 1986-2003 EDHS-88 EMCHS-91 EDHS-92 EDHS-95 EIDHS-97 EIDHS-98 EDHS-00 EIDHS-03 1986- 1990- 1990- 1993- 1995- 1996- 1997- 2000- Residence 19882 19911 19922 19952 19972 19982 2000: 20032 Urban-rural residence Urban 3.5 3.3 2.9 3.0 2.7 2.8 3.1 2.6 Rural 5.4 5.6 4.9 4.2 3.7 3.9 3.9 3.6 Place of residence Urban Governorates 3.0 2.9 2.7 2.8 2.5 2.7 2.9 2.3 Lower Egypt 4.5 U 3.7 3.2 3.0 3. I 3.2 3.1 Urban 3.8 3.5 2.8 2.7 2.6 2.4 3.1 2.8 Rural 4.7 4.9 4.1 3.5 3.2 3.2 3.3 3;2 Upper Egypt 5.4 U 5.2 4.7 4.2 4.3 4.2 3.8 Urban 4.2 3.9 3.6 3.8 3.3 3.3 3.4 2.9 Rural 6.2 6.7 6.0 5.2 4.6 4.5 4.7 4.2 TFR 15 -49 4.4 4.1 3.9 3.6 3.3 3.4 3.5 . 3.2 ' Rates are for the 12-month period preceding the survey. 2 Rates are for the 36-month period preceding the survey. U -Unavailable Source for rates 1986-2000: EI-Zanaty and Way, 2001, Table 4.4 Fertility [ 17 2.3 Proximate Determinants of Fertility This section explores EIDHS results relating to a number of factors other than contraception which affect a woman's chances of becoming pregnant and, thus, help to determine fertility levels in Egypt. The factors which are considered include: age at first marriage; age at first birth; length of the birth interval; and teenage pregnancy. Age at First Marriage The age at which women first marry is considered among the most important proximate determinants of fertility. When women delay marriage, they shorten the length of the period they are exposed to the risk of pregnancy and, thus, ultimately the number of children they will bear. Increases in the age at first marriage are, therefore, associated with declines in fertility levels. Table 2.4 shows the percentages of women who have ever married by selected exact ages and the median age at first marriage, according to current age. The results indicate that there has been steady increase over the past decades in age at which Egyptian women marry. For example, the median age at first marriage among women age 25-29 is 20.9 years, more than two years older than that among women age 45-49 (18.7 years). Table 2.4 also documents a marked decline in the proportion of women marrying at very young ages; the percentage of women married by exact age 15 dropped from 13 percent among women age 45-49 to only 3 percent among women age 20-24. Table 2.4 A~e at first marriage Percentage of women who were first married by exact age 15, 18, 20, 22, and 25, and median age at first marriage according to current age, Egypt 2003 Percentage of women who were married by exact ai~e: Percentage Current age 15 18 20 22 25 never married Number Median 15-19 1.3 NA NA NA NA 88.8 3,074 a 20-24 2.7 18.5 36.3 NA NA 45.9 2,537 a 25-29 5.8 23.9 40.8 58.0 78.8 14.0 2,073 20.9 30-34 8.9 28.3 43.7 62.0 80.0 6.6 1,514 20.6 35-39 11.6 38.1 53.9 67.9 81.0 3.0 1,638 19.5 40-44 10.9 37.6 54.3 67.2 81.8 2.3 1,413 19.4 45-49 12.7 43.7 60.8 73.7 85.8 1.6 1,300 18.7 25-49 9.6 33.4 49.7 65.0 81.2 6.2 7,937 20.0 NA-Not applicable "Omitted because less than 50 percent of women in the age group x to x + 4 have married for the first time by age x Table 2.5 presents differences in the median age at first marriage by selected background characteristics. Early marriage is more common in rural than urban areas; the median age at first marriage among rural women age 25-49 is 18.6 years, almost three years younger than the median age at first marriage among urban women. Marked differentials also are observed by place of residence. On average, women in rural Upper Egypt marry at younger ages (17.7 years) than women in rural Lower Egypt (19.3 years). Differentials in the median age at first marriage also exist between urban Upper Egypt (21 years), urban Lower Egypt (21.7 years) and the Urban Govemorates (22.3 years). The strong effect that education has on the age at which women marry is clear in Table 2.5. There is a difference of more than five years in the median age at first marriage between women with secondary education (23.2 years) and women who never attend school (17.6 years). Large differences in the age at first marriage are also evident according the rank on the wealth index. The median age at first marriage among women in the highest wealth quintile is 23 years, more than five years higher than the median age at first marriage among women in the lowest wealth quintile ( 17.5 years). 18 ] Fertility Table 2.5 Median age at first marriage by background characteristics Median age at first marriage among women 25-49 years, by current age and selected background characteristics, Egypt 2003 Current a~e Women Women Background age age characteristic 20-24 25-29 30-34 35-39 40-44 45-49 20-49 25-49 Urban-rural residence Urban a 22.4 22.3 21.5 21.7 20.5 a 21.8 Rural a 20.2 19.4 17.9 17.8 17.2 19.1 18.6 Place of residence Urban Governorates a 22.9 22.8 22.3 21.8 19.9 a 22.3 Lower Egypt a 20.9 20.5 19.4 19.2 18.7 a 20.0 Urban a 22.4 21.9 21.4 21.6 20.9 a 21.7 Rural a 20.6 20.1 18.6 18.4 17.8 19.7 19.3 Upper Egypt a 20.0 19.5 17.9 18.0 17.5 19.3 18.7 Urban a 21.3 21.7 20.6 21.5 20.4 21.0 Rural 19.7 19.2 18.4 17.1 16.9 16.8 18.3 17.7 Education No education 19.2 18.5 17.9 17.3 17.4 17.1 17.8 17.6 Some primary 19:6 19.1 17.9 18.2 18.5 18.2 18.6 18.5 Primary complete/some secondary 19.9 19.2 20.1 18.8 20.0 18.8 19.5 19:3 Secondary complete/higher a 23.0 22.6 23.3 23.9 24.0 a 23.2 Wealth index Lowest quintiLe 19.9 18.6 17.6 17.3 17.2 16.8 18.0 17.5 Second quintile a 19.9 19.1 17.8 18.1 17.5 18.9 18.5 Middle quintile a 20.6 20.1 18.5 18.4 17.5 19.8 19.2 Fourth quintile a 21.6 21.6 20.7 20.7 18.9 a 21.0 Highest quintile a 23.4 23.2 22.7 23.1 22.4 a 23.0 Total a 20.9 20.6 19.5 19.4 18.7 a 20.0 Note: Medians are not shown for women 15-19 and 20-24 because less than 50 percent have married by age 15 and age 20, respectively for most subgroups shown in the table. "Omitted because [ess than 50 percent of women in the age group x to x + 4 have married for the first time by age x Age at First Birth In Egypt , where v i r tual ly al l ch i ldbear ing occurs w i th in mar i ta l unions, the age at wh ich women marry is a p r imary determinant o f the age at wh ich ch i ldbear ing begins. The postponement o f the first birth resul t ing from the trend toward latter marr iage has been one o f the major factors in f luenc ing the overa l l fert i l i ty dec l ine in Egypt. Tab le 2.6 presents the distr ibut ion o f women by age at f irst birth, accord ing to their current age. The median age at f irst birth is not shown for women under age 25 because less than 50 percent o f women in those ages had g iven birth at the t ime o f the survey. The results in Tab le 2.6 indicate that there has been a noteworthy rise in the age at wh ich women begin chi ldbear ing. For example, 39 percent o f women age 45-49 had become mothers before age 20 compared to less than one--quarter o f women age 20-24. The marked change that has been occurr ing in the age at wh ich women begin ch i ldbear ing is also ev ident in the increase in the med ian age at f irst birth across age cohorts, f rom 21.4 years among women 45-59 to 22.7 years among women age 25-59. Tab le 2.7 presents the med ian age at f irst birth by background character ist ics. The table also examines the trend across di f ferent age cohorts wi th in the subgroups. The table is l imited to women age 25-49 years to ensure that ha l f o f the women have a l ready had a birth. Fertility I 19 Table 2.6 ARe at first birth Percent distribution of women age 15-49 by age at first birth, according to current age, Egypt 2003 Women Age at first birth Current with no Number of age births <15 15-17 18-19 20-21 22-24 25+ Total women Median 15-19 94.4 0.2 3.1 2.3 0.0 0.0 0.(/ I00.0 3,074 a 20-24 57.t 0.7 7.3 15.3 13.5 6.2 0.0 100.0 2,537 a 25 29 23.0 1.9 10.9 14.5 18.0 21.7 10.1 100.0 2,073 22.7 30-34 11.8 2.9 14.3 13.2 16.6 22.3 18.9 100.0 1,514 22.4 35 39 6.6 2.7 153l 18.5 16.4 19.0 21.9 100.0 1,638 21.7 40-44 6.1 3.5 12.7 17.8 16.4 19.6 23.9 100.0 1,413 21.9 45-49 5.3 3.2 18.2 17.7 15.8 19.1 20.6 100.0 1,300 21.4 25-49 11.6 2.8 13.9 16.2 16.8 20.4 18.4 100.0 7,937 22.1 "Omitted because less than 50 percent of women in the age group x to x + 4 have given birth for the first time by age x Overall, the median age at first birth for women age 25-49 is 22.1 years. However, the results in the table show that there are large differences across population subgroups in the age at which women have their first child. Rural women start their childbearing three years earlier than urban women (20.8 years and 23.7 years, respectively). Women from rural Upper Egypt had their first child earlier than women from rural Lower Egypt (20.4 years and 21.2 years, respectively). Looking at the patterns by education, highly educated women were nearly five years older on average than women who never went school when they had their first child. The difference in the median age at first birth between women in the highest and lowest quintiles on the wealth index is equally large. Table 2.7 Median age at first birth by background characteristics Median age at first birth among women age 25-49 years, by current age and background characteristics, Egypt 2003 selected Background Current age Women characteristic 25-29 30-34 35-39 40-44 45-49 25-49 Urban-rural residence Urban 24,0 23.8 23.5 23.6 23.2 23.7 Rural 21.7 21.2 20.3 20.4 20.1 20.8 Place of residence Urban Governorates 24.2 24.4 24,4 23.7 23.2 24.0 Lower Egypt 22.6 22.0 21,4 21.7 21.1 21.9 Urban 24.1 23.5 23,1 23.5 23.3 23.6 Rural 22.0 21.6 20.8 20.7 20.2 21.2 Upper Egypt 21.8 21.5 20.5 21.1 21.0 21.2 Urban 23.0 23.2 22.7 23.8 22.9 23. I Rural 21.2 20.5 19.8 20.0 20.1 20.4 Education No education 20.4 19.8 19.8 20.0 20.3 2(I.0 Some primary 20.5 19.5 20.3 20.9 20.4 20.5 Primary complete/some secondary 20.6 22.2 20.6 21.7 20.5 21.0 Secondary complete/higher 24.5 23.9 24.9 25.7 26.0 24.8 Wealth index Lowest quintile 20.5 19.7 19.8 20.1 20.5 20.1 Second quintile 21.4 20.9 20.2 20.5 20.0 20.6 Middle quintile 22.5 21.8 20.9 20.7 20.0 21.2 Fourth quintile 23.2 23.2 22.3 22.6 21.7 22.8 Highest quintile 24.8 24.5 24.5 24.9 24.6 24.7 Total 22.7 22.4 21.7 21.9 21.4 22.1 20 I Fertility Birth Intervals The period of time between two successive live births is referred to as a birth interval. Research has shown that children born soon after a previous birth are at greater risk of illness and death than those born after a long interval. In addition, short birth intervals may have adverse consequences for other children in the family. The occurrence of closely-spaced births gives the mother insufficient time to restore her health, which may limit her ability to take care of all her children. The duration of breastfeeding for the older child also may be shortened if the mother becomes pregnant. Table 2.8 shows the percent distribution of second order and higher (non-first) births in the five years preceding the 2003 EIDHS by the number of months since the previous birth. Table 2.8 Birth intervals Percent distribution of nonfirst births in the five years preceding the survey by number of months since the previous birth according to selected background characteristics, Egypt 2003 Background Months since previous birth characteristic 7-17 18-23 24-35 36-47 48+ Total Number Median Mother's age 15-19 16.4 20-29 12.7 30-39 6.2 40+ 4.8 Birth order 2-3 11.1 4-6 6.0 7+ 8.1 Sex of prior birth Male 8.3 Female 10.4 Survival of prior birth No 30.7 Yes 8.1 Urban-rural residence Urban 8.3 Rural 9.9 Place of residence Urban Governorates 8.8 Lower Egypt 8.8 Urban 6.6 Rural 9.6 Upper Egypt 10.0 Urban 9.4 Rural 10.2 Education No education 8.6 Some primary 5.9 Primary complete/some secondary 10.4 Secondary complete/higher 10.8 Work status Working for cash 9.6 Not working for cash 9.3 Wealth index Lowest quintile 11.7 Second quintile 8.2 Middle quintile 10.8 Fourth quintile 7.3 Highest quintile 7.9 Total 9.3 23.4 45.3 15.0 0.0 100.0 27 24.9 14.8 37.7 20.7 14.1 100.0 2,198 31.0 7.5 24.3 19.0 43.0 100.0 1,810 43.5 5.9 19.1 12.6 57.5 100.0 381 57.1 11.8 33.4 20.1 23.7 100.0 2,777 33.7 10.3 25.8 17.2 40.7 100.0 1,292 40.9 8.8 27.1 19.9 36.0 100.0 348 39.6 11.5 28.3 20.4 31.5 100.0 2,231 36.7 10.8 33.l 18.1 27.6 100.0 2,186 34.3 17.8 22.7 13.7 15.0 100.0 241 24.4 10.7 31.l 19.6 30.5 100.0 4,175 36.0 10.0 26.9 18.7 36.2 100.0 1,601 38.6 11.8 32.8 19.6 25.9 100.0 2,815 34.1 9.1 25.1 19.6 37.5 100.0 608 39.8 9.6 28.6 20.8 32.1 100.0 1,792 37.2 7.3 28.2 17.8 40.0 100.0 503 40.1 10.5 28.8 22.0 29.1 100.0 1,289 36.4 13.1 34.1 17.8 25.0 100.0 2,017 33.5 13.9 27.7 18.5 30.6 100.0 490 35.6 12.8 36.2 17.6 23.2 100.0 1,527 32.8 11.2 31.1 17.8 31.2 100.0 1,706 35.6 12.3 30.5 20.7 30.6 100.0 509 36.7 10.1 34.3 20.1 25.1 I00.0 710 34.0 11.1 28.5 20.0 29.6 100.0 1,491 35.8 9.3 20.7 21.7 38.7 100.0 553 40.9 11.4 32.1 18.9 28.3 100.0 3,864 34.8 11.6 35.2 16.7 24.8 100.0 1,069 33.1 11.9 32.3 21.1 26.5 100.0 942 34.8 11.0 30.4 20.4 27.3 100.0 885 35.2 10.9 29.3 19.0 33.5 100.0 867 37.3 9.7 23.0 19.6 39.8 100.0 653 40.7 11.1 30.7 19.3 29.6 100.0 4,417 35.5 Fertility ] 21 In general, birth intervals in Egypt are relatively long. However, around 20 percent of births in the five years before the E1DHS took place less than two years after a previous birth, and more than half of all non-first births occurred less than three years after a prior birth. The median interval is around 36 months, which is slightly longer than the median interval recorded in the 2000 EDHS (34 months). Younger women have shorter birth intervals than older women. Table 2.8 shows that the median interval varies with the age, from 25 months among women age 15-19 to 44 months among those age 30-39. The median birth interval is longer for fourth and higher order births than for second and third order births, and it is somewhat longer i f the previous birth was a boy than i f it was a girl. The average birth interval is twelve months longer in cases where the prior birth is alive than when that child has died (36 months and 24 months, respectively). As Table 2.8 shows, the median birth interval in urban areas is 39 months compared with 34 months in rural areas. Birth intervals are longest in urban Lower Egypt and the Urban Governorates (40 months). Within rural areas, the median birth interval is slightly longer in Lower Egypt (36 months) than in Upper Egypt (33 months). No clear association is observed between the woman's educational level and the average birth interval. However, intervals are longer for births to women who are working for cash than for births to other women (41 months and 35 months, respectively). There also is a clear association between the birth interval and household wealth; the birth interval rises from 33 months among nonfirst births to women in the lowest wealth quintile to 41 months for births to women in the highest quintile. Teenage Pregnancy and Motherhood Teenage pregnancy is a health con- cern because teenage mothers and their children are at greater risk of illness and death. Also, teenage preg- nancy and motherhood usually has an adverse impact on women's educa- tion. Table 2.9 shows that around 1 in 12 Egyptian teenagers have begun childbearing, with less than six per- cent having already given birth and around three percent pregnant with their first child. The proportion of teenagers that has begun childbearing rises rapidly with age, from one per- cent among girls age 15-16 to 13 per- cent among women age 17-19. In rural areas, the proportion of teen- agers who have begun childbearing is 11 percent, more than double the level among urban teens. Looking at place of residence, rural Upper Egypt (11 percent) has highest level of teenage childbearing, while the Urban Gover- norates have the lowest level (3 per- cent). Table 2.9 Teenage prcKnancy and motherhood Percentage of women age 15 19 who arc mothers or pregnant with their first child, by background characteristics, Egypt 2003 Percentage who are: Percentage Number Pregnant who have of Background with first begun women characteristic Mothers child childbearing 15-19 Age 15-16 0.7 0.3 1.0 1.307 17-19 9.2 4.2 13.4 1.767 Urban-rural residence Urban 2.9 1.8 4.7 1,269 Rural 7.5 3.0 1{I.5 1.809 Place of residence Urban Governorates 2.3 I 0 3.3 55 I Lower Egypt 5.6 2.8 8.4 1,325 Urban 2.8 2.1 4.9 362 Rural 6.6 3.1 9.7 961 Upper Egypt 7.1 2.9 10.0 1,206 Urban 4.0 2.8 6.8 358 Rural 8.4 3.0 I 1.3 853 Education No education 15.5 4.2 19.8 459 Some primary I 0. I 3.3 13.3 169 Primal~ complete/some secondary 2.8 1. I 3.9 1.764 Secondary complete/higher 4.9 4.8 9.7 692 Wealth index Lowest quintile 8.4 2.5 21.8 642 Second quintile 6. I 2.5 17.3 685 Middle quintile 5.5 4.1 19.3 654 Fourth quintile h.0 2.3 16.5 586 Highest quintile 0.9 0.9 3.6 513 Total 5.6 2.5 8.1 3,074 22 I Fertility The likelihood that a teen will have begun childbearing is related to both her educational level and to her position on the wealth index. The level of teenage childbearing among women in the lowest wealth quintile is 22 percent, around five times the level observed among young girls in the highest wealth quintile (4 percent). 2.4 Ferti l i ty Preferences An in-depth understanding of fertility preferences in a population is important for predicting future fertility behavior. Women were asked in the 2003 EIDHS about their intention to have another child in the future and about the family size they would prefer. Their responses to these questions are used to explore the level of wanted fertility in Egypt. Desire for More Children In order to obtain information on fertility preferences, currently married women who were not using female sterilization 4 were asked the following question: "Would you like to have (another) child or would you prefer not have any (more) children?" For pregnant women, the question was prefaced by the wording, "After the child you are expecting.". Women who wanted additional children were then asked about the t iming of the next child. Table 2.10 shows the percent distribution of currently married women by reproductive intention according to the number Of l iving children (including any current pregnancy). The results indicate that the majority (64 percent) of currently married women do not want any more children or are sterilized. Around 28 percent want another child. However, the latter group differs as to t iming desired for the next child; 12 percent want another child within two years, 15 percent want to wait at least two years, and one percent want another child but are not sure when. Table 2. I 0 FertiliN preferences by number of living children Percent distribution of currently married women by desire for children, according to number of living children, Egypt 2003 Desire for Number of living children t children 0 1 2 3 4 5 6+ Toml Wants within 2 years 90.5 25.3 9.5 2.6 1.2 0.3 0.4 12.2 Wants after 2+ years 0.4 60.4 20.6 5.2 1.6 0.9 0.0 15.3 Wants, unsure timing 0.3 1.9 1.4 0.9 0.1 0.0 0.1 0.9 Undecided 0.0 3.7 9.7 5.7 2.6 3.1 0.7 4.7 Wants no more 0.5 7.6 56.9 81.7 89.3 91.2 91.1 63.0 Sterilized 0.0 0.1 0.5 0.9 2.2 1.5 1.2 0.9 Declared infecund 8.3 1.0 1.4 2.9 2.9 3.0 6.5 3.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 509 1,288 1,874 1,899 1,244 759 872 8,445 Note: Women who have been sterilized are considered to want no more children. qncludes current pregnancy The desire for more children is associated with the living number of chi ldren the woman has. While more than nine in ten women with no living children want a child soon, only one in ten women with two children want another child within two years. The proportion desiring to cease childbearing rises rapidly with the number of children, from 57 percent among women with two children to 91 percent among women with six or more children. 4Stehlized women were considered to want no more children. Fertility [ 23 I dea l Number o f Ch i ld ren Another question in the 2003 EIDHS attempts to capture information on a woman's lifetime childbearing goals by asking about the ideal number of children the woman would choose to have in her life i f she were to begin childbearing again, regardless the number she already had borne. The results of these questions are presented in Table 2.1 1. Table 2.11 Ideal number of children Percent distribution of ever-married women by ideal number of children and mean ideal number of children for ever-married women and currently married women, according to number of living children, Egypt 2003 Ideal number Number of livin~ children / of children 0 I 2 3 4 5 64 Total I 2 3 4 5 6 Non-numeric response Total percent Number of women Mean ideal number Ever-married women Number of women Currently married women Number of women 7.6 4.5 1.8 1.8 0.9 0.6 1).3 2.2 42.1 56.7 54.5 28.6 25.6 20.3 15.4 37.0 [7.2 21.5 25.2 41.3 15.1 19.7 14.4 24.5 10.3 6.6 7.1 9.2 30.4 18.6 19.4 13.5 1.3 0.6 0.6 1.8 1.9 7.8 4.6 2.1 1.6 0.7 1.1 1.5 1.3 2.4 7.6 2.0 19.9 9.4 9.7 15.8 24.8 30,6 38.3 18.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 615 1,418 1,998 2.010 1,353 822 943 9,159 2.5 2.4 2.5 2.8 3.2 3.4 3.8 2.8 493 1.285 1,805 1,693 1.018 571 582 7,445 2.6 2.4 2.5 2.8 3.2 3.4 3.8 2.8 410 1.171 1.698 1.615 950 531 539 6,914 Note: The lncan excludes women who gave non numeric answers. tlncludes current pregnancy In ascertaining the ideal number of children, the respondent is required to perform the difficult task of considering abstractly and independently of the actual family size, the number of children she would choose of she could start again. A substantial proportion (19 percent) of women gave a non-numeric response, indicating the difficulty the women have with the question. In considering the results of Table 2.1 1, it also is important to remember that there is a correlation between the actual and ideal number of children. This is due to the |hct that women who want large families tend to have larger families. Also, women may rationalize the ideal number family size, such that, as the actual number increases, their preferred number of children also increases. Table 2.1 1 shows that most women want small families. Overall, the mean ideal family size among ever-married women is 2.8 children. Thirty-seven percent of ever-married women prefer a two-child family, and one-quarter consider a three-child family ideal. Around 18 percent reported four or more children as ideal. As discussed earlier, higher-parity women show a preference for more children; the mean ideal number of children among women rises from 2.5 children among women who currently have two children or less to 3.8 children among women with six or more children. The results in the table also indicate that many women have had more children than they would prefer, which suggests there is a considerable level of unwanted fertility. =~ i b~rtilit~' Table 2.12 presents the mean ideal number of children for ever-married women among various subgroups. The number of children considered ideal varies across age groups; in general, older women tend to want larger fami~,y than younger women. Women from the Urban Govemorates, urban Lower Egypt, women with a secondary or higher education, and women ranked at the top of the wealth index have the lowest ideal number of children (2.6 children). The highest ideal number is observed among women in rural Upper Egypt (3.3 children). T~ble 2.12 Mean ideal number of children by background characteristics Mean ideal number of children for ever mawied women, by age and selected background characteristics, Egypt 2003 Background characteristic Age of women 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Urban-rural residence Urban 2.6 2.4 2.5 2.7 2.7 2.8 3.0 2.7 Rural 2.6 2.7 2.8 2.9 3. I 3.3 3.5 2.9 Place of residence Urban Governorates 2.1 2.3 2.4 2.6 2.6 2.8 3.0 2.6 Lower Egypt 2.4 2.4 2.6 2.7 2.8 2.9 3.1 2.7 Urban 2.5 2.3 2.4 2.7 2.7 2.7 3.0 2.6 Rural 2.4 2.4 2.6 2.6 2.9 3.0 3.2 2.7 Upper Egypt 2.8 2.9 2.9 3.1 3.2 3.4 3.5 3.1 Urban 3.0 2.8 2.6 2.9 2.9 2.8 3.0 2.8 Rural 2.8 3.0 3.0 3.2 3.4 3.9 4.0 3.3 Education No education 2.6 2.8 2.8 3.1 3.0 3.4 3.5 3.1 Some primary 2.7 2.8 2.7 2.7 3. I 3.1 3.2 2.9 Primary complete/some 2.6 2.6 2.8 2.7 3.0 2.9 3.1 2.8 secondary Secondary complete/higher 2.5 2.5 2.5 2.6 2.7 2.6 2.7 2.6 Work status Working for cash 2.3 2.5 2.7 2.7 2.7 3.0 2.7 Not working lor cash 2,8 2.6 2.7 2.8 3.0 3.2 3.3 2.9 Wealth index Lowest quintile 2.6 2.8 2.8 3.1 3.0 3.5 3.6 3. I Second quintile 2.7 2.6 2.8 2.9 3.0 3.1 3.3 2.9 Middle quintile 2.6 2.5 2.7 2.8 3.0 3.2 3.5 2.9 Fourth quintile 2.4 2.5 2.6 2.7 2.9 2.9 3.2 2.7 Highest quintile 2.3 2.4 2.4 2.6 2.7 2.8 2.9 2.6 Total 2.6 2.6 2 .7 2.8 2.9 3.0 3.2 2.8 Wanted Fer t i l i ty Data from the EIDHS can be used to estimate what the fertility rate would be i f Egyptian women were to achieve the childbearing goals they reported in the survey. The wanted fertility rate is calculated in the same manner as the total fertility rate, but unwanted births are excluded from the numerator. Unwanted births are defined as those which exceed the number considered ideal by the respondent. For this purpose, women who do not give numeric response to the ideal family size question are assumed to want all their births. The wanted fertility rate may be overestimated to the extent that women are not wil l ing to say that they want fewer children than the number they currently have. Table 2.13 presents the total wanted fertility rates and total fertility rates for the three-year period prior to the EIDHS by selected background characteristics. Overall, the wanted fertility rate is 2.5 births per woman, 0.7 births less than the actual fertility rate. Thus, i f all unwanted births could be eliminated, the total fertility rate would drop by 22 percent. Fertility I 25 l.ooking at the difTerentials by residence, the gap between the wanted and the actual fertility rates varies ber, veen 0.5 and 0.8 births, with the largest gap evident among x~omen in rural Upper Egypt and the smallest gap apparent among women in the Urban Governorates. If women in the Urban Governorates were to avoid all unwanted births. they would achieve below replacement fertility ( 1.8 births pet woman). Among women who never attended school, the wanted t~l-tility rate is 3.1 births per woman, aroLmd 20 percent lower than the actual fertility rate t\)r this group (3.9 births). Women in other educational categories also report significant levels of unwanted fertility. Women in the highest quintile of the wealth index are closest to achieving their ideal f'amily size, i.e., the gap between actual and wanted fertility is smallest for these women (0.4 births pet- woman). The TFR l'or this group would have been substantially beh)w the replacement level if the women had had only the number of children they desire (Figure 2.2). The gap between the wanted and actual TFR is greatest liar the lowest wealth quintile; if w'omeo were to achieve the fertility they consider ideal, the TFR would fall fl'om 4 births to 3 births in this group. j';~lqe 2 13 Want¢~rt i l i ty roles Total wanted fragility lares and total l•nilitv rates [br the tinct years preceding the SLErvcy, by selected backgromld characteristics, Egypt 2003 Total wad/ted Total I~ackgtound t~cl'tilily Ik'ltility cllaractcristic rate rate 1. rban-rura l residence [Ji ban 21 26 I~,ural 2.9 36 Place of residence UFb~ln Govcl'lloraic?~ i S ~.]~ lower Egypt 2.4 3 / Urban 22 2.8 Rural 25 %.2 t Jppet [gypt 30 3.8 Ulban 23 29 Rural 34 4 ) Eduea|ion No education 31 39 Some primary 2.4 ~.2 Primary complete/some sccondalw 24 32 Secondary complete/higher 24 29 X~, ealth index [ owest quintile ~0 40 Second quintilc 2.6 33 Middle quintile 26 33 t:ourth quimile 23 29 Highest qtdntiIc 21 25 Total 25 32 4.0 Figure 2.2 Total Fertility Rates and Wanted Fertility Rates by Wealth Level 2.6 3.3 3.3 2.9 9 1 2.5 l+m~est quinlile Second quintile Middle quintile Fourlh quintile llighesl quintile • Total Wanted Fertil it) RAIL' lbtal l,'ertilil) Rate I [] 26 I l:erulio' 2.5 Premarital Examination: Knowledge and Practice The 2003 EIDHS survey was the first DHS survey to ask women questions about the practice of seeing a medical provider for a premarital examination. Women were first asked if they were aware of the practice. Women who heard about premarital examination were then asked if they had had an examination before their first marriage. Table 2.14 presents the percentage of ever-married women age 15- 49 knowing about premarital examination and the percentage of women who had an examination prior to first marriage. More than eight in ten women have heard about premarital examinations. Knowledge is most common among younger women, women from urban areas, women with secondary or higher education, women working for cash, and women who fall in the highest quintile of wealth index. Women in the lowest quintile of wealth index (61 percent), women with no education (67 percent), and women age 45- 49 years (71 percent), are least likely to have heard about premarital examinations. Despite the high levels of knowledge, only two percent of women had an exam before first marriage. Table 2.14 Premarital examination Percentage of ever-married women age 15-49 who have heard about premarital examination and ",vho had an examination prior to marriage, Egypt 2003 Percentage Percentage having knowing premarital about examination Number Background premarital before first of characteristic examinations marriage women Age 15-19 87.7 1.4 301 20-24 86.5 2.3 I, 187 25-29 86.3 2.3 1,538 30-34 85.5 1.2 1,210 35-39 80.6 1.5 1,279 40-44 76.9 0.6 1,061 45-49 71.2 0.4 9[0 Urban-rural residence Urban 90.3 2.0 3,529 Rural 75.3 1.1 3,956 Place of residence Urban Governorates 90.0 2.2 1,498 Lower Egypt 80.0 1.6 3,283 Urban 90.2 2.1 1,065 Rural 75.9 1.4 2.218 Upper Egypt 79.8 1.0 2,704 Urban 91.1 1.4 967 Rural 74.7 0.7 1.737 Education No education 67.3 0.4 2,322 Some primary 76.2 0.6 889 Primary complete/some secondary. 88.7 2.1 l, 126 Secondary complete/higher 96.2 2.7 3,147 Work status Working for cash 88.8 2.6 1,292 Not working for cash 80.4 [.3 6.193 Wealth index Lowest quintile 61.3 0.6 1,042 Second quintile 72.5 0.8 1,282 Middle quintile 84. I 1.2 1,576 Fourth quintile 92.0 2.0 1,781 Highest quintile 96.0 2.5 1,803 Total 81.7 1.5 7.485 Fertiliiy I 27 3 FAMILY PLANNING Egypt has had a family planning program for four decades. As a result, family planning services are widely available in both the public and private sector. The family planning program also has a strong education and communication program, which promotes family planning awareness through mass media. This chapter considers a number of indicators from 2003 E1DHS useful in monitoring the success of family planning eflbrts, including the level of family planning knowledge and use and exposure to media messages about family planning. The chapter also looks at the level of unmet need for family planning and attitudes toward family planning use. 3.1 Knowledge and Ever Use of Family Planning Information on knowledge and ever use of specific methods was collected in the 2003 EIDHS for eight modem methods (the pill, IUD, injectables, implant, foam/jelly/diaphragm, condoms, female sterilization, male sterilization) and three traditional methods (periodic abstinence, withdrawal, and prolonged breastfeeding). In addition, provision was made in the questionnaire to record other methods that respondents mentioned spontaneously. Table 3.1 presents information from the 2003 EIDHS on the levels of knowledge and ever use of family planning methods. Level of Knowledge The results in Table 3.1 show that knowledge of family planning methods 5 is almost universal among Egyptian women. All currently married women know about the pill and IUD, almost all are aware of the injectable (100 percent), and 94 percent have heard of the implant. Although female sterilization and the condom are less widely recognized, the majority of women also are familiar with these methods (68percent and 59 percent, respectively). Comparatively few women, however, know about male sterilization (12 percent). Prolonged breastfeeding is the most commonly recognized tradi- tional method (82 percent). Levels of Ever Use Table 3.1 also shows the percentages of currently married women who have ever used a family planning method by method. Overall, the results indicate that 81 percent of currently married women have used a family planning method at some time. Almost all currently women who have ever used a method have experience with modem methods. The most commonly used modem method is the IUD (61 percent), followed by Table 3.1 Family planning knowledge and ever use Percentages of currently married women age 15-49 who know family planning method and who have ever used a family planning method, by method, Egypt 2003 Know Ever used Methods method method Any method 100.0 81.0 Any modern method 100,0 78.5 Pill 100.0 39.7 IUD 100.0 61.4 Injection 99.6 20.2 Diaphragm/foam/jelly 34.6 0.7 Condom 58.7 4.1 Female sterilization 68.2 0.9 Male sterilization 12.0 0.0 hnplant 93.9 1.0 Any traditional method 84.8 15.2 Periodic abstinence 34.4 2.3 Withdrawal 32.9 1.6 Prolonged breast feeding 82. I 12.2 Other 0.7 0.3 Number of women 8,445 8,445 Sin collecting the information on knowledge in the 2003 EIDHS, no questions were asked to elicit information on depth of knowledge of these methods (e.g., on the respondent's understanding of how to use a specific method). Therefore, in the following analysis, knowledge of a family planning method is defined simply as having heard of a method. Family Planning I 29 the pill (40 percent). A much smaller proportion of women report that they have used the injectable (20 percent). Fifteen percent of currently married women have had experience using any traditional method. The most widely used traditional method is prolonged breastfeeding (12 percent), followed by periodic abstinence (2 percent). 3.2 Level and Differentials in Current Use of Family Planning The data on the current use of family planning is among the most important data collected in the EIDHS since it provides insight into one of the key determinants of fertility and serves as a central measure for assessing the success of the national family planning program. Level of Current Use by Residence The level of current use of contraception by method and residence is presented in Table 3.2. The table shows that 60 percent of currently married women in Egypt are using contraception, with 57 percent depending on modern methods and 3 percent using traditional methods. The IUD, pill, and injectables are the most widely used methods: 37 percent of married women are using the IUD, 9 percent currently rely on the pill, and 8 percent are using an injectable. Relatively small proportions of married women are using other modern methods, e.g., one percent each report using the condom, and implant. Prolonged breastfeeding is used by two percent of married women. The level of contraceptive use differs significantly by residence (Table 3.2 and Figure 3.1). The level of current use among urban women is 10 percentage points higher than the level among rural women (66 percent and 56 percent, respectively). Looking at the differentials by place of residence, the use rate is highest in the Urban Governorates (69 percent), followed by urban Lower Egypt (66 percent), while rural Upper Egypt has the lowest level (45 percent). There is a 20 percentage point difference in use levels between rural Upper Egypt (45 percent) and rural Lower Egypt (65 percent). The level of use among women in rural Lower Egypt is higher than the level of use in urban areas in Upper Egypt (60 percent). The IUD is the most frequently used method in all residential categories. The extent to which the IUD dominates the method mix varies somewhat across residential subgroups. The pill is the second most widely used method in all areas except rural Lower Egypt and rural Upper Egypt, where the proportion of women using the injectable is slightly higher than that relying on the pill. Women in the Urban Governorates and rural Lower Egypt rely on IUD more often than women from other areas. For example, women from both areas are roughly more than five times as likely to be using an IUD as the pill. In other residential areas, there are two to four times as many IUD users as pill users. 30 [ Family Planning rab/e ~ 2 ('~krrc l lxbe of fhmily plafltlmL.Lmetlmds hyrQs dc ce Percent distribution ol'cuHently married women age 15 49 by l~mfily pl mnh/g nacthod CtuTently used, according to urban rtual icxidence and j21acc of ~ebidence. E~ypt 2003 Place of residcncc [ Ji ban Lower E&Ypl Upper [gvpL ()reel . . . . Mclhod I Jlbatl Rural noiates "1 olaI [ than Rural Total {hbm~ Rtual Total Ally method 65 5 55.9 685 65.2 663 64.8 494 508 447 600 Any modern method 615 330 64.5 624 622 62> 45.7 5~)0 41.0 3(~f) Pill 11.0 8 I 9.4 96 13.4 80 9.0 107 82 93 l iD 423 325 46.4 4/.5 40.5 41 9 25.9 378 20.6 367 ]njcclion 48 t03 ~0 87 45 103 85 48 10.2 79 Oiaphragm/fk)amicl[y 0 1 00 0 1 0.0 0.0 00 0 1 02 00 0. l Condom I 4 0.5 15 0.7 14 0.4 09 13 07 0.9 I:cmale steriUzation 12 07 I 4 1.0 16 0.8 0.6 0(, 05 0.9 Implant (Norplanl) 07 (19 07 09 07 1.0 08 07 09 09 Any traditional method 4.0 3.0 4.0 28 4 ] 23 38 qg 3.8 34 Pciiodicabstinence 1.7 0.1 18 05 I.b 0.1 0.7 19 0 1 08 Withdrawal 0.7 0.2 07 05 1.2 02 02 03 0.1 04 Prolonged breastfi:cding I 5 2.5 1 ~, 17 14 151 2.8 1.5 33 ~.1 Other O0 0.2 O0 0. I 00 0. I 02 O0 02 01 Not using 34.5 44 1 3/.5 34.8 337 35.2 :~06 402 55.3 40(1 Total percent 100.0 1000 1000 1(1{} 0 100.0 1000 1000 H){},{} 100.0 100,{} NLmaber ol:womcn 3,589 4,856 1,533 3,797 1,083 2,713 3,116 973 2.143 8,445 65 Figure 3.1 Current Use of Modern Fami ly P lann ing Methods by Place of Residence 62 62 63 56 Urban "l-{}tal Urban Rural (;overnorales Lo~er Egypt T . ta l Urban Rural Upper Egspl k'amilv PlanninL, I 3 ; Differentials by Selected Other Background Characteristics Differentials in the levels of current use by background characteristics other than residence are presented in Table 3.3. Current use is clearly associated with a woman's age; younger and older women are less likely to be using contraception than women age 25-44. The lowest level of use is found among women age 15-19 (25 percent). The IUD is the most popular method among women in all age groups, with the highest levels of IUD use found among women age 30-44 (44 percent or more). Use rates for the pill peak in the 40-44 age group while injectable use is highest among women age 35-39. Contraceptive use is associated with the number of living children a woman has. Use levels increase from 45 percent of women with one child to 74 percent among women with three children and then drop off to 68 percent among women with four or more children. A negligible number of women use family planning before having the first child; only 0.2 percent of childless women are currently using a method. Looking at the patterns for specific methods, rates of pill and IUD use increase directly with the number of children before dropping off among women with four or more children. In contrast, use levels for the injectable increase steadily with the number of children, peaking at 14 percent among women with four or more children. There is association between current use and a woman's educational level, the proportion currently using a method varies from 57 percent among women with no education to 63 percent of those with secondary or higher education. The IUD is the most commonly used method among women at every level of education. The pill is most popular among women with a primary or higher education while the highest use rate for the injectable is observed among women who never attended school. Finally, the level of current use rises steadily across wealth quintiles, peaking at 68 percent among women in the highest quintile. IUD use rises steadily with the wealth quintile, from 26 percent in the lowest to 46 percent in the highest quintile. Pill use increases from seven percent among women in the lowest wealth quintile to 10 percent among women in the middle quintile, before peaking at 11 percent among women in the highest quintile. Injectable use exhibits the opposite pattern, with the peak use rate found among women in the lowest quintile (14 percent) and the lowest rate observed among women in the highest quintile (3 percent). 32 ] Family Planning Table 3.3 Current use of family olanning methods by background characteristics Percent distribution of currentl~¢ married women by family plannin~ method currently used, accordin~ to selected background characteristics. E~:~cpt 2003 Dia- Any Pro- Any phragrrd Female Implant tradi- Periodic longed Number Background Any modem lnjec- foam/ Con- sterili- (Nor- tional absti- With- breast- Not Total of characteristic method method Pill IUD tion )elly dora zation plant) method nence drawal feedin~ Other using percent women Age 15-19 25.4 23.0 5.7 14.3 2.7 0.0 0.0 0.0 0.2 2.5 0.0 0.0 2.5 0.0 74.6 100.0 332 20-24 48.0 44.2 8.7 29.1 5.6 0.0 0.2 0.0 0.7 3.8 0.2 0.0 3.6 0.0 52.0 100.0 1,343 25-29 57.2 53.6 8.8 35.8 7.3 0.0 0.8 0.1 0.9 3.5 0.1 0.2 3.2 0.0 42.8 100.0 1.703 30-34 69.2 65.2 9.8 43.5 9.7 0.0 0.8 0.5 0.9 4.0 0.8 0.1 3.0 0.0 30.8 100.0 1,346 35-39 73.3 70.1 10.8 45.5 10.3 0.1 1.5 0.9 1.0 3.2 0.8 0.8 1.2 0.3 26.7 100.0 1,462 40-44 71.9 68.8 11.6 43.6 8.8 0.2 1.1 2.0 1.3 3.0 1.6 1.0 0.3 0.2 28.1 100.0 1,205 45-49 46.9 44.0 6.8 25.7 7.0 0.0 1.3 2.9 0.3 2.8 2.2 0.5 0.1 0.0 53.1 100.0 1,054 Number of living children 0 0.2 0.2 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 99.8 100.0 806 1 45.1 41.7 9.7 29.3 2.2 0.0 0.2 0.1 0.1 3.4 0.5 0.3 2.6 0.0 54.9 100.0 1,240 2 70.1 65.9 10.9 47.6 4.9 0.0 1.2 0.5 0.8 4.2 1.0 0.6 2.6 0.0 29.9 100.0 1,774 3 74.3 69.7 11.2 46.0 9.6 0.2 0.9 1.0 0.8 4.5 1.4 0.5 2.6 0.0 25.7 100.0 1,837 4+ 68.1 65.0 9.6 37.4 13.6 0.0 1.2 1.8 1.5 3.1 0.7 0.4 1.7 0.2 31.9 100.0 2,788 Education No education 57.4 54.2 7.8 32.0 11.9 0.0 0.6 0.9 1.0 3.2 0.2 0.3 2.5 0.2 42.6 100.0 3,080 Some primary 59.0 55.9 8.6 35.8 8.4 0.3 0.7 0.7 1.4 3.0 0.4 0.1 2.5 0.1 41.0 100.0 1,053 Primary complete/ some secondary 59.2 56.7 11.8 35.5 7.5 0.0 0.5 0.7 0.7 2.6 0.4 0.5 1.7 0.0 40.8 100.0 1,190 Secondary complete/higher 63.2 59.1 10.1 42.0 4.1 0.1 1.4 1.0 0.6 4.0 1.7 0.6 1.6 0.0 36,8 100.0 3,122 Wealth index Lowest quintile 52.2 48.5 6.5 25.7 14.4 0.0 0.4 0.6 0.9 3.6 0.0 0.1 3.2 0.4 47,8 100.0 1,525 Second quintile 59.1 55.6 8.8 34.1 10.5 0.1 0.6 0.5 1.0 3.5 0.1 0.1 3.1 0.1 40,9 100.0 1,621 Middle quintile 57.5 54.8 9.8 34.8 7.5 0.0 0.8 0.8 1.1 2.7 0.5 0.3 1.9 0.0 42,5 100.0 1,742 Fourth quintile 62.0 59.3 10.4 40.6 5.3 0.1 1.1 1.1 0.6 2.7 0.5 0.6 1.6 0.0 38,0 100.0 1,793 Highest quintile 68.0 63.5 10.7 46.2 3.1 0.1 1.4 1.5 0.6 4.4 2.8 0.9 0.8 0.0 32,0 100.0 1,765 Total 60.0 56.6 9.3 36.7 7.9 0.1 0.9 0.9 0.9 3.4 0.8 0.4 2.1 0.1 40.0 100.0 8,445 3.3 Trends in Current Use of Family Planning Using results from the 2003 EIDHS as well as earlier surveys, the pattern of change in contraceptive use levels in Egypt since 1980 can be examined. Trend by Method Table 3.4 highlights the trend in family planning use at the national level between 1980 and 2003. The pace of change was rapid in the 1980s, with increases of around 1.5 percentage points annually during the eight-year period between 1980 and 1988 and a near doubling of use levels between 1980 and 1992 (from 24 percent to 47 percent). The use rate remained relatively stable at around 47 percent during the early 1990g to mid-1990s and then began to rise again, reaching 60 percent in 2003. Table 3.4 Trends in current use of family planning Percent distribution of currently married women by the family planning method currently used, Egypt 1980-2003 1980 1984 1988 1991 1992 1995 1997 1998 2000 Method EFS ECPS EDHS EMCHS EDHS EDHS EIDHS EIDHS EDHS 2003 EIDHS Any method 24.2 30.3 37.8 47.6 47.1 47.9 54.5 51.8 56.1 60.0 Any modern method 22.8 28.7 35.4 44.3 44.8 45.5 51.8 49.5 53.9 56.6 Pill 16.6 16.5 15.3 15.9 12.9 10.4 10.2 8.7 9.5 9.3 IUD 4.1 8.4 15.7 24.2 27.9 30.0 34.6 34.3 35.5 36.7 Injection U 0.3 0.1 U 0.5 2.4 3.9 3.9 6.1 7.9 Implant (Norplant) U U U U 0.0 0.0 0. I 0.0 0.2 0.9 Diaphragm/foam/jelly 0.3 0.7 0.4 U 0.4 0. I 0.2 0. I 0.2 0. I Condom 1.1 1.3 2.4 U 2.0 1.4 1.5 I. I 1.0 0,9 Female sterilization 0.7 1.5 1.5 U 1.1 I. I 1.4 1.3 1.4 0.9 Any traditional method 1.4 1.6 2.4 3.3 2.3 2.4 2.7 2.3 2.2 3.4 Periodic abstinence 0.5 0.6 0.6 U 0.7 0.8 0.6 0.8 0.6 0.8 Withdrawal 0.4 0.3 0.5 U 0.7 0.5 0.4 0.3 0.2 0.4 Prolonged breastfeeding U 0.6 l. I U 0.9 1.0 1.5 1.1 1.2 2.1 Other 0.3 0.1 0.2 U 0.1 0.1 0.1 0A 0.1 0.1 Not using 75.8 69.7 62.2 62.2 52.9 52. I 45.5 48.2 43.9 40.0 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 8,012 9,158 8,221 8,406 9,153 13,710 5,157 5,971 14,382 8,445 U - lnibnnation on the inethod was not collected or reported. Source: EI-Zanat~ and Associates, 1999, Table 3.2 and F. EI-Zanat~, and A. A. Wa~,, 2001, Table 6.1 The shift toward the IUD, which first became evident in the 1980s, continued during the 1990s although at a slower pace. 1UD use rose continuously, from 4 percent in 1980 to 37 percent in 2003. In contrast, the rate of use of the pill declined from 17 percent in 1980 to 9 percent in the late 1990s, where it has remained stable. Use of the injectable has risen continuously following its introduction into the family planning program in the 1990s, increasing from less than one percent in 1992 to 8 percent in 2003. Trend by Urban-Rural Residence and Place of Residence Table 3.5 presents trends in the rate of current use of family planning methods between 1984 and 2003 by residence. In urban areas, the current use rate rose most rapidly in the first half of the period, increasing by 12 percentage points between 1984 and 1992, from 45 percent to 57 percent. Urban use levels remained at that level between 1992 and 1995 and then increased at a somewhat slower rate, rising by 10 percentage points between 1995 and 2003. In rural areas, the decade of the eighties was also a period of substantial growth in contraceptive use. The rural use rate doubled between 1984 and 1992, from a level of 19 percent to 38 percent. At that point, the pace of change continued but at a 34 [ Family Planning slower rate; between 1992 and 2003, rural use levels increased by an average of 1.6 percentage points per year I Table 3.5 Trends in current use of fanfily planning b'¢ residence Percentage of currently married women currently using a family planning method by urban-rural residence and place of residence, Egl,pt 1984-2003 1984 1988 1992 1995 1997 1998 2000 2003 Residence ECPS EDHS EDHS EDHS EIDHS EIDHS EDHS EIDHS Urban-rural residence Urban 45.1 51.8 57.0 56.4 63.1 59.3 61.2 65.5 Rural 19.2 24.5 38.4 40.5 47.1 45.6 52.0 55.9 Place of residence Urban Governorates 49.6 56.0 59.1 58.1 67.0 62.1 62.7 68.5 Lower Egypt 34.1 41.2 53.5 55.4 61.6 592 62.4 65.2 Urban 47.6 54.5 60.5 59.1 65.9 62.2 64.9 66.3 Rural 28.5 35.6 50.5 53.8 59.9 58.1 61.4 64.8 Upper Egypt 17.3 22.1 31.4 32.1 37.4 36.5 45.1 49.4 Urban 36.8 41.5. 48.1 49.9 52.1 50.8 55.4 59.8 Rural 7.9 I 1.5 24.3 24.0 30.3 29.9 40.2 44.7 Total 30.3 37.8 47.1 47.9 54.5 51.8 56.1 60.0 Table 3.5 also shows that there were significant differences in the trends according to the place of residence. The greatest absolute increase in use during the period occurred in rural Upper Egypt. The increase in use in rural Upper Egypt was especially rapid between 1995 and 2003, when the rate rose from 24 percent to 45 percent. Rural Lower Egypt also experienced rapid increase over the period; the use rate in rural Lower Egypt rose by more than 20 percentage points between 1984 and 1995 (from 29 percent to 54 percent) and then increased by an additional 1 l percentage points to 65 percent in 2003. The Urban Governorates and urban areas in both Lower and Upper Egypt experienced moderate increases in contraceptive use rates during the period 1984-88. Between 1988 and 1992, use rates continued to rise at a moderate pace in urban areas in both Lower Egypt and Upper Egypt; however, there was noticeable slowing in the rise in the use rate in the Urban Governorates during that period. Between 1992 and 1995, contraceptive use levels in the Urban Governorates, urban Lower Egypt, and urban Upper Egypt remained virtually unchanged. After 1995, use rates experienced an upward trend again in all of the urban areas. Trend by Other Background Characteristics Table 3.6 presents trends in contraceptive use during the period between 1988 and 2003 by selected background characteristics of women for all methods and for the pill, IUD, and injectable. Looking at the entire period, the use rate increased markedly across all age groups. Similarly, the use level increased substantially in each family size category through the period, except among women who had not yet begun childbearing. Among childless women, a negligible percent were using at any time during the period. Considering education, the change in use over the period was greatest among women who never attended school; the use rate doubled from 28 percent in 1988 to 57 percent in 2003. Smaller increases were observed during the period among educated women. As a result the gap in use according to educational level narrowed substantially during the period. During the period, all groups experienced increases in the use of the IUD and the injectable and a drop in the use of the pill. Family Planning I 35 Table 3.6 Trends in current use of flamily planning by socio-economic characteristics Percentage of currently married women age 15-49 currently using any method, the pill. characteristics, Egypt 1988-2003 IUD and injectables by selected background Background Any method Pill IUD li\iection characteristic 1988 1992 1995 2000 2003 1988 1992 1995 2000 2003 1988 1992 1995 2000 2003 1988 1992 1995 2000 2003 Age 15-19 5.5 13.3 16,1 23.4 25.4 3.5 4.1 3,2 43 5.7 1.7 8.4 11.3 15.0 14.3 g.0 0.0 I.I 2,4 2.7 20-24 24.3 29.7 33.2 42.7 48.0 10.8 6,8 6.6 6.6 8.7 10.7 21.2 21.7 29.6 29.1 0.0 02 2.1 3.9 5.6 25-29 37.1 46.0 47.6 57.0 57.2 14.9 13.3 9.8 9.2 g.8 17.7 29.3 33.1 38.3 35.8 0.0 0.2 2.2 5.8 7.3 30-34 46.8 58.8 5g.I 67,2 69.2 19.2 16.2 13.3 11.3 9.8 20.2 36.7 37.3 42.9 43.5 0.2 0.5 3.2 7.8 9.7 35-39 52.8 59.6 60.7 68.0 73.3 23.2 18.2 13.8 12.4 10.8 21.2 34.0 37.2 42.8 45.5 0,1 0,8 3.2 7.8 10.3 40-44 47.5 55.5 58.8 63.4 71.9 15.5 14.0 12.5 113 11.6 18.5 28.9 34.4 37.4 43.6 03 1.1 2.5 %0 8.8 45 49 23.4 34.5 333 420 46.9 8.6 7.9 7.6 6.4 6.8 6.6 14.9 16.2 233 25.7 0.0 0.5 12 4.7 7.0 Number of living children 0 0.7 0.5 1.2 0.4 0.2 O.I 0.3 0,5 0.3 0.0 0.4 02 0.5 0.0 0.2 0.0 0,0 0.0 O.0 0.0 I 23.t 31.6 31.6 42.3 451 7.6 6.7 4.7 7.3 9.7 11.4 22.4 23.3 30.8 29.3 0.0 0.0 0.9 1.9 2.2 2 43.4 52.5 53.9 66.0 701 14.7 12.7 8.9 9,2 10.9 20.5 34.3 38.9 46.9 47.6 0.0 0.0 1.6 4.9 4.9 3 47.8 59.3 65.4 69.3 74.3 19.9 171 137 11.2 1[.2 19.6 34.8 40.3 47.[ 460 0.0 0.5 3.8 5.6 96 4+ 44.4 54.3 53.9 62,2 68.1 17.1 15.8 13.9 117 9.6 17.1 30.0 30.6 338 37.4 11.2 1.0 3.2 99 13.6 Education No education 27.5 37.5 40.6 51.5 57.4 13.4 12.0 11.0 8.9 7.8 10.0 20.7 23.8 29,6 32.0 0.1 0.5 2.3 8.3 11.9 Someprinlary 42.5 53.5 50.5 57.5 59.0 20.3 17.6 12.2 10.3 8.6 16.3 29.4 30.2 337 35.8 0.1 1t5 3.1 7.9 84 Prim. comp./ somesec. 52.3 56.1 51.2 57.2 59.2 15.6 13.7 10.1 II.9 11.8 23.9 34.g 32.8 36,3 355 11.0 06 2,3 4.4 7.5 Secondary comp/higher 53.2 58.0 56.5 61.2 63.2 13.8 9,8 8.3 8.9 10.1 271 40.0 39.g 43.9 42.0 0.1 0.4 20 3.2 4.1 Total 37.8 47.1 47.9 56.1 60.0 15.3 12.9 10.4 9.5 9.3 15.7 27.9 30.0 35.5 36.7 0.1 0.5 2.4 6.1 7.9 3.4 Need for Family Planning One of the major concerns of family planning programs is to define the size of the potential demand for contraception and to identify women that are most in need of contraceptive services. Table 3.7 presents estimates of unmet need and of met need for family planning services, and of the total demand for family planning in Egypt as a whole and for various subgroups. Women with an unmet need for family planning (shown in columns 1-3 of Table 3.7) include the following: Currently married women who are in need of family planning for spacing purposes. This group includes (a) pregnant women whose pregnancy is mistimed (i.e., wanted later); (b) amenorrheic women whose last birth was mistimed; and (c) nonusers who are neither pregnant nor amenorrheic and who either want to delay the next birth at least two or more years, are unsure whether they want another child, or want another child but are unsure when to have the birth. Currently married women who are in need of family planning for limiting purposes. This group includes: (a) pregnant women whose pregnancy is unwanted; (b) amenorrheic women whose last child was unwanted; and (c) nonusers who are neither pregnant nor amenorrheic and who want no more children. Menopausal and infecund women are excluded from the unmet need category as are pregnant or amenorrheic women who became pregnant while using a method. The latter group is considered to be in need of better contraception. 36 ] Family Planning Table 3.7 Need for family plannin~ Percentage of currently married women with unmet need for family planning and with met need for family planning, and the total demand for family planning, by selected background characteristics, Egypt 2003, and trend in the percentage with unmet need and met need and in the total demand for family planning, E~ypt 2000-2003 Met need for Per- Unmet need fbr family planning Contraceptive Total demand for centage family plannin~ I (currently using) 2 failure 3 family plannin~ 4 of For For For For For For For For demand Background spacing limiting Total spacing limiting Total spacing limiting Total spacing limiting Total satis- characteristics (I) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) fled Total Age 15-19 8.3 0.8 9.1 23.0 2.4 25.4 0.6 0.0 0.6 31.9 3.2 35.1 74.2 332 20-24 9.0 1.7 10.7 32.6 15.4 48.0 1.3 0.0 1.3 42.9 17.1 60.0 82.1 1,343 25-29 4.9 4.0 8.9 19.9 3%3 57.2 1.4 0.3 1.6 26.1 41.6 6%7 86.9 1,703 30-34 2.8 7.7 10.5 11.2 58.0 69.2 0.2 0.9 1.1 14.3 66.6 80.9 87.0 1,346 35-39 1.5 8.9 10.4 4.5 68.8 73.3 0.3 1.3 1.6 6.3 79.0 85.3 87.8 1,462 40-44 0.4 7.8 8.2 1.7 70.2 71.9 0.0 0.2 0.2 2.1 78.1 80.2 89.8 1,205 45-49 0.4 8.0 8.4 0.3 46.5 46.9 0.0 0.0 0.0 0.8 54.5 55.3 84.8 1,054 Urban-rural residence Urban 1.9 4.3 6.2 13.8 51.7 65.5 0.5 0.5 1.0 16.2 56.5 72.7 91.5 3,589 Rural 4.8 7.3 12.0 12.3 43.6 55.9 0.7 0.4 I.I 17.7 51.3 69.0 82.6 4,856 Place of residence Urban Govemorates 1.6 3.6 5.1 13.9 54.6 68.5 0.3 0.4 0.6 15.7 58.5 74.3 93.1 1,533 Lower Egypt 2.5 4.5 7.0 14.2 51.0 65.2 0.6 0.5 1.1 17.3 56.1 73.3 90.4 3,797 Urban 1.5 3.7 5.2 14.1 52.2 66.3 0.7 0.7 1.4 16.3 56.5 72.9 92.9 1,083 Rural 2.9 4.9 7.7 14.2 50.6 64.8 0.6 0.4 1.0 17.6 55.9 73.5 89.5 2,713 Upper Egypt 5.8 9.0 14.8 11.0 38.5 49.4 0.7 0.5 1,1 17.5 47.9 65.4 77.4 3,116 Urban 3.0 6.1 9.0 13.2 46.6 59.8 0.6 0.6 1.2 16.8 53.2 70.0 87.1 973 Rural 7.2 10.3 17.4 10.0 34.8 44.7 0.7 0.4 1.1 17.9 45.5 63.3 72.5 2,143 Education No education 3.6 8.2 11.8 7.6 49.9 57.4 0.2 0.6 0.8 11.4 58.6 70.0 83.2 3,080 Some primary 3.5 9.6 13.1 8.5 50.5 59.0 0.8 0.3 1.0 12.8 60.3 73.1 82.1 1,053 Primary comp./ some secondary 3.7 5.0 8.7 15.3 44.0 59,2 0.6 0.1 0.8 19.6 49.1 68.7 87.3 1,190 Secondary complete/higher 3.5 3.0 6.5 18.9 44.3 63.2 0.9 0.5 1.4 23.2 47.8 71.0 90.9 3,122 Wealth index Lowestquintile 5.2 9.0 14.2 9.3 42.8 52.2 0.7 0.6 1.2 15.2 52.4 67.6 79.0 1,525 Second quintile 4.7 7.1 11.9 10.5 48.5 59.1 0.9 0.3 1.1 16,1 56.0 72.1 83.5 1,621 Middle quintile 3.7 6.3 10.0 14.4 43.2 57.5 0.3 0.4 0.7 18.3 50.0 68.3 85.4 1,742 Fourth quintile 2.9 4.2 7.1 14.3 47.7 62.0 0.6 0.7 1.3 17.8 52.6 70.4 90.0 1,793 Highestquintile 1.6 3.9 5.4 15.6 52.4 68.0 0.5 0.2 0.7 17.6 56.5 74.2 92.7 1,765 Total 2003 EIDHS 3.5 6.0 9.5 12.9 47.1 60.0 0.6 0.4 1.0 17.1 53.5 70.6 86.5 8,445 Total2000 EDHS 3.6 7.6 11.2 11.4 44.7 56.1 0.4 0.5 1.0 15.4 52.9 68.2 83.5 14,382 J Unmet need for 3pac'tng includes pregnant women whose pregnancy was mistimed, amenorrheic women whose last birth was mistimed, and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are women who are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted, amenorrheic women whose last child was unwanted and women who are neither pregnant nor amenorrheic and who are not using any method of family planning and who want no more children. Excluded from the unmet need category are pregnant and amenorrheic women who became pregnant while using a method (these women are in need of better contraception) Also excluded are menopausal or infecund women, Us n 8 for spacing s det ned as women who are using some me hod of famdy planmng and say hey want to have ano her oh1 d or are undecided whether to have another. Using for limiting is defined as women who are using and who want no more children. Note that the specific methods used are not taken into account here. 3 Contraceptive failure includes pregnant or amenorrheic women who became pregnant while using a contraceptive method. These women are considered in need of better contraception. 4 Total demand includes pregnant or amenortheic women who became pregnant while using a method (contraceptive failure) in addition to the unmet and met need for family, planuin . Women with a met need for family planning (shown in columns 4-6 of Table 3.7) include those women who are currently using contraception. The total demand for family planning (shown in columns 10-12 of Table 3.7) represents the sum of unmet need and met need. In addition, the total demand includes pregnant and amenorrheic women who became pregnant while using a family Family Planning [ 37 planning method (i.e., women in need of better contraception). The percentage of the total demand that is satisfied is shown in the last column of Table 3.7. The total unmet need in Egypt is 10 percent; around a third of this need represents a desire to space the next birth and the remainder show an interest in limiting. The total met need for family planning (i.e., the proportion of women currently using contraception) is 60 percent. The majority of users are limiters, with 2l percent of users (i.e., 13 percent of all women) reporting a desire to delay the next birth for two or more years. Overall, the total demand for family planning comprises 71 percent of married women in Egypt. Presently, 87 percent of the total demand for family planning in Egypt is satisfied. A comparison of the 2000 EDHS and 2003 EIDHS survey findings indicates that both the total demand for family planning and the proportion of the demand that was satisfied rose slightly between the two surveys. Looking at the differentials in the percentage of the demand for family planning that is satisfied, the most striking finding in Table 3.7 is the fact that around three-quarters of the demand for services is satisfied in all subgroups. Overall, the level of satisfied demand is lowest among women in rural Upper Egypt (73 percent) and highest (93 percent) among those Jiving in the Urban Governorates, Urban Lower Egypt, and those who fall in the highest quintile of the wealth index. 3.5 Intention to Use Contraception in the Future To obtain additional information about potential demand for family planning services, all currently married women who were not using contraception at the time of the survey were asked abut their intention to adopt family planning methods in the future. Women who said they did not plan to use were asked about what was the main reason they had for not using. Women who indicated they would use in the future were asked about the method that they preferred to use. Intention to Use Table 3.8 shows the percent distribution of nonusers by their intention to use in the future, according to number of Jiving chil- dren. Among all currently married nonus- ers, 47 percent intend to use in the future, 50 percent do not plan to use in the future, and three percent are not sure about their intentions. There is a clear association be- tween the number of children the woman has and her intention to use. Nonusers with idw parity (I-3 children) have higher pro- portions intending to use in the future than other women. Table 3.8 Future use of family planning Percent distribution of currently married women who are not using a family planning method by intention to use in the future, according to number of living children, Egypt 2003 N umber of living children ~ Future intention 0 1 2 3 4+ Total Intends to use 36.3 60.9 58.2 52.4 35.7 46.8 Unsure about use 1.2 2.2 3.4 5.3 4.1 3. I Does not intend 62.5 36.9 37.7 41.7 60.2 49.9 Missing 0.0 0.0 0.6 (I.6 0.0 0.2 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 Number&women 805 681 531 472 889 3,378 Ilncludescurrentpre~nanc~ Reasons for Nonuse The reasons for nonuse given by those women who indicate that they are not planning to use in the future are of interest to the family planning program since they help to identify areas for potential interventions to encourage nonusers to adopt contraception. Since the reasons for nonuse typically vary with the age of the woman, Table 3.9 presents the distribution of currently married women who 38 [ Family Planning' are not intending to use family planning in the future for two age groups; under age 30 and age 30 and over. The main reason for not planning to use family planning is the desire for more children, mentioned by around half of women. As expected, the proportion of younger women who gave this reason (92 percent) is much higher than the proportion of older women who reported this reason (26 percent). Around 30 percent of the nonusers who are not planning to use believe that they are at low risk of pregnancy either because they are not sexually active or have sex infrequently (5 percent) or they consider themselves to be subfecund or infecund (24 percent). In addition, 10 percent are not planning to use because they are menopausal or have had a hysterectomy (10 percent). The proportion considering themselves unable or unlikely to become pregnant varies by age of the woman; around 57 percent of women 30 years or older indicated that they are unable or unlikely to get pregnant compared with 3 percent of those under age 30. Table 3.9 Reason for not using family planning Percent distribution of currently nmrried nonusers who do not intend to use in the future by main reason for not using, according to age, Egypt 2003 Reason 15-29 3049 Total Fertility-related 95.0 82.4 86.6 Not having sex 0.0 2.2 1.5 Infrequent sex 1.0 4.6 3.4 Menopausal/had hysterectomy 0.0 14.6 9.7 Subfecund/infectuld 2.3 35.5 24.4 Wants more children 91.7 25.5 47.6 Opposition to use 1.8 2.7 2.4 Respondent opposed 0.7 0.7 0.7 Husband opposed 0.9 1.9 1.5 Others opposed 0.0 0.0 0.0 Religious prohibitions 0.2 0.2 0.2 Method-related 3.1 12.4 9.4 Health concerns 0.9 7.4 5.3 Fear side effects 2.1 4.5 3.7 Lack of access 0.0 0. I 0, I Cost too much 0.0 0.1 0.1 Inconvenient to use 0.0 0.1 0.1 Interfere with body 0.0 0.2 0.I Other 0.1 1,9 1.3 Don't know/not sure 0.0 0.6 0.4 Total percent 100.0 100:0 100.0 Number of women 562 1,125 1,687 Around 1 in 11 women have method-related concerns part of the husband). Older nonusers are about four times as likely as younger nonusers to give these reasons for not planning to use in the future. Preferred Method Among nonusers who planned to use family planning in the future, Table 3.10 shows that the majority of women prefer modern contraceptive methods. More than one third of all nonusers prefer the 1UD. Following the IUD, the most popular methods are the pill (14 percent) and injectable (9 percent). A significant proportion reported that they will use the method that recommended by the doctor (17 percent). 3.6 Contact of Nonusers with Family Planning Providers The 2003 EIDHS collected information on whether or cited opposition to use (principally on the Table 3,10 Preferred Family planning method Percent distribution of currently married women who are not using a family planning method but who intend to use in the future by preferred method, Egypt 2003 Preferred method Total Pill 14.3 IUD 35.5 Injections 9.0 Female sterilization 0.6 Implant (Norplant) 1.8 Periodic abstinence 0.2 Withdrawal 0. I Prolonged breastfeeding 0.0 Other 0.8 As doctor recommends 17.4 Suitable method 2.4 Don't know 17.8 Total percent 100.0 Number of women 1,581 nonusers had any recent contact with family planning providers either through home visits or health facilities visits. Such contacts provide an opportunity to counsel the nonuser about the need for family planning. To obtain this information, nonusers were asked whether they had been visited at home at any anytime during the six months preceding the survey by a family planning outreach worker (e.g., a raiyda refia) or anyone else who had talked with them about family planning. They were also asked Family Planning [ 39 about any visits they had made to governmental health facilities or private doctors or clinics during the six months preceding the survey and, if they had visited any of these providers, whether anyone had spoken to them about family planning during their visit(s). Table 3.11 presents the results of these questions by background characteristics. Around half (46 percent) of nonusers had some type of contact with a health provider (26 percent at a public facility and 33 percent with a private provider) or family planning worker (4 percent) during the six months preceding the EIDHS survey. Family planning was discussed in only 19 percent of all of the encounters that nonusers had with family planning workers or health providers during the six-month period. Among all nonusers, only 9 percent had had any recent contact with a health provider or family planning worker in which family planning was discussed. Table 3.11 Contact of nonusers with family planning workers and health facilities Percentage of nonusers of family planning who were visited at home by a family planning worker, who visited a health facility, and who discussed family planning at a health facility, during the 6 months preceding the survey, according to selected background characteristics, Egypt 2003 Visited Visited Had some Discussed FP public Visited private Visited contact with with FP Visited at health PHF, health PrHF, FP worker worker or staff Background home by facility discussed facility discussed or health at health characteristics PP worker (PHF) FP (PrHP) FP facility facility Total Age 15-19 2.7 35.5 9.0 39.0 4.2 61.3 12.3 259 20-24 5.9 36.6 9.3 45.7 7.3 64.4 14.6 728 25-29 3.0 36.0 8.0 43.6 6.9 58.5 12.1 808 30-34 4.7 26.8 5.7 41.1 6.7 54.0 I 1.3 483 35-39 3.4 20.9 4.5 26.5 2.8 39.2 6.8 514 40-44 2.9 13.2 2.1 19.1 1.6 26.3 3.7 510 45-49 1.9 12.0 0.7 17.3 0.8 25,1 1.3 784 Urban-rural residence Urban 1.4 23.6 4.4 38.6 4.7 48.1 7.5 1,553 Rural 4.8 26.9 6. I 29.8 4.3 45.3 9.4 2,533 Place of residence Urban Governorates 0.1 23.4 4.8 39.0 5.6 48.5 8.3 615 Lower Egypt 3.2 28.9 5.7 38.5 4.7 50.7 9.0 1,625 Urban 1.1 25.6 2.6 43.1 4.0 50.7 5.6 460 Rural 4.0 30.3 6.9 36.7 5.0 50.7 10.4 1,165 Upper Egypt 4.9 23.5 5.4 26.5 3.8 41.8 8.5 1,846 Urban 3.2 21.8 5.5 33.8 4.1 45.2 8.5 478 Rural 5.5 24.0 5.4 23.9 3.6 40.6 8.5 1,368 Education No education 3.4 22.0 3.9 20.2 2.5 35.2 5.9 1,681 Some primary 3.7 25.4 5.2 29.3 4.6 42.4 8.7 543 Primary complete/some secondary 4.6 28.9 8.3 36.5 5.4 51.5 12.0 565 Secondary complete/higher 3.1 29.0 6.4 50.0 6.4 60.2 10.8 1,298 Wealth index Lowest quintile 5.9 23.2 5.4 19.4 2.1 36.1 7.2 904 Second quintile 5.2 26.2 5.3 27.0 3.5 42.2 8.0 810 Middle quintile 3.1 30.5 7.4 35.0 5.1 50.9 10.8 869 Fourth quintile 1.8 24.4 5.3 39.0 5.6 49.1 9.9 824 Highest quintile 0.9 23.4 3.3 49.3 6.3 55.9 7.4 679 Total 3.5 25.6 5.4 33.1 4.4 46.4 8.7 4,086 Look ing at the d i f ferent ia ls in Tab le 3.11, it is c lear that o lder nonusers , nonusers w i th no educat ion , and nonusers in the lowest qu in t i le o f the wea l th index are less l i ke ly to have had a recent contact w i th a hea l th prov ider or a fami ly p lann ing worker than other nonusers . Desp i te the lower level o f contact , the resu l ts ind icate that there remain a s ign i f i cant number o f 'm issed ' oppor tun i t ies for counse l ing 40 ] Family Planning women about family planning even among these groups. For example, while 35 percent of the nonusers who never attended school had had some contact with a health provider or a family planning worker in the six-month period before the survey, family planning was discussed in only 1 in 6 of these encounters. 3.7 Exposure to Family Planning Messages Since the mid-1980s, a strong mass media public information and education program conducted by the State Information Service with technical assistance from USAID has been one of the main components of the Egyptian family planning program. After focusing initially on general "population awareness" messages, the education and communication effort has increasingly moved to providing more specific advice and information on family planning. The 2003 EIDHS obtained information on the proportion of who have been recently exposed to family planning information and the channels through which they are receiving the information. This information may be useful in guiding future information and education efforts in Egypt's family planning program. Level of Exposure to Family Planning Messages Table 3.12 shows that two-thirds of ever-married women reported that they had heard or seen some type of family planning message during the six-month period prior the interview. Significant differences in the exposure to family planning messages exist among subgroups. Women were most likely to have been exposed to family planning messages i f they were from urban Upper Egypt (81 percent) or were in the highest quintile of wealth index (78 percent). Groups in which the level of exposure was lowest include women 45-49 (57 percent), women with no education (58 percent), and women in the lowest wealth quintile (55 percent). Recent Source of Family Planning Information Table 3.13 presents the distribution of ever-married women who had heard messages about family planning during the six-month period before the EIDHS survey by the most recent source of family Table 3.12 Exposure to family planning messages Percent distribution of ever-married women age 15-49 by whether they have heard or seen any message about family planning in the six months preceding the interview, according to selected background characteristics and use status, Egypt 2003 Heard/seen EP message Background Total Number characteristic No Yes percent of women Age 15-19 32.5 67.5 100.0 343 20-24 28.0 72.0 100.0 1,372 25-29 27.1 72.9 100.0 1,782 30-34 31.4 68.6 100.0 1,415 35-39 33.0 67.0 100.0 1,588 40-44 36.1 63.9 100.0 1,380 45-49 43.5 56.5 100.0 1,279 Urban-rural residence Urban 27.8 72.2 100.0 3,908 Rural 36.5 63.5 100.0 5,251 Place of residence Urban Governorates 30.3 69.7 100.0 1,666 Lower Egypt 37.7 62.3 100.0 4,105 Urban 32.7 67.3 100.0 1,181 Rural 39.7 60.3 100.0 2,924 Upper Egypt 28.1 71.9 100.0 3,388 Urban 18.6 81.4 100.0 1,061 Rural 32.4 67.6 100.0 2,327 Education No education 41.9 58.1 100.0 3,452 Some primary 38.2 61.8 100.0 1,167 Primary comp./some secondary 25.5 74.5 100.0 1,270 Secondary complete/higher 24.1 75.9 100.0 3,270 Wealth index Lowest quintile 44.7 55.3 100.0 1,699 Second quintile 37.8 62.2 100.0 1,769 Middle quintile 32.0 68.0 100.0 1,874 Fourth quintile 28.7 71.3 100.0 1,937 Highest quintile 22.2 77.8 100.0 1,879 Total 32.8 67.2 100.0 9,159 planning information. Television is the recent source of family planning information for the of women followed by medical providers (88 percent and 9 percent, respectively). majority Family Planning [ 41 Table 3.13 Most recent source of t'amilv planning intbrmation Percent distribution of ever-married women age 15-49 who heard about FP within the six months before the survey source of family planning information, according to selected background characteristics, Egypt 2003 News- Other Friends/ Background characteristic paper/ Pamphlet/ Medical rela- neigh- TV Radio magazine brochure Poster provider Husband tives bors Age 15-19 82.4 0.0 0.0 0.0 0.0 I 1.6 20-24 83.5 0.4 0.2 0.0 0.1 12.9 25-29 85.5 0.2 0.0 0.3 0.3 l 1.6 30-34 88.5 0.0 0.0 0.0 0.1 8.3 35-39 89.6 0.0 0.0 0.3 0.2 7.8 40-44 89.8 0.3 0.2 0.7 0.3 5.4 45-49 92.2 0.1 0.3 0.4 0.0 4.0 Urban-rural residence Urban 89.4 0.1 0.2 0.4 0.2 7.6 0.2 Rural 86.2 0.2 0.0 0.1 0.2 9.9 0.3 Place of residence Urban Governorates 88.6 0.0 0.4 0.5 0.2 7.9 0.4 Lower Egypt 83.5 0.3 0.0 0.4 0.3 12.1 0.1 Urban 85.9 0.3 0.0 0.7 0.3 9.8 0.2 Rural 82.4 0.3 0.0 0.2 0.3 13. I 0. I Upper Egypt 91.5 0.1 0.0 0.0 0.0 5.9 0.3 Urban 93.7 0.1 0.0 0.1 0.0 5.1 0.0 Rural 90.3 0.1 0.0 0.0 0.0 6.3 0.5 Education No education 90.0 0.2 0.0 0.0 0.0 6.8 0. I Some primary 86.6 0.0 0.0 0.0 0.2 9.6 0.6 Primary comp./ some secondary 88.8 0.0 0.0 0.2 0.0 8.3 0.2 Secondary complete/higher 85.6 0.2 0.2 0.6 0.3 10.4 0.3 Wealth index Lowest quintile 86.5 0.4 0.0 0.0 0.0 8.9 0.3 Second quintile 85.6 0.0 0.0 0.0 0. I 11.3 0.2 Middle quintile 88.2 0.1 0.0 0.0 0.2 9.5 0.2 Fourth quintile 89.2 0.1 0.0 0.2 0.3 7.7 0, I Highest quintile 88,0 0.2 0.4 0.9 0.1 7.4 0.5 Total 87.6 0.2 0.1 0.3 0.2 8.8 0.3 by most recent Total Number Other percent of women 0.8 3.4 1.8 0.0 100.0 232 0.2 2.0 0.8 0.0 100.0 988 0.2 1.0 0.9 0.0 100.0 1,299 0.5 1.1 1.3 0.2 100.0 970 0.0 0.8 1.2 0.2 100.0 1,063 0.3 2.1 0.7 0.3 100.0 882 0.2 1.8 0.8 0.0 t00.0 723 1.0 0.7 0.2 100.0 2,820 1.8 1.3 0.0 100.0 3,337 0.9 0.8 0.3 100.0 I,~61 1.9 1.4 0.0 100.0 2,557 1.8 0.9 0.1 100.0 795 2.0 1.6 0.0 100.0 1,763 1.2 0.7 0.1 100.0 2,438 0.4 0.4 0.2 100.0 864 1.7 0.9 0.1 100.0 1,574 1.8 I.I 0.0 100.0 2,006 1.2 1.8 0.0 100.0 721 1.6 0.8 0.0 100.0 946 1.2 0.8 0.3 100.0 2,483 2.2 1.7 0.0 100.0 939 2.1 0.7 0.0 100.0 1,100 0.6 1.0 0. I 100.0 1,274 1.6 0.8 0.0 100.0 1,381 1.2 1.0 0.3 100.0 1,463 1.5 1.0 0.1 100.0 6,156 3.8 Perceptions and Attitudes about Family Planning Use Nine in ten women interviewed in the EIDHS approved of the use of family planning (not shown in table). To obtain additional information on the attitudes of these women about family planning, the 2003 EIDHS included questions relating to their perceptions about the extent of contraceptive use in their community and their attitudes about the appropriate time to begin contraceptive use. Opin ion about Fami ly P lanning Use in the Communi ty To obtain informat ion on percept ions concern ing the extent o f fami ly p lann ing use in the communi ty , all women in the E IDHS sample were asked: "Wou ld you say that most, some, very few or none of the couples in the reproduct ive ages l iv ing in this area are us ing fami ly p lanning?" . They were also asked i f the use of fami ly p lanning was increasing, decreasing, or s tay ing the same in their communi ty . Table 3 .14 presents the results o f these quest ions. 42 [ Family Planning Overall, the majority of women consider that most couples (72 percent) are using family planning. However, there are variations in the extent to which women share this perception. For example, while 84 percent of women in rural Lower Egypt perceive that most couples in their community use family planning, only 56 percent of women in rural Upper Egypt have this perception. Looking at the question with regard to the trend in family planning use, the majority of women (79 percent) see use as increasing in their area. The percentages who share this perception again vary across subgroups. For example, 91 percent of women in rural Lower Egypt consider family planning use increasing compared with 66 percent in rural Upper Egypt. Table 3.14 Opinion about extent and trend in family planning use Percent distribution of ever~married women according to their opinion about the extent of family planning use and about the trend in family planning in their area, according to selected back~ound characteristics, Egypt 2003 Extent of family planning use Trend in family planning use About Number Background Don't Increa- Decrea- the Total of characteristic Most Some Few None know sing sing same Not sure percent women Age 15-19 69.3 16.6 3.4 0.7 9.9 76.9 2.1 8.8 12.3 100.0 343 20-24 72.0 15.7 2.9 0.6 8.8 79.9 1.8 5.9 12.4 100.0 1,372 25-29 74.4 14.6 2.5 0.4 8.0 80.0 1.6 6.5 11.8 100.0 1,782 30-34 75.9 14.2 2.5 0.4 7.0 83.0 1.4 4.7 10.8 100.0 1.415 35-39 71.3 16.0 2.7 0.2 9.7 77.1 1.7 6.7 14.4 100.0 1,588 40-44 71.8 14.3 2.0 0.3 11.6 78.0 1.3 6.2 14.6 100.0 1,380 45-49 69.2 15.2 3.1 0.5 12.0 76.4 2.5 6.5 14.6 100.0 1,279 Urban-rural residence Urban 73.4 9.8 1.8 0.2 14.8 77.9 1.0 4.4 16.7 100.0 3.908 Rural 71.7 18.9 3.2 0.6 5.5 79.9 2.2 7.5 10.3 100.0 5,251 Place of residence Urban Governorates 70.9 7.1 1.8 0.0 20.2 74.0 0.5 4.2 21.3 100.0 1.666 Lower Egypt 83.5 10.2 1.2 0.1 5.1 89.6 1.0 3.5 6.0 100.0 4,105 Urban 82.0 8.1 1.1 0.0 8.7 86.7 0.9 3.3 9.1 100.0 1,181 Rural 84.0 11.1 1.2 0.1 3.6 90.7 1.0 3.6 4.7 100.0 2,924 Upper Egypt 59.8 24.8 4.9 1.0 9.5 68.7 3.2 10.5 17.6 100.0 3.388 Urban 67.7 16.0 2.7 0.5 13.0 74.1 2.0 6.1 17.8 100.0 1,061 Rural 56,2 28.8 5.9 1.3 7.9 66.3 3.8 12.5 17.5 100.0 2,327 Education No education 65.6 21.0 3.3 0.7 9.4 73.9 2.3 8,5 15.4 100.0 3,452 Some primary 74.5 15.7 2.5 0.6 6.7 80.8 1.5 7.1 10.5 100.0 1,167 Primary complete/some secondary 77.0 12.7 2.5 0.2 7.6 83.1 1.8 5,2 9.8 100.0 1,270 Secondary complete/higher 77.1 9.5 2.0 0.1 11.2 82.2 1.1 3,9 12.8 100,0 3,270 Wealth index Lowest quintile 60.7 23.6 5.3 1.4 9.0 70.1 3.1 9.7 17.1 100.0 1.699 Second quintile 73.6 18.1 2.8 0.4 5.1 82.5 1.6 7.3 8.6 100.0 1,769 Middle quintile 75.2 16.7 1.9 0.1 6.1 81.8 1.6 6.3 10.3 100.0 1,874 Fourth quintile 77.3 11.0 1.9 0.2 9.6 81.6 1.5 5.6 11.3 100.0 1,937 Highest quintile 74.1 7.1 1.5 0.1 17.2 78.5 0.9 2.6 18.0 100.0 1,879 Total 72.4 15.1 2.6 0.4 9.4 79.0 1.7 6.2 13.0 100.0 9,159 Family Planning [ 43 Att i tude about T iming o f Use The 2003 EIDHS included questions about the appropriateness of a couple's use of family planning before the first pregnancy and after the first birth. These questions were not asked of the ever-married women who disapproved of a couple using family planning at all (2 percent of all ever-married women). The results presented in Table 3.15 indicated that most women (90 percent) consider it appropriate for a couple to start using family planning after the first child. However, only 5 percent consider use before the first pregnancy as appropriate. Women in the lowest quintile on the wealth index and in rural Upper Egypt are least likely to approve of family planning use either before the first pregnancy or after the first birth. Table 3.15 Timing of use of family plannine by newly married couples Percentage of ever-married women who do not disapprove of family planning use by atlitude about appropriateness of a couple's using family planning before the first pregnancy and after the first birth, according to selected background characteristics, Egypt 2003 Percentage believing family planning use is __ appropriate: Number Background Before first After first of characteristics pregnancy birth women Age 15-19 6.4 89.6 339 20-24 4.4 92.9 1,339 25-29 4.9 9 [. I 1,760 30-34 4.7 91.4 1,389 35-39 4.2 87.7 1,563 40-44 5.8 88.6 1,341 45-49 4.6 84.9 1,226 Urban-rural residence Urban 5.6 93.7 3,866 Rural 4.3 86.4 5,092 Place of residence Urban Governorates 5.9 94.8 1,650 Lower Egypt 5. I 91,2 3,989 Urban 5.4 93.0 1,162 Rural 5.0 90.4 2;827 Upper Egypt 4.0 85.0 3,319 Urban 5.3 92,9 1,054 Rural 3.4 81,3 2,265 Education No education 3.7 84.0 3,340 Some primary 5.2 89.0 I, [ 34 Primary comp./some secondary 4.8 90.7 1.256 Secondary complete/higher 5.9 9531 3,228 Wealth index Lowest quintile 3.3 81.2 1,638 Second quintile 3.6 88.6 1,71 I Middle quintile 5.6 89.5 1,834 Fourth quintile 4.7 92.3 1,911 Highest quintile 6.7 95.0 1.864 Approves of family planning Approves 4.9 90. I 8,887 Unsure if approves 0.7 16.4 71 Total 4.8 89.5 8,958 44 I Family Planning 4 FAMILY PLANNING SERVICES The 2003 EIDHS obtained information on a number of aspects of the family planning service delivery including the source from which users had obtained their method, the cost of obtaining services, and the wil l ingness to pay, and the extent of information provided to women obtaining family planning services from clinical sources. This information is presented in this chapter. 4.1 Source of Family Planning Methods Detailed information was collected in the 2003 EIDHS on the sources from which family planning methods were obtained. To obtain these data, current users of modern methods were asked for the name and location of the source where they got their methods at the beginning of the current segment of use. The findings of the 2003 EIDHS presented in Table 4.1 indicate that the users are more likely to obtain their methods from the public sector facilities (56 percent) than from private medical or other sources. Table 4.1 Source for modern family plannin~ methods Percent distribution of current users of modem family planning methods by most recent source, according to specific methods, Egypt 2003 Female Source Pill IUD Injection Condom sterilization Total Public sector 14.8 61.2 82.0 14.0 34.0 55.6 Urban hospital 1.8 7.5 7.7 1.5 16.0 6.9 Urban health unit 1.7 21.2 I 1.3 4.1 0.0 16.0 Rural hospital 1.1 4.1 8.2 0.0 2.4 4.0 Rural health unit 8.1 16.7 45.7 2.3 0.0 18.8 MCH centre 0.8 7.0 4.7 3.7 0.6 5.5 Mobile unit 1.1 3.1 3.3 2.0 0.0 2.7 Other MOHP unit 0.0 0.3 0.0 0.0 0.0 0.2 Teaching hospital 0.0 0.1 0.3 0.0 2.1 0. I Health Insurance Organization 0.0 0.6 0.3 0.3 0.0 0.4 Curative Care Organization 0.0 0. I 0.3 0.0 0.0 0.1 Other governmental 0.2 0.7 0.2 0.0 12.8 0.8 Private sector 84.4 38.7 14.7 83.2 62. I 43.5 Egypt Family Planning Association 0.0 1.7 1.0 0.3 0.0 1.3 Clinical Services Improvement project 0.0 2.6 0.4 0.0 0.0 1.7 Other NGO/PVOs 0.1) 0.3 0.3 0.0 0.0 0.2 Mosque health unit 0.0 1.6 0.8 0.0 2.1 1.2 Church health unit 0.0 0.3 0.2 0.0 0.0 0.2 Private hospital/clinic 0.2 1.9 0.5 0.0 10.4 1.6 Private doctor 23) 30.3 5.8 2.3 49.5 21.7 Pharmacy 82.2 0.0 5.6 80.5 0.0 15.6 Other 03) 0.1 3.1 0.5 4.0 0.7 Friends/relative 0.8 0.0 1.1 0.0 0.0 0.3 Other 0.0 0.1 2.0 0.5 4.0 0.5 Don't know 03) 0.0 0.3 2.3 0.0 0.1 Total percent 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 786 3,095 670 75 84 4,787 NGO-Nongovernmental organization PVO-Private voluntal3, organization Table 4.1 shows that the source for family planning methods varies markedly by method. The majority of current users of the IUD (61 percent) have the method inserted at a public sector source, mainly at Ministry of Health and Population (MOHP) facilities. In general, those users relying on a government Family Planning Services" ] 45 source fbr the IUD get the device inserted at a static facility; however, 3 percent of IUD users obtain the method from MOHP mobile clinics. Around one-third of IUD users go to private physicians, hospitals or clinics for the method, while 5 percent obtain the method at clinics operated by nongovernmental private voluntary organizations and an additional 2 percent get the method at Facilities operated by a mosque or a church. Table 4.1 shows that the public sector is the main source for injectables, with 82 percent of injectable users obtaining the method from governmental sources. As was the case with the IUD, most injectable users obtain their method at a static facility, especially rural health units (43 percent). Only three percent get the injectable from a mobile clinic. With regard to the sources for other methods, pill users mainly get their method from a pharmacy (82 percent), as do couples using the condom (81 percent). The small number of sterilization users is more likely to have had the operation performed at a private facility than public facility. Trends in the source of family planning methods during the period between the 1995 and 2003 DHS surveys are presented by residence in Table 4.2 for IUD users and fbr users of all modern methods. Overall, the table indicates that there has been an increase in the likelihood that a user will rely on public sector for family planning methods since 1995. The percentage of users of modern methods who obtained their method from a governmental provider increased from 36 percent in 1995 to 56 percent at the time of the 2003 EIDHS. Much of that change is due to increased reliance on the public sector for the IUD. Table 4.2 shows that the percentage of users who obtained the IUD at a public sector provider increased from 45 percent in 1995 to 61 percent in 2003. Table 4.2 Trends in source for modern Ihmily planning methods by residence Percentage of current users of IUD and all modern family planning methods who obtained their method fiom a public sector source, according to urban-rural residence and place of residence, Egypt 2003 IUD Total Residence 1995 2000 2003 1995 2000 2003 Urban-rural residence Urban 42.8 48~7 55.0 34.0 42.0 46.3 Rural 46.7 59.4 67. I 37.7 54.8 63.6 Place of residence Urban Governorates 46.5 48.8 59.3 39.7 43.5 51. I Lower Egypt 44.4 54.9 62. I 35.2 50.2 56.8 Urban 37.4 47.5 51.4 27.5 40.9 40.2 Rural 47.3 58.0 66.2 38.6 54. I 63.5 Upper Egypt 42.1 57.3 61.1 32.3 50.0 56.8 Urban 39.9 50. I 5 I. I 29.6 40.8 45.3 Rural 44.5 63.5 69.3 34.8 56.3 63.9 Total 44.5 54.0 61.2 35.7 48.6 55.6 Considering the variation by residence, the trend toward an increased reliance on public sector providers was observed among users in all areas. However, the magnitude of the increase was somewhat greater for rural users than urban users. Within rural areas, the trend was considerably more evident among users in rural Upper Egypt than among users from rural Lower Egypt. 46 I Family Planning Services 45 Figure 4.1 Trends in Percentages of Users Obtaining IUD and All Modern Methods from Public Sector Providers gll m 61 54 1995 211011 2003 • I[;D El All Modern Methods ] 4.2 IUD Use IUD users represent ll]O['C than hvo-thirds o f all users. Informat ion was col lected fl-om women using an IUD on the actual cost of" obta in ing the method ( inser l ion and purchasing) and also on their wi l l ingness lo pay specif ic amounts l\~r the method. Actual Cost Table 4.3 presents the actual amount that IUD users paid. F ive percent had the method inserted for free. Around two-th i rds (62 percent) paid 15 pounds or less to obtain the method, with 52 percent paying 5 pounds or less. The median amount IUD users paid for the method was 4. I pounds; this is 1.7 pounds be low the median cost reported in the 2000 EDHS. The cost di f ferential is largely due to flw greater number o f users obta in ing the method at publ ic sector faci l i t ies m 2003 than in 2000. Pe]cetlt distribution of current usels o f lUD by cost of lhe lnclhod {in pounds), according to the type of plovidcl, Fgypt 2003 Public Plivate NGO/ MOSqLIC/ health doctill PVO church (ost ot IUD fhcility clinic clinic clinic [ otal Flee 74 2.4 0.9 Off 5.3 3 pot,nds 4-~ 4 0.5 7.1 39 28.3 3 5pounds 357 19 22.2 11 ~ 235 6 10pounds 54 4.4 68 94 52 ' 11-15 pounds 2.2 6.7 27.8 I81 52 16-20pounds 10 148 17.0 15.7 64 21 30 pounds 0.9 227 9.5 21.4 8.8 31 50 pounds 0.• 22.2 3.8 147 7.9 51 pounds ol more 02 I 1.o 1.0 2 8 40 Don't know/missing 13 13.2 4.0 2.8 53 ] ota[ 100.0 100.0 100.0 100.0 1000 N unlbcl Of" \volllcn 1,893 999 142 60 3,095 i Medim 29 277 128 179 4 I Mean 38 32.5 14.0 21.1 13.1 t=amilv Planning Sere'ices ] 47 The amount that a user paid to obtain an 1UD varied by type of provider. The lowest median amount a user paid was observed among users who got the 1UD inserted at public facility (2.9 pounds). The median cost paid at a private doctor (27.7 pounds) is around ten times the cost paid at a public facility, while the median cost of lUD at the mosque/church clinic is about six times the cost that at the public sector facility (17.9 pounds). Willingness to Pay To investigate whether higher prices might be charged for IUD, all current IUD users were asked about their willingness to pay various amounts for the method. The amounts asked about ranged from 5 to more than 200 pounds. The results in Table 4.4 indicate that many IUD users would be willing to pay considerably more for the method than they currently pay. As expected, the proportion willing to pay a specific amount decreases as the suggested amount increases. Virtually all IUD users (96 percent) would be willing to pay 5 pounds, and 85 percent say they are willing to pay 10 pounds. Almost 60 percent of women would be willing to pay 25 pounds, and 33 percent express a willingness to pay 50 pounds. Relatively few women would be willing to pay 100 pounds or more for an IUD; 10 percent of IUD users say they would pay 150 pounds for an IUD, and 6 percent would be willing to pay more than 200 pounds. Table 4.4 Amount users are willing to pay for IUD insertion Percentage of current users of the IUD willing to pay various amounts tor the method, Egypt 2003 Amount Total 5 pounds 964 I0 pounds 85.3 25 pounds 58.4 50 pounds 32.6 100 pounds 16.5 150 pounds I 0.0 200 pounds 7.(1 More than 200 pounds 5.5 Number of users 3,095 The large degree of variance between what users currently pay for the 1UD and the amounts that they say they would be willing to pay suggests that the method may be considerably underpriced in both the public and private sector. However, some caution must be exercised in interpreting the results in this manner. The question on willingness to pay is hypothetical, and women may have been embarrassed to tell an interviewer that they were unwilling to pay more for the method. 4.3 Pill Use Overall, 15 percent of all family planning users rely on the pill. In the 2003 EIDHS, current users of the pill were asked questions on the brand of pills they used, the cost of a pill cycle, and the amount that would be willing to pay for a cycle. Brand Information about the brands used by women was collected by ask- ing pill users to show the packet of pills. If the packet was available, the interviewers recorded the name of the brand. I ra user was unable to show the EIDHS interviewer the packet, she was asked to name the brand she was using. Around a quarter of all users of the pill were not able to show a packet or identify the brand they were using. Table 4.5 shows that that Microvlar is the most commonly used brands (44 percent each), followed by Triovlar and Nordette (11 percent and 8 percent, respectively). Table 4.5 Brand of pill used Percent distribution of pill users by the brand of pill currently used, Egypt 2003 Brand I'ota[ Microv[ar 43.5 Nordette 7,9 Triovlar I 1.3 Norminest (1.7 Primovlar 0.9 Other 12.3 Don't know/missing 23.4 Total percent 100.0 Number of women 786 48 I Family Planning Services Cost of Pill To obtain information on cost, current users were asked about the amount that they paid for the most recent packet of pills. According to the results in Table 4.6, virtually all pill users are paying more than 50 piastres for a cycl e of pills, 42 percent pay more than one pound (100 piastres), and around one-quarter pay more than two pounds (200 piastres). The median cost of a cycle is 100.4 piastres, somewhat higher than in the 2000 EDHS when median price for a pill cycle was 95.2 piastres. Willingness to Pay Pill users were asked about their willingness to pay specific amounts for the pill in order to ascertain whether they would be likel3, to pay a higher price for the method. The amount asked ranged from 50 piastres to more than 5 pounds. Table 4.7 indicates that many of pill users would be willing to pay more than they do. As expected, the proportion expressing a willingness to pay is directly associated with the amount mentioned. Almost all pill users would be willing to pay 50 or 75 piastres, and 93 percent would be willing to pay one pound. Three-quarters of pill users (76 percent) would be willing to pay two pounds. There is greater reluctance to pay higher amounts, with around a half of pill users indicating that they would be willing to pay 5 pounds and two-fifths said that they would be willing to pay more than 5 pounds for a cycle of pills. 4.4 Injectable Use Table 4.6 Cost of method for pill users Percent distribution of current users of the pill by cost of a cycle of pills (in piastres), Egypt 2003 Cost of pill Total Free 1.4 1-50 piastres 0.1 51-75 piastres 36.8 76-100 piastres 15.8 101-200 piastres 16.6 More than 200 piastres 25.8 Don't know/missing 3.5 Total 100.0 Number of women 786 Median 100.4 Mean 315.5 Table 4.7 Amount users are willing to pay for the pill Percentage of current users of pill willing to pay various amounts to obtain the method, Egypt 2003 Amount Total 50 plashes 99.9 75 piastres 97.8 1 pound 92.8 2 pounds 75.7 5 pounds 48.1 More than 5 pounds 39.9 Number of women 786 Overall, 13 percent of all current family planning users are using an injectable. In the 2003 EIDHS, current users of the injectables were asked questions on the periodicity of receipt the injectable, the cost of an injectable, and the amount that would be willing to pay for an injectable. Type of Iniectable Most injectable users (95.7 percent) indicated that they received an injection every three months (not shown in table). Only a small percentage reported that they received the injectable at one-month intervals (3.6 percent). The small number of remaining users either reported getting the injectable at a two-month interval or was unable to specify the interval at which they received the injection. Family Planning Services [ 49 Actual Cost Table 4.8 shows that five percent of injectable users get the method for free, and around three-quarters (72 percent) paid less than 3 pounds for the method. The median cost was 1.7 pounds, which is lower than the average cost for the injectable at the time of 2000 EDHS (2.3 pounds) and substantially lower than the average cost MOHP reduced the cost of the injectable to one pound in late 1999 and provided the method for free at mobile clinics from that point. This is at least in part responsible for the decline in the average cost of the injectable since MOHP facilities provide the method to the majority of injectable users. Willingness to Pay Injectable users were asked about their willingness to pay specific amounts for the method in order to ascertain whether they would be likely to pay a higher price for the method. The amounts asked about ranged from 2 to more than 20 pounds. Table 4.8 Cost of method for iniectablc USerS Percent distribution of cunent users of injectables by the cost of the method (in pounds), Egypt 2003 Cost of injectable Total Free 5.0 <3 ponnds 71.7 34 pounds 7. I 56 pounds 5.9 %8 pounds 4.7 0-10 pounds 27 I I+ pounds 23 Don't kn,aw/missing 0.8 Total 100.0 Number of women 670 Median 1,7 Mean 2.3 Table 4.9 indicates that many injectables users would be willing to pay more for the method. As expected, willingness to pay is directly associated with the amount mentioned. Almost all injectable users (96 percent) would be willing to pay 2 pounds for the method, around three-quarters would pay 5 pounds, and around 40 percent would be willing to pay 10 pounds. Considerably fewer users expressed a willingness to pay larger amounts for injectables, with only 8 percent reporting they would be willing to pay more than 20 pounds. 4.5 Service Assessment Indicators All current users were asked a series of questions in order to assess the quality of services from the source from which they obtained "Fable 4.9 Amount users are willing to pay foriniectables Percentage of current users o[ injectables willing to pay various amounts to obtain the method, Egypt 2003 Amount willing to pay tbr an injectable Total 2 pounds 95.6 5 pounds 75.9 10 pounds 38.5 15 pounds 17.6 20 pounds I 1.7 More than 20 pounds 7.8 Number of women 670 the method. The results of these questions are presented in Table 4.10. Overall, they suggest that there is adequate information exchange in only about half of the encounters between current users and the providers from which they obtain their methods. Looking at specific items, more than half of users (56 percent) reported that the provider told them about other methods than the one the user received. Providers described the side effects to also more than half of the users, while around 46 percent of current users reported that the provider told them what to do about side effects. The level of information exchange differed by method, with IUD users generally likely to receive more information from providers than users of other methods. For example, providers advised 48 percent of IUD users about what to do if they experienced side effects compared with 34 percent among pill users and 40 percent of users relying on other methods. The level of information exchange also differed according to the type of provider. In general, private providers appear to be somewhat better at counseling users than public sources. 50 ] Family Planning Services' Table 4.10 Service assessment indicators lbr clinical providers Percentage of current users consulting a clinical source at the beginning of the segment of use (since January 1998) who reported they were advised about various aspects of the method they obta!ned according to type of source and method, Egypt 2003 NGO/ Private Public PVO clinic/ Service assessment indicator clinic clinic doctor Total IUD Told about other methods 54.4 61.5 58.6 56. I Told about side effects During current segment of use 46.9 56.6 59.3 51.5 Ever but not during current segment 7.1 5.2 5.1 6.4 Told what to do about side effects 44.7 52.1 54. I 48.2 P ILL Told about other methods 53.3 73.3 55.8 Told about side effects During current segment of use 29.4 49.8 32.0 Ever but not during current segment 9.9 17.0 10.8 Told what to do about side effects 31.4 51.6 33.9 OTHER METHODS Told about other methods 54.7 63.9 56. I 55.1 Told about side effects During current segment of use 44.6 21.0 51.7 45. I Ever but not during current segment 6.4 7.1 7.6 6.6 Told what to do about side effects 39.0 21.0 46.0 39.6 TOTAL Told about other methods 54.4 61.7 58.6 55.9 Told about side efl~cts During current segment of use 45.5 53.1 58.5 49.5 Ever but not during current segment 7.1 5.4 5.5 6.6 Told what to do about side effects 42.6 49.1 53.3 45.9 NGO Nongovernmental organization PVO Private vo[untat-y organization Family Planning Services J 51 5 MATERNAL HEALTH Both mother and child benefit when a woman receives proper medical care during pregnancy and childbirth. To obtain data on women's utilization of maternity care services, E IDHS respondents were asked a series of questions relating to the types of health care services that they received during pregnancy, at delivery and in the postnatal period for each birth during the five-year period before the survey. This chapter reviews these data and also examines trends in key maternal health indicators. 5.1 P regnancy Care Antenata l Care Coverage Early and regular antenatal checkups by medical providers are very important in assessing the physical status of women during pregnancy. Table 5.1 presents data from the 2003 EIDHS on the coverage of antenatal care services for births during the five-year period prior to the survey. A birth is considered to have received antenatal care i f the mother said that she had made at least one antenatal care visit, i.e., a visit to a medical provider for care for the pregnancy. Egyptian women received antenatal care from a medical provider for more than two-thirds of the births occurring during the five-year period before the survey. Most women saw a doctor for the care with less than one percent reporting that they had had care only from a trained nurse/midwife. Women were more likely to obtain antenatal care from a private doctor or clinic (45 percent) than a public provider (23 percent). At least four antenatal visits are recommended during a woman's pregnancy to ensure proper care. Most women who obtained antenatal care at all reported that they had regular care. Overall, women received regular antenatal care (i.e., they made four or more visits to a provider) for 56 percent of all births prior to the survey. Considering only those births for which care was received, the median number of antenatal visits was 6.9. It is also recommended that a woman have the first antenatal checkup early in the pregnancy to help prevent problems. EIDHS respondents saw a provider for care for the first time before the sixth month of pregnancy for more than 9 in 10 of the births for which antenatal care was reported (i.e., in 65 percent of all births). In order to detect problems that might affect the delivery, a woman should also see a provider late in the pregnancy. Respondents saw a provider within the last two months of pregnancy in 9 in 10 of the which the mother had any antenatal care (i.e., in 62 percent of all births). Table 5.1 Antenatal care Percent distribution of births during the five- year period before the survey by type of provider for antenatal care, the type of facility where ANC care was sought, the number of antenatal care visits, and the stage of pregnancy at the time of the first and last visits, Egypt 2003 Total ANC provider Doctor 68.6 Trained nurse/midwife 0.1 Daya/missing 0.1 No care 31.2 Source for ANC Public sector 23.4 Hospital 5.0 Health unit 15.6 MCH center 2.7 Private doctor/clinic 44.9 Other/missing 0.5 No care 31.2 Antenatal visits for pregnancy None 31.2 1 1.3 2 3.9 3 5.6 4 or more visits 55.6 Don't know/missing 2.4 Median 6.9 Timing of first antenatal check No antenatal care 31.2 Less than 4 months 50.2 4-5 months 14.5 6-7 months 3.0 8+ months 0.8 Don't know/missing 0.3 Months pregnant at last visit No antenatal care 31.2 < 4 months 0.5 4-5 months I. I 6-7 months 4.6 8+ months 62.3 Don't know/missing 0.3 Total / 00.0 Number of births 6,314 Maternal Health [ 53 Coverage of Tetanus Toxoid Vaccinations Tetanus toxoid injections are given to women during pregnancy to prevent infant deaths from neonatal tetanus. Neonatal tetanus can result when sterile procedures are not followed in cutting the umbilical cord following delivery. Table 5.2 shows that women received at least one tetanus toxoid (TT) vaccination in the case of 78 percent of the births during the five-year period prior to the EIDHS. In the case of slightly more than 2 in 5 of these births, mothers received two doses of the TT vaccine. More than 9 in 10 women who received a TT injection reported they obtained it from a public sector provider. The MOHP has stressed the importance of using the contact providers have with pregnant women during the provision of the TT vaccinations to encourage women to obtain regular antenatal care and to discuss the use of family planning. To assess the impact of this effort, the 2003 EDHS collected information from women who had received a TT vaccination prior to the last birth on whether anyone had encouraged them to seek antenatal care and whether anyone had talked with them about family planning at the time that they received the injection(s). The results in Table 5.2 indicate that 29 percent of the women who received a tetanus toxoid injection prior to the last birth (i.e., 22 percent of all women) reported that they were encouraged to obtain antenatal care, and 15 percent (i.e., 12 percent of all women) said that someone talked to them about family planning. Medical Care Unrelated to the Pregnancy Table 5.2 Tetanus toxoid coverage Percent distribution of births during the five- year period before the survey by the number of tetanus toxoid (TT) injections and source for injections and, among births where the mother reported receiving a TT injection, the percent distribution according to the type of advice given about ANC or family planning at the time of the TT injection(s), Egypt 2003 Total Tetanus injections None 21.2 One dose 43.4 Two doses or more 34.6 Don't know/missing 0.8 Source for TT injection Public sector 73. I Hospital 6.7 Urban/rural health unit 60.6 MCH center 5.8 Private doctor/clinic 4.3 Other/missing 1 4 No TT injection 21.2 Total 100.0 Number of births 6,314 Advice about ANC/FP Advised to seek ANC t2.4 Told about FP 2.7 Both ANC and FP discussed 9.4 Neither ANC or FP discussed 54.0 No TT injection/missing 21.6 Total 100.1) Number of last births 4,574 In addition to the questions on antenatal care and tetanus toxoid vaccinations, the 2003 EIDHS included a number of questions designed to determine whether women received other medical care during pregnancy. These questions were asked both of women who reported receiving antenatal care and those who did not report seeing anyone for care for the pregnancy. They were intended to ascertain the full range of medical care women received during pregnancy and, particularly, to identify women who did not have antenatal care but had received medical care unrelated to the pregnancy. Table 5.3 takes this information into account in looking at the overall proportion of births in the five years preceding the survey for which women reported receiving any type of medical care during pregnancy according to the type of care received. Overall, women saw a medical provider during pregnancy for some type of care in 92 percent of all births that occurred during the five-year period prior to the survey. Women received both antenatal care and at least one TT injection prior to around half of the births. Tetanus toxoid coverage was not universal among women who had had antenatal care; women reported that they received antenatal care but had not had a tetanus toxoid vaccination in the case of 13 percent of the births. Similarly, Table 5.3 shows for around 22 percent of births women got a TT injection without seeing anyone for antenatal care. 54 ] Maternal Health T~lble ~ 3 M~'c {)the)" thai1 visit fbr antenatal ca ie or tetamis toxoid iniectintlduring pkcgnancy Perccnl distribution of births during the five year period bcl)re the survey by mother'sreporl of sechlg doctor o~ other health worker at any time during the pregnancy Ibr care other than antenatal care (ANC) checkup or tetanus toxoid (TT) injection, according to mothcr'sANC and TT status. Egyp~ 2003 ANC Neither ANC Received olher medical ANC and TT TI iRiection nor 1T car,: du) ing plcgnancy only ii!jection only injection To~al Had other care 16 6.4 3 2 1.3 12.6 No other cal e 11.5 49.2 192 7.6 87.4 "1 otaI ] 3. I 55.6 22.4 8.9 100,0 Finally, wolnen reported seeking medical care for an illness or problem unrelated to the pregnancy in the case of 12 percent of the births. Most of the women who reported they had seen a medical provider for care unrehttcd to their pregnancy had also seen a provider for antenatal care and/or a TT injection. Different ia ls in P regnancy Care lndicaturs Table 5.4 presents differences across subgroups for five pregnancy care indicators: any antenatal care during pregnancy, regular antenatal care, at least one tetanus toxoid injection, medical care unrelated to the pregnancy, and any type of medica[ care during pregnancy. Looking at the age patterns, the differentials are mixed. In general, however, mothers age 35 and over are least likely to report receiving any type of care during pregnancy. The association between the child s birth order and the care indicators is negative, except in the case of care unrelated to the pregnancy. The various care indicators are generally higher for urban than rural births. For example, the percentage of urban births in which the mother received regular antenatal care is substantially higher compared to the proportion among rural births (74 percent and 45 percent, respectively). 111 the case of tetanus toxoid coverage, however, the level is slightly higher tbr rural than for urban births (82 percent and 71 percent, respectively). Births in Upper Egypt rank lowest on all of the pregnancy care indicators. Coverage of antenatal care services is especially low in rural Upper Egypt (Figure 5.1 ). I 00 80 60 40 20 0 m [ rban ( ;o~er- norRtes m Total Figure 5.1 Antenatal Care by Place uf Residence m m m i Ilrban Rural Total Urban Littler Egypt Upper Egypt • Four+~isits El 1-3 visi(s m Rural 3/[aZcrna/Hen/Us J 55 Table 5.4 Care during pregnancy Percentage of births in the five-year period before the survey whose mother received any antenatal care and regular antenatal care from a medical provider, one or more tetanus toxoid injections, other medical care unrelated to the pregnancy and any medical care during the pregnancy, by selected background characteristics, Esypt 2003 Antenatal care One or Other Any Number Background more TT medical medical of characteristic Any Regular injections care care births Age at b i r th < 20 66.8 52.1 84.7 12.0 93.9 735 20-34 69.9 56.9 79.6 12.4 93.7 4,905 35-49 62.1 50.3 59.2 14. I 81.4 674 Birth order I 80.3 68.9 84.3 12.6 97.4 1,858 2-3 69.9 56.3 79.6 12.3 94.4 2,816 4-5 59.5 45.5 71.8 13.8 88.6 1,038 6+ 43. I 28.9 62.2 I 1.7 74.2 602 Urban-rural residence Urban 82.7 73.5 71. I 15. I 95.8 2,362 Rural 60.3 44.9 82.1 1 I. 1 90.4 3,952 Place of residence Urban Governorates 83.9 75.4 66.2 19.0 96.0 911 Lower Egypt 75.0 6 I. I 83.6 10.7 95.9 2,688 • Urban 85.8 76.4 75.0 11.0 96.3 751 Rural 70.8 55.2 86.9 ] 0.5 95.7 [ ,937 Upper Egypt 57.4 43.5 76.5 12.3 87.8 2,715 Urban 77.8 68.0 73.5 14.2 95. I 700 Rural 50.3 35.0 77.5 I 1,6 85.2 2,015 Education No education 48.8 34.4 76.8 10.2 84.2 2,142 Some primary 61.1 45.8 79.2 12.7 91.3 638 Primary complete/some secondary 69.0 56.3 82.2 15.0 95.9 1,023 Secondary complete/higher 87.5 75.9 77.1 [ 3.6 98.3 2,511 Work status Working for cash 8 I. I 71.3 71.9 13.5 93.7 755 Not working for cash 67.0 53.5 78.8 12.4 92.2 5,559 Wealth index Lowest quintile 45.2 29.2 75.8 I 1.3 83.3 1,366 Second quintile 58.7 44.4 82.9 10.3 90.5 1,279 Middle quintile 71.4 56.0 83.4 12.0 93.8 1,323 Fourth quintile 81.6 70.7 81.9 15.3 97.2 1,319 Highest quintile 92.4 84.9 62.9 14.4 98.9 1,029 Total 68.7 55.6 78.0 ~ 2.6 92.4 6,314 Note: A birth is considered to have received antenatal care if there was at least one antenatal care consultation with a medical provider during the pregnancy. Regular care refers to four or more antenatal visits during the pregnancy. A birth is considered to have received any medical care if the mother reported at least one antenatal care visit, at least one tetanus toxoid injection, and/or at least one visit to a provider for medical care that the mother considered to be unrelated to the pregnancy. There generally is a positive association between the women's education status and the various pregnancy care indicators. The relationship is particularly marked in the case o f regular ANC, with such care being more than twice as common among births to women who have a secondary or higher education than among births to women who have never attended school. Except for tetanus toxoid, the levels for the pregnancy care indicators are higher for births to women who work for cash than other women. Both the likelihood a woman will receive any antenatal care and the likelihood she will receive regular care increase markedly with a household's position on the wealth index• TT coverage 56 I Maternal Health is more variable, with women living in households ranking in the highest quintile having the lowest coverage levels. 5.2 Content of Pregnancy Care In the 2003 EIDHS, women who reported that they received antenatal care, tetanus toxoid injections or other medical care unrelated to the pregnancy were asked questions related to the types of routine screening they may have received during the visit to their provider for the care. These women were also asked if they had been told about the signs of pregnancy complications, and, if they were told, whether they received any information about where to go if they experienced any complications. Finally, women were also asked if they were given iron tablets or syrup. Iron supplementation during pregnancy is recommended to prevent iron deficiency anemia, which is a common problem among pregnant women. Table 5.5 6 shows that around half of the mothers were given a maternal card. In the case of around three-quarters of births in which mothers who saw a medical provider during pregnancy, the woman reported that she had been weighed or her blood pressure monitored. Mothers reported that urine and blood samples were taken in around 3 in 5 births while the mother's height was measured in the case of a little more than half of the births. Iron tablets/syrup were received or bought in 45 percent of the births. Mothers were advised about the complications that they might experience in the case of 32 percent of the births and told were to seek assistance if they actually had problems in the case of 28 percent of the births. Table 5.5 shows that the proportions who reported the various care items were generally somewhat higher among women who received regular antenatal care than among other mothers. In turn, mothers who had some but not regular antenatal care were more likely than mothers who had had no antenatal visits to indicate that routine antenatal care procedures were performed, that they had had advice about pregnancy complications, and they had received or bought iron supplements. Marked differentials in the content of care are evident by the demographic and socioeconomic characteristics shown in Table 5.5. For example, there is a very strong negative association between the child's birth order and routine antenatal care procedures. In general, the procedures were more likely to have been performed in the case of urban than rural births, with particularly low levels found for births in rural Upper Egypt. A positive association is observed between the woman's education status and the indicators of the quality of pregnancy care presented while a negative association exists between the proportion reporting receiving a pregnancy care indicator and the household's position on the wealth index. The indicators were also more common among births to women who worked for cash than other births. %pine caution must be exercised in considering the information in Table 5.5 since it is dependent on the mother's understanding of the questions, e.g. her understanding of what blood pressure measurement involves. It is also dependent on the mother's recall of events during visits to the provider that may have taken place a number a number of years before the 2003 EIDHS interview. Nonetheless, the results are useful in providing insights into the content of the care Egyptian women receive during pregnancy. Maternal Health [ 57 Table 5,5 Content of pregnancy care Percentage of births in the five-year period before the survey whose mothers received any care during the pregnancy, by content oftbe care and selected background characteristics, Egypt 2003 Told Given Received/ Told about where to mater- Height BP bought iron signs of go for Number Background nal mea- mea- Urine Blood tablets/ compli- compli- of characteristic card Weighed sured sured sample sample syrup cations cations births Medical care during pregnancy Had ANC 68.7 89.1 68. I 90.6 75.9 77.5 58.4 40.3 35.8 4,338 Four or more visits 70.5 90.2 69.6 92.5 78.3 79.9 61.4 41.7 37.2 3,511 Fewer than 4 visits 60.9 84.5 61.9 82.5 66.0 67.4 45.7 34.4 30.0 827 NoANC 18.1 47.3 26.7 39.4 23.4 26.4 16.0 13.2 10.8 1,976 TT or other care 23.9 62.3 35.2 51.9 30.8 34.7 19.4 17.4 14.1 1,496 Type of provider Public sector 52.0 78.2 55.7 69.6 55.9 58.2 34.4 25. I 21.5 2,503 Private sector 54.2 80.9 59.8 90.3 68.7 68.9 59.3 44.4 39.9 1,018 Both 64.6 87.8 64.4 89.1 72.1 75.2 59.2 40.3 35.7 2,291 No care/missing 1.3 1.4 1.1 1.2 0.9 0.9 6.0 0.9 0.9 502 Age at birth <20 50.7 77.3 54.2 72.5 60.5 64.1 42.2 31.4 27.7 735 20-34 54.0 77.4 56.4 76.3 60.6 62.6 46.7 32.4 28.2 4,905 35-49 47.1 64.5 47.3 64.2 50.4 50.9 37.2 28.3 26.4 674 Birth order 1 61.5 84.4 62.3 84.6 71.6 74.3 53.0 38.5 33.8 1,858 2-3 53.1 78.0 56.9 76.4 59.9 61.6 46.7 31.0 27.4 2,816 4-5 46.6 68.9 49.9 65.1 49.8 52.1 37.2 28.0 24.2 1,038 6+ 35.8 53.1 34.5 51.3 36.9 38.0 27.2 21.3 19.2 602 Urban-rural residence Urban 62.4 83.0 64.8 84.9 70.5 71.0 56.6 39.2 35.1 2,362 Rural 47.2 71.8 49.4 68.4 52.9 55.8 38.3 27.4 23.7 3,952 Place of residence Urban Governorates 65.2 84.2 67.3 88.2 75.2 76.2 62.0 45.9 42.3 91 I Lower Egypt 59.8 81.1 56.0 82.6 64.5 67.7 47.2 36.4 31.2 2,688 Urban 66.3 84.3 64.9 86.6 72.0 72.6 56.8 45.2 39.2 751 Rural 57.3 79.9 52.5 81.1 61.6 65.8 43.5 33.0 28.1 1,937 Upper Egypt 41.9 68.2 50.3 62.0 49.3 50.5 37.4 22.5 20.0 2.715 Urban 54.6 80.1 61.3 78.9 62.7 62.7 49.4 24.2 21.5 700 Rural 37.4 64.1 46.5 56.2 44.6 46.2 33.3 21.9 19.4 2,015 Education No education 40.9 63.8 44.6 58.8 45.0 48.0 29.7 21.7 18.7 2,142 Primary incomplete 46.7 70.6 47.4 67.5 49.9 51.5 37.3 28.3 24.3 638 Primary complete/ some secondary 51.1 79.4 53.8 78.8 61.4 62.7 44.8 34.1 30.3 1,023 Secondary complete/ higher 65.3 86.4 66.7 88.1 73.5 75.1 60.4 40.4 35.9 2,511 Work status Working for cash 63.7 81.5 63.7 82.5 72.0 72.4 55.6 40.2 34.1 755 Not working for cash 51.4 75.3 54.0 73.5 57.8 60.0 43.7 30.7 27.2 5,559 Wealth index Lowest quintile 35.1 60.8 39.4 55.6 42.5 45.2 28.3 20.6 17.7 1,366 Second quintile 47.2 71.8 50.9 69.2 53.3 55.3 36.6 28.0 24.7 1,279 Middle quintile 57.0 78.3 55.7 75.7 61.9 65.7 43.7 35.1 30.5 1,323 Fourth quintile 61.8 82.3 61.0 84.1 65.9 68.1 55.6 37.4 32.4 1,319 Highest quintile 66.7 90.4 73.4 92.7 78.4 77.2 66.5 40.0 36.7 1.029 Total 52.9 76.0 55.2 74.6 59.5 61.5 45.1 31.8 28.0 6,314 58 [ Maternal Health 5.3 Perceptions about ANC Coverage The 2003 E IDHS inc luded two quest ions re lat ing to women's percept ions about antenata l care. The first quest ion re lated to the woman's percept ion about the extent to wh ich women seek antenata l care. Table 5.6 shows that 61 percent o f ever -marr ied women thought that most Egypt ian women rece ived antenata l care, 21 percent bel ieve at least some seek care, f ive percent i re o f the opinion that very few women get care, and 13 percent were unsure. Table 5.6 Perceived coverage of antenatal care Percentage of ever-married women age 15-49 by perceptions of coverage of antenatal care and lrend in antenatal care coverage, E~ypt 2003 Women go for prenatal care How many women seek antenatal care are increasin$ or decreasin~ Stay- Background Very Don't lncrea- Decrea- ing Don't Num- characteristic Most Some few None know Total sin~ sin[~ same know Total ber Antenatal eare Had birth 61.9 22.0 5.2 0.5 10.4 100.0 70.9 2.0 8.3 18:7 100.0 4,574 Antenatal care 66.3 19.8 3.4 0.3 10.2 100.0 75.3 1.7 6.9 16.0 100.0 3,326 No care 50.2 27.7 9.9 1.1 11.0 100.0 59.2 2.9 12.0 25.9 100.0 1,248 No birth 59.8 20.1 4.3 0.4 15.4 100.0 69.1 1.4 7.4 22.1 100.0 4,585 Age 15-19 55.8 21.3 4.6 0.9 17.4 100.0 65.6 1.6 8.4 24.3 100.0 343 20-24 62.5 20.6 5.4 0.2 11.2 100.0 71.1 2.1 7.0 '19.7 100.0 1,372 25-29 63.0 21.0 4.7 0.5 10.8 100.0 70.7 1.5 8.3 19.5 100.0 1,782 30-34 62.7 21.4 4.7 0.2 11.1 100.0 72.8 1.6 7.2 18.4 100.0 1,415 35-39 59.4 22.0 4.6 0.7 13.3 100.0 68.7 1.9 8.4 20.9 100.0 1,588 40-44 59.8 19.7 4.1 0.6 15.8 100.0 68.8 1.5 7.4 22.2 100.0 1,380 45-49 58.5 21.4 5.0 0.3 14.9 100.0 68.9 L5 8.4 21.2 100.0 1,279 Urban-rural residence Urban 63.8 15.2 2.4 0.2 18.4 100.0 72.1 0.7 5.0 22.3 100.0 3,908 Rural 58.7 25.4 6.5 0.6 8.8 100.0 68.4 2.5 10.0 19.1 100.0 5,251 Place of residence Urban Governorates 63.4 I 1.4 1.7 0.1 23.4 100.0 72.0 0.2 3.6 24.2 100.0 1,666 Lower Egypt 66.6 18.8 4.5 0.5 9.6 100.0 76.6 1.3 5.3 16.8 100.0 4,105 Urban 68.9 15.4 1.9 0.4 13.5 100.0 75.5 0.7 4.4 19.4 100.0 1,181 Rural 65.7 20.2 5.6 0.5 8.0 100.0 77.1 1.5 5.7 15.7 100.0 2,924 Upper Egypt 52.6 28.5 6.5 0.6 11.8 100.0 61.0 2.9 13.0 23.0 100.0 3,388 Urban 58.8 20.9 4.0 0.3 16.1 100.0 68.6 1.3 7.7 22.4 100.0 1,061 Rural 49.8 32.0 7.6 0.7 9.9 100.0 57.6 3.7 15.4 23.3 100.0 2,327 Education No education 53.9 25.9 6.5 0.8 13.0 100.0 63.4 2.5 11.0 23.1 100.0 3,452 Some primary 58.9 24.4 4.3 0.4 11.9 100.0 70.7 1.4 8.7 19.2 100.0 1,167 Primary comp./some secondary 64.3 20.0 4.7 0.1 11.0 100.0 72.7 1.2 8.7 17.4 100.0 1,270 Secondary comp./ higher 67.6 15.1 3.1 0.2 14.0 I00.0 75.7 1.1 4.0 19.2 100.0 3,270 Work status Working for cash 64.2 16.9 4.2 0.4 14.3 100.0 74.0 1.4 5.7 18.9 100.0 1,455 Not working for cash 60.2 21.8 4.8 0.4 12.7 100.0 69.3 1.7 8.3 20.7 100.0 7,704 Wealth index Lowest quintile 46.6 29.9 9.2 1.2 13.1 100.0 56.6 3.8 14.0 25.6 100.0 1,699 Second quintile 61.9 23.8 5.3 0.3 8.7 100.0 69.8 2.3 10.0 17.9 100.0 1,769 Middle quintile 64.1 22.0 4.4 0.3 9.2 100.0 74.3 1.3 7.4 17.0 100.0 1,874 Fourth quintile 66.5 17.4 3.0 0.2 12.8 100.0 75.8 0.6 5.2 18.3 100.0 1,937 Highest quintile 63.7 13.3 2.2 0.2 20.6 100.0 72.0 0.7 3.5 23.7 100.0 1,879 Total 60.9 21.0 4.7 0.4 12.9 100.0 70.0 1.7 7.9 20.4 100.0 9,159 MaternalHealth I 59 The second question asked women to provide an opinion about the trend in antenatal care in Egypt. Seven in ten women said that it was increasing, eight percent thought it was remaining at the same level, and less than two percent felt it was declining. The proportion of women who were unsure about trend was 20 percent. Looking at the differentials, it is clear that a woman's own experience with antenatal care is associated with her responses to these questions. Women who had had a recent birth and who had not themselves received antenatal care prior to the birth(s) were among the least likely to think that most Egyptian women were getting antenatal care and also the least likely to see ANC coverage going up. In general, other demographic and socioeconomic differentials in the distributions of women on these two questions follow expected patterns; younger women, rural women, women from Upper Egypt, women with no education, women who are not working or working in a job for which they are not paid in cash are less likely than other women to perceive that most women receive antenatal care and see antenatal care as becoming more common. Women living in households in the bottom quintile on the wealth index and ~vomen living in rural Upper Egypt are the least likely to believe that most women receive care and to see antenatal care as increasing. 5.4 Exposure to Safe Pregnancy Messages Media messages designed to make women more aware of the danger signs during pregnancy are part of the information, education and communication campaign to promote safe pregnancy. The 2003 EIDHS asked all respondents if they had heard or seen any message about pregnancy danger signs during the six month period prior to the survey and, if so, the last source from which they had received the information. Table 5.7 shows that slightly more than half of ever-married women had received information on the danger signs to watch for during pregnancy. Women age 45-49, women with no education and those living in households ranked in the lowest quintile on the wealth index were least likely to have heard a message (41 percent, 43 percent, and 40 percent, respectively). Women with a secondary or higher education (62 percent) were the most likely to have heard or seen a message. With regard to the most recent information source, 71 percent of these women said that they had last received the information through television. With the exception of medical providers who were the most recent source of information for 20 percent of women, less than 5 percent of women mentioned other information sources (e.g., radio or print media). Television was cited most frequently by women living in rural Upper Egypt (85 percent). The largest proportions mentioning medical providers were found among women under age 30, especially women 15-19, women living in the Urban Goveruorates and Lower Egypt, women with a secondary or higher education, and women from households in the two highest quintiles on the wealth index. 60 J Maternal Health Table 5.7 Coverage of safe Dreffnancv messazes Percentage of ever-married women age 15-49 reporting they had received information about danger signs women must be aware of to have a sa~ pregnancy during the six months prior to the survey and, among women receiving information, the percent distribution by the last source from which they received information, according to background characteristics, Egypt 2003 Background characteristic Percentage Number receiving Source of information of inlbrmation Med- women on Number ical Other Frierids/ Total receiving pregnancy of News- Pamph- pro- Hus- rela- neigh- per- informa danger signs women TV Radio papers let Poster vider band tives bors Other cent tion Antenatal care Had birth 56.3 4,574 70.9 0.2 0.3 0.3 0.3 20.7 0.3 4.1 2.8 0.1 100.0 2,575 ANC 59.4 3,326 69.1 0.1 0.2 0.4 0.3 22.4 0.3 4.1 3.0 0.1 100.0 1,974 NoANC 48.1 1,248 77.0 0.2 0.5 0.3 0.4 15.3 0.2 4.0 2.0 0.0 " 100.0 601 No birth 47.8 4,585 70:4 0.2 0.3 0.4 0.4 18.4 0.2 5.5 3.8 0.3 100.0 2,192 Age 15-19 59.2 343 51.7 0.6 0.0 0.0 0.0 34.3 0.4 9.0 4.0 0.0 100.0 203 20-24 58.7 1,372 61.8 0.4 0.4 0.3 0.3 28.6 0.2 5.2 2.9 0.0 100.0 806 25-29 59.0 1,782 68.6 0.2 0.1 0.4 0.5 24.7 0.1 3.2 1.8 0.2 100.0 1,052 30-34 56.2 1,415 71.7 0.0 0.3 0.2 0.6 19.0 0.5 4.0 3.6 0.0 100.0 795 35-39 49.6 1,588 75.7 0.0 0.8 0.2 0.3 14.2 0A 4.6 3.9 0.3 100.0 788 40-44 43.7 1,380 78.9 0.3 0.0 0.6 0.1 9.8 0.1 5.4 4.2 0.7 100.0 604 45-49 40.6 1,279 77.3 0.2 0.5 0.5 0.3 10.6 0.6 5.9 4.0 0A 100.0 519 Urban-rural residence Urban 53.9 3,908 68.6 0.1 0.5 0.6 0.5 22.3 0.3 3.8 2.9 0.4 100.0 2,106 Rural 50.7 5,251 72.3 0.3 0.2 0.2 0.2 17.6 0.2 5.5 3.6 0.0 100.0 2,662 Place of residence Urban Governorates 49.7 1,666 65.8 0.0 1.1 0.3 0.5 24,1 0.4 2.8 4.2 0.7 100.0 827 Lower Egypt 50.9 4,105 61.8 0.4 0.3 0.5 0.6 24.3 0.2 7.2 4.7 0.0 100.0 2,088 Urban 57.3 1,181 62,8 0.4 0.3 0.9 1.0 25.3 0.3 6.2 2.9 0.0 100.0 677 Rural 48.2 2,924 61,3 0.4 0.3 0.3 0.4 23.8 0.1 7.7 5.6 0.0 100.0 1,411 Upper Egypt 54.7 3,388 82.9 0.1 0.0 0.2 0.0 12.5 0.3 2.8 1.2 0.1 100.0 1,852 Urban 56.7 1,061 79.1 0.0 0.0 0.5 0.0 16.4 0.2 2.4 1.[ 0,3 100.0 602 Rural 53.8 2,327 84.7 0.1 0.0 0.0 0.0 10.6 0.3 3.0 1.3 0.0 100.0 1,251 Education No education 43.2 3,452 77.9 0.1 0.0 0.1 0.1 14.3 0.1 4.0 3.4 0.0 100.0 1,492 Some primary 44.1 1,167 69.5 0.0 0.0 0.3 0.2 17.8 0.0 7.3 4.8 0.0 100.0 515 Prim. comp./ sorne secondary 57.6 1,270 72.6 0.5 0.0 0.2 0.3 19.3 0.1 4.4 2.5 0.0 100.0 732 Secondary complete/higher 62.0 3,270 64.9 0.2 0.8 0.6 0.5 24.2 0.5 4.7 3.0 0.4 100.0 2,029 Work status Working for cash 55.4 1,455 68.0 0.2 0.6 0.7 1.5 19.4 0.3 4.6 3.9 1.0 100.0 806 Not working for cash 51.4 7,704 71.2 0.2 0.3 0.3 0.1 19.7 0.3 4.8 3.1 0.0 100.0 3,961 Wealth index Lowest quintile 40.4 1,699 77.4 0.I 0.0 0.0 0.0 14.5 0.2 5.4 2.4 0.0 100.0 686 Second quintile 50.6 1,769 72.9 0.0 0.3 0.2 0.3 17.7 0.1 4.6 3.8 0.0 100.0 895 Middle quintile 54.9 1,874 71.1 0.3 0.0 0.3 0.2 19.1 0.0 5.3 3.4 0.2 100.0 1,029 Fourth quintile 56.8 1,937 68.6 0.5 0.1 0.5 0.5 22.3 0.2 3.8 3.5 0.0 100.0 1,101 Highest quintile 56.2 1,879 66.2 0.0 1.1 0.5 0.6 22.5 0.7 4.8 2.9 0.6 100.0 1,056 Total 52.1 9,159 70.7 0.2 0.3 0.3 0.3 19.7 0.3 4.7 3.3 0.2 100.0 4,767 Maternal Health ] 6l 5.5 Delivery Care Hygienic conditions and proper medical assistance at the time of delivery can reduce the risk of complications and infection for both the mother and the new born baby. For all births in the five- year period before the survey, the 2003 EIDHS collected information on whether the mother was assisted by medical personnel or not and on the place of delivery. These results are presented in Table 5.8. In the majority of the births (69 percent) during the five-year period preceding the survey, the mother was assisted at delivery by a doctor or a trained nurse/midwife. Most of the remaining births were assisted by dayas (traditional birth attendant). With respect to the place of delivery, around 6 in 10 births are delivered in a health facility, with women being more likely to deliver in a private than in a public sector facility (36 percent and 24 percent, respectively). Table 5.9 presents differentials in the percentage of medically- assisted births and in the percentage of births taking place in a Table 5.8 Delivery characteristics_ Percent distribution of births in the five year period before the survey by the type of person assisting at the delivery and the place o['delivery+ Egypt 2003 [otal Assistance dur ing delivery Doctor 63.8 Trained nursc/midwii~ 56 Daya 282 Relative/other 2. I No care/missing 0.~ Place of deliver) Health ihcility 59.0 Public sector 23.4 Private sector 35.7 At home 40.9 Don't know/tnissing 0 I ['otal 100.0 N um bet 6,314 health facility. As expected, women who saw a medical provider for antenatal care during the pregnancy, especially those who received regular antenatal care, were more likely to have been assisted at delivery by a doctor or trained nurse/midwife and to have delivercd in a health facility. The mother's age is only very slightly associated with the type and place of delivery. The child's birth order is negatively associated with both of the delivery indicators; for example, the proportion of medically assisted deliveries births ranges from 82 percent among first births to 47 percent among births of order 6 or higher. Looking at other characteristics, both the likelihood that a birth will be assisted by medical personnel or that it will take place in health facility is greater among urban households, especially those living m the Urban Governorates, than among rural households. The proportions increase with the woman's education level, are higher llsr women who work than those who do not, and rise with the wealth index. With respect to the latter variable, women whose bousehold ranked in the bottom quintile on the wealth index were less than half as likely women whose household was ranked in thc lowest quintile (95 percent and 43 percent, respectively). 5.6 Postnatal Care Care following the delivery is very important for thc mother and her child, particularly when the birth is not assisted by medical personnel. It is generally recommended that mothers receive the first postnatal checkup within two days of delivery in order to detect problems that may lead to maternal death. Care for the Mother Table 5.10 looks at whether or not mothers received postnatal care following delivery |br all births during the five-year period before the 2003 EIDHS. Births are classified according to whether a medical provider assisted at the delivery or not and by the place of delivery (in a health facility or clse,,yhcre). Where a medical provider was present at thc delivery, the postnatal care refers to any checkup the woman may have received other than that which may have taken place at the time of the 62 J Malermd Hea/th Table 5.9 Medically assisted deliveries by background characteristics Among birlhs in the five-year period before the survey, percentage whose mothers were assisted at delivery by medical provider and whose mother delivered in a health facility according to selected background characteristics, Egypt 2003 Percentage Percentage assisted by delivered medical in health provider facility All births Medical care during pregnancy Had ANC 81.0 70.2 4,338 Four or more visits 84.6 74.5 3,51 I Fewer than 4 visits 65.9 51.6 827 No ANC 43.8 34.6 1,976 TT or other care 46.5 37.6 1,496 No medical care 35.2 25. I 479 Age at birth < 21") 67.5 57,2 735 20-34 69.8 59.3 4,905 35 49 68.0 59.2 674 Birth order 1 82.1 71.7 1,858 2-3 69.6 59.7 2,816 4 5 58.8 46.8 1,038 6+ 47.2 37.9 602 Urban-rural residence Urban 86.7 78.0 2,362 Rural 59.0 47.7 3,952 Place of residence Urban Governorates 90.2 82.5 91 I Lower Egypt 76.5 65.7 2,688 Urban 91.0 81.0 751 Rural 70.9 59.8 1,937 Upper Egypt 55.3 44.5 2,715 Urban 77.4 69.1 700 Rural 47.6 36.0 2.015 Education No education 47.8 38.5 2,142 Primary incomplete 62.9 52.2 638 Primary complete/some secondary 71.4 59.5 1,023 Secondary complete/higher 88.6 78,0 2.51 I Work status Working tot" cash 83.4 74.3 755 Not working lhr cash 6"/.5 57.0 5.559 Wealth index Lowest quintile 43.2 33.8 1,366 Second quintile 55.5 45.0 1.279 Middle quintile 73.1 61.2 1,323 Fourth quintile 86.2 74.5 1,319 ttighest quintile 95.0 87.3 1,029 Total 69.4 59.0 6,314 Maternal Health I 63 Del ivery care. For births assisted by dayas, re lat ives or other indiv iduals wi thout medical training, the postnatal care refers to any checkup from a medical prov ider occurr ing after the del ivery. Overa l l , mothers reported rece iv ing a postnatal checkup in the case o f around 4 in 10 births dur ing the f ive-year per iod before the survey. Among the mothers who had any postnatal care, around 70 percent had a checkup with in two days o f the del ivery. Table 5.1 ft Postnatal care tbr mother Percent distribution of births during the five-year period belbre lhe sur~ey, by timing, type oI provider and location of the first postnatal checkup for mother, according to the type of assistance at delivery and place of delivery. E~wt 2003 Type of assistance at delivery Place of delivery Delivery Medically assisted by Within Outside assisted daya/ health health Postnatal care delivery I other li~eility [ileility All births Timing of first postnatal checkup Within 2 days of birth 38.8 7.2 430 9 1 29.1 3-7 days of birth 9.6 5.1 100 5.7 8.2 8 27 days of birth 2.5 1,9 2.6 2.0 2.3 4+ weeks after birth 3.2 2 4 3.1 27 2 9 No care 45,8 83.4 41.4 805 57.3 Don't know/missing 0 1 0. I 0. I tl I 0. I Provider for first postnatal care checkup Doctor 51.3 80 56.9 10.7 38.0 Trained nurse/midwife 2.8 1.4 1.7 3.3 2.4 Daya 0. I 7.2 0.0 5.s 2 2 No care 45.8 834 41.4 80.5 573 Source for first postnatal checkup Public sector 16.2 1.2 20.7 2.9 I I.h Hospital 14 1.8 18.9 1.0 15 ttealth unit 0.5 0.1 1.3 1.8 0.3 MCtl center 31.3 3.5 0.5 0. I 22.8 Private doclor/clinic 4.4 9.6 3q.5 4.4 60 Home 0.3 04 24 I 1.1 0.3 Other location 0.2 00 /hO I. 1 0. I No care 45.8 83 4 41 4 80.5 57.3 Total percent 100.0 100.0 100.0 I/){h0 i 00.(l Number of births 4.380 1,914 3,732 2,582 6.314 Delivery ~as assisted by doctor or trained nurse/midwaY. Postnatal care checkups were much more common in births in which the mother was assisted by medica l personnel (54 percent) than among other births (17 percent). V ir tual ly all mothers who had a medica l ly -ass is ted del ivery also saw a medical prov ider for the first postnatal care checkup, and thc checkup took p lace in a health faci l i ty. Mothers who del ivered without medical assistance were seen a lmost as often by a daya as by a medica l prov ider for the first postnatal checkup, and the checkups frequent ly occurred at home. 1"able 5.10 also shows the patterns o f postnatal care for the mother accord ing to the place o f del ivery. As expected, postnatal care was more common for mothers who de l ivered in a health faci l i ty (59 percent) than for mothers who de l ivered outs ide a health Facility (19 percent). As expected a lmost all mothers who.de l ivered in a health faci l i ty saw a medical prov ider for the first postnatal care checkup, and the checkup genera l ly took p lace in a health Facility. Among mothers who del ivered outside a health faci l i ty and had a postnatal checkup, the major i ty saw a medica l provider for the first checkup, but many o f the checkups occurred in the home. 64 J Maternal Health Table 5.11 controls for the type of assistance at delivery in looking at differentials in the likelihood that the mother received postnatal care from a medical provider] The mother's age is not consistently related to the postnatal care indicators presented in the table. Although not uniform, the association between the child's birth order and the likelihood the mother will receive postnatal care is generally negative. Table 5.11 Postnatal care for mother by background characteristics Percentage of births in the five-year period belbre the survey for which the mother received at least one postnatal care checkup from a medical provider and for which the mother had the first checkup within two days of the delivery by type of delivery assistance, according to selected background characteristics, Egypt 2003 Medically-assisted Delivery assisted by delivery I daya/other All births Postnatal Postnatal Postnatal checkup checkup checkup within two Any within two Any within two Any Number Background days of postnatal days of postnatal days of postnatal of characteristics delivery care delivery care delivery care births Age at birth < 20 33.3 50.3 5.8 16.8 24.4 39.4 735 20-34 39.2 54.7 7,4 16.6 29.6 43.2 4,905 35-49 41.9 55.0 6.7 14.8 30.6 42.1 674 Birth order I 41.6 60.2 6.0 14.8 35.2 52.0 1,858 2-3 38,6 53.7 6.5 15.2 28.8 42.0 2,816 4-5 36.5 47.2 9.9 21.7 25.6 36.7 1,038 6+ 30.6 41.1 6.2 14.3 17.7 27,0 602 Urban-rural residence Urban 43.0 59.3 7.7 18.7 38.3 53.9 2,362 Rural 35.1 49.8 7.0 16.0 23.6 35.9 3,952 Place of residence Urban Governorates 46.0 63.4 7.9 22.8 42.3 59.4 91 I Lower Egypt 39.8 55.4 7.2 20.6 32.2 47.2 2,688 Urban 41.2 57.1 8.7 17.0 38.2 53.5 751 Rural 39.2 54.5 7.0 21.0 29.8 44.8 1,937 Upper Egypt 33.5 47.6 7.0 13.8 21.6 32.5 2,715 Urban 40.7 55.9 7. I 17.1 33,1 47.2 700 Rural 29.4 42.9 7.0 13.3 17.7 27.4 2,015 Education No education 35.6 4~,. I 6.6 15.2 20.4 30.9 2,142 Primary incomplete 40.8 51.8 7.5 17.6 28.5 39.1 638 Primary comp./some sec. 37.3 50.5 7.6 16.7 28.8 40.8 1,023 Secondary complete/higher 40.4 58.7 8.4 19.8 36.8 54.3 2,51 I Work status Working tbr cash 42.5 60.3 5.1 16.3 36.3 53.0 755 Not working for cash 38.2 53.2 7.2 16.4 28.1 41.2 5,559 WeaLth index Lowest quintile 28.2 41.3 4.3 13.0 14.7 25.2 1,366 Second quintile 36.6 48.6 8.7 17.2 24.2 34.6 1,279 Middle quintile 37.8 52.6 9.8 21.9 30.3 44.3 1,323 Fourth quintile 36.2 53.2 6.8 16.1 32.2 48. I 1,319 Highest quintile 50.8 69.0 13.3 23.4 49.0 66.7 1,029 Total 38.8 54.2 7.1 16.4 29.1 42.7 6,314 Delivery was assisted by doctor or trained nurse/midwife. 7Differentials in postnatal care levels by place of delivery are similar to those presented in Table 5.11 and, thus, are not shown separately in the report. Maternal Health ] 65 Urban mothers are more l ikely to rece ive postnatal care than rural mothers. Mothers in rural Upper Egypt have the lowest percentage report ing any postnatal care (27 percent) and women in the Urban Governorates have the h ighest percentage (59 percent). The percentage rece iv ing postnatal care increases wi th both the woman's educat ional level and with household wealth. It is also h igher in this group for women who work tbr cash than for other women. Care for Ch i ld Tab le 5.12 looks at whether or not the chi ld rece ived any postnatal care fo l lowing del ivery for the last birth dur ing the f ive-year per iod before the 200

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